Archive for category Midlevel Providers

Medicare For All — what does that mean?

Bernie Sanders popularized the idea of US national healthcare during his 2016 campaign. He described the idea as “Medicare For All”. That was a genius idea since most Americans have a family member with that program for seniors. In fact, with its 44 million participants it represents a very large, although incomplete, national healthcare program. It is very popular among seniors since it reduces insurance premiums dramatically.

There are two major versions of Medicare: Standard and Advantage.

Medicare Standard

  1. It sets the allowed price for hospital and medical provider services
  2. It pays 80% of the “allowed” price leaving 20% for the individual or a “medical supplement”.

Medicare Advantage

  1. Limits participants to one insurance company or organization
  2. Has lower premiums
  3. Wraps Medicare and a supplement together

What about Medicare For All

  1. What about premiums or supplements or services? (the specifics need to be chosen, not guessed at.) It’s like a dream house, but without a drawing or a list of deliverables.

The Choices

This is really the nuts and bolts of a national plan no matter what you call it. And, if the current providers sense they will make less money, the self-serving complaints will be very loud. Who will complain if patients don’t get a better deal — not very many people. That’s because not very many people understand healthcare. So, what do you as a consumer want?

☐ Same old insurance, high drug prices and poor quality
☐ Premiums paid via payroll deduction
☐ Premiums paid via annual income tax
☐ Allow supplemental insurance for non-covered items (like plastic surgery or special drugs)
☐   Profits for drug companies limited to 5%

All covered medications available for $10/month
☐ All approved hospital days available for $400/day

☐ Out of pocket annual expenses limited to $5000/year
☐ Approved child medical care is free
☐  0.5% of premiums for research
☐ Regional claim processing (by current insurance carriers, limited to 5% profit)
☐ Limited list of available medications, generics are required where available, brand name drugs are selected by the plan
☐ 30% of provider payments linked to quality and quantity measurements
☐ Medical school tuition paid in exchange for 5 years of service in designated (poorly served) areas
☐ Mental health service included same as other health care (includes PhD psychologists)
☐ Maternity care, including midwife care at home when safe

☐ Primary care provider available for all persons
☐ Physicians and surgeons are salaried (not paid by number of services)
☐ Same day service for urgent problems
☐ Clinics open nights and weekends
☐ Massive increase in numbers of physician assistants and nurse practitioners with tuition paid in exchange for service

☐ Video visits with providers via Internet if desired
☐ Hospitals paid according to diagnosis (DRGs)
☐ Regional specialty hospitals (5% for growth and development)
☐ Local general hospitals
(5% for growth and development)
☐ Providers all use the same secure medical record
☐ Annual adjustment of payment levels based on a budget

☐ Ongoing and up-to-date quality measurements on all services
No need for malpractice suits — immediate compensation for injuries instead
☐ Strong quality system capable of sanctioning administrators and providers (important!! may need lawyers here)

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The Emergency Room — high cost of care

ER signPeople go the the ER but often do not get admitted to the hospital.  Why does this happen?  Do they think the problem is an emergency or do they just not have access to other health care?  The CDC presented the following data from 2011:
ER_1 ER_2 ER_3

(note respondents could answer yes to multiple items)

The bottom line:  people who go to the ER but do not get admitted do so because they think the problem is serious, but 80% also say they lack access to other providers.

Social factors often force the ER visit:

  • No primary care provider has been established
  • Primary care does not have enough walk-in capacity
  • In rural communities once the few primary care offices close there is no other alternative
  • Work hours force evening or night care for family members
  • ER is closer than other options
  • ER is more willing to see someone without insurance
  • Patients seek continuity of care once they have been seen at the ER — they return.

A not uncommon scenario is when a single parent picks up a child from day care only to find they are sick but doctor’s offices are closed.  And, the parent is expected back at work early in the morning.

