Mistaking Failure for Success

It would be easy to think of hospitals as the crown jewels of our health care system.  After all, they are the largest single component of health care spending, accounting for almost $1 trillion of our $3 trillion total.  They've outspent and outmaneuvered all the other players in vertical and horizontal consolidation.  And everywhere I go I see scaffolds up near hospitals, as they keep building additions and renovating existing facilities. 

Let's face it: hospitals are -- implausible as it may sound -- sexy.  You see a lot more television shows set in hospitals than you do set in, say, doctors' office or pharmacies (and certainly none are set in health plans!).  Local news programs love to feature the local hospital's latest piece of (expensive) technology.  They get the best, most expensive new technologies (although they aren't always so good about getting rid of older ones).  According to The New York Times, hospitals now pay their CEOs like rock stars -- making even more than surgeons.

Instead of seeing hospitals as our crown jewels, though, perhaps we should look at them as symbols of our failures.

Think about how we measure hospital performance: how many patients die or get an infection during their stay, or are readmitted soon after they leave.  Those are all measures of failure, not success.  Would Toyota compete on the basis that fewer of their cars catch on fire, or would Apple brag that only a third of their customers return their iPhones?

I don't think so.

Contrary to how hospitals measure it now, success isn't discharging a patient alive; success is keeping people from needing to be admitted in the first place. 

Oh, sure, we're starting to use patient satisfaction scores (HCAHPS) to measure hospitals but I'm not convinced that either clinicians or administrators view them as much more than part of a "value-based" payment/ penalty. Then, again, hospitals historically haven't liked to be measured at all, aside from their bond rating or stock price.

All this is supposed to change through the advent of value-based purchasing and patient-centered care, but somehow I don't think hospitals are going to change without a fight. 

I enjoy reading articles about futuristic hospitals and hospital rooms, like those envisioned by Kaiser Permante, Patient Room 2020 or Swisslog.   The buildings tend to look like luxury hotels, with snazzy yet welcoming decor and furnishings.  The rooms are upscale as well, with high-tech yet comfortable beds, wireless monitoring, and rich patient entertainment options.  Maybe some robots.  It's all very exciting, but I can't help but thinking all this redesign is going to make our already too-expensive hospitals even more expensive.

Health care futurist Joe Flowers recently wrote a great piece about tech in health care that I think applies well here.  Everyone seems to agree that there is too much waste in health care, but Flowers notes that: "we have so much waste because we get paid for it."  Even more than that:

In an insurance-supported, fee-for-service system, we don't get paid to solve problems. We get paid to do stuff that might solve a problem. The more stuff we do, and the more complex the stuff we do, the more impressive the machines we use, the more we get paid.

Nowhere does that apply more than in hospitals.
 
What I would like to see is for a health system to do sort of a mortality and morbidity review committee on steroids.  I'd have them go through every patient, every admission, and do a deep dive on why the patient ended up in the hospital -- and what could have been done to avoid it.  That doesn't mean just the most immediate cause, but tracking each patient's health problem(s) way upstream to determine what, if any, earlier interventions could have avoided the need for an admission.

It's like zero-based budgeting for admissions. 

Instead of investing in further new, expensive technologies in the hospital, I'd then want the hospital invest in the infrastructure that would have prevented those admissions, or most of them.  We should declare a halt to the hospital facilities arms race, or at least change it to one funding outpatient/at-home solutions.  Hospitals should have the mindset that, instead of reaping lots of money for each admission, they owe someone -- maybe even the patient -- money if a patient ends up in a hospital bed.

That would get administrators' attention real fast.

