Posted by mooreds 9 hours ago
A doctor spends a decade working 60 to 80 hour weeks studying medicine whereas an NP is a Master degree, I think which can be obtained online.
There doesn't appear to be clear results yet in studies on the outcomes of NP's vs MD's (see reference).
Another argument is that maybe all that medical school training is overkill in Primary Care and this is perfect setting for NP's or PA's. And also maybe most doctors are not ambitious and forget most of the training they're not using on a daily basis anyway.
I think it would be pretty funny if after more studies NP's showed no different outcomes than MD's.
Interesting write up on NP outcomes.
The article is relevant, but it is a case of "you get what you pay for".
We saw a great doctor on our first visit, then our next visit we didn't even get to see a doctor, just a nurse practitioner... Kinda annoying I don't want parenting advice from a nurse... So on our way out when scheduling we asked if we could see the same Dr next time.
"Oh sorry she only works Tuesdays"
"Okay weird but this is 2 months out though so that should be fine"
"Actually Tuesday would put you over a week away from when the appointment was requested I can schedule you with ..."
3 visits later and we still haven't seen a doctor once. Not even a 30 second pop in the room to say hi.
We've gotten like 20 immunizations from nurses and can't ask doctors about any of it..
Like cool cool all for these peopl advancing their careers without med school but like ... Usually you want your doctor's to have gone through medical school
Is your kid sick? If not, you don't need a doctor.
The amount of bad and actually hazardous parenting advice I've gotten from nurses and PA's is staggering.
When we were discharged from the hospital, the pediatric nurse actually told us it was safe to feed him in the car seat on the drive home.
Sure. None of this requires a doctor, though.
> pediatric nurse actually told us it was safe to feed him in the car seat on the drive home
This is bad advice. But I'm failing to find studies that quantify the risk. You're correct that they shouldn't have said this. But I'm not convinced no doctor would advise similarly.
If everyone wants their kid to be seen by a doctor, we either need to lower the standards of doctor or normalise perfectly-well kids being seen by NPs. (That or a higher billing code if a patient demands a doctor for routine care.)
I'm sure you can get all kinds of dated advice from board-certified physicians too.
When literally googling your question is more reliable than asking your 'doctor', something is in need of fixing.
Google can't administer vaccines. It also can't fill out a chart that might be important in an emergency.
We ended up going to another one of their offices 30 minutes away which had availability (i.e. lower population density?).
For the receptionist that said "it would put you a week away"...that's when you should just push back and say that's fine. There are very few appointments that need to be exact. And you know what, if you're not sure and you're there, ask the doctor if it's ok :)
Also because I'm trying to spread awareness and you'll likely encounter this: Be aware of "hospital/facility fees".
https://www.theguardian.com/us-news/article/2024/jun/09/pati...
This happened to us, with a Northside Imaging center in a shopping plaza. A chest x-ray that's normally $50 at a regular center is costing us $500.
At least part of it seems to be that the price system is completely screwed up, the doctors need to be payed more and it's obvious that the institutionalized insurance system is a root cause. When government (or their heavily regulated proxies, or any third-party for that matter) sets prices, expect services and products to deteriorate in quality.
Everyday non-emergency care should be a transaction directly between a doctor and patient. That WWII screwed up the whole system through price controls on wages and locked us in, path-dependency style, to forever paying a useless third party is nothing short of infuriating.
I can't believe I of all people am calling for less regulation, but the amount of bullshit it seems like doctors have to go through to provide basic service seems counterproductive.
It's hard not to see the parallel between healthcare and education where the parasitic overhead has been completely unchecked and enabled by federal subsidies. There's a similar deal with food, housing and other areas. It's absurd the amount of money that has been spent by the federal government in these areas with so little to show, the average person feels not only a lack of progress but decline.
Want to know what food and housing was like before regulation? Read the jungle.
Do you think we have deteriorated since then?
Maybe the prosperity you think has deteriorated was not due to lack of regulation, but due to black swan events like… i dunno conquering and industrializing the entire North American continent, all peer nations blowing each other to bits in two world wars, etc?
It's not easy to inject nuance into a discussion that feels like you have millions of people on each side of a tug-of-war rope that goes from "MORE REGULATION" to "LESS REGULATION".
