08 May 2009

The future of primary care

Nurses: A Key to Health Care Reform - Swampland – TIME.com
One of the few things that just about all sides agree upon in this health care debate is that we need more primary care providers -- lots more. And an already serious shortage will only get worse if we succeed in expanding coverage to some or all of the 47 million Americans who now lack it.  [...]  The good news, however, is that there is a large army of reinforcements out there--primary care providers who are proving their worth every day, particularly in underserved areas like rural America. They're called ... nurses. More specifically, nurse practitioners. In 2006, there were nearly 145,000 nurse practitioners--registered nurses with advanced training--practicing in America. In 2007, another 3,700 graduated from masters degree and postmasters programs.
Karen Tumulty has been exceptional in her health care writing lately.  This piece, while entirely accurate, has a disquieting element to it.  Physician-provided primary care is dying, and in the future will be provided by Mid-Level Providers (including NP's and PA's).

This is not altogether a terrible thing.  There's an efficiency argument for MLP's in primary care: they are more affordable in large numbers.   And there are not enough physicians to provide the needed service.  Quality is more concerning.  Within a limited scope of practice and with reasonable supervision, MLPs can provide great quality primary and acute care.  But MLPs are not physicians.  I've worked with a lot of MLPs over the years, and many of them were very good at what they did.  My experience, however, is that even the less-exceptional physicians I have worked with had a deeper breadth of knowledge and skills than the best MLPs.   So while I see a role for MLPs and I respect them for the abilities they have, supervision is essential.  But, as referenced in the article, many states allow near-independent practice by NPs in particular, and then greatest need for MLPs is in sites where physicians are not available.  When a provider gets in over their head, it can be very dangerous, especially when they do not realize that they are out of their depth.

This situation is suboptimal.  The ideal would be to have enough physicians to provide these services without compromising quality.  But the deathgrip that proceduralists have had on the compensation system (the RUC) has bled primary care dry financially and in personnel.  Even if the health market reform rejuvenates primary care training, it will be five to ten years before the new PCPs hit the market in meaningful numbers.  If Obama is successful in accomplishing universal coverage, this lag time will be too long, and MLPs may fill the market niche in the interim.


  1. What we need are confident and well trained generalist physicians to handle the majority of medical problems people have without getting the high cost specialists involved. not sure that will happen with midlevels, who by definition won't have the training and confidence a physician would have.

    Additionally, if it becomes clear to med students that midlevels are doing a lot of primary care, and that seems to be a model we are "moving toward" they will avoid going into primary care even more than they are now. Why take your high priced services into a field where it will be valued at a nurse or PA level?

  2. What's the training like to become an NP?

  3. I continue to be amazed that physicians -- particularly primary care -- don't agitate more to change their method of compensation, which seems tailor-made to force physicians to treat care like a 15-minute commodity.

  4. The deathgrip that proceduralists have had on the compensation system (the RUC) has bled primary care dry ...If medical school included a few courses in Econ it would be obvious to you that the problem with the RUC isn't "proceduralists."

    The problem with the RUC is that it is part of a centralized price control system. Such systems always (every time) cause shortages.

    In this case, the shortage is in PCPs. And, I hate to break this to you, but what you hilariously call "reform" is only going to create more such problems.

  5. Catron,

    For once I agree with you -- Med School *should* include some economic and financial literacy courses. Not every MD needs to have a MHA or MBA etc, but the illiterates that come out of medical school and residency are embarrassing and dangerous.

    More on topic, are you *advocating* a centralized price controlled system? That seems out of character for you. If not, what's your solution to the inevitable shortages caused by its lack?

  6. There needs to be SERIOUS financial and lifestyle motivators for people to go into primary care. The pay is too low, the hours too long, the debt too high. Certainly when you can go into a procedural specialty and make 5-10X the income, who would go into primary care if they were not a saint?

  7. Are you advocating a centralized price controlled system?We already have one for 50% of the health care economy. For Medicare, Medicaid, SCHIP, Tricare, etc., the government sets arbitrary prices via IPPS, OPPS, etc. If a Medicare patient goes into a hospital for CHF, the hospital gets paid a set price regardless of what treatment costs or how long the patient stays.

    That's why there are shortages of PCPs in many parts of the country (the parts where most of the patients are on Medicare and Medicaid) and a growing number of rural counties without hospitals. There would be even more "hospital-less" counties if not for the waiver "critical access" institutions get from this centralized price control system.

    Unfortunately, when the vaunted "public option" is imposed on the system, and most of the populace gets suckered into signing up, the situation will become far worse and the price controls will be even more arbitrary than they are at present. Then there will be general shortages throughout the system as in Canada, the UK, etc.

    Not that the people who screwed the system up will get the blame. They will just trot out some Republican hobgoblin and announce that it is once again time for the obligatory two minutes of hate.

  8. Certainly when you can go into a procedural specialty and make 5-10X the income, who would go into primary care if they were not a saint?I'm going to say something that is a heresy now. But is it possible that doctors and lawyers (who on average make about 50% what doctors make) are overpaid? Is it possible that the push back from patients and clients that we are experiencing now is a market correction?

    I realize the notion that it is the primary care doctors and the government lawyers that are really making the appropriate (defined as what the market can bear over the long term) salaries is terrifying, but it may be true.

    BTW, Shadowfax claims that among doctors, it is an article of faith that lawyers make more than doctors. I'm sure he is not giving you guys enough credit and that you are in fact capable of reviewing the data on the topic.

  9. Shadowfax -- I'd be interested to hear what you think should be changed in medical education. Students go into hiding for several years with med school and residency (and maybe a fellowship), then come out with a high debt burden. It seems to me that there's something wrong with it if students come out in that much debt.

    I know I'm not willing to do it, and I'd make pretty good doctor, perhaps even of the PCP variety. Instead, I'm enjoying being a volunteer EMT as I pursue a career in an entirely different field. And my strengths do not lie in the short-term, fixed procedural approach of emergency medicine (at least in the prehospital setting), but more in the diagnosis, long-term tracking, and ability to synthesize a large amount of information that PCPs do. But I'd rather have flexibility to take classes for my career from a community college while working in my field than to be saddled with so much debt with a solid chunk of lost time in my 20s. If there were another path to becoming an MD/PCP, I wonder how many others would take it, though it's possible I'm in the scant minority.

  10. I think the idea would be to have PAs (who have to work closely with physicians as a team) and docs who are dedicated enough and smart enough to practice in a team based environment, providing supervision and leadership as necessary. Two PAs to each doc in primary care is a pretty good ratio.

  11. I think the value of primary care given by MD's is understood by many, but not all. In my opinion, we are headed for a two tiered (or 3 tiered) system where those with $ (who value higher quality care) will pay for a primary care practitioner who is an MD. Those who cannot, will settle for a PA or NP. --signed by a primary care MD.

  12. Fools! We hold the power, the license! All we have to do is make a stand. It will happen when enough PCPs get fed up and organized. You have not seen It here, in the lower 48, But I have seen It In AK. When the PCP doctors unionize then the buck stops and the union dictates terms to Management. This can take the form of cash only or negotiated group minimum hourly wages, but the denial of care by PCPs for all but emergent care is a check that stops the system. The ED and the Hospitals can't take the overflow and accommodation and negotiations follow quickly .

    Not so cold Doc

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    to health that avoids invasive procedures or addictive drugs.
    Houston Chiropractic Clinic


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