Most of you know that I live, work, and practice in Minnesota....which has one of the most liberal practice acts for PA's. I can prescribe Sched II-V, and basically do pretty much anything as long as it is allowed in my practice agreement, and is within my physicians practice standards. In EM, that covers a lot.
However, I also practice in an academic environment, which I enjoy for the most part, however, there are some detractions as well. I get to precept MS III's and IV's, and teach the residents occasionally, but too often, procedures will get passed to the residents. Not LP's of course, as I have done more of those than I ever care to think about, but chest tubes, intubations, and central lines often get re-assigned to the residents. I understand that they need to complete so many, as part of their training, but sometimes I like to do those things as well. At my other ER's I occasionally do them, and as I usually tell PA students, knowing WHEN, and WHY you want, or need to do these procedures is 1000 times more important than actually doing them.
I'm also heavily vested in research, particularly physician/medical workforce issues.
Occasionally, however, my faith is rewarded. Recently I got to do an elective cardioversion in the ED. Propofol sedation, Fentanyl, 100 joules biphasic, and BAM....NSR.
At another ER, I recently had to intubate someone as well. So, while the opportunities may be more limited than some of the EM PA's who work in non academic environments, I am for the most part, happy as a clam at mine.
Saturday, April 10, 2010
Friday, April 9, 2010
Interstate Insurance competition.....
Another fancy reform gadget that is thrown around by both parties is the concept of “increased competition”, as if Adam Smith’s magical hand will wave over the marketplace and prices/premiums will magically lower. It is not true for a number of reasons, but a real discussion of free market economics in healthcare can wait for another day. Today, we will discuss insurance competition. There is much to discuss, although interstate competition has not been allowed, there is often substantial instate competition.
The health insurance market has been traditionally regulated in a federalist model with each state being responsible for various regulations, including coverage limits, financial solvency of both the individual, as well as the insurance company, and to help protect against fraudulent behavior, ensuring that members/enrollees are provided the benefits as promised. State regulations have also imposed rating, and rate banding legislature to prevent health insurers from charging too much for certain “high risk” patients (Kofman, Pollitz, 2006). Additionally, there is variance between states as pertains to a “guarantee of issue”, as many states have different qualifications, this could potentially destabilize the market by causing an asymmetry, as sicker patients would not likely qualify for out of state insurance, while healthier patients could opt for cheaper out of state plans. Kofman and Pollitz also describe how the detection, and prosecution of fraudulent activity would be quite difficult, and might even raise some state constitutionality issues when trying to enforce different state laws. This creates a murky situation at best, and potentially exposes many patients to fraud, and potential predatory pricing tactics, as well as many companies to unfavorable market conditions. As mentioned above, another potential problem that arise with sales of health insurance across state lines, is the risk of creating an adverse risk pooling. Health insurance, like any other insurance commodity, relies on pooling of risk, meaning that costs need to be spread across both sick and healthy people in order to maintain a stable economic foundation. By allowing the sale of insurance across state lines, out of state insurers will get to “cherry pick” individuals, and because there is no guarantee of issue for an out of state transaction, healthier individuals may be offered lower rates than they can obtain locally, while sicker individuals will be denied coverage. This will result in the in-state insurers covering an increasing percentage of sick individuals resulting in an adverse risk selection bias. This will undoubtedly cause prices to rise in-state, and overall health insurance premiums will increase as a result. This is especially important when we realize that only 5% of our population accounts for 49% of healthcare spending (Stanton M, 2006). By denying insurance companies that ability to pool risk, and to spread healthcare costs throughout a specific population, they will have no choice but to increase premiums for those who are sick, or have chronic medical conditions. When we examine the interstate sales of health insurance, it appears on the surface to be a good idea, however, real time examination of current markets may reveal otherwise. An important concept in financial exchanges is leverage, and companies and institutions will attempt to use whatever leverage is available to negotiate better financial terms. In healthcare, this frequently occurs between health insurers and healthcare providers/institutions. When one party gains leverage on the other it is used to either raise, or lower prices depending on the entity involved. When we look at certain markets, as BNET reported, for example Milwaukee, where there is no dominant insurance company, leverage is given to the healthcare providers and hospitals, and many physicians will not accept less than 200% of Medicare rates, in contrast to a nearby city like Chicago, where typical payments for private payers are only 112% of Medicare rates (Terry K, 2009). Which raises an interesting dilemna.
Providers in the example provided via BNET, are actually driving costs higher, due to decreased market share in the insurance industry. I got all excited, and actually though of doing this as a full on study, using the Herfindahl index and getting to play around with some fancy math, but the NBER beat me to it...unfortunately, they found that an increased concentration in the marketplace, could only account for an increase of 2% in premiums over an 8 year time span, with health insurance premiums rising an average of 10% or more per year over that same time period.
PAPER HERE
We examine whether and to what extent consolidation in the U.S. health insurance industry is leading to higher employer-sponsored insurance premiums. We make use of a proprietary, panel dataset of employer-sponsored healthplans enrolling over 10 million Americans annually between 1998 and 2006 to explore the relationship between premium growth and changes in market concentration. We exploit the differential impact of a large national merger of two insurance firms across local markets to estimate the causal effect of concentration on market-level premiums. We estimate real premiums increased by 2 percentage points (in a typical market) due to the rise in concentration during our study period. We also find evidence that consolidation facilitates the exercise of monopsonistic power vis a vis physicians, whose absolute employment and relative earnings decline in its wake.