Some quick examples of the kinds of things that can allow admissions to be avoided:

• The FDA just approved a blood pressure monitor that allows remote monitoring of patients with congestive heart failure.  Its maker, CardioMEMS, thinks it could benefit as many as a million patients a year.  It is expensive to implant, but would pay for itself by avoiding a single admission.  
• The ClearCell^® FX System from Clearbridge BioMedics that can track circulating tumor cells from blood tests, allowing much more real-time monitoring of the progression of cancers and avoiding more invasive and expensive tests.
• Samsung beat Apple to the punch by unveiling their digital health products that focus on health tracking through a variety of health trackers and a "data broker" for all the data generated.
• Even stodgy Intel is getting in the game, announcing their "smart wearable shirt" to track vitals associated with exercise.  Intel expects it to be the first of many.wearable monitors. 

I won't belabor the point, but the folks at MobiHealthNews just did an in-depth discussion of how patient-generated care is going to change not just how, when and where care is delivered, but how we think about care.  It is a brave new world, and hospitals are old school.

I just worry that the cost of all these new technologies end up being additive, as we tend to do in health care (see MIT researcher Jonathon Skinner's fine analysis The Costly Paradox of Health-Care Technology).  If we have all these big hospitals with lots of patient beds waiting to be filled and lots of expensive equipment waiting to be used, there's still going to be pressure to use them.  Hospitals are not buying all those physician practices just because they like doctors.


Dr. Kenneth Davis, the CEO and President of Mt. Sinai Health System, recently wrote that what we think of as hospitals have to become integrated delivery systems, featuring pro-active, community-based care and focused on population health management.  As he says, "instead of measuring hospitals by the number of beds filled with patients being treated for illnesses, the hospital of tomorrow will be judged more by its ability to maintain a community’s health."

Or as health architect Robin Guenther told the Pittsburgh Post-Gazette, "the days of hospitals being seen as islands of disease in an otherwise healthy city are over." 

Bravo.

Certainly there will always be some patients who need the intensive care and services only hospitals currently provide, but I'll bet that number can -- and should -- be a lot less than it is now.  I think that only comes when we start accepting that we've failed (most) patients if their health gets to the point they need to go to a hospital.  

It's not just hospitals, of course.  Physicians and other health care professionals have to move away from a mindset of treating unhealthy people -- usually with some sort of acute incident or concern -- to truly managing the health of the people in the community.

One sign of success may be when we stop using the term "patients," with its connotations of illness and of literally being patient for whatever health care professionals decide to do to them.  Shouldn't we just think of them as people?

The Myth of the Sovereign Consumer

The title of this post comes from a provocative article by Bruce Vladeck in a recent Health Affairs Web First edition focused on provider consolidation.  I'll get back to Dr. Vladeck shortly, but anyone who has been following my posts knows that provider consolidation has been a source of much concern to me (such as in Not Choosing Very Wisely), so the four articles in this HA edition were of much interest.

PwC just reported that M&A deal activity in the U.S. health sector rose 152% in Q1 2014.  That's not a typo.  Growth in M&A deals continues in most sectors of the health sector, not just hospitals, so this special HA edition was quite timely.

Paul Ginsburg and Gregory Pawlson's article takes it as a given that providers have been consolidating, are going to consolidate, and that, left unchecked, this would tend to raise prices.  They outline a fairly comprehensive list of potential strategies to deal with this impact.  They confess it is not clear that market approaches will succeed, and may require more direct government involvement, including direct regulation of payment rates, which they confess may not be politically easy nor clear-cut as to how to make effective.

Another article, from economist Martin Gaynor, reviews the issue of consolidation, some of the research on it, and the various ways that competition is regulated.  My big takeway from his article was his point that:

There is no federal competition policy entity for the economy overall, let alone specific to health care...Competition policy in health care is made by many different actors, at both the federal and state levels, and effective policy requires harmonizing their actions.

That's not going to make it easy to ensure we're regulating this in a desirable manner, especially not with the existing health sector's lobbying power I mentioned in Not Choosing Very Wisely.

