The Regrettable, Fixable State of Preventive Medicine
This week's TIME Magazine has a story about how nurse practitioners—who have substantially less training than doctors, but are authorized to make many of the same treatment decisions—are growing more important due to a growing shortage of internists (that is, doctors who provide "primary" or "preventive" care—things like your annual physical):Nurse practitioners may be a stopgap solution, but their growing role is unfortunate. It's great that they can take their time with patients. But a doctor who takes her time will bring more training and expertise to the table, and have a better chance of catching problems early. Detection of early stage cancers, for example, often turns on subtle and eminently overlookable anomalies in patients' lab results—and often saves lives, not to mention substantial amounts of money. A doctor who is forced to see six patients an hour, or a nurse who has more time but lacks the expertise to hone in on early warning signs, is simply not as good. The obvious step is to narrow the pay and prestige gap between primary care and other specialties. Sometimes people talk about a ten percent increase in the rates paid to primary care physicians. Given how bad things currently are, however, that won't be enough. We might save money and lives with physicals that last thirty or forty minutes, rather than seven or ten, but it would take a fundamental realignment of a pay structure that currently forces primary care physicians to rush through their analyses of lab results and patient complaints. We should work backwards from the world we want—the one in which primary care does not represent a substantial opportunity cost for new doctors, relative to other specializations—and set fees to give us that world, with unhurried physicals and robust early interventions.Even without reform, experts on the health-care labor force estimate there is currently a 30% shortage in the ranks of primary-care physicians. Fewer than 10% of the 2008 graduating class of medical students opted for a career in primary care, with the rest choosing more lucrative specialities [sic]. That could pose problems if a national health-care bill is enacted. After Massachusetts enacted mandates for universal health insurance in 2006, those with new coverage quickly overwhelmed the state's supply of primary-care doctors, driving up the time patients must wait to get routine appointments. It stands to reason that primary-care doctors could be similarly overwhelmed on a national scale. . .
But there is an existing group of providers that health reformers are hoping can help fill this gap: nurse practitioners. Depending on the state in which they practice, nurse practitioners, with advanced training often including master's degrees in nursing, can often treat and diagnose patients, as well as prescribe medication. And they can do these things at a lower cost than doctors — Medicare, for example, reimburses nurse practitioners 80% of what is paid to doctors for the same services.
While pay incentives are important, I think you may be underestimating another important consideration: doctors’ interest. Many aspiring docs want to be the next “House,” solving some convoluted and/or obscure pathology. Constantly reminding patients to take their blood pressure meds is seen as banal and beneath folks who’ve undergone intensive training for many many years. Combine that with deteriorating compensation and increasing workloads for general practitioners, I really think that the era of MDs as GPs is coming to an end. You bring up some good points about how that will negatively impact patients though, and I think its unfortunate that there is no way around this situation.
— Dankoba · Aug 3, 07:18 PM · #
I’m not sure I agree with your assessment of the rise of nurse practitioners either (or, really, PA’s, who are in many ways equivalent). It’s one of those “it depends” things. The PA can be really, really specialized — I’ve worked with PA’s who deal mostly with heart surgery patients, cancer patients, etc., and have done so for years. Nurse practioners and PA’s need to be overseen by an MD who signs off on what they do and basically what you need to do is not say, the PA is a bad thing relative to the MD (which I think is just wrong) but rather that exactly what constitutes oversight of his/her work by the MD needs to be properly calibrated. At present it varies some (both what constitutes oversight, and what the nurse/PA is allowed to do vary) from state-to-state, maybe that also needs to change depending on how health care reform is realized.
— Sanjay · Aug 3, 07:47 PM · #
Sure, but saves it for who? It doesn’t save it for the doctor, because he gets paid to treat, not to make people healthy. Saving one life in the time it would take to order expensive tests for six other patients takes money out of his pocket. It’s not in his interest to spend that kind of time.
It doesn’t save it for the insurer, since by the time they’d see the ultimate benefits of preventative care, the patient has changed insurers (because they changed jobs or moved or found a better price elsewhere). So, sure, it saves money; it just doesn’t save any money for the people who would have to be doing it. Preventative care is in a “regrettable” state because for-profit medicine creates substantial incentives against it.
— Chet · Aug 3, 09:06 PM · #
Anyone care to explain what exactly that means? Did he mean to say “lost” instead of “cost?”
I’m not sure what Mr. Robinson is getting at, but it sounds like he wants someone to decide how much someone else is going to get paid, which is, frankly, not a good idea. That IS what Obama and his ilk want to do, after all.
As to nurse practitioners vs. MDs. My sister is an NP, here in the states. She thought the specialist—an internist—who finally diagnosed our mother’s pancreatic cancer should have done so about 4 months earlier, judging by the symptoms our mother had. Doctors are not necessarily better just because of their advanced training.
My younger sister is an NP in Toronto, one of the first they had there. She was diagnosed with breast cancer. The same sister above—the NP here in the States—was absolutely livid because the medical folks in Toronto not only missed symptoms of cancer, but waited way too long to start treatment.
Just two observations of completely unrelated incidents.
What an incredibly ignorant statement.
As to the whole point of the article. There is new research questioning the value of preventative medicine as a cost saving measure. It’s not to say that preventative medicine is not good, just that it’s expensive and probably will not cut costs.
— jd · Aug 3, 09:36 PM · #
Which I supported with argument and examples. Could you address them, perhaps?
— Chet · Aug 4, 12:05 AM · #
I have to disagree here. The vast majority of medical visits are not about cancer or any other difficult-to-diagnose conditions. Most medical visits involve check-ups, relatively minor acute illnesses and minor injuries. Nurse practitioners can certainly treat these. If a set of symptoms is puzzling, or the condition persists despite treatment then it’s time to call in a fully credentialed MD. But how often is this the case?
— JonF · Aug 4, 12:52 AM · #
“Preventative care is in a “regrettable” state because for-profit medicine creates substantial incentives against it.”
I work for such a company. I know of no demonstrably effective preventative that we don’t pay for (assuming it a “medical” intervention. We don’t pay for membership at the Club). I don’t know of other insurers denying standard preventative. Maybe you’re suggesting unproven preventatives?
— C3 · Aug 4, 01:00 AM · #
If the state-by-state variation in NP responsibility at a primary/preventative care level has been going on for any significant length of time, shouldn’t there be actual data on whether or not primary/preventative care by an NP affects health outcomes?
— edianes · Aug 4, 02:37 AM · #
JonF is absolutely right. Health care is really just very complicated, very important technical support. Most problems, along with routine maintenance, can and should be handled by a front line of less highly trained (and paid) staff, like an RN. If that fails, up to the next level, NP, then PA, Internist, and eventually a specialist. The problem is that the health care process, as currently implemented, would take 6 months to go through this hierarchy. This is silly.
Would Dell or IBM survive if it took six months to speak with a specialized technician about a particularly complicated problem? No, and neither should our health care system.
— Joel Martin · Aug 4, 01:16 PM · #