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ERs are hiring fewer doctors to save money

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Re: ERs are hiring fewer doctors to save money

#101

Post by mikeyouse »

oaktrout wrote: post #98
mikeyouse wrote: post #95

Earlier quoted context omitted.

Claiming as a fact that non-physicians cost more money based on the back of one random study from a Mississippi health system might be a bit rash. Especially since almost every other bit of research has shown the opposite; "Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum" - https://journals.lww.com/lww-medical…

Truly it's a nuanced topic and you cannot say that across the board NPs cost more than physicians. I have no doubt that NPs and PAs can be cost saving when employed appropriately. An issue with your first study is that some NP care was attributed to physicians (as a result of NPs billing under a physicians NPI), hence decision making that was done by an NP is being analyzed as if it was done by a physician. In the st…

Trying to apply "first principles" approaches to something as complicated as medical billing and reimbursement is a fools' errand. As a quick example before I move onto more pressing things, you ask, "If your ED visit is billed the same whether you're seen by an MD or NP, how would an NP go about saving you money?"

It'd be helpful to know that they aren't billed the same!

From CMS:

> When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides the substantive portion of the E/M encounter with the patient, then the service may be billed under either the physician's or the PA's or NP’s UPIN/PIN number. If the physician does not provide the substantive portion of the encounter even if the physician participated in the service by reviewing the patient’s medical record, then the service may only be billed under the PA's or NP’s UPIN/PIN. In this scenario payment will be made at 85 percent of the Medicare physician fee schedule.

Re: ERs are hiring fewer doctors to save money

#102

Post by wahnfrieden »

antisthenes wrote: post #88
wahnfrieden wrote: post #73

Earlier quoted context omitted.

I'm asking why the difference? Why is it good for society sometimes, and sometimes terribly wrong, in your view?

Externalities of the absence of something can be small, large, positive or negative. What do you think are the externalities of _not_ having healthcare available to majority of your population ?

You rephrased the question

Re: ERs are hiring fewer doctors to save money

#103

Post by 908B64B197 »

shiftpgdn wrote: post #5
wyldfire wrote: post #3

> While diagnosing and treating patients was once doctors' domain, they are increasingly being replaced by nurse practitioners and physician assistants, collectively known as "midlevel practitioners," who can perform many of the same duties and generate much of the same revenue for less than half the pay. IMO, PAs and NPs are a good idea for medicine overall. Especially since lots of folks who would consider a career…

Counterpoint: You can go read the “Noctor” subreddit or ask any practicing physician why it’s bad for patient outcome. Ultimately we need more doctors and less hospital administrators.

> You can go read the “Noctor” subreddit

There's just no way I would take medical advice (like which provider to choose from) from a site that's basically anonymous creative writing.

And let's be frank: just browsing this subreddit, it reeks of sexism and racism (it's no coincidence that the demographics for nurses are different than doctors). There's also not a single verifiable claim or study that would prove their point. And a lot of comments about IQ that sounds eerily similar to the current discourse of "race realists"...

Re: ERs are hiring fewer doctors to save money

#104

Post by oaktrout »

908B64B197 wrote: post #100
oaktrout wrote: post #22

Earlier quoted context omitted.

I'm sure the high paid software engineers at boeing said something similar when jobs were being outsourced "we need more US engineers". Look at the software problems they had and tell me they were wrong. Just like software engineers are best qualified to evaluate software quality, doctors know medicine better than anyone else. Just because they are incentivized to protect their job doesn't mean they are wrong.

> Just like software engineers are best qualified to evaluate software quality, doctors know medicine better than anyone else. Just because they are incentivized to protect their job doesn't mean they are wrong. It was rather trivial for Boeing engineers to show, without a doubt, that the cheap offshored programmers didn't write software as good as they did. The design simply spoke for itself and didn't perform to sp…

With the Boeing engineers the outsourcing wasn't obviously an issue to individuals outside the system until the 737 MAX was grounded and 346 people were dead. Requiring such a sentinel event before the value of US engineering was known to the public suggests to me that it was not trivial for the Boeing engineers to prove their value.

Doctors are at a greater disadvantage as there is not likely to be a sentinel event that kills 189 people at once. Nothing about the US medical system is trivial.

Consider the private equity run emergency department in the article, I am sure that they could make more profit off of NPs and that doctors wouldn't save private equity costs. The article suggests that NPs are saving private equity money while costing patients and taxpayers more. Speaking of quality, why should private equity care about quality if it doesn't effect their bottom line?

Re: ERs are hiring fewer doctors to save money

#105

Post by mondocat »

wahnfrieden wrote: post #25
azinman2 wrote: post #23

Earlier quoted context omitted.

We need to outlaw for profit anything with healthcare. The incentives are misaligned with society’s needs.

Why only healthcare specifically?

Because there shouldn't be a variety of price points, and innovation should not be hoarded. Healthcare should be uniformly the best it can be.

Re: ERs are hiring fewer doctors to save money

#106

Post by seattle_spring »

oaktrout wrote: post #99
seattle_spring wrote: post #97

Earlier quoted context omitted.

