Tag Archives: Midlevels

The Economics of Mid-Levels

Another old post from The Physician Executive with currency in today’s environment. 


I was once a family physician delivering babies in an East Coast big city.

No, I am not a masochist, I was a family practice residency faculty.

Given the intense turf wars caused by an oversupply of competing specialists, it was an unpleasant environment to work. The concentration of specialty providers in big cities and urban areas poses some problems when it comes to costs. Frequently, one looks to mid-levels as a way of addressing problems in health care. Indeed Physician Assistants and Nurse Practitioners have a potentially important role to play in health care, but where?

Jason Shafrin at the Health Economist takes a look at midwives (included in the ranks of nurse practitioners for most of the latter part of the past century.)

I like midlevel providers like nurse practitioners and physician assistants because of their ability to bolster the ranks of primary care, the main engine of cost containment in health care. They can be invaluable in rural areas where it is difficult to entice specialists, even where there is a critical mass of demand for their services.

On the other hand, Jason’s post appears to be looking at midwives as a less costly alternative to obstetricians. A commenter on my site reminded me of Milton Friedman’s assertion that licensing leads to higher costs without assuring quality. In medicine, we have established a complicated and lengthy licensing process in the secure belief that the alternative was the chaos of snake-oil salesman that populated the United States at the turn of the last century. In other words, there was a compelling societal reason to limit and license people delivering health care.

I’m not sure what we accomplish by looking at mid levels as alternatives to established specialty providers. Moreover, specialists and midwives are equally maldistributed, being over-represented in metropolitan areas, where competition finds a way of increasing costs. Yes, health care acts strangely and higher concentrations of specialists tends to increase costs rather than reduce prices as one would expect.

On the other hand, finding an incentive to better distribute physicians may be a subtle way of improving physician incomes and health outcomes and reduce costs.

I want to make it clear once again, this is not a tirade against nurses or midwives. Nurses have saved my backside too often not to be collaborative and old school midwives working in labor and delivery taught me everything I know about delivering a baby.

I am questioning how we make policy in the face of a web of data and mess of potential starting points from which to approach the data.

Family Medicine in the New Healthcare Landscape

A couple of weeks ago, I was invited to our local residency graduation party to give a few words on behalf of the Clark County Medical Society. It was more of a party than anything else, but there was so much I wanted to say. It was supposed to be about the residents, they had a keynote speaker, and I had five minutes to promote the society. I also kept getting ideas right up to the time of the speech. I cannot tell you how many rules of public speaking I broke. I read most of the speech, way too fast, couldn’t keep eye contact with the audience and improvised on the fly… not really sure if the main points came through. It was probably more of an essay, probably more multi-layered than it should be for a simple five minute talk.
So here it is in blog format.

You are graduating into the single most exciting period in the past century of medicine. Sweeping changes to how healthcare is delivered is being contemplated and actually being enacted.
The last time this much change was going on at the same time was.. well, it was when I was graduating. They told me the same thing. From my  In the late 1980’s and early 90’s, a pharmaceutical revolution had reduced hospital stays and the technological revolution of minimally invasive surgery was about to threaten the need for beds across the country. HIV had been isolated and drugs were emerging that could potentially provide hope for a treatment. The practice of medicine was coming to be viewed more and more as a business and restrictions on physician advertising were being rolled back, along with the introduction of pharmaceutical direct-to-consumer advertising that was just starting at the time. Managed care was growing, HMO’s were felt to be the inevitable wave of the future and the first wave of integrated health systems was about to begin, with physicians selling their practices to hospitals that were reaching out blindly to won as many practices as they could.
Since then, we saw the boom of primary care in the HMO era, the consumer backlash that followed, and the unwinding of integrated health systems. It was painfully apparent by then that FP’s did not always have a good business sense and many lost money taking on capitated patients with exposure to too much risk. The hospitals realized they needed to pay attention to what they were buying when they bought a practice and for more than a decade, they were very cautious in such enterprises. The pharmaceutical industry seems to have split in two: the “me-too” drug manufacturers and the biotechs. The success of specialty drugs is perhaps nowhere felt more than in oncology where survival started increasing in the most stubborn of cancers like lung and pancreas. Indeed breast cancer is now more of a chronic disease than an acute illness and this may yet occur with other conditions. In fact, think of HIV/AIDs which is a persistent, annoying and important public health problem, now also best managed as a chronic disease. Some of our internal medicine colleagues, not known for being well remunerated have entered a golden age of their own, think of rheumatologists and the spread of biologicals in lupus and RA.
So maybe I’m wrong, maybe every age is the most exciting age in the history of medicine and the pace of change is merely accelerating. That means you will have to be accustomed to constant change throughout your careers. Such a thought can be a little sobering, because we all need some constants in our life. Living with constant change sometimes feels like living in the eye of a hurricane.
On the other hand, consider the following… no matter how much the content and context of medical care changes around you and your patients, some things do not change… a physician and a patient behind a closed door discussing their health. The generalist physician, in particular, is the one who does the troubleshooting. This never changes. Family medicine defined this way, is an integral part of the health care system. Worldwide, many experiments are under way in horizontal care with nurse practitioners, physician extenders, community health workers and the like… At the center of any program is a generalist physician who encourages, fosters and actively participates in caring professional relationships with people who may or may not know what kind of healthcare they need.
A mature specialty does not ask for the respect of its colleagues; it merely acts knowing that it is contributing to the well-being of everyone it touches by the individual acts of its practitioners.
A mature specialty does not criticize its colleagues for acting according to their immediate pecuniary interests. It recognizes its inherent power to guide and direct patients to where they will get the greatest value for their money. It also recognizes that much of its credibility in the eyes of the populace rests in the network of specialists to which they have access. People see value in getting to the right specialist quickly.
Primary care will be at the center of the future healthcare system and the fact that family physicians alone see all patients along the age spectrum provides a huge market advantage. I speak as an employer now. I have asked family physicians to step aside if they were uncomfortable with caring for certain age groups to step aside. I’d rather have an internist.
So how about some free advice to be valued as such from a doc who is now old enough to be looking downfield for a Hail Mary pass:
Family Medicine will be fine as long as you focus on certain things:
  1. Focus on the health of the population. In so doing, you will always be able to see the amount of value you are contributing to the communities where you work, no matter how little you actually get paid!
  2. Focus on the fact that without generalist physicians, the goal of a safe, efficient, effective health care system cannot be achieved.
  3. Focus on the fact that you need to work well with everyone in the allied health fields: PA’s, NP’s, pharmacists, home health aides, radiology technicians, lab porters… Medicine was never supposed to be a turf war and what you do depends on the contributions of so many, it is best to remember them in everything you do.
  4. Remember that nothing makes competition irrelevant than a change in the landscape. Your competition is not against PA’s, NP’s, specialists and the like… it is with them you must work to improve the health of populations.
  5. It is OK to say no to working more for less. There are settings where you can deliver better care with less effort and mean more to people. (And maybe make more money.)
  6. Stay involved.
    Medical and specialty societies are both important. In this county the WAFP is not as strong as the WSMA, but there are other counties where the opposite is true. Get involved in both. It’s not about how they represent you, but rather that when you get involved, you start driving how it represents you. There is nothing more important to understanding how a new relationship between family medicine and the rest of medicine will work until you see how family physicians are getting involved all the way up to the AMA.
I would like to leave you with this one final thought on how important your contribution is
“Family physicians are the guardians of the House of Medicine; the last credible proponents of sensible care.”