Yep. The midlevels are supported by automatic protocols in Epic (e.g. sepsis, DKA -> put these dozens of orders in with 5 clicks) that physicians decide on and approve. They also rely more heavily on imaging instead of a physical exam and history. When unsure, they can consult a physician, even a specialist.

It’s a very polarizing topic in medicine that patients generally aren’t privy to. Especially for resident physicians who often make half as much as these midlevels yet have more education, there’s a lot of bitterness. The federal government is ultimately to blame… having a fixed number of residency spots to artificially limit the supply of new physicians is terrible, and this is the predictable result.

I think hospitals support inefficient midlevels because they can bill patients for the increased resource usage, but it’s not good for the system overall when unnecessary scans and consults are done, and more complex patients don’t get comprehensive care. Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.

>Many foresee a two-tiered system developing, where the rich see physicians, and the poor see midlevels.

There already was a tiered system, with rich people being able to buy concierge medicine and getting preferred treatment based on who knows who on the hospital's board or if their name is on a wing of the hospital.

The change now is a more visible and more granular price segmentation.

There’s no price segmentation. You pay the same for a visit with a PA or NP as for one with a physician, so why see someone with less than a tenth the experience who may have gone to an online only school with 100% acceptance rate and shadowed for 500hrs of “clinical experience“ right out of nursing school?

It will happen via in network and out of network agreements.

Healthcare providers with greater proportion of NP/PA will be selling for cheaper, so MCO will sell access to only them in their lower price plans, and healthcare providers where you get to see doctors will be in higher price plans.

This already happens, especially with many healthcare providers not accepting lower reimbursed Medicaid patients.

A two tiered system might actually be better for improving access to affordable health. Mid-level providers seem to achieve equivalent outcomes for routine cases at lower cost.

I agree that Congress should increase funding for residency programs.

https://www.ama-assn.org/education/gme-funding/ama-seeks-mor...

I generally dismiss these “equivalent outcome” studies. Any midlevel will (and should) bounce the more complicated cases to their supervising physicians. Outcomes at that point are meaningless.

There’s definitely a trade off between resources devoted to education vs. acceptable risks from failed procedures, missed/delayed diagnoses, and increased utilization of imaging and referrals (and the physician radiologists and others who participate in that - it goes full circle). Physicians now are probably on one extreme end of that, and midlevels on the other.

On the topic of servicing rural areas… the problem is that nobody with better options (which includes midlevels) wants to live in these places. These educated, high-earning people want to live in urban areas, and they can. CMS has tried to incentivize this with billing by offering higher reimbursement rates to rural places that have a midlevel on staff. That’s about it, though.

> the problem is that nobody with better options (which includes midlevels) wants to live in these places.

Or the problem is that people are not offered enough money to make the sacrifices they would make by living in rural places.

> I generally dismiss these “equivalent outcome” studies. Any midlevel will (and should) bounce the more complicated cases to their supervising physicians. Outcomes at that point are meaningless.

If midlevels can successfully detect complicated cases to a supervising physician, and handle a whole lot of other care independently... and the net result is equivalent outcomes... this isn't a massive win? You've conserved the really expensive and contended resource for where it's needed and not made anything worse...

It's not so clear cut for a few reasons.

#1 - Funky/misleading statistics - Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients. It's not claiming that of any randomly selected patient, regardless of who they see, the outcome is the same. Therefore, if uncomplicated patients saw physicians, outcomes for the physicians could improve. In primary care managing hypertension or diabetes, this isn't as pertinent. For something like anesthesiology, it's more so counting how many times shit hits the fan, and brain cells die when the anesthesiologist takes time to be summoned.

#2 - They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here! The patient no longer has use of their interphalangeal joints. The physician would probably try to shine a light through it, note the patient's Scandinavian ancestry and family history of plantar fasciitis, and tell them to live with it and come back if it changes.

No resources were saved here, but the patient's DASH score (disability of the arm, shoulder, and hand) is still 0 so the outcomes are the same.

This happens all the time.

#3 - Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.

#4 - It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor... in many places, that doesn't necessarily need to be an anesthesiologist, and the surgeon performing the procedure can suffice. The AANA recently changed its name to the "American Association of Nurse Anesthesiology"... It used to be "Anesthetists". The CEO and president (two different people) of the American Nurses Association both refer to themselves as "Doctor" in a healthcare setting even though one holds a DNP and the other a PhD. It's pervasive.

> Generally they claim that these NPs with uncomplicated patients do as well as physicians with complicated patients.

The studies I've seen have compared practices where NPs are seen first vs. physicians are seen first.

> They're not conserving expensive resources. Imagine a patient comes in with a lump on their hand. An NP might see a weird lump, order an MRI which gets read by a radiologist, refer to an orthopedic surgeon who specializes in the hand, who removes tissue to send to a pathologist, who determines it's a common benign tumor of the fascia. That's three physicians who spent much more time here!