The health insurance market has been traditionally regulated in a federalist model with each state being responsible for various regulations, including coverage limits, financial solvency of both the individual, as well as the insurance company, and to help protect against fraudulent behavior, ensuring that members/enrollees are provided the benefits as promised. State regulations have also imposed rating, and rate banding legislature to prevent health insurers from charging too much for certain “high risk” patients (Kofman, Pollitz, 2006). Additionally, there is variance between states as pertains to a “guarantee of issue”, as many states have different qualifications, this could potentially destabilize the market by causing an asymmetry, as sicker patients would not likely qualify for out of state insurance, while healthier patients could opt for cheaper out of state plans. Kofman and Pollitz also describe how the detection, and prosecution of fraudulent activity would be quite difficult, and might even raise some state constitutionality issues when trying to enforce different state laws. This creates a murky situation at best, and potentially exposes many patients to fraud, and potential predatory pricing tactics, as well as many companies to unfavorable market conditions. As mentioned above, another potential problem that arise with sales of health insurance across state lines, is the risk of creating an adverse risk pooling. Health insurance, like any other insurance commodity, relies on pooling of risk, meaning that costs need to be spread across both sick and healthy people in order to maintain a stable economic foundation. By allowing the sale of insurance across state lines, out of state insurers will get to “cherry pick” individuals, and because there is no guarantee of issue for an out of state transaction, healthier individuals may be offered lower rates than they can obtain locally, while sicker individuals will be denied coverage. This will result in the in-state insurers covering an increasing percentage of sick individuals resulting in an adverse risk selection bias. This will undoubtedly cause prices to rise in-state, and overall health insurance premiums will increase as a result. This is especially important when we realize that only 5% of our population accounts for 49% of healthcare spending (Stanton M, 2006). By denying insurance companies that ability to pool risk, and to spread healthcare costs throughout a specific population, they will have no choice but to increase premiums for those who are sick, or have chronic medical conditions. When we examine the interstate sales of health insurance, it appears on the surface to be a good idea, however, real time examination of current markets may reveal otherwise. An important concept in financial exchanges is leverage, and companies and institutions will attempt to use whatever leverage is available to negotiate better financial terms. In healthcare, this frequently occurs between health insurers and healthcare providers/institutions. When one party gains leverage on the other it is used to either raise, or lower prices depending on the entity involved. When we look at certain markets, as BNET reported, for example Milwaukee, where there is no dominant insurance company, leverage is given to the healthcare providers and hospitals, and many physicians will not accept less than 200% of Medicare rates, in contrast to a nearby city like Chicago, where typical payments for private payers are only 112% of Medicare rates (Terry K, 2009). Which raises an interesting dilemna.
Providers in the example provided via BNET, are actually driving costs higher, due to decreased market share in the insurance industry. I got all excited, and actually though of doing this as a full on study, using the Herfindahl index and getting to play around with some fancy math, but the NBER beat me to it...unfortunately, they found that an increased concentration in the marketplace, could only account for an increase of 2% in premiums over an 8 year time span, with health insurance premiums rising an average of 10% or more per year over that same time period.
PAPER HERE
We examine whether and to what extent consolidation in the U.S. health insurance industry is leading to higher employer-sponsored insurance premiums. We make use of a proprietary, panel dataset of employer-sponsored healthplans enrolling over 10 million Americans annually between 1998 and 2006 to explore the relationship between premium growth and changes in market concentration. We exploit the differential impact of a large national merger of two insurance firms across local markets to estimate the causal effect of concentration on market-level premiums. We estimate real premiums increased by 2 percentage points (in a typical market) due to the rise in concentration during our study period. We also find evidence that consolidation facilitates the exercise of monopsonistic power vis a vis physicians, whose absolute employment and relative earnings decline in its wake.
Let's talk tort reform....
Lot’s has been said about the holy grail of tort reform by those in the medical field. The problem is, most of it isn’t true. Physicians and providers are very good at assigning the blame for rising costs on every one else. We are good at describing the “evil” insurance companies, and “greedy” pharmaceutical companies (partly true here), and those “bastard” lawyers. However, this blame game ignores the fact that while all of those players are culpable to a degree, it is the provider that also shares a significant amount of blame for cost increases.
Tort reform is currently the shiny object over in the corner of the room. That’s not to say that it can’t help, but the latest CBO estimates are a savings of 54 billion over ten years, or roughly 5.4 billion per year. In a 2.4 trillion dollar healthcare system, that doesn’t amount to much. Latest estimates are 0.5% savings. I would posit, that perhaps it might be closer to 1% once defensive practices are slowed. However, I don’t think the CBO is too far off here.
