<p>
</p>
<p>Personally, I support the AMA in this - the curriculum of basically all of the NP programs I’ve looked at is an absolute joke. IMO, they shouldn’t even be practicing supervised, much less independently. The solution to the physician shortage is more physicians - there is no substitute for education/training.</p>
<p>Cardinal Fang I didn’t read all the links, but does it seem that the NP’s would prefer running their own business to working for groups or an MD? That would be interesting. The opposite seems to be happening with the MD’s.</p>
<p>In California the MD has to review 10 percent of the cases, usually at the NP or PA’s discretion. There Is also a rule about the physician being on site, but I don’t think anybody cares unless there Is a bad outcome, THEN they include the physician and her medmal in the suit.</p>
<p>I liked this comment on another forum, edited by yours truly.</p>
<p>"…The futile quest for perfection and the threat of lawsuits for anything less have driven medical training to be far longer and more expensive than necessary…The reality is that probably 90% of primary care …complaints that will get better on their own…It doesn’t take 7-8 years of post-collegiate training to take care of those…Most pts need nothing more than reassurance and somebody to talk to for a while…most physicians MUST charge too much for such services to cover their own costs, thus family practitioners are being priced out of the market and being replaced by NPs and PAs. Pediatricians don’t have that problem because they already earn so little …"</p>
<p>Of course, none of this applies to folks frequenting CC. :D</p>
<p>Good morning. CF, I realize the fact that I resonated with the idea that outcomes are patient influenced doesn’t mean it entirely explains disparities. I do think it can influence disparities. (eg my friend had this procedure and it worked…I want this procedure…) Obviously, the physician’s influence and predilection to perform a procedure is a heavily weighted variable too 
And in some cases, availability of the procedure or related specialist will also make a big difference. As they say, everything looks like a nail if you have a hammer (and economic motivation to use it.) I take it, CF, your working theory is that a big golden hammer is driving the regional disparities I don’t know that I would disagree that forms a big part of it, but I’d sure like to see someone research this to figure out the dynamic!</p>
<p>With respect to Lergnom’s reference to the study where the US is ranked 46th out of 48th, I suspect the ordering was heavily skewed by the per capita spend, which as I mentioned before is almost double that of some countries with similar and better outcomes in terms of mortality.</p>
<p>Since ACA does not appear to be quite truly universal nor single payer in impact, I’m not certain that rank will necessarily be improved in the short term…though it may if access is a key to extending mortality, and it may through increased transparency, admin caps, and review guidance on procedural efficacy and cost. It will be interesting to see if that rank moves in a few years.</p>
<p>CF (and anyone else who does it,) do you not see how you generalize? I don’t know where you are, but our NPs (and a PA) are scheduled based on either what appt slot is available or we can request one of them. And, often we do. They are highly competent. It was the NP who knew I needed to be sent immediately to ER. I don’t see any such thing as them being focused on “some poor people” or any reason to imply their care is subpar or even lesser.</p>
<p>Texas, we had an NP at the pediatrician’s and she was super.</p>
<p>I also have a friend training now to become a PA- arduous few years while she made up for missing science classes, now into a multi-year training program. Highly committed.</p>
<p>Is there some thought going around that all visits are so complex that seeing the NP or PA is being shunted down the chain?</p>
<p>When I am paying for a doctor and I expect to see one. Nothing that anyone here tells me will change my mind. I rarely visit the doctors and so I have no reason to develop a rapport with someone who might be equally competent who works for them. </p>
<p>As they say on CC, YMMV.</p>
<p>I am paying for access to the right medical competence, advice, care and oversight. Not everything requires the doctor. It depends.</p>
<p>You seem to have an interesting situation, texas. On one hand, you want the doc. On the other, you imply you disregarded some advice re ulcers or GERD. On another thread, I think it was you I argued with, that docs do not have strict procedures to follow, for each and every med situation out there.</p>
<p>A lot of our care starts with standard parts of an exam. Understanding normal vs abnormal initial findings (how do your lungs sound? does your liver appear to be enlarged? These are not based on visually inspecting the organ.) A lot is intuitive, putting the pieces together. </p>