I think housing, which you mention, is an excellent example. Yes, we need regulation in housing because without it, people will die from shoddy structures collapsing on them, electrocution, gas leaks, etc. But at the same time, in the USA there are absolutely regulations in housing with very little benefit and absolutely massive costs, where we have examples of first-world countries without those regulations that do just fine. I'm talking about things like the requirement that all apartments have 2 stairwells. Or mandatory setbacks and minimum lot sizes and parking requirements. edit -- and of course zoning codes, where we've shifted the market toward building housing that's so big that people can only afford to share it with strangers. And while people used to live in crowded, cramped tenements, driving housing prices up by restricting supply leads to people living on the street.
In medicine, there are diminishing marginal returns to making doctors go through more schooling, and the cost is simply that fewer people choose to be doctors, and people just go without health care. And even within that simple dilemma of "should we make it harder or easier to be a doctor", i'm sure there is a universe of alternate ways to move the needle in different dimensions. Requiring more or less schooling, more or less time in residency, changing limits on the number of hours doctors and nurses can be scheduled in a week, tightening or loosening malpractice law in different ways, etc. Each of these has some positive and negative effects, and I'm sure we have a ways to go before we hit the optimal point. And even then, you have to choose how to balance quality of patient care against doctors and nurses quality of life!
Or take drug approvals. There are drugs in development that show lots of promise, that probably should be made available to people who are dying anyway and want to try them. The FDA does not allow that. We have to balance against companies trying to scam people with fake medicine. No policy is 100% without harm. I believe that, even for policies I strongly advocate.
Or laws that were originally targeted at local environmental protection, that are now being used by nearby residents to stop solar farms from being built, stopping us from reducing fossil fuel usage. Those regulations were written in the blood of wildlife -- and now they're cause much more harm than good to wildlife all across the world.
So if you are asking if we've deteriorated since The Jungle, in many ways, no, of course we've improved safety of working conditions massively, and lots of other things. But in other, important ways, we've gone somewhat backwards. I believe it's absolutely possible to improve our society by removing some regulations, but I think it takes a lot of careful, small, targeted tweaks, where we've carefully weighed the costs and benefits. Though in rare cases, like as in parking minimums, the evidence is that they are so harmful that just scrapping the regulation entirely is the way to go.*
Not convincing since you're reducing the entire time period to The Jungle which was sensationalized fiction, effectively political propaganda.
But to your broader point, things improved directly from capitalism and markets. My reading recommendation? Deirdre McCloskey "Why Liberalism Works" on the absurd increase in living standards brought about through innovation enabled by capitalism, we're talking some 3,000% in average income over the course of time you're referring to.
Hospital admin, doctors orgs, pharmacy benefit managers are all much more interested in things being overly complex, under-staffed, etc. Insurance companies just want to sell insurance with the % profit that is typical of insurance (eg Cigna's profit margin is the same as Allstate).
Besides, if insurance was to blame, it would work better in Canada and other countries that rely on private insurance less. But Canadians don't seem very pleased with their longer waits.
At least in the US, this is true. The pervasiveness of interaction with insurance and the power they wield turns them into a rent-seeking layer with the massively negative economic effects of socialism.
Insurance is meant to insure you against massive economic damage caused by unlikely events, like breaking your spine. It is not meant to be used for routine care appointments. It's meant to be risk-pooling, not cost-sharing. The very fact that you have to pull out your insurance card at a yearly doctor checkup should tell us that something is very wrong.
The problem with this model is that often very catastrophic things can be caught during routine care, so it actually makes a lot of sense for insurance to pay for a yearly physical. Otherwise a lot of people are going to wait until their spine is blown out and their knees need replacement to seek any kind of care at all, at which point their care is 100x more expensive than if they did a yearly.
Any other kind of care like going to the doctor because you're sick is entirely the point of insurance. It covers your medical care for unanticipated problems.
Insurance has no business paying out for you going in for strep throat or the Flu or an annual checkup. These are normal things everyone gets multiple times throughout your lifetime, and should easily be taken care of via market forces for a very reasonable fee.
The problem with US healthcare can be entirely boiled down to a principle agent problem. Someone else is always paying, so no one actually really cares that much about the cost of things and the incentives always are to increase costs and use more services since there is no actual market competition.
You're making a bald assertion that "insurance has no business paying out for you going in for strep throat or the flu or an annual checkup." Imagine, for a moment, that you run an insurance company, and you have a lot of people who need knee surgery or hip replacements or spinal surgery or who have triple bypasses or COPD or name any chronic or acute disease that requires expensive treatment.
