A fourth of U.S. health visits now delivered by non-physicians

The number of new physicians in the US are restricted because you need to go through residency and the number of residency slots are limited because they have to be funded by Medicare (why ?).

There's a huge lobby (AMA) to keep it that way, to ensure their members salaries remain high.

PAs and NPs don't have the same restriction so hospital systems are pushing to have them handle office visits as much as possible. This also has the advantage of being more profitable because they can charge the same.

In the last 5 years me and my wife have never been able to see a doctor, only a PA, even though we pay the same.

It wouldn't be so bad, except so many MDs, PAs, and NPs are just bad. This is coming from someone who has been traveling with a sick family member for a few years. There are great (read: skilled, thoughful, patient, investigative, this.patient data driven) professionals out there, but they are badly outnumbered and booked for months near a year into the future. A huge bunch display the interest, skill, or attention of someone working a a declining fast food franchise. Worst of all, most of the good medical practitioners don't even have their own practices, they can't afford the combo of liquidity and red tape, at least that's what a couple have told me.

> Ive had chronic health issues for 3 years now without much relief, despite having been to the doctors office 20+ in that time.

This is the problem with all of these systems that try to violate the laws of physics (aka: free market economics). They invariably results in substandard care, if you receive care at all. Keeping people alive isn't the same thing as actually solving problems with quality care.

This is my big gripe with the ACA (Obamacare) in the US. It's a shit system that was sold as a quality system. There are so many things wrong with it I am sick of listing them.

My wife is a doctor, so I've been privy to behind the scenes effects. If you think your doctor gives a shit about you when you come to the office with one of the stupid plans, enjoy the fantasy.

Doctors do care. However, they can't see thousands of patients at a loss. They have bills to pay, just like anyone else. More than anyone else, actually. And do, what happens in a lot of practices, is that doctors are forced to become numb to their caring impulse upon realizing that there's a dividing line between quality care and going broke. And so, they churn through patients at a rapid rate because the only way to make it is quantity.

My wife was telling me that the office next to hers has four PA's. They each see 40 to 50 people per day. That's an average of 10 minutes per patient. That's not care. That's medical professionals being forced by a shit system to push on the cash register button as quickly as they are able to just to make it.

It is important to keep context in mind when thinking about some of these things. Imagine an office with a couple of MD's, a few PA's, a few medical assistants and one or two administrators. Collectively, this is a group of people with somewhere around, say, $1.5 million dollars in student loans to repay. They each have homes, cars, kids and other bills to support.

That sets-up a situation where it is impossible for that medical practice to exist below a certain revenue threshold. More accurately, below a certain profit level. If the insurance system they have to work with is shit, they have two options: Close the doors and everyone becomes an Uber driver or keep them open and run as many people as possible through the doors with a $10 to $50 per person gross profit probability per person.

No, do the math. Don't just react to this through emotion. People have to get paid for their work, just like you.

So, let's assume $50 per person average profit (not sure that's a good assumption, it depends on the practice). What I mean by "profit" here is what you get paid (not what you bill, because sometimes you don't get what you bill) vs. what it costs for a medical professional (say, a PA) to provide that service.

Now assume you can churn through 100 people per day. That means $5,000 per day in gross profit. If you are open 20 days per month, the gross profit is $100K per month.

You now have to pay, say $25K per month for rent, utilities, insurance and various other expenses. That means $80K per month. Let's say two MD's own the practice and each gets paid $25K per month salary. You are left with $30K in the bank. You likely have other expenses that will easily consume half of that, cleaning, legal, accounting, software licenses, IT, etc. You are now down to $15K. Which is a formula for going bankrupt.

What do you do? Well, you have to crunch through more people per day and try to maintain the same cost structure per patient. So, you try to see 150 to 200 people per day --if you can, not all practices can do that-- and pump them through as fast as possible. In other words, you cannot prioritize quality care.

Anyone thinking "Just provide better care and bill for it". It doesn't work that way. Say you decide to see only 50 patients per day. Obamacare shit plans are not going to magically pay you double for taking someone's pressure and temperature or going through a basic diagnostic check. The limit function here is that these plans are shit, they don't pay for quality care, they pay for delivering the fantasy of having medical care.

Not to mention the horrible problems of Medicaid/Medicare. That's another half dozen paragraphs.

Yes, everyone should have access to *quality* healthcare at a reasonable cost. No, that isn't possible if imbeciles in government make the decisions. These are the same people who, through incompetence and mismanagement can't seem to give us a world without war and misery. What makes anyone think they can actually deliver solid quality healthcare?

BTW, my wife and her partners finally had enough. They launched a boutique medical care office. They provide high quality care at a reasonable price. Patients are well taken care of, employees make a sustainable salary and nobody has to engage in the soul-crushing practice of treating patients like cattle.

In a very meaningful way the line between physician and non-physician had been blurring anyway.

There's a software called Epic which is used by virtually all large healthcare centers, and while most know it as a database system to store patient history and health records (problems and conditions they've been diagnosed for, lab work results, medicine they're currently taking or have taken in the past), it also has a little tab where a healthcare worker can put in some keywords, e.g. the symptoms a patient has, and Epic guidelines gives the health-provider an action plan for that patient, as well as guiding them with differential diagnoses for non-simple issues.

Of course for common ailments a nurse practitioner knows as much as a primary care physician anyway and their treatment plans wouldn't differ, but the thing is a physician basically effectively will also only follow one script that the healthcare/insurance system in-place allows for, that Epic will spit out also.

In the same way some of us see the task of building a CRUD app as something fairly unremarkable (owing to existing frameworks, existing 'best practices' etc), a physician's day-to-day work is really not challenging, and a "people-person" non-physician equipped with Epic software could arguably work to deliver equal or if not better healthcare outcomes.

i already understand the economics, these types of systems exist everywhere, usually to the detriment of everyone. However, all they need to do is not deflect me from specialist care, so im not sure it applies 100% here. Check back in a month when i go to the office again and insist on seeing a specialist.