A third article, from MD/JD Professor William Sage, suggests that the problem is not so much provider consolidation as it is "getting the product right."  He argues that much of our health care system isn't as competitive as it could be because a "..long history of regulation and subsidy has distorted prices, quality, and innovation."  He further posits that:

Because of regulations and subsidies, what pass for products in health care are often professional process steps that have uncertain value to patients. Instead, they serve the economic interests of physicians, hospitals, and other suppliers within an established administrative framework of health insurance.

Hard to argue. 

I love the phase "professional process steps" to describe what we are buying now.  Professor Sage notes, for example, that the entire CPT process is developed and owned by the AMA, illustrating that they have a certain vested interest in the status quo.  Rather than paying for these historically-based process steps, he urges development of more obvious competitive bundles that better reflect what consumers find valuable.  He doesn't spare health plans from his criticism either.    

I couldn't agree more that we've lost sight of the product in health care.  Furthermore, I suspect many health care professionals are aghast to think of health care as being a product of any sort.  Still, I'm not sure that even Dr. Sage is going deep enough in his proposed redefinition.

The fourth, and most fun, article was from Dr. Vladeck, who is always a good read.  He doesn't seem as worried about either provider consolidation or the ultimate need for government rate setting (although he acknowledges it is not politically likely).  He views the Sage and Ginsburg/Pawlson articles as being based too much on what he calls a "fundamentally obsolete conceptual model": the myth of the sovereign consumer. 

Dr. Vladeck seems skeptical of Sage's proposals to redefine the product, and sees consumers as being clearly worse off than twenty years ago, especially since:

...consumers are regularly inundated with self-serving or downright erroneous information from health insurers, providers, and entrepreneurs alike about health care services and their use that carries the implicit message that any illness or financial difficulty is essentially the fault of the consumer.

Huh?

Dr. Vladeck concludes that large payors, including the government, may be the best bet to control prices, but concludes that "instead of continuing to try to impose axiomatic and solipsistic theories on a reality to which they increasingly fail to apply, we need to figure out what kind of health care system we really want and how much we are prepared to pay for it."

I don't disagree with his conclusion, just most of what preceded it.



Chip Kahn, President of the Federation of American Hospitals, used the HA edition to post his thoughts on consolidation.  Not surprisingly, he's all for it, citing what he sees as the more ominous consolidation on the health plan side.  He points to what he calls the reality that proves consolidation is good: "price growth in health care generally, including hospitals, has been in a steady decline for years."

That's not that prices are going down, or that price growth for hospitals isn't happening, or isn't happening faster than in other parts of the economy -- just that they are not going up quite as fast as they once did.  The Milliman Medical Index just reported that it costs over $23,000 to cover a family of four in an average employer plan.  The rate of increase may be smaller, but the cost has doubled in the past ten years, and the rates of increase are still well above overall CPI. 

If this is victory, I don't think we can take too much more winning.



Neither Mr. Kahn nor Dr. Vladeck seem to credit a slowdown in the rate of increases to the last recession, or to changing consumer behavior due to increased cost-sharing and less confidence in their economic prospects.  In the health care world, people skipping or avoiding care is usually seen as a bad thing, even when many experts cite widespread unnecessary care.  They just want to be the ones deciding what is unnecessary, not the patients.

Which leads back to Dr. Vladeck's "myth of the sovereign consumer."  Yeah, I'd have to agree that the record is pretty poor about consumers taking good care of their own health, as witnessed by our declining exercise habits and increasing weight, both with the subsequent health consequences.  I'd also have to agree that the full impact of increased cost-sharing is, as yet, unclear -- it probably is causing consumers to seek less care, but it is uncertain about when that proves positive and when it proves short-sighted. 

At the end of the day, though, given a choice between having responsibility for my health or abdicating it to someone else, I'd rather have it, and I think most people would agree.  It's not that the "sovereign consumer" is a myth, it's that we haven't ever really tried it, not in our convoluted, paternalistic health care system.  We should give it a try; after all, it'd be hard to do much worse than we've been doing.

