Doctors, Nurse Practitioners and Medicare

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kiryan
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Doctors, Nurse Practitioners and Medicare

Postby kiryan » Wed Apr 14, 2010 5:47 pm

http://news.yahoo.com/s/ap/20100414/ap_ ... urse/print

Theres been a decades long shortage of doctors which has driven an increase in "nurse practitioners" and physician assistants. MDs try to protect their turf and NPs and PAs try to get authority to do more and more and receive higher and higher compensation. I won't point out how the government created this problem in the first place with their license requirments artificially decreasing the labor supply of MDs. What I do want to point out is this.

"Medicare, which sets the pace for payments by private insurance, pays nurse practitioners 85 percent of what it pays doctors. An office visit for a Medicare patient in Chicago, for example, pays a doctor about $70 and a nurse practitioner about $60.

The health care overhaul law gave nurse midwives, a type of advanced practice nurse, a Medicare raise to 100 percent of what obstetrician-gynecologists make — and that may be just the beginning."

So two things. First, MDs getting 85% of what they pay a doctor. basically a general practice doctor compared to a nurse practitioner since NPs don't have specialities (yet). NPs go to about 7 years of school and docs go to 8 + residency. So pretty similar, but the training is no where close to being the same. What I think is hillarious about this is that as a whole doctors don't want to service medicare/medicaid because they aren't paid enough, but they'll pay a NP 85% of what they'll pay a doctor and NP's are exploding. Its pretty clear to me that they've set NP pay at a premium and MD at less than fair.

second thing which is truly outrageous is the healthcare reform increase for nurse midwives to 100% of what a baby doctor makes. baby doctors get paid pretty well as a speciality, not radiology/oncology well, but 2x better than your family doctor. These guys go to school for 8 years, and then an additionl 2-3 years for their speciality plus a longer residency. Nurse midwives really can't do jack shit if anything goes wrong... really all they can do is a very basic delviery. Any problem and its off to the hospital (increasing practice of actually doing it in the hospital with a nurse midwife) and call in the specialists. So why the hell would they pay them the same as a obygyn?

This is just awesome. Medicare and the government man are touted for its ability to hold down costs, but realistically they are enriching some and reducing quality (whether its training or access) and claiming that its an apples to apples comparison. The statistics do show that NPs and general practice MDs provide the same quality of care so why are NPs paid less? Why even pay doctors to do it if its something nurses can do cheaper? Something is clearly wrong with the market forces here. Is the government "fixing" it or is it the cause.

Seeing as how they now pay nurses almost as much as doctors, and doctors have been leaving medicare for years and general practice doctors wages have gone down over time (and they each year delay the doctor pay cut), I'm going to say its a function of medicare / government run healthcare. Lets talk about that decades long doctor shortage again... why would people get into general practice if they aren't being fairly compensated by the biggest payer out there (medicare). I wonder if that has anything to do with the MD shortage. *DUH* So this is what we have to look forward to. More nurses, less doctors and being told that its the same care for what is currently 15% cheaper. Yea government saved us 15% on our healthcare costs... or will they when NP start arguing that they should be paid fairly based on the service provided, you know like nurse mid wives... you deliver a baby you get the same $$.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Botef » Wed Apr 14, 2010 6:04 pm

While I agree with most of your viewpoints here about compensation and incentive, I'd have to disagree about quality of service. NP's are in most general situations able to provide the exact same standard of care as a real MD and imo are often more attentive than a doctor is to symptoms and signs of abnormal conditions. In fact many nurses are equally capable if they have worked in a standard practice long enough because they are the first ones to identify and point out symptoms to the doctor. I've always viewed MD's in a general practice as a kind of supervisory position. They come in, take a quick peek and conclude the findings of the nurse who saw you before the doctor did. Unless something out of the ordinary or of particular concern comes up their role is pretty minimal in respect to hands on care. Having an MD look at you for simple stuff is a bit wasteful in a large general practice, and I trust a nurses education to be able to conclude if I have the flu/cold/etc just as well as an MD in most of those situations.
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Re: Doctors, Nurse Practitioners and Medicare

Postby kiryan » Wed Apr 14, 2010 6:16 pm

I'm not sure how much we disagree... I'm pointing out how theres a problem here somewhere. If NPs can do the same job then why are they paid 85% of what a MD is. Is a 15% premium really valid for the differences in training and education or has medicaid been underpaying doctors and then touting them as "savings" and "bending the cost curve"... meanwhile destroying an entire segment of healthcare.

