Wonkblog is reporting on some good news that will continue to bend the cost curve while providing better access to healthcare to more people:
The most recent wins came in West Virginia and Florida, where after many years of trying, lawmakers passed measures freeing up “advanced practice” nurses — those with more graduate education than just a nursing degree — to administer a wider range of care and prescribe most drugs without having to maintain a relationship with a physician….
They also had political muscle. After years of sitting on the sidelines, AARP made the bill a top priority, arguing that freeing up nurses is essential to care for the state’s aging population. The liberal West Virginia Citizen Action Group got involved. And Americans For Prosperity, the Koch-funded free markets organization, took up the cause as part of a broader push to wipe out barriers to entry in skilled fields.
Certified Registered Nurse Practitioners (CRNP) are mostly practicing in either a primary care specialty or a first tier specialty (endocrinology, cardiology, gerontology etc). These are the areas that the US doctor guilds have limited numbers and limited pay. They are also the areas where we need more people practicing. Most people who are touching the medical system in any given year don’t need a lot of complex care. They need monitoring, they need coaching, they need early warning, they need management and they will eventually need a trusted relationship to tell them either bad news or that they need to get their act together to prevent bad news. Primary care is where there is a great need, especially in rural and economically depressed areas where it is hard to recruit doctors because being in the middle of nowhere is no fun.
CRNP’s and physician assistants are not a cure-all, but they are a source of relief on the PCP shortage in this country and they are a chance to increase the probability of more effectively managing, minimizing and preventing long term lifestyle/wellness based chronic conditions. Fewer people transitioning from pre-diabetes to medication controlled diabetes is a cost win and a health win.
Furthermore, these types of political fights are the next wave of cost control challenges as this is the nitty gritty of cost control, breaking local barriers to entry and practice:
This is not sexy, this is not lucrative, this is not the way political programs are built as the slogan “Minor administrative changes to marginally increase competition by redefining scope of service delivery laws when do we want them —NOW” does not fit on a bumper sticker.
However these are the types of gains that need to be made to reduce the guild power of high end medical providers. Most of the people, most of the time, don’t need high end care. Their basic needs can be met by trained individuals who are not over-trained. Part of the training, of course, needs to be on the recognition of situations which are above the current level of training and therefore the patient needs to go up the ladder of care. But basic dental services, basic primary care services, basic preventative services can often be performed perfectly adequately at the master or bachelor level clinician level instead of a doctorate level clinician level. Those rules are overwhelmingly determined at the state level, so that is where the long slow slog of reform needs to come.
Missing a “not” there.
Thanks for this. I feel like we need a lot of insurgent political training in MANY fields to deal with our fractured system. From education to enviromentalism and etc… There are many places where incremental but targeted change needs to happen.
pseudonymous in nc
How do you bend the cost curve in medical specialisation? As Atul Gawande has suggested, the nature of American med school — from that first semester’s tuition bill — drives people towards lucrative specialities. Everybody wants to be a dermatologist. Primary care is seen as the fallback for those who graduated towards the bottom of their class. Federal incentives like the NHSC’s loan repayment schemes are nowhere near as broad as they could be.
Pushing responsibility onto CRNPs and PAs is all well and good, but you’re still basically shrugging and saying that East Bumfuck County just ain’t gonna get no family doctors. Perhaps there’s no objective difference to the care offered by experienced nurses — and perhaps it’s an improvement! — but it’s still a bit fucking third world.
The (potential) downside here is that licensing independent practitioners at a sub-MD level serves as another disincentive for physicians to go into underserved/income capped specialties. Those “routine cases” are what keep offices open.
big ol hound
Having grown up seeing country doctors in their kitchen “office” I would much rather see a nurse practitoner who was educated in this country’s medical system than someone who emigrated here after being educated overseas. My very personal experience is these newcomers do not understand that quality of life may be more important than just being alive whereas a primary care nurse understands completely.
@big ol hound: I know many doctors educated here that have no understanding about quality of life. And many primary care nurses are also educated overseas.
I also know many doctors educated overseas who place a higher value on quality of life than many American educated doctors do.
I go see a CRNP for all my primary care. Living out here it’s either that or wait. Robin has always been very good, taking the time to listen to everything I say and explain the meaning of this that or the other result, which is rare for a doctor to do in my experience. What is more, she has “saved my life” on 2 different occasions. I can see no reason to go to a doc for anything but specialized care.
What is the point of expensively educating people to handle health problems that does not require such expertise? Doctors can find their skills dulled by constantly being confronted with low level issues.
You need a doctor around, certainly. But being called in on a series of tricky things will keep them sharper than confronting yet another sore throat.
I’ve been reading a lot about the state of medicine over the last few years. This situation recalls the work of that team which showed that, the more “care” you got, the worse off you actually became.