Frankly, in many ways, it is pointless to decry provider consolidation, because it is going to happen, just as it is happening in virtually every other sector of the economy.  I don't mind if provider systems are large or even vertically and horizontally integrated -- as long as I still have real choices, and those systems know consumers will avoid them if they don't focus on improving the quality of care and maintaining competitive prices. 

With evolving options like retail clinics, telemedicine or medical tourism, there's no reason consumers couldn't find great care outside the normal catchment areas, unless licensure restrictions or narrow networks doom us to settling for what happens to be close.  The FTC and other oversight bodies really need to be thinking outside the box about what is good for consumers.


The Commonwealth Fund is "searching for the next breakthrough in health care, by which they mean "an idea, a paradigm, a strategy that positively and profoundly disrupts the status quo."  Finding ways to truly empower consumers -- not just paying lip service to it -- may just be such an idea.

Breaking the Choice Habit?

Marcus Merz, the President and CEO of MN-based health plan PreferredOne, recently described his company's narrow network strategy to The New York Times by saying "we have to break people away from the choice habit that everyone has."

That may be the best quote I've read this week.  Maybe this month, or even this year.  By "best" I don't mean most insightful or most eloquent, but I do mean most memorable -- and maybe most misguided.

I have to wonder: if we're trying to make our health care system be more patient-centered, more consumer-driven, why in the world would we possibly want to break the choice habit?

I do not mean to pick on Mr. Mertz or on PreferredOne.  After all, they are hardly alone in pursuing a narrow network strategy, especially among exchange health plans.  And, hey, it worked for them, winning a larger-than-expected chunk of the Minnesota exchange market.  There has been extensive coverage of this trend over the past year, especially as it became clear that narrowing the networks was an integral part of health plans' exchange strategies, but the consumer and regulatory backlash is only beginning.

I mentioned narrow networks in my last post, and wrote a longer piece on it last fall (It's a Narrow World After All), and I didn't intend to revisit the topic quite so soon.  But, after all -- break people away from their choice habit?  That's hard to resist.

Last month CBO optimistically updated their ACA projections, citing in particular that "the plans being offered through the exchanges this year appear to have, in general, lower payment rates for providers, narrower networks of providers, and tighter management of their subscribers’ use of health care than employment-based plans do."  These restrictions helped lower their estimates of premiums for those plans.


Indeed, a Kaiser Family Foundation tracking poll found that, overall, consumers preferred higher premiums in return for broader access, but among the young, the lower income, and the previously uninsured, they were quite willing to give up such access.  Whether we like it or not, price can trump access, especially among people not getting much care already.

One way to think about narrow networks is to use the analogy of a restaurant which offers a buffet, and which decides to hold its prices by putting out fewer options.  If all you care about is getting some food, that might be all right.  If you are a gourmet and aren't worried about cost, you're probably not eating at the buffet anyway.  But if you are on a more restricted budget and have some critical food-related needs (perhaps peanut allergies, for example), then the restaurant cutting back on your options could have a big impact on your health.  It could mean life or death.

So it is with narrow networks.

Their advertising campaigns aside, no hospital is the best at everything.  No city -- or state, for that matter -- has all the best care.  So narrow networks are going to end up with some patients not being able to get the (in-network) care that is the best for their conditions.  Those patients might not have tried to find the best providers in any event, but for the ones who are that empowered, I hate that narrow networks make that decision more difficult.

Let's go back to the choice habit that Mr. Merz refers to.  The second part of his quote referred to consumers' "fixation on open access and broad networks."  That is, after all, the aftermath of the attempts in the 1990s to offer narrow, tightly managed networks (and, in the interest of full disclosure, I ran such a health plan at that time).  Big networks became virtually required for health plans, with few visible restrictions.  Mr. Merz is absolutely right in this regard.

But I think we're looking at the problem wrong if we think it is choice itself that is the problem.  The problem is lack of discerning choice.