<p>We let moms decide if they want to try chicken soup first. We look at what Dr Google has to say. Sometimes, in a practice, if you can’t see Dr X, they will fit you in with Dr Y. I am confident of the medical practice we use.</p>
<p>
</p>
<p>Excuse me? Did you mean to aim that comment at texaspg, who said, “I don’t think they bill any less for an NP and so it begs the question - are they trying to push lower trained people on poorer people because Medicaid reimbursements might be lower?” I was trying to refute that by pointing out that my non-poor area has NPs.</p>
<p>Shrinkrap, yes, the NPs want to be able to practice independently, but the AMA supports legislation that forces NPs to work under the supervision of a doctor.</p>
<p>
</p>
<p>I’m not sure what Shrinkrap’s interlocutor wanted me to take away from this. It sounds like the writer wants physicians to handle minor problems and be able to charge a lot of money for them, even though the minor problems could perfectly well be handled by an NP who could charge less.</p>
<p>But what I do take away from it is that there are many many minor medical problems that don’t need a physician, but do need medical attention and personal, reassuring attention from a professional. After all, the problem most likely will get better by itself, but the patient doesn’t know that, and some problems don’t get better by themselves.</p>
<p>But, mysteriously, even though </p>
<ul>
<li>these simple medical problems could be handled by an NP, and </li>
<li>that would free up MDs for more complex problems that needed their training, and </li>
<li>some MDs don’t even want to handle minor problems,</li>
<li>right now we don’t have enough MDs to handle both the routine problems and the complex problems</li>
</ul>
<p>the AMA vigorously opposes letting NPs practice independently.</p>
<p>
</p>
<p>That’s not my working theory about practice variation, because that doesn’t explain variation. If I thought that doctors were just greedy jerks out for all they could get, then how would I explain that doctors in one place do twice, three times, four times as many of some kind of elective surgery than doctors in another place? If doctors are all greedy, why aren’t they all doing those elective surgeries at those rates.</p>
<p>No, when I talk about doctor fashion, that’s really what I mean. Doctors in one area develop a group consensus about when surgery is necessary. And that’s why I want more enforcement of science-based guidelines, and less “clinical judgement” that is actually ill-informed groupthink.</p>
<p>The big golden hammer is also present, though. I’d prohibit doctors from having ownership in free-standing surgical centers, because when doctors own those centers, surgery rates skyrocket. Somehow, sending a patient for surgery looks more appropriate if you own the facility where the patient would get the surgery.</p>
<p>I have not been impressed by the nurse practitioners that I have seen. There has also been a doctor that I was unimpressed by, and I immediately stopped going to her. But when I want to see the doctor that I like and am familiar with, and that my insurance company is going to pay hundreds of dollars for a quick visit to, I don’t want to see a nurse practitioner. I’m sure there are great ones that people prefer seeing often, though, but not me.</p>
<p>The current practice I go to doesn’t even ask you if you want to see a NP.</p>
<p>CF; I looked up interlocutor, and I still don’t understand. </p>
<p>I think the point being made in what I copy and pasted is that your approach sort of makes sense; NP’s can do as much hand holding and watchful waiting as MD’s, they cost less, and folks feel they spend more time. </p>
<p>I think most MD’s in agreement there, that is why they are willing to “supervise” NP’s in their practices. True; some MD’s worry, perhaps without justification, that the NP might not know what she does not know, and some feel they order more tests and make more referrals to specialists. There is also research says they get sued just as much, and the payouts are higher, but that could be because a lot practice in high risk settings like anesthesia. Of course, all of that could be AMA lies, and I will not debate that here. </p>
<p>My experience here is, that NP’s do not have private practices in Californai, but the seem to practice pretty independantly. Folks don’t know that they are not doctors, they have there own “panels”, write scrips. I am not sure if they can do disability paperwork or take folks off work, and that’s where it gets tricky. As far as I know, the use the same billing codes ; 99211,99213,99214,and all of use get reimbusred based on the comlexity of the medical decision making. I don’t know if the reimbursement is lower when NP’s code the same as MD’s. I know Psychologist, Psychiatrist, LCSW’s and MFT’s are often offered the same rates for providing therapy. I seem to recall one company gives me an extra $5.00 if I do therapy with meds. </p>