Let’s look at Texas, in 2003, they introduced the most aggressive tort reform legislation to date in the US. It is true that this reform, after 2003 lowered malpractice premiums, and increased physician supply to the state. However, Texas, since 2004 has seen a growth in testing expenditures that has outpaced the national average by more than 50% (Arkush, Gosselar, Hines, Lincoln, 2009). Additionally, the same report found that Medicare spending per patient had doubled between 2003 and 2007, in contrast to the decline in Medicare spending that was noted prior to the laws enactment. They also found that Texas has the highest rate of uninsured patients in the country, both prior to the law, and accelerating after the law was passed. The additional physician presence has only increased because of an increasing population as well, and there was only an increase of 0.4 physicians per capita after the law was passed. In addition, ACEP gave Texas an “F” on access to emergency care in 2009. Lastly, the National Board of Economic Research (NBER) commissioned a comprehensive study, which concluded that a targeted reform may have some impact, but that overall, it would be neglible (Lakdawalla, Seabury, 2009). Additionally, they found that for every 10 percent reduction in medical malpractice costs related to liability, there is a 0.2% increase in patient mortality. The NBER article is particularly poignant, and I have posted the summary here, as the article is 60 pages long, and the economic math is quite intensive.
HERE
The impact of liability for medical malpractice on the cost of medical care has been one
of the highest profile issues in debates over the U.S. health care system for many years.
Malpractice payments have grown enormously over the past 15 years, but this has likely had a
modest impact on the cost of health care in the US. It may have other significant effects, such as
decreasing the supply of physicians or changing the nature of treatment. Our findings, however,
suggest that limiting malpractice liability is no panacea for rising health care costs.
Moreover, while the mortality benefits of malpractice may be quite modest, these seem
more likely than not to justify its direct and indirect health care costs. Therefore, we conclude
that — for values of statistical life traditionally employed by US regulators —reducing
malpractice costs is not likely to be a worthwhile policy goal in itself. As emphasized by Currie
and MacLeod (2008), however, specific policies must be evaluated on a case-by-case basis, as
they can have unexpected effects on physicians’ expected liability and incentives. In addition,
there may be policies that reduce malpractice costs but have other social benefits; we do not rule
those out, but note that the case for their adoption rests on their auxiliary effects.
At a minimum, our analysis reveals the tenuousness of the case for tort reform, but it is
important to note its limitations. First, we account only for impacts of tort reform on medical costs and mortality, excluding its impacts (if any) on morbidity, physician utility, and patient
satisfaction. These quantities are extremely difficult to measure objectively. In addition, we do
not account for the adjustment costs (e.g., on the utilization of the health care system) that would
be induced by any large-scale reform project. The size and even direction of these excluded
effects is not clear. Finally, even if we ignore these limitations and accept the estimates at face
value, the probabilistic nature of our analysis means we cannot rule with (even approximate)
certainty for or against tort reform over conventionally accepted values of life.
Putting our results together with earlier work suggests that malpractice may have
substantial impacts on the care and costs of specific patient subgroups — like heart attack
patients — but much more modest impacts on the average patient, and on health care spending as
a whole. Future research should endeavor to determine whether tort reform can be targeted
toward these subgroups in a cost-effective manner.
Another important avenue for future work is to evaluate whether malpractice has effects
on more fine-grained outcomes in the health care system, such as morbidity, disability, or the
nature of care delivery. Medical costs and mortality are likely to be the first-order costs and
benefits of changes to the malpractice system, but the auxiliary effects may be quite significant.
If, for example, malpractice risk has had limited impacts on costs but appreciable positive
impacts on average outcomes other than mortality, the malpractice “crisis” may be anything but.
If, on the other hand, it has negative impacts on outcomes, the major costs of malpractice may be
in health rather than in dollars.
Tort reform is currently the shiny object over in the corner of the room. That’s not to say that it can’t help, but the latest CBO estimates are a savings of 54 billion over ten years, or roughly 5.4 billion per year. In a 2.4 trillion dollar healthcare system, that doesn’t amount to much. Latest estimates are 0.5% savings. I would posit, that perhaps it might be closer to 1% once defensive practices are slowed. However, I don’t think the CBO is too far off here.
Let’s look at Texas, in 2003, they introduced the most aggressive tort reform legislation to date in the US. It is true that this reform, after 2003 lowered malpractice premiums, and increased physician supply to the state. However, Texas, since 2004 has seen a growth in testing expenditures that has outpaced the national average by more than 50% (Arkush, Gosselar, Hines, Lincoln, 2009). Additionally, the same report found that Medicare spending per patient had doubled between 2003 and 2007, in contrast to the decline in Medicare spending that was noted prior to the laws enactment. They also found that Texas has the highest rate of uninsured patients in the country, both prior to the law, and accelerating after the law was passed. The additional physician presence has only increased because of an increasing population as well, and there was only an increase of 0.4 physicians per capita after the law was passed. In addition, ACEP gave Texas an “F” on access to emergency care in 2009. Lastly, the National Board of Economic Research (NBER) commissioned a comprehensive study, which concluded that a targeted reform may have some impact, but that overall, it would be neglible (Lakdawalla, Seabury, 2009). Additionally, they found that for every 10 percent reduction in medical malpractice costs related to liability, there is a 0.2% increase in patient mortality. The NBER article is particularly poignant, and I have posted the summary here, as the article is 60 pages long, and the economic math is quite intensive.
HERE
The impact of liability for medical malpractice on the cost of medical care has been one
of the highest profile issues in debates over the U.S. health care system for many years.