Also realize that NPs are being scrutinized and they are cherry picking stories to present. Once this becomes common and accepted, expect some movement in the results. Today most NPs probably have 10+ years in nursing before they make the step to NP, tomorrow you'll have NPs with 7 years of school and no experience.

but I agree with you, having to see the doctor in order to get a routine simple stuff done like a vaccination is almost as ridiculous as a CNA (certified nursing assistant) being unable to give a 80 year old man his prescribed medication... or even a damn tylenol.
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Re: Doctors, Nurse Practitioners and Medicare

Postby teflor the ranger » Wed Apr 14, 2010 6:32 pm

Nurse practitioners in many states can only work under the supervision of an MD. This might help except that in many states, they can work independently as well.
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Re: Doctors, Nurse Practitioners and Medicare

Postby kiryan » Wed Apr 14, 2010 6:49 pm

might help at what? blurring the distinction between a general practice MD and a less qualified (in terms of education) NP? Whats next, the NP cardiologist who gets paid 85% of what an MD oncologist makes?

When you are licensed to practice medicine you are a doctor. When you are licensed to follow doctor's orders like give shots, dispense medication, clean bed sores you are a nurse. If you want to practice medicine, you need to go through the training to be a doctor. If you have the training through a NP program, then you should be called a doctor and be paid like a doctor.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Sarvis » Wed Apr 14, 2010 6:54 pm

Except that an NP does not have the training or depth of knowledge that a doctor does.
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Re: Doctors, Nurse Practitioners and Medicare

Postby kiryan » Wed Apr 14, 2010 6:59 pm

except apparently nurse mid wives vs obygyns.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Ragorn » Wed Apr 14, 2010 7:54 pm

I neither understand what kiryan is all enraged about, nor understand how it is Obama's fault. But I'm sure it's "something" and "health care reform" somehow.

Are we all uppity because people who have less training are paid less, or something?
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Re: Doctors, Nurse Practitioners and Medicare

Postby Sarvis » Wed Apr 14, 2010 7:55 pm

I think that's the general idea... I really only skimmed a couple of the posts though.
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Re: Doctors, Nurse Practitioners and Medicare

Postby teflor the ranger » Wed Apr 14, 2010 8:17 pm

kiryan wrote:might help at what? blurring the distinction between a general practice MD and a less qualified (in terms of education) NP? Whats next, the NP cardiologist who gets paid 85% of what an MD oncologist makes?

When you are licensed to practice medicine you are a doctor. When you are licensed to follow doctor's orders like give shots, dispense medication, clean bed sores you are a nurse. If you want to practice medicine, you need to go through the training to be a doctor. If you have the training through a NP program, then you should be called a doctor and be paid like a doctor.

Physicians assistants came about with the need for more trained medical personnel during World War II. Having an in-between in the medical system promotes the medical system's capacity and capability. The same idea applies generally to PNs.

Of course, it leads to a lower standard of care with the idea being that increased capacity will make up for it.

NPs make so much money because they're worth it. Because of shortages of doctors, the whole industry is inflated and comes as no surprise that a hospital group or practice will hire any monkey with a prescription pad and pay them big bucks to sit in a room with sick people.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Corth » Wed Apr 14, 2010 8:42 pm

Not going to comment on whether midwives should be compensated at the same rate as obstetricians. Ideally the market would have determined that. But since the subject came up I'm going to make my obligatory plug in favor of nurse midwives for routine pregnancies. In most of the industrialized world including Europe, midwives handle the vast majority of all births. The US has some of the worst statistics for infant and maternal mortality in the industrialized world even though almost all births are handled by doctors. The fact of the matter is that it's idiotic to have doctors handling routine births. Nurse midwives generally have hospital privileges and in my experience are much more attentive and simply better than doctors at routine matters. If a complication arises they are qualified to recognize it and refer it to a doctor. It's absurd that in many metropolitan areas the c-section rate is at 50% or higher. Most c-sections and episiotomies are complete unnecessary. Obstetricians are basically a branch of surgeon, and that is what happens when you put a bunch of surgeons in charge.
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Re: Doctors, Nurse Practitioners and Medicare