Your claim is this kind of excessive testing and referral doesn't happen with physicians? Do you have some kind of evidence this is more common with NPs?

This kind of overtesting leading to unnecessary procedures and bad outcomes has been pervasive through care in the US. Don't blame it on NPs.

> Bad incentives - Medicaid would not in a million years cover this, but the game of medical pinball where patients bounce around through in-network referrals can funnel those with decent insurance into procedures. Especially when most people have poor health literacy. A hospital executive probably just splooged in his pants seeing how much money their loss-leader of primary care is driving to radiology and the surgical specialties where they actually make money.

Ditto

> It's insincere. All of this can be viewed as possibly successful when the midlevels are part of the healthcare _team_ and know their limitations. But the NP groups are increasingly pushing for independent practice and prescribing rights in state legislatures across the country. CRNAs require a physician supervisor...

Welp, we're not creating anywhere near enough residencies to create enough physicians to do the work, so I'd suggest we'd figure out ways to either do that or use people with lower levels of training well (preferably both!).

I'm having a hard time understanding why they would be bitter. Residency is temporary and a part of the training process. Once completed, doctors will make 2x-3x+ compared to midlevels for the rest of their careers.

Residency has a lot of problems. The match is stressful enough. Medical school graduates carry a huge amount of debt, but must complete residency before earning enough to meaningfully pay it off. Residencies pay 40-85k and most resident physicians are expected to work 80+ hours per week. 80 is the theoretical maximum, but that doesn’t count time arranging work, studying, taking board exams, etc.

All this, and if you don’t complete your residency, you have no prosperous future as a doctor. You might re-match to another residency if you’re very lucky. The hospitals know this and act accordingly. Residents and even medical students paying tuition (!) were assigned to treat COVID patients and couldn’t really decline without risking the future they’re heavily invested in.

Keep in mind, the federal government pays ~150k per year to the hospital for having the resident. Yet the residents are often more indentured workhorses than trainees. It’s not uncommon for entire departments to run overnight with only residents, but no attending physicians.

Now imagine being in this situation, and not being allowed into the “providers lounge” because you’re a resident. Or using a broad-spectrum antibiotic instead of something more specific and being scolded for poor antibiotic stewardship, while the NP who has “completed their training” can’t even properly decide antibiotics are indicated some of the time. And if that NP were ever treated the way a resident is, they could go get a job at the hospital on the other side of town and start in a week.

Because the future is for doctors to not make 3x compared to them. The mid levels are being used to increase supply of healthcare, using the doctor’s license for liability, in order to reduce the price doctors collect (per unit of time and effort).

Basically, they are watching their expected wealth / purchasing power be reduced.

If someone was making more than twice as much as you, working half as many hours as you, seeing half as many patients as you, and were less qualified for their similar role, you would be upset too.

Not to mention the fact they offload all the legal liability to the actual doctors since they have to approve everything.

You can read r/noctor if you want examples

It's happening because hospital corporations love them.

Corps can pay less, and since they have a tenth of the education, they order tons of profitable tests, consults, and scans because they don't know otherwise.

This is why insurances are moving toward capitated plans. Instead of paying for services provided health care providers get paid per patient they care for. That way the perverse incentive created by asymmetric information is removed.

I thought it was the opposite, that everything is moving towards value based payment, or at least it seems to be for government funded healthcare:

https://www.chcs.org/its-not-just-risk-why-the-shift-to-valu...

Well implemented capitated plans are value based. Value based just means there are incentives for better than expected health outcomes and disincentives for bad outcomes. If you have a non-value based capitated plan health care providers would reduce the quality of care, so value based strategies were implemented to ensure patients receive good care even though providing it costs money.

Oh, thanks for the clarification. I thought they were not compatible.

This is a mischaracterization of P.A.s (well, not the being-paid-less bit). Do you know any personally?

It's a mischaracterization for PAs because doctors only have ~7.5x minimum more clinical training and not 10x, 15000 clinical hours (for med school + family medicine, the shortest residency program) vs 2000hrs. Ask any radiologist you know what they think about the imaging orders from NPs and PAs and that will give you your answer.

He's exaggerating significantly, but the core point is true. pAs and NPs will be the future of hospital care.

>Corps can pay less, and since they have a tenth of the education, they order tons of profitable tests, consults, and scans because they don't know otherwise.

Hence the purpose of managed care organizations (MCOs, health insurance companies) employing people to approve and deny (or design systems that approve or deny) payment for unnecessary tests, consults, and scans. And in a taxpayer funded system, the government employs people to performs the same roles.