Think about how many of those people wouldn't need that treatment if they went to the doctor every year. If your company had to pay out for treatment on every single one of those cases, wouldn't it be smart to spend a small amount every year to try to prevent people from becoming one of those serious cases?
What are the "market forces" that you cite here? Is this another one of those magical invisible hand arguments? Have you considered that insurance companies offering these yearly physicals is a result of some market force where business-people figured out that it was cheaper to do that then let peoples' minor problems blow up into major problems and then pay out on that instead?
I have long wanted to get rid of the insurance/employer tie, but I'm a minority and so nothing gets done.
Healthcare is a utility masquerading as a profit based industry. Squeeze the profit and inefficiency out, any comp should be going directly to systems and people providing care. Insurance companies? Gone [2]. Pharmacy benefit managers? Gone [3]. Lock private equity out of owning anything healthcare related [4] [5] [6]. I don’t want to knee jerk “union” for individual contributors, but you need some sort of governance mechanism so the CEO of a non profit hospital isn’t taking home $1M/year [7] [8] [9] while doctors and nursing are fighting for proper compensation and work life balance (including patient ratios, which are used to increase labor load without increasing labor costs or hiring more practitioners [10]).
[1] https://thehill.com/changing-america/well-being/prevention-c...
[2] https://penncapital-star.com/uncategorized/americans-suffer-...
[3] https://www.ftc.gov/news-events/news/press-releases/2024/07/...
[4] https://www.amjmed.com/article/S0002-9343(23)00589-2/fulltex...
[5] https://www.washingtonpost.com/business/2024/10/17/private-e...
[6] https://www.theguardian.com/business/2024/oct/10/slash-and-b...
[7] https://www.npr.org/sections/shots-health-news/2024/08/19/nx...
[8] https://www.audacy.com/wwjnewsradio/news/national/revealed-c...
[9] https://arstechnica.com/health/2023/10/nonprofit-hospitals-s...
[10] https://healthjournalism.org/blog/2023/09/a-primer-for-cover...
I agree we have a shortage, but to offer a counter-argument:
We shouldn't need a 100% full-blown doctor for everything doctors do today. We could also help address the shortage by splitting out some responsibilities that are restricted to just doctors among professionals that only have 80% (or 60%, or 50%) of the training / certifications of an MD.
We've already presumably been doing this in the US with physician assistants and nurse practitioners. It hasn't solved it, but the problem would undoubtedly be many times worse without them.
[1] https://en.wikipedia.org/wiki/Nurse_practitioner
[2] https://www.ama-assn.org/practice-management/scope-practice/...
Having a nurse is probably better than no medical care at all, so a tiered system where poor people get nurses without realizing they're worse than doctors would have that advantage, but the right overhaul imo would be reducing the years of schooling required to become a real doctor (undergrad, med school, residency, maybe fellowship, finally attending). If doctors skipped undergrad and cut out some med school or fellowship requirements, they'd start working earlier and could afford to choose specialties that pay less. As well as expanding residency slots and moving insurance compensation to family medicine and pediatrics.
edit - here's a good example, https://old.reddit.com/r/medicine/comments/1f6m5i9/its_scary... the good news is they'd agree with you that midlevels do have a role, the problem with scope creep is defining what that role is, and the assumption that the training is 80% or even 50% there
In Houston, the renowned Texas Children's Hospital did layoffs — after paying millions to their CEO and other executives. FTA: "Over a seven-year period from 2016 – the earliest year of data published by the Internal Revenue Service – to 2022, the average pay for Texas Children’s 10 highest-paid leaders ballooned from $963,971 to nearly $2.2 million, an increase of 125%. (The latest tax filings do not reflect how much leaders at Texas Children’s earned this year, after the hospital reported major financial losses.)" [0]
The usual response defending such high compensation is something like, "We have to pay our execs so much because we're competing for talent with the for-profit hospitals." OK, one possible solution might be returning marginal income tax rates — across the board — to what they were in the 1950s. That would help neutralize the constant craving for more money as one of the main ways that execs judge their personal career success. "The top income tax rate reached above 90% from 1944 through 1963 ...." [1]
[0] https://www.houstonchronicle.com/projects/2024/texas-childre...
[1] https://www.wolterskluwer.com/en/expert-insights/whole-ball-...
Like for people with recurring prescription meds, maybe don't require them to make an appointment every month to get their meds? Even if we consider extreme examples like opiates, it's not like cutting off drug abusers or people selling their meds does anything to curb the opiate crisis. Opiates are already available everywhere and the supply is much more dubious and dangerous.