According to Pew Research Center, only 17% of internet users consulted online reviews of physicians or other providers, and only 14% did so for hospitals.  The Altarum Institute similarly found that 27% used online quality ratings of physicians, but only 16% for cost information.

Many proponents claim that consumer-directed health plans will spur consumers to shop more effectively, but EBRI has found that people in CDHPs use quality information at about the same rate as those in other types of plans, and use cost information only slightly more.  Still, no more than one in three used this kind of objective data in their decisions, and usually not even that high.  They seem to be more likely to avoid care than to shop for it.

We've blundered our way into a system where we offer consumers broad networks, but with few incentives to pick the best or most cost-effective providers.  We've allowed consumers to think of health plan spending as OPM -- other people's money -- when, in fact, it is their own money and that of healthier people covered by the health plan.  We've persuaded consumers that they should pay as little as possible for their care, especially for preventive care. 

Yes, we've trained consumers to frequent in-network providers to an astonishing level -- often 90% or higher -- but have done a pitiful job of training them how to weigh potentially higher out-of-pocket costs against better health outcomes.  Even the many transparency solutions still focus mostly on differentiating in-network providers, not helping consumers search for the best match for them regardless of network participation status.

Now we're squeezing down the number of in-network options.  I suspect health plans and their regulators will work to ensure those networks provider adequate access, if access is measured by simple standards like distance to hospitals or to a certain number of physicians and other providers, but that's different from ensuring the highest quality providers are accessible.


Worse than that, consumers still often have no compelling reasons to question the value of some of the treatments they are receiving.  A new study in JAMA Internal Medicine found that up to 42% of Medicare beneficiaries may be getting services that they don't need.  The authors caution that these services only account for less than 3% of Medicare spending, but may also only be the tip of the iceberg.  And, of course, 3% of Medicare spending is still a lot of money. 

Think about a health plan that has identified a surgical practice and a health system that does, say, bypass surgery very cost-effectively.  They do enough procedures to have it all run very efficiently, and their outcomes are best-in-class.  The health plan negotiates a favorable bundled payment with them.  Now, why should they ever pay more to other surgeons or health systems? 

If it sounds like reference pricing, that's because it is.  EBRI recently did an analysis and concluded that we could save close to $10b by adopting reference pricing for just a handful of tests and procedures.  They refer to it as another form of defined contribution for health care, but at a more service-level approach than the movement by employers that puts workers in private exchanges which is also often considered defined contribution.

Reference pricing is still in an early stage of development and needs to have a lot of kinks worked out, not the least of which is getting consumers to approach it as empowering them rather than abandoning them.  Choice has consequences, including the possibility that some people will make bad choices or not want to have the responsibility.  Welcome to life.

I've written on the following idea before (20th Century Health Plans in the 21st Century), but I think we should scrape the idea of networks entirely -- and negotiated payment rates as well.  Health plans should be assisting consumers search for the best/most appropriate providers, and paying a market-based amount towards their care.  Consumers will have to make their own choices about out-of-pocket costs versus reputation, convenience or other factors. 

Narrow networks are a paternalistic approach to solving the wrong problem.  Instead of trying to manage costs by restricting consumers' access, let's instead open up that access and help them make smarter choices. 

It can't be any worse than what we've already tried.

Not Choosing Very Wisely

A new study by the ABIM Foundation -- the sponsors of the Choosing Wisely campaign that aims to reduce the incidence of unnecessary services -- found that nearly three-fourths of physicians think that unnecessary tests and procedures are a serious problem for our health care system, and about the same percent say the average physician orders those at least once a week.

No kidding.

The physicians seem to put a lot of the blame on patient demands, with 47% reporting they get such requests at least once a week.  The physicians overwhelming (87%) claim they always/almost always try to talk patients out of unnecessary tests, and that patients usually (70%) follow their advice, but most (53%) admit they likely would give in if a patient was insistent, even if the physician knew the test or procedure was unnecessary.  Given all those unnecessary ones that still happen, there must be a lot of insistent patients.