Postby teflor the ranger » Wed Apr 14, 2010 9:01 pm

http://online.wsj.com/article/SB1000142 ... stpop_read
Medical Schools Can't Keep Up
As Ranks of Insured Expand, Nation Faces Shortage of 150,000 Doctors in 15 Years
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Re: Doctors, Nurse Practitioners and Medicare

Postby kiryan » Wed Apr 14, 2010 9:44 pm

Corth wrote:Not going to comment on whether midwives should be compensated at the same rate as obstetricians. Ideally the market would have determined that. But since the subject came up I'm going to make my obligatory plug in favor of nurse midwives for routine pregnancies. In most of the industrialized world including Europe, midwives handle the vast majority of all births. The US has some of the worst statistics for infant and maternal mortality in the industrialized world even though almost all births are handled by doctors. The fact of the matter is that it's idiotic to have doctors handling routine births. Nurse midwives generally have hospital privileges and in my experience are much more attentive and simply better than doctors at routine matters. If a complication arises they are qualified to recognize it and refer it to a doctor. It's absurd that in many metropolitan areas the c-section rate is at 50% or higher. Most c-sections and episiotomies are complete unnecessary. Obstetricians are basically a branch of surgeon, and that is what happens when you put a bunch of surgeons in charge.


First, from what I've read the birth statistics and infant mortality rates in the USA are heavily skewed due to premature babies. Its not an apples to apples comparison and certianly not as simple as saying obstricians suck.

second, csection rate is driven by a lot of factors primarily defensive medicine and secondarily "medical expert councils". So in short, this is mostly a problem caused by lawyers and lack of tort reform.

Third, lets assume it is idiotic for doctors to be doing routine deliveries. Nurse midwives now make the same as an obstrician. How much should an obstrician make? Obviously more than nurse midwives right? Why shouldn't nurse midwives make 85% or less of what Obstricians are?

--

I agree teflor that NPs make so much because they're worth it in a market sense. They are worth it because only certified individuals are licensed to practice medicine and there is a huge shortage of doctors because medicaid/care don't pay doctor's what they are worth and so people don't become doctors or don't accept meidcaid. However, increasingly the answer is to overpay nurses to provide these services which should obviously justify increased pay for doctors. If they were paying NP's 60% of what they pay a doctor, I would just shut up. But the pay is so close to doctors I think it makes it obvious that doctors are underpaid (or nurses are overpaid) either way I get to zing government for distorting the market by either A) causing a shortage of doctors by price fixing their wages or B) causing wage inflation in general despite claiming to provide care cheaper than anyone else.

--

ragorn I think you were the first to mention obama. This is a problem of medicare/medicaid and government run healthcare. healthcare reform is going to make this worse, but the systemic problems already existed and I'm not focused on the completely predictable massive shortage of doctors and wage inflation that healthcare reform will result in. I'm focused on what I think is an obvious compensation problem that hints at the root causes of so many other problems. A NP makes close to the same amount as a doctor; no wonder there aren't more doctors.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Corth » Wed Apr 14, 2010 10:46 pm

Most c-sections are the result of unnecessary medical interventions. Your doctor gives you petocin to speed up contractions but that causes the pain to increase exponentially so now you are given an epidural for the pain but as a result you can't walk around. Gravity is one of the best ways to get labor going so labor slows down. After 24 hours of labor they will usually do a c-section (even though that time period is arbitrary).

As for the question of whether obstetricians should make more than nurse midwives. My answer would be, for doing what? It's kind of like suggesting a doctor should make more money for putting out fires than a fireman. Ok so the doctor has all that education, but putting out fires is not a proper use of their skills. Likewise, normal childbirth is not a proper use of an obstetrician's skills.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Ragorn » Thu Apr 15, 2010 12:04 am

Corth wrote:Not going to comment on whether midwives should be compensated at the same rate as obstetricians. Ideally the market would have determined that. But since the subject came up I'm going to make my obligatory plug in favor of nurse midwives for routine pregnancies. In most of the industrialized world including Europe, midwives handle the vast majority of all births. The US has some of the worst statistics for infant and maternal mortality in the industrialized world even though almost all births are handled by doctors. The fact of the matter is that it's idiotic to have doctors handling routine births. Nurse midwives generally have hospital privileges and in my experience are much more attentive and simply better than doctors at routine matters. If a complication arises they are qualified to recognize it and refer it to a doctor. It's absurd that in many metropolitan areas the c-section rate is at 50% or higher. Most c-sections and episiotomies are complete unnecessary. Obstetricians are basically a branch of surgeon, and that is what happens when you put a bunch of surgeons in charge.