Malpractice payments have grown enormously over the past 15 years, but this has likely had a
modest impact on the cost of health care in the US. It may have other significant effects, such as
decreasing the supply of physicians or changing the nature of treatment. Our findings, however,
suggest that limiting malpractice liability is no panacea for rising health care costs.
Moreover, while the mortality benefits of malpractice may be quite modest, these seem
more likely than not to justify its direct and indirect health care costs. Therefore, we conclude
that — for values of statistical life traditionally employed by US regulators —reducing
malpractice costs is not likely to be a worthwhile policy goal in itself. As emphasized by Currie
and MacLeod (2008), however, specific policies must be evaluated on a case-by-case basis, as
they can have unexpected effects on physicians’ expected liability and incentives. In addition,
there may be policies that reduce malpractice costs but have other social benefits; we do not rule
those out, but note that the case for their adoption rests on their auxiliary effects.
At a minimum, our analysis reveals the tenuousness of the case for tort reform, but it is
important to note its limitations. First, we account only for impacts of tort reform on medical costs and mortality, excluding its impacts (if any) on morbidity, physician utility, and patient
satisfaction. These quantities are extremely difficult to measure objectively. In addition, we do
not account for the adjustment costs (e.g., on the utilization of the health care system) that would
be induced by any large-scale reform project. The size and even direction of these excluded
effects is not clear. Finally, even if we ignore these limitations and accept the estimates at face
value, the probabilistic nature of our analysis means we cannot rule with (even approximate)
certainty for or against tort reform over conventionally accepted values of life.
Putting our results together with earlier work suggests that malpractice may have
substantial impacts on the care and costs of specific patient subgroups — like heart attack
patients — but much more modest impacts on the average patient, and on health care spending as
a whole. Future research should endeavor to determine whether tort reform can be targeted
toward these subgroups in a cost-effective manner.
Another important avenue for future work is to evaluate whether malpractice has effects
on more fine-grained outcomes in the health care system, such as morbidity, disability, or the
nature of care delivery. Medical costs and mortality are likely to be the first-order costs and
benefits of changes to the malpractice system, but the auxiliary effects may be quite significant.
If, for example, malpractice risk has had limited impacts on costs but appreciable positive
impacts on average outcomes other than mortality, the malpractice “crisis” may be anything but.
If, on the other hand, it has negative impacts on outcomes, the major costs of malpractice may be
in health rather than in dollars.
Tuesday, March 30, 2010
Real Effects of the legislation.
I got this email from a friend who also works in the health policy arena. I thought is particularly poignant, and obtained his permission to post it here. It is sometimes easy to get lost in the data and statistics, and forget, that there are REAL people out there, and this will have REAL effects.
I turned on the television tonight and saw a newsflash that the last vote had been taken on health care reform. For some reason it hit me – the sheer magnitude of the events of the last week, the last few months, and the last few years.
It made me think of my dad. Born in 1952, he has lived his life with a form of muscular dystrophy that has deteriorated the muscles in his legs. He has lived his life as a hard working farmer, as the sole owner/operator of an auto body shop, and as the best role model I’ve ever known. Considering his medical condition and his line of work, he has always had to purchase his own insurance – and has never been able to afford it.
No insurance plan would ever cover my dad’s condition and he has never received the kind of therapy that he truly needs.
He has now applied for disability as he is no longer able to work, an incredibly difficult decision for a proud, hardworking man. He is only months away from spending the rest of his life in a wheel chair, and this would have been preventable if he only had access to medical care.
The work that we have done, and the work that we will continue to do, is important as it truly impacts people’s lives.
With the new health care reform legislation, my dad now qualifies for the immediate high risk insurance pool until he is eligible for Medicaid, and is approaching Medicare eligibility. But, more importantly, millions of individuals like my dad will now be able to afford insurance and seek high quality health care from the finest medical institutions in our great country, and never reach the point where they are on disability and have to give up their livelihood.
My sister, born in 1981, has the same muscular dystrophy as my dad, and is currently uninsured. She will now be able to afford insurance through the exchange and receive the type of therapy early in her life that my dad was never able to afford.
My family owes each of you a debt of gratitude, individuals and families across this country owe each of you a debt of gratitude, and I am proud of what this team has accomplished.
I am going to celebrate. You should celebrate. And we should celebrate this historic accomplishment together.
I honestly believe that every day of our lives is a momentous day, and considering how many individuals like my dad and sister who will truly benefit from this health care reform, this is especially true of our collective days over the last few years.
Thank you for all you’ve done and all you continue to do. And thank you for the continued dedication we will all carry with us as we enter a new era of health care reform.
Josh
I turned on the television tonight and saw a newsflash that the last vote had been taken on health care reform. For some reason it hit me – the sheer magnitude of the events of the last week, the last few months, and the last few years.
It made me think of my dad. Born in 1952, he has lived his life with a form of muscular dystrophy that has deteriorated the muscles in his legs. He has lived his life as a hard working farmer, as the sole owner/operator of an auto body shop, and as the best role model I’ve ever known. Considering his medical condition and his line of work, he has always had to purchase his own insurance – and has never been able to afford it.
No insurance plan would ever cover my dad’s condition and he has never received the kind of therapy that he truly needs.