The tests and procedures may or may not have potential adverse health impacts on patients, but they certainly have cost implications.  Still, 57% of physicians reported talking about costs of tests and procedures half of the time or less.  19% never discuss costs at all, which was about the same as those who claim to always/almost always do so.  That's disappointing -- but not surprising.

The physicians do see themselves as being in the best position to address the problem of reducing unnecessary services (58%, compared to only 15% for the next highest party, the government), which leads one to wonder why they are not doing so already.

Maybe they're just not paying attention.  Heck, only 21% of the physicians have even heard about the Choosing Wisely initiative (at least unaided -- after being read a short description a whopping 38% thought they knew something about it).

I wrote about a similar issue a year ago (It Was Those Other Guys), when a JAMA study found that physicians cited everyone other than themselves for being responsible for rising costs.  There's a certain head-in-the-sand aspect of all this that I just have to shake my head at.  

Maybe handling demands for those unnecessary tests help explain results of another new study.  Guilherme Del Fiol and colleagues did a meta-analysis of studies that looked at clinical questions raised during patient care -- and found that clinicians only followed up on the questions only 51% of the time.  To be fair, when they did pursue the questions, they found answers 78% of the time, but I'll bet patients wouldn't be too happy if they knew it was only 50/50 (well, 51/49) that their clinician will follow-up on their own clinical questions.

I like to believe that the open questions were ones that, in the scheme of things, were just not considered important, rather than ones that simply fell through the cracks.  In any event, it makes me wish patients were more insistent about getting those questions answered instead of insisting on those pesky unneeded tests and procedures.


Dr. Del Fiol's study suggested that perhaps technology could help clinicians track and ensure follow-up on such questions, and I hope they're right.  Of course, a recent RAND report found that, while they like EHRs in principle, physicians are often dissatisfied with certain aspects, including the difficulty of data entry.  So I wouldn't hold my breath for better documentation of those clinical questions.

The unnecessary tests and open clinical questions certainly are a problem, but I fear we're making poor choices on a broader, more structural level that may haunt us for a long time.  A new study on market consolidation caught my attention due to its important (although unsurprising) results.  Laurence Baker and his Stanford colleagues found that hospital ownership of physician practices does increase hospital prices and spending.  Prices went up 2-3% for every time market share increased by one standard deviation.

The data for the study was from 2001-2007, and may not reflect "newer" strategies such as shared savings models, but still suggest that there is a difference between vertical integration designed to wring out supply chain savings (think Walmart or Amazon) and vertical integration aimed at knocking out competition.

Dr. Baker's study did find that some looser forms of integration, such as PHOs or IPAs, did not appear to have quite the same increase in spending, but those don't seem as preferred as outright acquisitions

This is not the first time these kind of results have been found (see, for example, last fall's Hospitals, Market Share and Consolidation by Cutler and Morton), but the results add to the warnings about what we're getting ourselves into with these acquisitions and other types of consolidation efforts.  I have to wonder why the community leaders -- including the board members of the non-profit health systems and the largest local purchasers -- are not raising harder questions about these consolidations. 

While economists are still studying the issue, health systems are busy acting: hospital mergers and acquisitions continue their dizzying pace, up 51% in 2013 relative to 2010.  Acquisition of physician practices also has continued.


The FTC is starting to wake up about the problem, especially if the health system in question is named St. Luke's (e.g., the Boise and Toledo cases).  As Deborah Feinstein, the director of the bureau of competition for the FTC, told The Washington Post, "We have seen, over the last couple of years, hospital-doctor combinations that are troubling to us.  And we are looking at it."

I feel better already.

I can't think about provider consolidation without thinking about ACOs.  One doesn't necessarily imply the other, but it'd be foolish to ignore the potential connection.  According to consulting firm Oliver Wyman, there are now 522 ACOs -- more than double a year ago -- which serve some 17% of all Americans.  Two-thirds of Americans live in an area served by an ACO, although only 40% live in an area served by two or more. 