My daughter was born with a hospital midwife, and I second Corth's support. We chose in-hospital care rather than home birth on the off chance of complications, and the midwife was excellent.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Thilindel » Thu Apr 15, 2010 2:42 am

Bout time people realize that a doctor is just fluff. There are several ARNP's (advanced registered nurse practitioner), like me, who have found things that have been overlooked by a physician in the past. Experience > education. Statistics show that paramedics can diagnose ECG readings better than not only an ER physician, but also a cardiologist. Paramedic certification does not even require a college degree. Licensure does, however...but a licensed medic doesn't really get paid any more than a certified (search Texas to find out how effective this route is).

Medical in general is purely lopsided. Who's more important? A nurse, or a paramedic? A paramedic on scene that misdiagnoses a 3rd degree AV block or an especially blind one not realizing ventricular fibrillation can get a patient killed. A nurse' scope doesn't touch that responsibility in the first place. Yet the nurse makes 50% more money. To be an RN, is two years. Again, to be a paramedic science degree is two years. Paramedic's liability is nearly infinitely higher, as well as responsibility as per an entire group, than a nurse's.

BSN and lower nurses cannot even give an aspirin or even oxygen without a doctor's orders. A paramedic can RSI your ass on scene. Anyhoo, the gist is for anyone to realize that a -seemingly- less impressive title of MD vs. ARNP does not necessarily mean a compromise in care or capacity.

Lastly, a physician assistant (PA) is a logical step for a paramedic to step in advancement. That's a lot of experience to bring into a clinical setting. There are very few doctors who were EMT's, EMT-P's, etc let alone keeping up with their NREMT registry...
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Re: Doctors, Nurse Practitioners and Medicare

Postby teflor the ranger » Thu Apr 15, 2010 3:51 am

A doctor also has a far wider body of knowledge in medicine and needs it to catch all the things medics, PAs, PNs, and RNs miss.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Thilindel » Thu Apr 15, 2010 4:24 am

For -most- medical applications, unless you need a specialist, a MSN, ARNP, or PA is fully capable of diagnosing and treating. None of these will ever equal or surpass a doctor/physician/surgeon. The road to being a physician is ridiculously rough. Med students are not given enough sleep, time, and so forth. For some reason, the path is very, and unnecessarily hard. Heaven forbid, existing doctors can drop their ego (Most doctors) and accept that another human has attained the status of doctor, thus requiring acknowledgment of being equal.

In this area, there are two doctor types: They are either exceptionally intelligent and caring, or exceptionally narcissistic and demeaning with the bedside manner to match. In nature, the lesser practitioners are more humble in acknowledging their lacking PhD status.


For the general trauma and medical needs of a patient, a plain BSN can handle it. When it comes to biological medical needs, such as virus, germs, fungi, molds, the hideous bacterial endospores (which some autoclaves don't even kill), obviously a higher medical status would be needed.

The news should have posted just what it takes to attain a practitioner's status, and the curriculum involved in each path. There's not a whole lot of difference. I'm not putting lesser practitioners on Olympus, just saying they are quite involved too. One wouldn't want to take a truly sick, or gross trauma patient/family member to a lesser practitioner. For the frugal patients, you often get what you pay for..
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Re: Doctors, Nurse Practitioners and Medicare

Postby teflor the ranger » Thu Apr 15, 2010 4:29 am

I agree that most of the time a PA or PN is completely sufficient, like when I need a refill or check up for a cold that I'm pretty sure is a cold. I even ask to see the PA at my doctor's practice because I like her better than the doctor.

But if it comes down to a serious question about health or a physical, I'm looking for the reputable, experienced MD - narcissist or nice.