He has now applied for disability as he is no longer able to work, an incredibly difficult decision for a proud, hardworking man. He is only months away from spending the rest of his life in a wheel chair, and this would have been preventable if he only had access to medical care.
The work that we have done, and the work that we will continue to do, is important as it truly impacts people’s lives.
With the new health care reform legislation, my dad now qualifies for the immediate high risk insurance pool until he is eligible for Medicaid, and is approaching Medicare eligibility. But, more importantly, millions of individuals like my dad will now be able to afford insurance and seek high quality health care from the finest medical institutions in our great country, and never reach the point where they are on disability and have to give up their livelihood.
My sister, born in 1981, has the same muscular dystrophy as my dad, and is currently uninsured. She will now be able to afford insurance through the exchange and receive the type of therapy early in her life that my dad was never able to afford.
My family owes each of you a debt of gratitude, individuals and families across this country owe each of you a debt of gratitude, and I am proud of what this team has accomplished.
I am going to celebrate. You should celebrate. And we should celebrate this historic accomplishment together.
I honestly believe that every day of our lives is a momentous day, and considering how many individuals like my dad and sister who will truly benefit from this health care reform, this is especially true of our collective days over the last few years.
Thank you for all you’ve done and all you continue to do. And thank you for the continued dedication we will all carry with us as we enter a new era of health care reform.
Josh
Saturday, March 27, 2010
Healthcare Reform Talk....
Well, I had to give a talk at the national SEMPA meeting this past Wednesday on "Healthcare Reform: Where are we now?" It was quite interesting. I arrived in Tucson on Sunday evening to find many of the other providers I know surrounding a TV in, of all places, the bar. They were watching the vote, and when it passed, a cheer erupted, with a few simultaneous groans. The president of our organization turned and looked at me with a grin, and said, "Well, I bet you have a little re-write to do" Ummmm. Yep. I almost asked if security would be provided. Holed up in hotel room I proceed to re-write and amend my initial talk. I was prepared, ready for an intense, emotional, intellectual debate. Unfortunately, attendance was small. I think this is because many were either so happy, or so angry that hearing anything more about it would be too much.
The talk went well.
The talk went well.
Tuesday, March 23, 2010
Healthcare Insurance Reform...
The most groundbreaking, and comprehensive reform in healthcare was signed into law by President Barack Obama today, less than 48 hours after the house passed it. One side is decrying the legislation and claiming the ruination and destruction of the known universe. The other side is claiming that healthcare reform has finally been achieved.
As usual, they are both wrong. There are three distinct and separate components to healthcare reform, and this only addressed one of them. By no means, am I trying to diminish the symbolism of this achievement, but would rather caution that this is but the first ten miles of a grueling marathon.
I noted that President Obama was careful with his language today, and called this the "most comprehensive piece of health insurance legislation ever passed".
We still need to address healthcare financing reform (ie; how do we PAY for healthcare?) which this does to a very partial degree, but only through subsidies that remain somewhat murky as to the details of their financing.
The biggest hurdle, is perhaps the most important one. We desparately need healthcare delivery system reform. We need to reform the way that care is delivered. We need to develop strong comparative effectiveness data. We need to reduce the primary care income disparity gap, and we need start paying for value. We don't do this now. We pay for volume. We pay for quantity, not quality.
So there is still much to be done, and I will be on the front lines, carrying the banner of the PA profession into the fray.
As usual, they are both wrong. There are three distinct and separate components to healthcare reform, and this only addressed one of them. By no means, am I trying to diminish the symbolism of this achievement, but would rather caution that this is but the first ten miles of a grueling marathon.
I noted that President Obama was careful with his language today, and called this the "most comprehensive piece of health insurance legislation ever passed".
We still need to address healthcare financing reform (ie; how do we PAY for healthcare?) which this does to a very partial degree, but only through subsidies that remain somewhat murky as to the details of their financing.
The biggest hurdle, is perhaps the most important one. We desparately need healthcare delivery system reform. We need to reform the way that care is delivered. We need to develop strong comparative effectiveness data. We need to reduce the primary care income disparity gap, and we need start paying for value. We don't do this now. We pay for volume. We pay for quantity, not quality.
So there is still much to be done, and I will be on the front lines, carrying the banner of the PA profession into the fray.
Tuesday, March 9, 2010
Recent Study by Macy suggest changes to PA legislation...
This was a good workforce study recently completed by the Macy Panel, which as part of their conclusion suggests:
Coupled with efforts to increase the number of physicians, nurse practitioners, and physician assistants in primary care, state and national legal, regulatory, and reimbursement policies should be changed to remove barriers that make it difficult for nurse practitioners and physician assistants to serve as primary care providers and leaders of patient-centered medical homes or other models of primary care delivery. All primary care providers should be held accountable for the quality and efficiency of care as measured by patient outcomes.
I like their conclusions....
The complete study can be found HERE
Coupled with efforts to increase the number of physicians, nurse practitioners, and physician assistants in primary care, state and national legal, regulatory, and reimbursement policies should be changed to remove barriers that make it difficult for nurse practitioners and physician assistants to serve as primary care providers and leaders of patient-centered medical homes or other models of primary care delivery. All primary care providers should be held accountable for the quality and efficiency of care as measured by patient outcomes.
