5 ms·

I'm a bit disturbed and/or upset about the way licensing issues in the US are often covered. Typically you see an article like this, in a news outlet that's aim

I'm a bit disturbed and/or upset about the way licensing issues in the US are often covered. Typically you see an article like this, in a news outlet that's aiming for financially motivated and/or well-off individuals, complaining about licensing for beauticians and doing a hand-wavy thing about medical professionals. The argument is "beauticians don't need licenses but all this other stuff is fine." The problem with this is while it's true that beauticians don't cause the same damage as a medical provider (usually), they also don't have the same financial impact on the US economy as a whole. We don't hear people complaining about haircut costs, we hear people complaining about healthcare and higher education costs. When it does get discussed, it seems like those discussions are always targeting those who threaten the status quo, and there's very little discussion of underlying issues. So for example, you have pieces complaining about NP or PAs replacing doctors in clinics, ignoring the fact that it's not the NP or PA degrees necessarily, it's that you're taking people out of a 2 year program and putting them directly into practice with no residency or training program. Similar things play out with other provider types, where there's a lot of FUD and playing on stereotypes without discussing actual training backgrounds encountered within degrees, or the requirements that are actually necessary to complete tasks. If you look at current MD programs, many of them are pushing hard to go to a 1.5 year coursework, 2.5 year clinical training model, followed by residency. Compare that to a PA program that is what? 1.5 years of coursework followed by clinical training. Many PA programs now also require licensed healthcare practice before you even enter the program too. So it's really hard for me to accept the argument that PAs + 6 years of supervised training aren't similar to an MD + 4 years of supervised training. You can extend this to all sorts of aspects of the medical system. Many medications that are now prescribed really don't actually require prescriptions, especially some of those that someone has been taking for years. Others could be overseen by a pharmacist (probably better in many cases than a physician), or a psychologist, dentist, or optometrist with the right additional training. The idea that provider skills in a given area are only ever possibly obtained by the MD degree model is preposterous to me. Sure, there are probably some domains where this is currently true, but there's a lot of domains where it's not. These discussions need to stop treating healthcare as if licensing is a totally different issue there — although it is probably in terms of risks but also in terms of costs, the fundamental problems are the same. I could go on and on. Even among MDs, the specialty and subspecialty accreditation requirements can be grossly excessive and unnecessary. Conversely, there's also the fact that MDs sometimes are making decisions that they're not actually trained to deal with because their degree gives them a kind of blanket legal authority. Everyone has anecdotes about poor care, but I can say the same just about any type of provider I've had contact with. I can think of grossly irresponsible care that I've had from physicians, where we've been saved in a sense by PAs, RNs, or NPs. I can also think of cases where the MDs were great, and the PAs, RNs, and NPs didn't know what they were talking about. Healthcare licensing is a complete mess and it is a major unrecognized source of increased healthcare costs. Even with all of the push to deregulate, I don't see it being addressed effectively anytime soon because the discussion gets so distorted and because it often feels like the way it bubbles up into public consciousness is through bad actors leveraging deregulation for undesirable reasons.

sarchertech 2y ago
An MD or DO has 12-16k clinical hours when the finish training. That is very regulated closely supervised training. An NP can finish training with 500-750 hours and a PA with 2000. And that training is nowhere near equivalent to resident training because NPs and PAs are handed the lower acuity and less complex patients. In the NP case there is also very little oversight over the kind of training they receive, so the quality is extremely variable (much more so than resident training). After training the NP or PA could go on to work at minute clinic where they have almost zero direct supervision. Or they could go work at a doctor’s office where they handle low acuity and less complex patients. After 6 years of running strep tests and overprescribing antibiotics in a minute clinic, they are by no means equivalent to an MD. Residency is an intense 3-7 year 80-100 hour a week training program that includes academic components. In addition to being closely supervised, attendants are actively teaching them. They frequently go to lectures and have homework to complete. Residents are routinely evaluated by dozens of doctors and have to make significant progress or they are forced to repeat some or all of it. This is far more rigorous than “you showed up for work for 6 years and didn’t get fired.” 6 years working as an NP or PA is just not equivalent. To replace this, you’d need to force them to have a similar residency program. Then you need to look at the scores of the average person coming into PA or NP programs vs MD or DO programs. And finally at the material covered. It is not equivalent. And it shouldn’t be. They do different jobs. There are certainly long practicing PAs and NPs that have equivalent medical knowledge to many even most MDs. But the only way to ensure that this is the case is to add a structured mandatory residency requirement, and increase the amount of information taught, and the number clinical hours during the program. If you do this, you’ve just recreated an MD program for no real reason. Physicians salaries only make up 8.5% of healthcare spending. Even if you somehow manage to figure out a way to train NPs and PAs to completely replace doctors at half the salary, you’re telling a 4% reduction in spending. That’s a rounding error that will just end up being absorbed by the hedge funds that own the clinics, hospitals, and physicians groups. Another thing worth noting is that when NPs and PAs start practicing independently their malpractice insurance premiums go way up, further down eating into the small savings you’ve made.
- derbOac 2y ago
  >If you do this, you’ve just recreated an MD program for no real reason. If there was a dramatic increase in the number of medical schools, I'd see no reason maybe. But I think flexibility of educational tracks is another. My point is these are the kinds of discussions that need to happen. And it's also important to keep in mind the question of whether or not X training in Y field is actually necessary or if it's unnecessary overhead. We assume a certain educational model is necessary for safety but that's not clear at all, especially as you get into specialties. As some have pointed out, current residency practices might even decrease patient safety in a lot of ways. Arguments about curriculum rigor also seem questionable to me if you consider, eg all the foreign medical school graduates and DO graduates practicing just fine. I'm not trying to cast aspersions on them, just they also tend to have lower scores etc and have long respectable practices. >Physicians salaries only make up 8.5% of healthcare spending. For what it's worth I don't think it's the salaries per se, it's the cost multipliers due to lack of options. I think NPs and PAs are just one example. The question is, if other service provision models were adopted, how would it decrease service costs? I don't think it's possible to extrapolate costs of service from physician salaries in this model to costs of service in a different model. Let's say eg you required vaccines to be administered by a physician. There would be huge costs associated with that that wouldn't be represented by salaries alone. There would be delivery bottlenecks that could be leveraged by unscrupulous actors, an increase in price solely due to bottlenecks and so forth. And that's not even getting into patient satisfaction due to increased choice, that might not be reflected in costs at all. Also it's important to clarify I am not in favor of private equity run care, and in fact would prefer (single payer) public health care provided for all citizens. I just think there's a lot that more types of providers could be providing now.