It's worth noting that the higher tiers of nurses have at least a masters degree, and like more time working than a doctor spends in residency. They are highly trained/skilled professionals.

I would guess that most people entering NP programs at this point have less than 3 years of work experience as a nurse, a job where you are not diagnosing, coming up with treatment plans, performing procedures or doing any other physician tasks.

I don't know if 500hrs of shadowing after a 2yr part-time online only program that you don't need any nursing degree or experience to enter would count as highly trained or skilled. Here's a list of direct entry nursing masters programs - https://nursinglicensemap.com/nursing-degrees/masters-in-nur...

Here's Johns Hopkins doctor of nursing practice program's curriculum - https://nursing.jhu.edu/academics/programs/doctoral/msn-dnp/... - where more than half of your classes are not medicine related and which requires an astounding 1000 clinical hours and less than 10 credits a semester before you can call yourself "doctor". Most medical students will have 1000hrs after 3 months in 3rd year, where they will be expected to diagnose and come up with treatment plans vs just shadowing, and they still have 9 more months of 3rd year, 4th year, and a minimum of 3 more years in residency. Doctors will likely end up with a minimum of 15000 hours of training. The difference really is that large, and I feel bad for the patients and for the NPs who have no idea how deficient their education is. PAs have 2000hrs of clinical experience. Here's a chart - https://i.imgur.com/Cj5z4f8.jpg

I didn't say that nurses have the same medical training as a doctor of medicine; just that they are highly trained professionals with a fair amount of experience. If you match the 3 years of residency with 3 years of working as a nurse (they're clearly not the same thing, but both are "experience" for the purposes of this discussion), a starting medical doctor has 2.5-3 more years of training/school/experience than a nurse practitioner. That's a lot; but it doesn't reduce the fact that the NP has a lot of training. The post I was replying too sounded like it was dismissing the amount of training/experience being a NP takes, and it bothered me.

the real problem with NP/PA is now what they know. It is that they don't even know what they don't know. There's a large body of basic science, biology, that a doctor has to acquire that helps underpins a lot of the clinical medicine they practise. It's not just following guidelines and algorithms. It is understanding why the guidelines are, it is understanding why what looks like a typical case isn't, but is that one rare thing you absolutely can't miss.

Honestly, if not for the weirdness of the US system, mid-level providers shouldn't exist. But we are where we are. There absolutely is no room for independent practise for mid-level providers.

Is there any evidence that patients of NPs actually have worse outcomes? Given the current physician shortage would it be better to wait to see one, or get an appointment with a NP right away?

My expectation is that the outcomes would be similar for the common issues, and would start to deviate as you got into more uncommon problems. A doctor will have a lot more "background knowledge" to be able to consider things that are outside the every day. At least in my mind, it's not unlike someone in software development with a degree in it vs not. For most things, the person without a degree will do a fine job; but for some things, they won't be able to consider many of the possible options/tools, because they just haven't been exposed to them.

correct. except the person doesn't even know when they don't know. and that's the most dangerous part. If you at least know what you don't know, you can re-direct to the right resources.

Many studies comparing NP and physician outcomes will have the NPs under supervision by physicians, which is ideally how they would be used, but in practice the true supervision level varies widely. I wouldn't see an NP for my care personally, and I doubt there are many physicians who would. The wait time to see primary care physicians is typically less than a week in most places and would be worth it. If you're experiencing something you feel is too serious to wait a week I would visit the ER (and make sure to ask to be seen by the physician also). It's your health. Personally I would only trust mine to the people who are the experts in their subjects, and not those who have less training and can switch between specialties without any additional training.

I don't have anything against NPs when the supervision is close, but more and more doctors are put into positions where they are acting as liability sponges for de-facto independent NPs/PAs.

Here are a few studies - (CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625

Comparing urgent care visits between MD/DOs and Midlevels. Doctors saw more complicated patients, addressed more complaints and deprescribed more. https://link.springer.com/article/10.1007/s11606-021-06669-w

NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/

Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/

Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082

Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullar...

Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696

The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)...

Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/

I will add my anecdotal perspective as a rheumatologist at a tertiary care centre to your second last reference. I have a lot of respect for the work my NP/PA colleagues do, particularly on the ward. Yet I see a notable difference in the quality of referrals from MDs vs. most NPs/PAs whether it be from clinic, ER, or ward. With some exception it's often please see for [subjective complaint], a + random test that was checked, and query [disease that goes with that antibody] or a misunderstanding of what I see in my discipline. Not to say that MDs have it perfect but I'm not sure if it's the shorter training, more algorithmic focus, less confidence in their physical exam that drives this. As a healthy 20 year old I'd have said an NP/PA is great for primary care but I just don't see it as a solution as people age and get more medically complicated.

Why are all the universities on board for this? All these midlevel degrees are devaluing their own medical schools.