For ACOs to be successful, they require partnership not only between hospitals and physicians, as well as other providers, but also between the ACO and payors.  They're not starting off on great footing for the latter.  ReviveHealth's 2014 Payor Survey found that on a scale of 0-100, hospitals' trust in payors scored 53.2, which would be an "F" in most grading situations.  The highest rated payor -- Cigna -- only scored 63.1, which is still at best a "D."

United Healthcare drew the lowest ratings on virtually every aspect, even though the Blues tended to pay even less.  The Blues were seen as most trusted by consumers and most honest in contract negotiations.

Despite the lack of trust for payors, hospitals are drinking the Kool-Aid about joining narrow networks, with 47% reporting they are already in the works to be in one and another 13% planning to do so.  They may be hoping they can consolidate their market enough so that they are the narrow network.

I've expressed my skepticism about narrow networks previously (It's a Narrow World After All).  They may appear less expensive in the short term but it's hard for me to believe that they are best for patients in the longer term.

With CMS pressing the accelerator for ACOs and FTC putting on the brakes for consolidation, many are wondering where federal government is driving the health system.  As Robert Field, a law and health policy professor at Drexel University in Philadelphia, told the Post, “The federal government has a schizophrenic attitude toward provider consolidation.”

Maybe schizophrenia explains why we're not making better choices.

Vive la Différence

I read with some interest a recent op-ed titled Nurses Are Not Doctors, largely because I was intrigued by the self-evident title.  The author (Sandeep Jauhar) is a physician, and he was lamenting New York legislation that will soon allow nurse practitioners to practice primary care without physician oversight.  As I read the piece, though, I couldn't help thinking of that French expression (which is usually used in a different context): vive la différence!

This particular battle has been fought -- and is still being fought -- across the country, resulting in a patchwork system where nurse practitioners have fairly full autonomy in some 17 states plus D.C., and varying degrees of restriction and physician oversight in others.  Physicians claim that patient safety would be jeopardized if they aren't overseeing nurse practitioners, while the nurse practitioners think they can handle most primary care situations just fine on their own, including prescribing.


It's interesting to me that nurse practitioners seem to be very active in trying to expand their scope of practice, while physician assistants appear to be taking a more subtle approach, agreeing to work as part of a physician-led team but happy to get broadly delegated authority.  And the desire to get a wider scope of practice is not limited to these two types; for example, pharmacists wouldn't mind getting ability to prescribe and possibly diagnose, as they can in some other countries.

Like most things, I suspect the truth is somewhere in the middle, although I confess I tilt more towards the NP's side.  The fight revolves around how to best increase issue of access to primary care.

Some of the facts are clear.  The U.S. has one of the lowest ratios of primary care physicians to specialists among the OECD countries.  The annual rate of visits is much higher for specialists than for primary care physicians, something that wasn't true even ten years ago.  And, of course, specialists make much more than primary care physicians -- almost twice as much on average, with some specialists making a lot more.

Surveys of medical school students' career intentions show continued low interest in primary care, which is not surprising not only because of the perceived lower income and worse work/life balance but also because residency slots are limited -- and often not even offered by larger and most prestigious hospitals.  Only about 30% of medical school graduates are filling primary care residency slots.

Some of the projections are slightly less clear, but still generally dire.  HRSA projects a shortage of 20,000 primary care physicians by 2020, while the American Association of Medical Colleges projects twice that.  In total, AAMC says there will be a shortage of some 91,500 physicians by 2020.

Not everyone agrees with these projections.  Physicians/policy wonks Scott Gottlieb and Ezekiel Emanuel proclaimed No, There Won't Be a Doctor Shortage.  They think we can get by through making physicians practice more effectively, and by expanding the scope of practice laws for nurse practitioners and pharmacists to help deliver primary care, along with making better use of technology.  It's the kind of thing Dr. Jauhar is opposed to.