I like their conclusions....
The complete study can be found HERE
Interesting Ideas concerning PA evolution....
FROM a PA who went back to the Medical School, and became a physician. I don't see it happening, but interesting nonetheless.
PA’s are as diverse in personality, background and desires as the sands of the sea. A young PA will have differing opinions on various subjects than an older PA. Times change, exams change,people change but human beings are basically competative by nature. Anyone ever run a race to come in second place? My comments to you all are very contemporary, political but with “YOU” in mind. I recently spoke at a conference where a group of NP’s addressed a fellow DNP by the title Doctor. I was recently at a rural clinic where an older PA and a younger PA apparently had issues with a Doctorally trained PA using the titile “Dr.Jones the associate Physician” I didn’t have a problem with that but the two PA’s apparently did. My goodness the PA had a Doctorate degree in Public Health and 18 months of residency training under his belt and I as an MD would not insult this man, brush aside his skills and great bedside manner to consider him my assistant but rather my associate.
To the gentleman who erroneously states PA’s are not considered second class medical citizens check this out and then tell me what you think, then I will answer Daves question as to what the profession needs to do. I propose a scheme for PA’s that would answer the question of why some people got into the medical field and not the PA profession particularly. I think outside of the box so my proposals take into account the group that loves the assistant role and being supervised versus the group which recognizes the practice of medicine boils down to good training and a lot of experience, not a “HAZING” process of brutal medical school training with 3 years of inhumane residency slavery.
Proof that the medical community sees you as second class citizens.
The Michigan state medical board without letting you all know, listed podiatrists as supervising physicians of PA’s. How respected is the PA profession when foreign-trained doctors working in Federal facilities can get a PA license without any didactic or clinical training in a PA program? see
http://www.aapa.org/policy/unlicensed-med-grads.html
http://www.bop.gov/jobs/job_descriptions/physician_assistant.jsp
When a medical organization accepts a model of licensure that designates its practitioners as lifelong “interns/residents” needing supervision,(Post Graduate year 1/2 medical students). That profession is doomed to accept practice guidelines involving supervision by “any” independant healthcare professional, (podiatrist).
Statement by AMA to increase medical student seats to increase the primary care force. PA’s are not even considered a viable option. Physician workforce shortage: Yes, no, or maybe? e-mail story | print story In the March 2005 issue of the GME E-letter, we wrote, “It appears we are facing a national shortage of doctors. This shortage is currently confined to some regions and specialties, but the bulge of aging baby boomers threatens to widen the gap. “The Association of American Medical Colleges (AAMC) has called for a 15 percent increase in the number of medical school graduates by 2015--but that won’t solve the whole problem. We will need more GME positions as well. “To be feasible, this expansion will require removing the current caps on the number of federally funded residency positions as well as finding additional funding sources for GME. But how should these residency slots be distributed geographically and among the specialties? And how should we develop national policy on medical workforce issues such as these?”
http://www.ama-assn.org/ama/pub/category/14908.html
So when a Doctor gets disciplined or has his/her license revoked and the state medical board publishes this statement;
“Dr. John doe was placed on 2 years probabtion and is prohibited from SUPERVISING PA’s and NP’s”
So when those PA’s/NP’s just lost their job because of the MD’s incompetence and the underlying tone of such statements imply that a PA/NP can’t function without the valid,unrestricted license of an MD I have 2 questions;
a) Why then do you have PA/NP licensing agencies?
B) Why take exams,do clinical rotations,take CME’s or even have conferences?
Dave it was a Doctor who created the P.A profession now the PA’s should move the profession forward by doing the following;
1) Change your title to “Associate Physician”. The word Assistant in 33 standard dictionaries means “Clerical”.
2) Create a Doctorate Associate Physician (DAP). Read the history of DO’s then you will see that this just follows an already established precedent. A DO colleague of mine once said that “MD’s may look down upon me because I am a DO but at least I’m not a PA” the DAP degree needs to be created and granted with completion of accredited postgraduate clinical residency training programs. This should be a clinical degree, and you should use a doctoral title. Optometrist,opthomologist,psychologist and psychiatrist don’t have a problem with an established precedent of “Degrees”. I suggest the following licensing scheme to keep all Associates and Assistants happy;
4 year degree, Bachelors, Associate Physician. (BAP)
7-8 Year degree,(bachelors and 3 years of additional
training) Masters, Associate Physician(MAP)
7-8 Year degree, with Post-Graduate training,
Doctorate, Associate Physician (DAP)
This would be the key in a licensing system as defined;
Distinction/educational level is clear in this scheme.BAP, MAP and DAP. The bachelors trained professionals
are the only ones that need to follow the current PA-Physician supervisory model. This would keep all the assistants happy. If you want to be an assistant then stay here. The MAP and DAP should be independant practitoners however. In this scheme a seasoned, experienced Associate Physician could actually move up the career chain after many years of practice if they choose, or 26-30 year olds fresh out of medical school residency training will become supervising Physicians of a 30 year practicing PA. Doesn’t make sense to me. I had to put a 1 year out of residency training Board certified 30 year old FP in his place because the 50 Year old PA of whom he was the supervising Physician was correct regarding the use of basal -vs- bolus insulin in a Diabetic patient. It was quite obvious this board certified rookie learned all this detail about Lantus but didn’t understand you don’t use basal insulin for Bolus random blood sugar elevations, the 50 year old PA his “assistant” knew however.