It doesn't weed out people who will be bad doctors, it weeds out people that can't handle the abuse.
It’s almost assuredly an insurance/PBM billing issue, not a regulatory thing.
The Canadian system is suffering from doctor shortages and other problems and the article lists a lot of reasons why (at least for Alberta).
What countries are the shining examples of how to do it? How is access to excellent, modern healthcare in Japan? Sweden? Spain? Ireland? Australia? It's all about tradeoffs, what countries do you think make the best tradeoffs?
In the western hemisphere? Cuba.
It’s easy to imagine a small, rich region in the US / Canada / UK running its own system and doing well at it.
The scale of caring for an entire country is a challenge onto itself.
But I’m in Calgary. There’s still a big, expensive challenge in providing care in the tiny towns. Alberta is pretty much infinitely large compared to Singapore.
Another aspect is that some of Alberta’s money goes to subsidize other provinces which is something else Singapore doesn’t have.
Just because the US, Norway, and Singapore are all categorized as countries doesn’t mean you can compare their stats directly without adding some asterisks for further context each time you do it.
As with all healthcare systems if there is a shortage of workers or it is not properly funded it will deteriorate. The U.S. healthcare system sucks for people who have no real access to it. The wait time of someone with no access to the system is effectively infinity.
Socialism, capitalism, communism, fascism, etc. are merely economic systems and all of them suck if not properly administered.
It totally can be done, but it's expensive. I, personally, hope to see taxes rise to pay for this system to work as it should.
Private healthcare is already digging in its claws in the UK due to the fall in availability of state-provided care and (from my experience) it's not a good experience; and it's still expensive!
The UK's state provided system is pretty good, but it runs too much on good will right now.
Conservatives massively cut funding to public services, private insurance for healthcare also increased in that time and private premiums have also increased.
As much as the media fixates on Prime Minister Justin Trudeau, it's important to remember that Canada's healthcare is administered provincially, and most provinces have Conservative governance.
Publicly-funded healthcare is much less-expensive with respect to public health outcomes compared to the American system, but it's not so cheap that you can cut it to the bone without creating awful negative consequences.
You are implicating private for-profit insurance, however. And maybe forgetting about all the top-ranked government socialized medical systems in The Netherlands, Norway, Sweden, Japan, and others - all ranked higher than the US in quality and efficiency of care. There’s contrary evidence refuting the claim that when government sets prices quality will decline.
This is what happens every time a Canadian doctor moves to the US for the money.
The U.S. has limited supply of doctors in rural areas, and that’s not due to government pricing. So what justification is there for pointing at government pricing at all? Why is that relevant here, and what makes you believe there’s a broad, general, or causal truth here, given the fact that it’s not true everywhere.
If those rates are too low for some doctors or potential future doctors, they’ll:
- leave to the US
- never go into medicine and study something else instead
So Canada ends up with doctors who are very good but are also too scarce, driving the overall experience down.
The same dynamic goes with all price caps. If you cap rent, capital flows away from real estate construction and towards other things. If you cap the price of eggs, marginal producers exit the egg market altogether.
With medical insurance it’s a really hard balance to get right. The insurer doesn’t have an infinite budget to throw at doctors, and has to balance competing demands from the supply and demand sides. In Canada, the insurer also has to get re-elected.
I would hardly describe any of the governments of Canada or the UK in the past, what, 50(?) or so years as being socialist...
But accepting "Have government involved in the economy, not too much. Mostly markets" means you have to actually know about the specific industry and surrounding economic factors and that makes discussions boring. It's way more fun to have Cage Match: Capitalism vs Socialism, this Saturday on pay-per-view.
I know a guy training to do lasik surgery. Turns out it's easy. You could easily train a lasik tech to do it, but that's not allowed. We require it to be done by a doctor making $500k a year who has 12 years of higher education, only 1 year of which is focused on lasik surgery. But we insist on continuing this overly broad training when most modern doctors only practice in a single specialized area. It's like if we required the guy at the oil change place to have a PhD in mechanical engineering. Of course it's going to cost a fortune.
I want to see far more involvement in direct patient interaction happen with nurse practitioners and physician assistants, with doctors supervising cases to ensure no one falls through the cracks. I'd love to see more specialization of NPs and PAs to handle cases that are complex but routine within a speciality.
The problem is a lack of respect for NPs and PAs, with many patients only wanting to see a doctor. We need to promote these occupations as the highly trained and licensed professionals that they are and make sure they get the respect they deserve.
