5 ms·

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,

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.

plucas 5y ago
This is a mischaracterization of P.A.s (well, not the being-paid-less bit). Do you know any personally?
- SkyPuncher 5y ago
  He's exaggerating significantly, but the core point is true. pAs and NPs will be the future of hospital care.
- jac241 5y ago
  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.
RHSeeger 5y ago
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.
- jac241 5y ago
  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-nursing/direct-entry-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/dnp-adult-acute/index.html 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 https://i.imgur.com/Cj5z4f8.jpg
  - nradov 5y ago
    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?
    - RHSeeger 5y ago
      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.
      - naijaboiler 5y ago
        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.
    - jac241 5y ago
      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 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 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/ 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/ 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 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/fullarticle/1939374 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 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)00732-5/abstract 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/ https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/
lotsofpulp 5y ago
>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.
colinmhayes 5y ago
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.
- lotsofpulp 5y ago
  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-value-based-payment-is-also-about-provider-flexibility/ https://www.chcs.org/its-not-just-risk-why-the-shift-to-valu...
  - colinmhayes 5y ago
    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.
    - lotsofpulp 5y ago
      Oh, thanks for the clarification. I thought they were not compatible.

plucas 5y ago

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

SkyPuncher 5y ago
He's exaggerating significantly, but the core point is true. pAs and NPs will be the future of hospital care.
jac241 5y ago
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.

RHSeeger 5y ago

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.

jac241 5y ago
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-nursing/direct-entry-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/dnp-adult-acute/index.html 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 https://i.imgur.com/Cj5z4f8.jpg
- nradov 5y ago
  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?
  - RHSeeger 5y ago
    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.
    - naijaboiler 5y ago
      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.
  - jac241 5y ago
    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 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 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/ 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/ 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 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/fullarticle/1939374 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 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)00732-5/abstract 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/ https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/

lotsofpulp 5y ago

>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.

colinmhayes 5y ago

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.

lotsofpulp 5y ago
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-value-based-payment-is-also-about-provider-flexibility/ https://www.chcs.org/its-not-just-risk-why-the-shift-to-valu...
- colinmhayes 5y ago
  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.
  - lotsofpulp 5y ago
    Oh, thanks for the clarification. I thought they were not compatible.