There is evidence that nurse practitioners can provide care just fine, and more cost-effectively.  A 2013 study in The Journal of Nurse Practitioners (OK, perhaps not an unbiased source) surveyed the literature on NPs versus MDs and found outcomes the same or better for NPs.  In California, the Bay Area Council just released a study that claims expanding NP scope of practice could save $1.8b over 10 years while increasing use of preventive services. 

A survey done by Karen Donelan and colleagues and reported in NEJM found strong support among both physicians and nurse practitioners that the latter should be able "to practice to the full extent of their education and training," but they disagreed on most everything else, especially NP scope of practice.  Why am I not surprised?

As I read about physicians criticizing nurse practitioners' training, I keep wondering: why are only something like 80% of physicians board-certified?  It supposedly provides clear benefits, yet one-fifth of physicians don't have the advanced training their own specialty societies say they should have? 

This fight over scope of practice may usually be framed around patient safety, but it's about the money, of course.  Most physicians may not want to get into primary care themselves (and I can't resist noting that Dr. Jauhar is actually a cardiologist), but they don't want that money going to anyone else either.

If the physicians' argument is going to be patient safety, though, they're not starting with a very impressive record.  I've written on patient safety before (Patients Come Second) and on health care's often unfortunate culture (Health Care Culture Wars).  I wish I could say there were encouraging signs, but, if there are, I'm not seeing them.

The Commonwealth Fund's 2014 State Health System Scorecard found that "on a significant majority of measures, the story is mostly one of stagnation or decline. In most parts of the country, performance worsened on nearly as many measures as it improved."

Similarly, The Leapfrog Group's latest hospital safety score found only "incremental improvements," with (only) one-third of hospitals making improvements of 10% or more, and an overall improvement of only 6.3%.  Leah Booker, the President and CEO of the Leapfrog Group, was happy just to see any movement at all, which should be depressing. 



The supposedly self-policing state medical boards don't seem to be doing much policing (as I wrote about a few years ago).  Analysis of the recent Part B data released by CMS has already found numerous cases where physicians who lost their license in one state or were barred from state or federal programs continued to practice -- and collected millions from Medicare alone.  CBS News recently reported on the questionable (over)use of spinal fusions, including ones from physicians who had prior bad histories.  An investigation article by the Syracuse Post-Standard focused on the persistent problem of bad behavior by doctors, citing in particular the issue of a local surgeon who allegedly would slap sedated patients on their buttocks while also verbally insulting them. 

I am not making that last example up.

It's not that there are some bad doctors -- there are some bad members in every profession -- as it is that they are tolerated by their colleagues and coworkers, even long after it is clear their behavior is bad for patients.  Physicians protecting other physicians, even when incompetent, is sometimes called the "white coat of silence," and it is not acceptable. 

Perhaps once physicians get around to improving this kind of bad behavior and requiring the kind of practice-specific training for themselves that they say nurse practitioners should have, then I'll have more sympathy for their arguments.

We have kind of a Goldilocks situation.  Some people happen to get the right care from the provider best trained to provide it, while others get less than ideal care from providers who aren't trained to treat their condition -- and still others have trouble getting access to care at all.


We should be seeking to ensure access to the right care from the most appropriate providers, and worrying less about fitting certain kinds of providers into practice limits based more on historical precedents or cultural stereotypes than on competence or training.  It's about really making a patient-centered health system, not simply trying to maintain a physician-centered medical system.

No, nurses are not physicians.  Neither are nurse practitioners or physician assistants.  For that matter, though, internists are not cardiologists, and cardiologists aren't neurosurgeons.  Nor are physicians nutritionists or personal trainers.  Each type of professional brings their own set of skills and knowledge to helping patients, and we should celebrate and fully utilize those.  Vive la différence indeed!