I think the problem is - you don't always know when you need a serious doctor.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Talona » Thu Apr 15, 2010 5:56 am

I bet I can RSI better than you!

HAR!

Seriously though, the 'midlevels' / ancillary medical staff are vital to medicine as it exists in this country. However, the argument that NPs, etc, have found things that doctors have missed and are therefore equally as competent is a fallacy of composition. If you ask any RN, NP, EMT, or the like who went on to medical school it becomes clear. They simply don't know what they don't know in many instances. Same as for the general public. Again, I'm not trying to discredit each's place in the medical realm, just state how I see it. There are bad midlevels and there are equally bad doctors.

Further, I'd like to see the stats on this EKG reading mentioned. I mean if the ER guy can't determine VF and 3rd degree AV block then he's probably been sampling from the med room.

P.S. I think Corth is ambulance chasing...
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Re: Doctors, Nurse Practitioners and Medicare

Postby kiryan » Thu Apr 15, 2010 6:12 pm

You can have the debate all day long at whether the stats show doctors or nps or apparently emt folks are better, but no matter which side you come down on, there is still some sort of gross imbalance in the system today because of the artificial controls placed on it and those are a result of government intervention regulation ect.. much through medicare/medicaid.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Thilindel » Thu Apr 15, 2010 7:54 pm

Talona wrote:However, the argument that NPs, etc, have found things that doctors have missed and are therefore equally as competent is a fallacy of composition.

I never said they were equal. I didn't even imply it. The things that PA's and ARNP's can do is just that, what they can do. It's in their scope of practice. In something specialized, I'd never suspect a PA to notice anything wrong. Just was saying that en route to becoming a doctor, some things are rudimentary, relatively. Hell, every EMT-P has probably had his or her ass saved by an EMT, for example. Just because someone has a higher level of education doesn't make them infallible to oversight or negligence that can be noticed or corrected by someone underneath..

Talona wrote:Further, I'd like to see the stats on this EKG reading mentioned. I mean if the ER guy can't determine VF and 3rd degree AV block then he's probably been sampling from the med room....


Same guy IO'd -three- different ADULTS in one day! And would you believe he's still employed?!
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Re: Doctors, Nurse Practitioners and Medicare

Postby Thilindel » Thu Apr 15, 2010 8:45 pm

kiryan wrote:You can have the debate all day long at whether the stats show doctors or nps or apparently emt folks are better, but no matter which side you come down on, there is still some sort of gross imbalance in the system today because of the artificial controls placed on it and those are a result of government intervention regulation ect.. much through medicare/medicaid.


EMS and Hospital/Post-hospital is apples and oranges. The EMS personnel are pretty much NOT in it for the money. For example, in some areas, EMT's get paid just above minimum wage. *but lowest level nurses make basically as much as a paramedic* EMS is also unfortunately scapegoated too. Performing, usually in front of crowds, patient's family, etc., takes a lot of mettle! They really never get enough acknowledgment nor respect.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Thilindel » Thu Apr 15, 2010 9:42 pm

Had to clarify: When I said being a doctor is just fluff, I mean that when an average person has an average problem, the level of medical knowledge needed to diagnose or treat is well below a doctor's training. So it's the same Bugatti Veyron in order to hit 120 mph. Overkill.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Corth » Fri Apr 16, 2010 3:07 am

If EMT's are working for minimum wage - that is exactly what they are worth. Like anything else, from an economics perspective the value of your labor is determined by supply and demand. If they couldn't find enough EMT's to fill the necessary positions, they would start paying them more - which would cause more people to become EMT's.
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Re: Doctors, Nurse Practitioners and Medicare

Postby Thilindel » Fri Apr 16, 2010 3:21 am

Well, there are a ton of EMT's, and hardly any paramedics relatively...
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Re: Doctors, Nurse Practitioners and Medicare

Postby kiryan » Fri Apr 16, 2010 2:50 pm

There are a ton of NPs and PAs coming out of the education system now too... and the reason for that is its a better value to become one than to become a doctor. In terms of time and effort and cost vs reward. You make 85% of a doctor on a significantly easier track. Government is picking winners and losers through medicare reimbursement rates and thats a bad place to be.

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