It is a bit rash, but it’s the exact same study trotted out literally thousands of times by disgruntled residents on Reddit, fuming that there exists a profession that can practice medicine without years of humiliating residency. Whenever someone uses that study as a citation, it’s immediate reason to discredit anything else they’re going to say. Just spend a few minutes looking at that “Noctor” subreddit the guy sha…

Truly reddit is a place full of idiots on all sides, do you have specific criticisms of the study I posted though? Or specific criticisms of the study in the NPR article?

https://xkcd.com/882/

Re: ERs are hiring fewer doctors to save money

#107

Post by oaktrout »

mikeyouse wrote: post #101
oaktrout wrote: post #98

Earlier quoted context omitted.

Truly it's a nuanced topic and you cannot say that across the board NPs cost more than physicians. I have no doubt that NPs and PAs can be cost saving when employed appropriately. An issue with your first study is that some NP care was attributed to physicians (as a result of NPs billing under a physicians NPI), hence decision making that was done by an NP is being analyzed as if it was done by a physician. In the st…

Trying to apply "first principles" approaches to something as complicated as medical billing and reimbursement is a fools' errand. As a quick example before I move onto more pressing things, you ask, "If your ED visit is billed the same whether you're seen by an MD or NP, how would an NP go about saving you money?" It'd be helpful to know that they aren't billed the same! From CMS: > When an emergency department E/M…

Please correct me if I'm wrong here: You save $45 on the professional services, but you still pay the same facility fee (~$1000), the CT scan still costs the same (~$5000), labs are still the same (~$110)... etc. So maybe you have saved ~1% seeing an NP, hence why I said "billed the same", although you are correct that they are not the exact same. Now imagine that a NP orders a CT scan that was unneeded 1% more often than a physician, at this point it costs more on average to see the NP.

Re: ERs are hiring fewer doctors to save money

#108

Post by seanmcdirmid »

mikeyouse wrote: post #82
seanmcdirmid wrote: post #78

Earlier quoted context omitted.

> What risk? Malpractice coverage is provided by the hospital, or more typically, the private equity group that owns the ER physician practice. Stress isn't alleviated just by insurance. Sometimes people care about doing their job right and "winning". ER docs are just put on the spot constantly. > I don't think the average person realizes that Blackstone is one of the largest employers of ER docs... It doesn't really…

The popular conception of an ER doc is completely divorced from the day-to-day reality.. This isn't House, they're not "put on the spot" constantly like they're on some island. They are part of a care team and they call for IM/ID/Cardio/Radiology consults when they have any question about a diagnosis. They certainly have stressful jobs but no moreso than the floor physicians or other providers who work the same shift…

If being an ER doctor is such a cushy deal for more money, doctors who would otherwise choose internal medicine would just choose that. There is plenty of variation in medical specialties, but, at least for people who are going to medical school today, I'm sure they are well informed what is in demand and what isn't. At least in this case, I don't see non-market forces at work (whereas medicine has plenty of those in other places).

Re: ERs are hiring fewer doctors to save money

#109

Post by mikeyouse »

oaktrout wrote: post #107
mikeyouse wrote: post #101

Earlier quoted context omitted.

Trying to apply "first principles" approaches to something as complicated as medical billing and reimbursement is a fools' errand. As a quick example before I move onto more pressing things, you ask, "If your ED visit is billed the same whether you're seen by an MD or NP, how would an NP go about saving you money?" It'd be helpful to know that they aren't billed the same! From CMS: > When an emergency department E/M…

Please correct me if I'm wrong here: You save $45 on the professional services, but you still pay the same facility fee (~$1000), the CT scan still costs the same (~$5000), labs are still the same (~$110)... etc. So maybe you have saved ~1% seeing an NP, hence why I said "billed the same", although you are correct that they are not the exact same. Now imagine that a NP orders a CT scan that was unneeded 1% more often…

Again - this is far too complex to "first principles" your way out of. You need to be clear who you're talking about when you talk about savings (savings to the patient?, to the private insurer?, to medicare/medicaid?,to the hospital?, to the taxpayer if it's a public health system?) and even still, it will vary massively given that much of our care is state-driven.

Your figures e.g. for a CT scan are wildly wrong if you're talking about anything government-paid. The reimbursement for a differential chest CT to the facility is closer to $150 from the government (https://www.cms.gov/medicare/physician-fee-schedule/search?Y...) but again, that varies depending on a million other things.

So making some claim like the 15% savings from an NP reimbursement is only 1% of the total cost of a visit needs a heck of a lot more specificity than your gut feeling on what things might cost.

Re: ERs are hiring fewer doctors to save money

#110

Post by wyldfire »

ourmandave wrote: post #14

My last ER visit I was seen by a PA, which is fine. They're more than competent. The part I didn't like was how they made me get out a credit card while they we're treating me. Which, according to a story by the NY Times, is a common thing. Send a nurse around with a swipeable tablet to ask how you'd like to pay. https://www.nytimes.com/2023/01/25/podcasts/the-daily/nonpro...

All businesses are like this - it saves them money on collections. If your insurance refuses to pay up -- or you refuse to pay up -- or you decide to pay your car payment instead of the medical bill -- they lose out.

It might be a bit distasteful to do it in proximity to medical care. But just tell them that they can bill you, make up an excuse if you need to.

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