Possible solutions:

  • Encourage urgent care or “community ER” clinics.  In many larger cities doctors or hospitals have opened urgent care clinics — they are not intended to provide continuity of care but just service when needed.  In the UK such clinics are often staffed by nurse practitioners.
  • Assign one provider in a primary care office to walk-in duty — thus increasing the capacity for unscheduled visits and allowing the other providers uninterrupted time to see scheduled patients.
  • Locate some primary care clinics with extended hours next to the ER.  The patients can see a primary care provider at a lower cost — but if the problem really is critical the ER is next door.
  • Use the phone more.  Also, use Skype since it is encrypted and should meet HIPPA guidelines.  Cost would be lower for everyone if health care providers made better use of technology.  Accountable care organizations (with less fee for service incentive) should find the lower cost aspect very attractive.
  • Provide more mobile care.  Some enterprising ambulance services provide service on location and don’t actually transport the patient to the ER.  Unfortunately, the overhead cost is rather high — but the same can be said for the ER in general.  It’s like the guy who comes to your driveway to replace a car windshield.  Instead, you might get a laceration sutured in your kitchen!  Or your child with a sore throat could be checked with a strep-screen.

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Empathy in Health Care

Daniel H. Pink proposed a simple test of empathy in business whereby the subject is asked to write the letter “E” on their forehead.  If they write the letter so others can read it then they are empathetic.  Clearly not a scientific test although there are other tests developed by psychologists which do measure how empathetic a person might be.  Empathy is an attribute we all want in our health care provider and some have more of it than others.

The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy.    Stefano Del Canale, MD, PhD, et al.  Acad Med. 2012 Sep;87(9):1243-1249.

The above article suggests a link between empathy and better results for patients.  Recently the Wall Street Journal published a list of things to be considered when choosing a primary care provider (below).  The first on the list is about empathy:

  1. Does the physician make you feel comfortable and listen to your concerns and opinions.
  2. Does the office seem to function smoothly?  How easy is it to get an appointment or get care outside regular office hours?
  3. Does the practice track your care and alert you to gaps?
  4. Do specialists’ results automatically get sent back to your doctor and discussed with you?
  5. Does the practice accept your insurance, or charge your directly?  Will it help you keep costs down when possible?

When you are looking for a health care provider finding one who will take new patients is hard enough.   Trying to pick one who is empathetic from the phone book is just not reasonable.  In fact, there are lots of traits one would like to have in a provider like timeliness, honesty, communication skills, medical knowledge, and surgical skill just to name a few.   A good recommendation from a friend is worth a lot.  Be careful when picking a highly charismatic provider since charisma  is not the same as empathy or skill.

Health care providers self-select a specialty to some degree based on personality.  Family doctors and nurses tend to have good interpersonal skills.  Nurse practitioners often are very empathetic people.   Pathologists and radiologists don’t have much (live) patient contact for a reason.  Some surgeons (who work while your are asleep) don’t always have high empathy scores — but in that circumstance surgical skill really is what you want.

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The Rise of the Midlevel Provider

Several recent articles have commented on the shortage of physicians.  In particular, the Atlanta Journal-Constitution reported “The number of physicians in the U.S. grew from 737,764 in 1996 to 954,224 in 2008, a 29 percent increase, according to a 2011 American Medical Association report. But the number of physician assistants went from 29,161 to 73,893 and the number of nurse practitioners from 70,993 to 158,348 in the same period. That’s an increase of 153 percent and 123 percent, respectively.”

The US healthcare system is adjusting to the difficult and expensive problem of training new physicians (MD and DO) by training midlevel providers (nurse practitioners or physician assistants).  The midlevel providers must go to college and then have 2-3 years of additional training as opposed to the additional 7-10 years for physicians.

The midlevel providers are a welcome addition to the health care workforce.  They fit an interesting gap not well filled by physicians.  They provide more face to face time with patients, they provide excellent health care education for patients, they tend to follow evidence based guidelines more closely than physicians and they excell at routine type patient interactions.(see examples below).  Physicians will always have the advantage in diagnosis of illness and complex problem solving due to the nature and duration of their training (some claim this advantage fades as midlevel providers gain  experience in their area of practice over several years)

So, how should patients take advantage of the growing number of midlevel providers?  Seek providers (MD and DO) that are part of organizations that include midlevel providers in a ratio of about 1 – 2 midlevels to 1 MD or DO.  Look for a team approach to patient care where the midlevel providers do a lot of the routine visits but the MD and DO providers are on the front line for acute or new problems.  This type of a setting helps to improve access to care — better access hopefully means longer visits, better education and higher satisfaction.  If a patient calls a primary care provider’s office for an appointment with a new problem it should be with the MD or DO.  In the course of a routine visit if a problem clearly needs a specialist the midlevel should be able to make the referral just like an MD or DO.


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