So are we "investing" resources in young and people who will still work and pay taxes?
Or do we invest in people who are already retiring or "incurable".
The older you get the less resources you will be available for you on the social healthcare.
Not saying the US system is sane or one option is better than other.
But the best system is the one that gives you option (and govt hates giving option to you).
1. Want social care? Ok. xx% will be deducted from your paycheck.
2. Want private care? No deductions, you are on your own. And If you don't have money and is charged we will generate a federal debp + 10% for processing fees.
But no... That can't happen. because it would expose the govt or private sector failures.
1. the “socialist” system AKA healthcare for everyone has insane waiting times because everyone needs healthcare & there aren’t enough doctors.
2. the “capitalist” system seems better for the people that can afford it because the people that can’t afford it don’t go so they have no waiting time because a part of the people that need healthcare aren’t getting it due to the price.
It’s silly to say / imply that system 2 is the better way of doing it
USA here, I think we need to pay them less. It's basically become a game of how little can they do and how much can they charge. Many already don't care about your symptoms, or bother to do any research. They just prescribe stuff as it's pushed. If they aren't already, I'm sure your doctor will soon just be entering your symptoms into ChatGPT.
(2) and (3) are related since "dealing with insurance companies" == arguing for reimbursement from those companies, which means they're losing time arguing and losing money when they lose those arguments.
You know it's okay simply not to have an opinion on something if you can't spend more than 5 minutes or so thinking about it.
2) When they do have other people for it (which yes, is very often to your point), they're paying those people
3) When you pay other people, you need to make more money to pay them with
4) To make more money, you need more volume
5) To get more volume, you need to spend less time with each patient
You've changed nothing about the core dynamic of the system, just interjected with a meaningless and not-even-totally-true detail.
Maybe video visits were supposed to make it easier to generate billing with less driving, but it didn't work out that way.
Ultimately I went with an HMO, where the doctors can provide the same minimal amount of care but not jump through hoops to do it.
Really they should be charging as high as possible directly to consumers until doctors are attracted into the profession. Cut out the middleman, there is no reason that routine expenses like a sick visit that gets routine labwork or medication need to be insured.
It'd be better to reroute the software developers that construct complex systems to SERVE ADS and addict people to scrolling.
But AFAICT mostly it's their lack of constructive new models. Alberta has been fiddling at the margins with changes like dividing up the province into districts. OTOH BC introduced a wildly successful new physician pay model almost 2 years ago. I indirectly know several doctors who moved from Saskatchewan & Ontario to BC partly because of that.
P.S. I should emphasize that the new BC physician pay model not only attracts new doctors but it also encourages rostering, encouraging doctors to become the single point of generalist GP that is becoming scarce in Alberta according to the article.
I've essentially stepped out of the system. I get the cheapest, biggest deductible policy through my employer to cover a big emergency. But for my personal care, I do Direct Primary Care where I pay my doc $175/mo for my family of 4 and any time I need him, he's there "for free" no office visit fees, etc.
If I'm sick, I can always get same-day telehealth or next day in-office visits. For routine care, I may have to book out a week or so. He's never rushed because his incentive is consult me to keep me healthy so that I _don't_ need to see him. His incentives are not to keep me coming back for more visits.
During my last routine yearly visit, we had a hour long conversation about all the little nagging things that were happening has I get older, and we made a good plan on what to do.
I love this model and I could see it scaling like this:
Rather than forcing (individual mandate) ACA-specified insurance purchases, you are "forced" to put that cost into a HSA-like account (government supplemented for if you can't afford it), and then use the HSA to buy the insurance and/or DPC memberships you want and work for you. That would put downward pressure on price since you're making the decisions not the insurance/government. And you adds competition on service since you choose your providers.
I personally have not had a PCP singular doctor or doctor group in years. I use an urgent care franchise as my PCP.
I have a chronic ailment that requires daily medicine and the medical staff at the urgent care has been more than capable of providing care, writing scripts, and providing referrals to specialists.
In my life, as a generally healthy person working in the software industry, I have switched health insurance plans almost as many times as I've needed medical attention. What's the point of going through the trouble to establish a relationship with a PCP when you will see them at most twice, likely only once, before you have to start over after taking your next job?
Urgent care is much easier.
For primary care. I believe that's where the name Primary Care Provider comes from.
The difference from urgent care is long term. Having the same PCP for long periods of time provides an opportunity for deep insight and developing a personal relationship.