Both my partner and I have used CRNPs at various times in healthcare, and I/we’ve been satisfied. The cartel behavior of doctors is a problem, but so is the absurd cost of getting doctors educated, which pushes some of the income-protecting behavior (only some of it).
I waited a couple months to see a dermatologist recently. She told me that her hospital residency in Phoenix, AZ, only had slots for two dermatology specialists per year, despite the fact that people wait a long time to see dermatologists in many cities. And that it was because of the demands of existing doctors there that the pipeline was so tightly pinched.
I’ve only seen her the once, so I have no idea if now that she’s practicing if she is doing anything to change the situation, but I could tell she thought it was stupid. I mean, what if the thing on my arm had been cancer? I’d have been waiting, watching it grow for 75 days because other dermatologists want to protect their income? That is unconscionable, and I suppose that delay could in a few cases of aggressive melanoma be f-ing deadly.
Love my PA.
I have a rheumatologist for my RA, but everything else is taken of by my NP, who I only see once a year for PAP smear and the other routine things. I don’t think I have ever been happier with my care.
The Kock sucker brothers helped?! Shit – now I wonder what’s wrong with this idea…
Big Ol Hound
@japa21: Lucky you. My experience is just the opposite and of course their are exceptions to every generality.
WereBear. Exactly so.
The ACA contains a few provisions to boost the use of NPPs (and PCPs) but a lot of the barriers to mainstreaming NPPs are emotional.
On the physician side you see physician organizations claiming patients will suffer serious harm if NPPs are allowed to treat them without some sort of physician supervision. (It isn’t that doctors will lose money if NPPs set up their own private practices, honest!)
On the patient side, people – in part because of the doctors screaming ‘yer gonna die!’ – are still resistant to being treated by an NPP.
pseudonymous in nc
That’s fine enough, but what happens when you get regions that aren’t attractive places for PAs and NPPs? Give prescribing privileges to local cosmetologists?
@pseudonymous in nc:
But that’s just it. It’s not fucking third world if you are providing good or equivalent care. What appears to be hard to overcome is the credential snobbery of wanting a “real” doctor even if one is not needed.
This kinda reminds me of stories of people with health insurance who deliberately go to emergency rooms because they believe that this will give them access to the best doctors and state-of-the-art equipment.
a hip hop artist from Idaho (fka Bella Q)
Exactly, and providing equivalent care with a different license allows MDs/DOs more time to work on cases that require their expertise.
Hi Richard, OT – you got an interesting whistle question at the end of the weekend referee thread, in case you didn’t see it.
The payoff for the training is diagnostic skill, and knowing what’s “simple” and what isn’t.
I just read a book which dug into the real world consequences of “state of the art.” For instance, bypass. There are big differences in what your cardiologist will recommend… based on where in the US one lives.
NOT the state of the heart arteries. NOT one’s insurance. Simply what local hospitals and doctors THINK is the best way to treat. In the study I read about, being in Texas compared to the NE increases one’s changes of being sent for bypass by 30-50%.
With no real difference in patient outcomes. Except… borderline people with the highly expensive and invasive procedures, the ones who got them in Texas but not in New York, wound up worse off. Side effects of the heart-lung machine, exposure to hospital germs, a cocktail of drugs because of the procedure; all of this added up to a net loss of health.
When you have an expensive suite of ORs and machines, everything looks like a nail.
And it’s not just profit-seeking, though that is a problem. It’s also the culture. NE doctors are more cautious, and turn to highly invasive procedures as a last resort. In Texas, such procedures are viewed as best for the patient long-term. Whether they are, or not.
For a great many patients, it’s NOT.
@pseudonymous in nc:
Nurse practitioners have pretty advanced training — it’s at least master’s degree level if not a little higher. So they’re not going to stick you with seeing someone with an associate’s degree.
I admit, I’m biased in favor of NPPs because I know several and they’re all smart, driven people who wanted more patient contact than you can get as a physician these days. And, yes, they couldn’t afford $100K in loans to go to medical school.
Right now, US medicine is a classic example of the pitfalls inherent in “what you know, that ain’t so.”
For instance, statins. Pushing them at a patient with “high” cholesterol is now considered a standard of care.
Even though they haven’t shown any benefit for women. Even though the only patients who do show a slight benefit are middle-aged men who have already had a heart attack. Even though patients with fewer heart attacks wind up getting more cancer. Even though they have some fearsome side effects, such as muscle aches, memory problems, and possible Lou Gehrig’s disease if you have the right combination of genes.
All for NO drop in total mortality.
This is what the statistics show. That’s not what doctors and patients alike think they show.
But that is the facts.
Anonymous At Work
Where did the nominal libertarian groups actually fall? Kochs are an odd group to back this for long-term advantage but groups like Institute for Justice should have been all over this, if they were intellectually honest.