<p>My question to you is; what is not to like about the way they practice here? Is it that they want to set up private practices? If so, that would be interesting, since most of the physicians around here seem to be bailing on that.</p>
<p>A NP scared me to death when I saw her last year. I was so concerned that I immediately made an appointment with the doctor. My husband even came to the appointment with me. The doctor, in so many words, said the NP was wrong and there was nothing to worry about. So from now on, I will insist on seeing the doctor.</p>
<p>What’s not to like is that NPs want to be able set up private practices, but they can’t, because of legislation vigorously supported by the AMA. They find it degrading to be told they can’t practice independently. </p>
<p>And it’s a little condescending to say to NPs, Oh, don’t worry your pretty little heads about independent practices; we doctors have discovered that we don’t want to practice independently any more, so it’s perfectly fine that we’ve made it illegal for you to practice independently.</p>
<p>(Interlocutor just means the person with whom you’ve been having a conversation, or a participant in a discussion. It was meant as a neutral term.)</p>
<p>Hmm. One NP makes a mistake and you conclude all NPs are incompetent and should be avoided. Are you sure you made the right generalization here? Was the NP short? Perhaps short people are incompetent. Was the NP female? Maybe all women medical professionals are incompetent. Was the NP black, Indian, Hispanic, Polish, Methodist? Maybe black/Indian/Hispanic/Polish/Methodist medical practitioners are to be avoided. Hey, maybe it was the school where the NP got their degree-- everyone from that school is a dope who knows nothing.</p>
<p>Or, y’know, maybe you shouldn’t generalize on the basis of one example.</p>
<p>I just read about a grocery store chain closing one of its under performing stores. The full time workers had a choice of being laid off or working part time at other stores. The part time workers were guaranteed part time jobs at other stores. </p>
<p>I was looking at a government website for jobs. One job after the next was for 29 hours. </p>
<p>The ACA is forcing full time workers to become part time workers. Sad. Very sad.</p>
<p>I see; it’s degrading. Okay, thanks. </p>
<p>“And it’s a little condescending to say to NPs, Oh, don’t worry your pretty little heads about independent practices; we doctors have discovered that we don’t want to practice independently any more, so it’s perfectly fine that we’ve made it illegal for you to practice independently”</p>
<p>I feel like I was asking a legitimate question, and you are being hostile. “Pretty little head”? Seriously? You are saying “we’ve” made it illegal, when maybe 10 percent of doctors are in the AMA, and most don’t feel “they” represent “us”. You might know better, since you seem to follow the AMA closely. </p>
<p>I am also asking because while am still trying to practice independantly, while NP’s around here work for groups, get benefits, and some make more than I do, and more than any pediatrican who try’s to make a go of it in private practice without them. Perhaps that is part of what is “degrading”. </p>
<p>I don’t think I begrudge them, but I want to understand what’s not to like. I told my kids if they wanted to go into medicine, NP or PA was the way to go.</p>
<p>Just got off the phone with my insurance broker…</p>
<p>As of right now, CA. has not published exchange rates. CA has not identified any specific plans, nor obviously signed any contracts with any health insurance companies. Guaranteed/promised/mandated roll is about 40 days away! The rumor mill says CA will ask for an extension on exchange implementation. </p>
<p>Oregon has already asked for an extension and will not have the exchanges up by October 1st.</p>
<p>So, ‘they’ have had 2 years to implement this plan…and yet here we are.</p>
<p>Also…the catastrophically large loophole regarding the penalty is still not closed. As it stands, one can drop their insurance (or never buy it to begin with), incur a penalty (which the IRS levies but has not authority to collect)…wait until insurance is needed for something costing more than the premiums(for those who had previous insurance) and then run to the exchange and buy a plan.</p>
<p>OUCH!</p>
<p>Shrinkrap, I’m sorry. On rereading my post, I see that it was unnecessarily snarky. I apologize.</p>
<p>And actually I do know that the AMA doesn’t reflect the views of all doctors. But I only learned that recently; it’s not commonly known. The AMA represents itself as a voice for doctors. If the majority of doctors disagree with its position, there’s no way to for a layman to know that. Legislation to allow other medical professionals to practice independently is defeated because of lobbying of groups who say they represent doctors.</p>
<p>
</p>
<p>Incorrect. The $63 fee that busdriver has complained about goes to the subsidies.</p>
<p>
</p>
<p>So, so incorrect. But we all knew that.</p>