Why am I on here? I don’t want my fellow hardworking, intelligent and innovative colleagues to go through the “Hell” I went through to move away from the clinical handcuffing I went through as a PA, going through medical school, residency training only to end up doing the same thing I did day in and out but now with a title change. Now with a better income and incentive pay. With hospitalist, I don’t need to manage patients in the hospital etc.....Wake up my friends and move forward. The grass is green on your side please water it properly.
Interesting, and timely discussion....
PA’s are as diverse in personality, background and desires as the sands of the sea. A young PA will have differing opinions on various subjects than an older PA. Times change, exams change,people change but human beings are basically competative by nature. Anyone ever run a race to come in second place? My comments to you all are very contemporary, political but with “YOU” in mind. I recently spoke at a conference where a group of NP’s addressed a fellow DNP by the title Doctor. I was recently at a rural clinic where an older PA and a younger PA apparently had issues with a Doctorally trained PA using the titile “Dr.Jones the associate Physician” I didn’t have a problem with that but the two PA’s apparently did. My goodness the PA had a Doctorate degree in Public Health and 18 months of residency training under his belt and I as an MD would not insult this man, brush aside his skills and great bedside manner to consider him my assistant but rather my associate.
To the gentleman who erroneously states PA’s are not considered second class medical citizens check this out and then tell me what you think, then I will answer Daves question as to what the profession needs to do. I propose a scheme for PA’s that would answer the question of why some people got into the medical field and not the PA profession particularly. I think outside of the box so my proposals take into account the group that loves the assistant role and being supervised versus the group which recognizes the practice of medicine boils down to good training and a lot of experience, not a “HAZING” process of brutal medical school training with 3 years of inhumane residency slavery.
Proof that the medical community sees you as second class citizens.
The Michigan state medical board without letting you all know, listed podiatrists as supervising physicians of PA’s. How respected is the PA profession when foreign-trained doctors working in Federal facilities can get a PA license without any didactic or clinical training in a PA program? see
http://www.aapa.org/policy/unlicensed-med-grads.html
http://www.bop.gov/jobs/job_descriptions/physician_assistant.jsp
When a medical organization accepts a model of licensure that designates its practitioners as lifelong “interns/residents” needing supervision,(Post Graduate year 1/2 medical students). That profession is doomed to accept practice guidelines involving supervision by “any” independant healthcare professional, (podiatrist).
Statement by AMA to increase medical student seats to increase the primary care force. PA’s are not even considered a viable option. Physician workforce shortage: Yes, no, or maybe? e-mail story | print story In the March 2005 issue of the GME E-letter, we wrote, “It appears we are facing a national shortage of doctors. This shortage is currently confined to some regions and specialties, but the bulge of aging baby boomers threatens to widen the gap. “The Association of American Medical Colleges (AAMC) has called for a 15 percent increase in the number of medical school graduates by 2015--but that won’t solve the whole problem. We will need more GME positions as well. “To be feasible, this expansion will require removing the current caps on the number of federally funded residency positions as well as finding additional funding sources for GME. But how should these residency slots be distributed geographically and among the specialties? And how should we develop national policy on medical workforce issues such as these?”
http://www.ama-assn.org/ama/pub/category/14908.html
So when a Doctor gets disciplined or has his/her license revoked and the state medical board publishes this statement;
“Dr. John doe was placed on 2 years probabtion and is prohibited from SUPERVISING PA’s and NP’s”
So when those PA’s/NP’s just lost their job because of the MD’s incompetence and the underlying tone of such statements imply that a PA/NP can’t function without the valid,unrestricted license of an MD I have 2 questions;
a) Why then do you have PA/NP licensing agencies?
B) Why take exams,do clinical rotations,take CME’s or even have conferences?
Dave it was a Doctor who created the P.A profession now the PA’s should move the profession forward by doing the following;
1) Change your title to “Associate Physician”. The word Assistant in 33 standard dictionaries means “Clerical”.
2) Create a Doctorate Associate Physician (DAP). Read the history of DO’s then you will see that this just follows an already established precedent. A DO colleague of mine once said that “MD’s may look down upon me because I am a DO but at least I’m not a PA” the DAP degree needs to be created and granted with completion of accredited postgraduate clinical residency training programs. This should be a clinical degree, and you should use a doctoral title. Optometrist,opthomologist,psychologist and psychiatrist don’t have a problem with an established precedent of “Degrees”. I suggest the following licensing scheme to keep all Associates and Assistants happy;
4 year degree, Bachelors, Associate Physician. (BAP)
7-8 Year degree,(bachelors and 3 years of additional
training) Masters, Associate Physician(MAP)
7-8 Year degree, with Post-Graduate training,
Doctorate, Associate Physician (DAP)
This would be the key in a licensing system as defined;
Distinction/educational level is clear in this scheme.BAP, MAP and DAP. The bachelors trained professionals
are the only ones that need to follow the current PA-Physician supervisory model. This would keep all the assistants happy. If you want to be an assistant then stay here. The MAP and DAP should be independant practitoners however. In this scheme a seasoned, experienced Associate Physician could actually move up the career chain after many years of practice if they choose, or 26-30 year olds fresh out of medical school residency training will become supervising Physicians of a 30 year practicing PA. Doesn’t make sense to me. I had to put a 1 year out of residency training Board certified 30 year old FP in his place because the 50 Year old PA of whom he was the supervising Physician was correct regarding the use of basal -vs- bolus insulin in a Diabetic patient. It was quite obvious this board certified rookie learned all this detail about Lantus but didn’t understand you don’t use basal insulin for Bolus random blood sugar elevations, the 50 year old PA his “assistant” knew however.