@WereBear: and even worse, CMS is pushing statin adherence as a quality metric with some serious money attached to it.
Is this a US medicine problem, or a modern medicine problem?
This is fascinating, although I have no idea how you would factor this into medical care.
The differences between the effectiveness of statins on women and middle aged men suggests that “modern” medicine is not as modern as we would like for it to be.
The US and the UK and Canada tend to be in similar boats as far as combining expensive and ineffective. The French eat a lot better than we do (there is no French paradox, we had diet wrong) and so avoid much of our lifestyle diseases.
The Germans have been doing some head to head comparisons for cost control and have concluded that herbs can be just as effective, or more so, as some of the overpriced pharm drugs. Vitamin D3 in proper quantities works as well as a flu shot.
Countries who do not allow drug advertising have populations who do not expect all their issues to be handled with pills. Their medical system is more likely to be careful with diagnosis in the first place, and push healthy life choices, in the second place.
The US is the MOST likely country to ignore the true cause of illness and prescribe symptom-handling medicines. Doctors have decided on what pill the patient needs within 18 seconds.
That’s when they stop listening.
Poorer countries do not rely on MRIs or have been trained to wait for lab tests. They have doctors who actually listen to patients and are actually more likely to figure out what is really causing the patient’s problems.
@Richard Mayhew: This is very troubling because studies now indicate that with seniors, especially the older seniors, higher cholesterol increases their state of health.
And these are the very patients for whom side-effects are noticed the least; aches & pains and memory issues are going to be ignored… even if they are sudden onset!
I see that herbs are often used in Germany. I do not belief that herbs can be just as effective as pharm drugs (of course, it could be that some pharm drugs are just as ineffective as herbs). That Vitamin D3, in any quantity, works as well as a flu shot defies reason.
I agree with you that sometimes doctors don’t listen, but I have a hard time with the loosey goosey notion of “the true cause of illness.” This reminds me of a recent “program” that I saw on the local educational tv station here, in which a snake oil salesman was pitching the idea that just eating healthy and taking some supplements would immunize you from almost all illness.
ETA: saw an article saying that the German health care system subsidizes 40 percent of the cost of herbal supplements. That’s a lot of money for junk science.
Once again Richard Mayhew is lying to you.
He’s telling you that expanding the scope of practice of RNs will “bend the cost curve” of the broken collapsing U.S. health care system.
But will it?
Let’s take a look at the hard cold facts:
An angioplasty in America costs $61,000. In France, the same angioplasty costs $7500. Is Mayhew telling us RNs will perform angioplasty? Seriously? On what planet, Mayhew?
Heart bypass surgery in America costs $150,000. In the Netherlands, the same heart bypass surgery costs $14,000. Is Mayhew telling us RNs will perform open heart surgery? Please. Get real, Mayhew.
A hip replacement costs $88,000 in America. In Spain, the same hip replacement costs $7,700. So now we’re supposed to believe that RNs will be doing hip replacement surgery instead of surgeons?
Mayhew, if you’re going to lie to us, at least do it intelligently. You’re insulting our intelligence.
Aside from the insanely stratospheric cost of American medical procedures (on average 10x what the same medical procedure costs in Europe or Japan — from MRIs to hip replacements to knee surgery, all cost 1000% more in America than any other first-world country), WereBear zeroes in on another problem America’s broken collapsing medical-industrial system…namely, America’s ignorant incompetent doctors.
Doctors in America persist in prescribing treatments which studies show don’t work. Worse: the treatments often damage the patient’s health. (Example: arthroscopic knee surgery. Studies show that moderate exercise produces superior healing rates to arthroscopic surgery.) Yet stupid ignorant incompetent doctors continue to prescribe those treatments, impervious to evidence.
See the article “Believing in Treatments That Don’t Work,” The New York Times, 2 April 2009:
@pseudonymous in nc:
Well, who’s providing medical care in those places now? It’s not like increased availability of NPPs is going to somehow make an underserved area even more so.
The answer is, I don’t know. But your question is basically bitching that a good partial solution doesn’t fix the whole problem. Such areas are more likely to be able to bring in a NPP than a doctor, but there’s always the chance that they still may be able to bring in nobody at all. But that doesn’t leave them any worse off than now.
And it’s a hell of a lot easier for a small college-turned-university to start up a nursing program than to open a med school. I used to teach at a place called King College in Bristol, Tennessee, which is close enough to smack dab in the middle of Appalachia as to make no difference. The vast majority of their student body was from within 75 miles of there, and heavy on the first-generation college students. Shortly after I left there, they initiated a nursing program as part of their becoming a university. Seems like you’d have a lot of those nurses with an interest in serving the Appalachian communities they came from.
So this is a more solvable problem with NPPs than with physicians.