sarchertech 2y ago

An MD or DO has 12-16k clinical hours when the finish training. That is very regulated closely supervised training. An NP can finish training with 500-750 hours and a PA with 2000. And that training is nowhere near equivalent to resident training because NPs and PAs are handed the lower acuity and less complex patients. In the NP case there is also very little oversight over the kind of training they receive, so the quality is extremely variable (much more so than resident training). After training the NP or PA could go on to work at minute clinic where they have almost zero direct supervision. Or they could go work at a doctor’s office where they handle low acuity and less complex patients. After 6 years of running strep tests and overprescribing antibiotics in a minute clinic, they are by no means equivalent to an MD. Residency is an intense 3-7 year 80-100 hour a week training program that includes academic components. In addition to being closely supervised, attendants are actively teaching them. They frequently go to lectures and have homework to complete. Residents are routinely evaluated by dozens of doctors and have to make significant progress or they are forced to repeat some or all of it. This is far more rigorous than “you showed up for work for 6 years and didn’t get fired.” 6 years working as an NP or PA is just not equivalent. To replace this, you’d need to force them to have a similar residency program. Then you need to look at the scores of the average person coming into PA or NP programs vs MD or DO programs. And finally at the material covered. It is not equivalent. And it shouldn’t be. They do different jobs. There are certainly long practicing PAs and NPs that have equivalent medical knowledge to many even most MDs. But the only way to ensure that this is the case is to add a structured mandatory residency requirement, and increase the amount of information taught, and the number clinical hours during the program. If you do this, you’ve just recreated an MD program for no real reason. Physicians salaries only make up 8.5% of healthcare spending. Even if you somehow manage to figure out a way to train NPs and PAs to completely replace doctors at half the salary, you’re telling a 4% reduction in spending. That’s a rounding error that will just end up being absorbed by the hedge funds that own the clinics, hospitals, and physicians groups. Another thing worth noting is that when NPs and PAs start practicing independently their malpractice insurance premiums go way up, further down eating into the small savings you’ve made.

derbOac 2y ago
>If you do this, you’ve just recreated an MD program for no real reason. If there was a dramatic increase in the number of medical schools, I'd see no reason maybe. But I think flexibility of educational tracks is another. My point is these are the kinds of discussions that need to happen. And it's also important to keep in mind the question of whether or not X training in Y field is actually necessary or if it's unnecessary overhead. We assume a certain educational model is necessary for safety but that's not clear at all, especially as you get into specialties. As some have pointed out, current residency practices might even decrease patient safety in a lot of ways. Arguments about curriculum rigor also seem questionable to me if you consider, eg all the foreign medical school graduates and DO graduates practicing just fine. I'm not trying to cast aspersions on them, just they also tend to have lower scores etc and have long respectable practices. >Physicians salaries only make up 8.5% of healthcare spending. For what it's worth I don't think it's the salaries per se, it's the cost multipliers due to lack of options. I think NPs and PAs are just one example. The question is, if other service provision models were adopted, how would it decrease service costs? I don't think it's possible to extrapolate costs of service from physician salaries in this model to costs of service in a different model. Let's say eg you required vaccines to be administered by a physician. There would be huge costs associated with that that wouldn't be represented by salaries alone. There would be delivery bottlenecks that could be leveraged by unscrupulous actors, an increase in price solely due to bottlenecks and so forth. And that's not even getting into patient satisfaction due to increased choice, that might not be reflected in costs at all. Also it's important to clarify I am not in favor of private equity run care, and in fact would prefer (single payer) public health care provided for all citizens. I just think there's a lot that more types of providers could be providing now.