Why am I on here? I don’t want my fellow hardworking, intelligent and innovative colleagues to go through the “Hell” I went through to move away from the clinical handcuffing I went through as a PA, going through medical school, residency training only to end up doing the same thing I did day in and out but now with a title change. Now with a better income and incentive pay. With hospitalist, I don’t need to manage patients in the hospital etc.....Wake up my friends and move forward. The grass is green on your side please water it properly.
Interesting, and timely discussion....
Tuesday, March 2, 2010
Example of Cost Increases.....
So, some time ago, I had a younger, obese female patient present to the ED. She came with a complaint of a breast lump with skin discoloration. At first, I thought of potential mastitis, could she have a ductal abcess, something bad...right? Nope. This had been present for 2 months duration, and she had done a "lot of research on the internet". That is not usually a good statement to hear from your patient, primarily because there is just so much BAD information out there, and you often spend a great deal of time correcting misinformation, or even more often, MISINTERPRETATION of information. Anyway, she saw her local MD, who referred her to a breast physician locally. She was extremely concerned that she had Invasive Ductal Carcinoma. In fact, she had already staged herself, and was concerned that she had already progressed to stage II. Mind you, she had not seen a breast physician yet. She had been concerned, and had already called our breast clinic, for which she had an appointment in 2 days.
This was unacceptable apparently. The patient wanted an MRI (which we rarely ever do in the ED, and only in the instance of a severe emergency), or to have it biopsied in the ED. I explained to her calmly that I could not offer her either of those options. I explained some alternative ways that she could potentially move up her appointment.
A completely unnecessary visit, which cost hundreds of dollars, and added nothing to her care. I don't blame her. I blame the system in which this is encouraged. This is not even an unusual story, as there are dozens of patients who present every day with complaints that should have likely been seen in an outpatient clinic.
This was unacceptable apparently. The patient wanted an MRI (which we rarely ever do in the ED, and only in the instance of a severe emergency), or to have it biopsied in the ED. I explained to her calmly that I could not offer her either of those options. I explained some alternative ways that she could potentially move up her appointment.
A completely unnecessary visit, which cost hundreds of dollars, and added nothing to her care. I don't blame her. I blame the system in which this is encouraged. This is not even an unusual story, as there are dozens of patients who present every day with complaints that should have likely been seen in an outpatient clinic.
Wellpoint CEO....
Well, those of you who follow this blog, know that I don't have a lot of empathy for insurance companies, and some of their practices.
THAT being said, I agree with the CEO of Wellpoint Angela Braly's recent stance. She's right, while some of the insurance industries practices are a bit distasteful, such as recission, and denial of claims. The insurance industry is not the main reason costs are increasing. Hospitals, physicians, and other providers are raising rates. Add in a tumbling economy, and you get a risk selection bias as healthier individuals forego insurance, and an increase in COBRA enrollment, which is almost universally full of sick individuals. This creates a problem for the insurance company. While I am not going to say I feel sorry for Wellpoint, I believe that most people are missing the point of Ms Braly's comments.
She's right, we need more than simple health insurance reform. We need DELIVERY system reform, and right now, we're not getting it.
How about this idea. If we are going to mandate that all patients have insurance, and we are going to mandate that all insurance companies cannot deny pre-existing conditions, or cancel policies, and must have higher MLR ratios, then how about MANDATING that all providers accept Medicare patients. Tie it to their DEA number. If they refuse to see new Medicare patients, they lose their DEA number.
Providers need to have some skin in the game too.
More HERE
THAT being said, I agree with the CEO of Wellpoint Angela Braly's recent stance. She's right, while some of the insurance industries practices are a bit distasteful, such as recission, and denial of claims. The insurance industry is not the main reason costs are increasing. Hospitals, physicians, and other providers are raising rates. Add in a tumbling economy, and you get a risk selection bias as healthier individuals forego insurance, and an increase in COBRA enrollment, which is almost universally full of sick individuals. This creates a problem for the insurance company. While I am not going to say I feel sorry for Wellpoint, I believe that most people are missing the point of Ms Braly's comments.
She's right, we need more than simple health insurance reform. We need DELIVERY system reform, and right now, we're not getting it.
How about this idea. If we are going to mandate that all patients have insurance, and we are going to mandate that all insurance companies cannot deny pre-existing conditions, or cancel policies, and must have higher MLR ratios, then how about MANDATING that all providers accept Medicare patients. Tie it to their DEA number. If they refuse to see new Medicare patients, they lose their DEA number.
Providers need to have some skin in the game too.
More HERE
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