[goodells]

Yep. The midlevels are supported by automatic protocols in Epic (e.g. sepsis, DKA -> put these dozens of orders in with 5 clicks) that physicians decide on and approve. They also rely more heavily on imaging instead of a physical exam and history. When unsure, they can consult a physician, even a specialist.

It’s a very polarizing topic in medicine that patients generally aren’t privy to. Especially for resident physicians who often make half as much as these midlevels yet have more education, there’s a lot of bitterness. The federal government is ultimately to blame… having a fixed number of residency spots to artificially limit the supply of new physicians is terrible, and this is the predictable result.

I think hospitals support inefficient midlevels because they can bill patients for the increased resource usage, but it’s not good for the system overall when unnecessary scans and consults are done, and more complex patients don’t get comprehensive care. Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.

[lotsofpulp]

>Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.

There already was a tiered system, with rich people being able to buy concierge medicine and getting preferred treatment based on who knows who on the hospital's board or if their name is on a wing of the hospital.

The change now is a more visible and more granular price segmentation.

[jac241]

There’s no price segmentation. You pay the same for a visit with a PA or NP as for one with a physician, so why see someone with less than a tenth the experience who may have gone to an online only school with 100% acceptance rate and shadowed for 500hrs of “clinical experience“ right out of nursing school?

[lotsofpulp]

It will happen via in network and out of network agreements.

Healthcare providers with greater proportion of NP/PA will be selling for cheaper, so MCO will sell access to only them in their lower price plans, and healthcare providers where you get to see doctors will be in higher price plans.

This already happens, especially with many healthcare providers not accepting lower reimbursed Medicaid patients.

[nradov]

A two tiered system might actually be better for improving access to affordable health. Mid-level providers seem to achieve equivalent outcomes for routine cases at lower cost.

I agree that Congress should increase funding for residency programs.

https://www.ama-assn.org/education/gme-funding/ama-seeks-mor...

[goodells]

I generally dismiss these “equivalent outcome” studies. Any midlevel will (and should) bounce the more complicated cases to their supervising physicians. Outcomes at that point are meaningless.

There’s definitely a trade off between resources devoted to education vs. acceptable risks from failed procedures, missed/delayed diagnoses, and increased utilization of imaging and referrals (and the physician radiologists and others who participate in that - it goes full circle). Physicians now are probably on one extreme end of that, and midlevels on the other.

On the topic of servicing rural areas… the problem is that nobody with better options (which includes midlevels) wants to live in these places. These educated, high-earning people want to live in urban areas, and they can. CMS has tried to incentivize this with billing by offering higher reimbursement rates to rural places that have a midlevel on staff. That’s about it, though.

[lotsofpulp]

> the problem is that nobody with better options (which includes midlevels) wants to live in these places.

Or the problem is that people are not offered enough money to make the sacrifices they would make by living in rural places.

[mlyle]

> I generally dismiss these “equivalent outcome” studies. Any midlevel will (and should) bounce the more complicated cases to their supervising physicians. Outcomes at that point are meaningless.

If midlevels can successfully detect complicated cases to a supervising physician, and handle a whole lot of other care independently... and the net result is equivalent outcomes... this isn't a massive win? You've conserved the really expensive and contended resource for where it's needed and not made anything worse...

[goodells]

It's not so clear cut for a few reasons.

#1 - Funky/misleading statistics - Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients. It's not claiming that of any randomly selected patient, regardless of who they see, the outcome is the same. Therefore, if uncomplicated patients saw physicians, outcomes for the physicians could improve. In primary care managing hypertension or diabetes, this isn't as pertinent. For something like anesthesiology, it's more so counting how many times shit hits the fan, and brain cells die when the anesthesiologist takes time to be summoned.

#2 - They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here! The patient no longer has use of their interphalangeal joints. The physician would probably try to shine a light through it, note the patient's Scandinavian ancestry and family history of plantar fasciitis, and tell them to live with it and come back if it changes.

No resources were saved here, but the patient's DASH score (disability of the arm, shoulder, and hand) is still 0 so the outcomes are the same.

This happens all the time.

#3 - Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.

#4 - It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor... in many places, that doesn't necessarily need to be an anesthesiologist, and the surgeon performing the procedure can suffice. The AANA recently changed its name to the "American Association of Nurse Anesthesiology"... It used to be "Anesthetists". The CEO and president (two different people) of the American Nurses Association both refer to themselves as "Doctor" in a healthcare setting even though one holds a DNP and the other a PhD. It's pervasive.

[mlyle]

> Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients.

The studies I've seen have compared practices where NPs are seen first vs. physicians are seen first.

> They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here!

Your claim is this kind of excessive testing and referral doesn't happen with physicians? Do you have some kind of evidence this is more common with NPs?

This kind of overtesting leading to unnecessary procedures and bad outcomes has been pervasive through care in the US. Don't blame it on NPs.

> Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.

Ditto

> It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor...

Welp, we're not creating anywhere near enough residencies to create enough physicians to do the work, so I'd suggest we'd figure out ways to either do that or use people with lower levels of training well (preferably both!).

[itg]

I'm having a hard time understanding why they would be bitter. Residency is temporary and a part of the training process. Once completed, doctors will make 2x-3x+ compared to midlevels for the rest of their careers.

[goodells]

Residency has a lot of problems. The match is stressful enough. Medical school graduates carry a huge amount of debt, but must complete residency before earning enough to meaningfully pay it off. Residencies pay 40-85k and most resident physicians are expected to work 80+ hours per week. 80 is the theoretical maximum, but that doesn’t count time arranging work, studying, taking board exams, etc.

All this, and if you don’t complete your residency, you have no prosperous future as a doctor. You might re-match to another residency if you’re very lucky. The hospitals know this and act accordingly. Residents and even medical students paying tuition (!) were assigned to treat COVID patients and couldn’t really decline without risking the future they’re heavily invested in.

Keep in mind, the federal government pays ~150k per year to the hospital for having the resident. Yet the residents are often more indentured workhorses than trainees. It’s not uncommon for entire departments to run overnight with only residents, but no attending physicians.

Now imagine being in this situation, and not being allowed into the “providers lounge” because you’re a resident. Or using a broad-spectrum antibiotic instead of something more specific and being scolded for poor antibiotic stewardship, while the NP who has “completed their training” can’t even properly decide antibiotics are indicated some of the time. And if that NP were ever treated the way a resident is, they could go get a job at the hospital on the other side of town and start in a week.

[lotsofpulp]

Because the future is for doctors to not make 3x compared to them. The mid levels are being used to increase supply of healthcare, using the doctor’s license for liability, in order to reduce the price doctors collect (per unit of time and effort).

Basically, they are watching their expected wealth / purchasing power be reduced.

[jac241]

If someone was making more than twice as much as you, working half as many hours as you, seeing half as many patients as you, and were less qualified for their similar role, you would be upset too.

[matheusmoreira]

Not to mention the fact they offload all the legal liability to the actual doctors since they have to approve everything.

[rcpt]

You can read r/noctor if you want examples