Dr. Nurse? Why not just Doctor?

Get ready for Dr. Nurse, who will call himself/herself "Doctor," but who, after 4 year bachelor's degree in nursing, has gone to the Doctor of Nursing school for two years with a one year internship -- that's compared to the 4 years of college, 4 years of medical school, followed by at least 3 years of residency that Family Physicians, Pediatricians and Internal Medicine docs devote to training..

The Wall Street Journal reports (please let me know if you can't access this page) that the National Board of Medical Examiners will begin testing these "DrNP" candidates this fall.

From the Wall Street Journal:

As doctors face shrinking insurance reimbursements and rising malpractice-insurance costs, more medical students are forsaking primary care for specialty practices with higher incomes and more predictable hours. As a result, there could be a shortfall ranging from 85,000 to 200,000 primary-care physicians by 2020, according to various estimates.

So,the supposed reasoning behind the new doctorate is this shortage of primary care doctors. That shortage has been artificially encouraged by all sorts of federal interventions. For some reason, no one's considered paying Family Doctors more!

Instead, there are schemes to divide and re-divide the Medicare "Pie." There are the rural health clinics, which are paid more by Medicare and Medicaid than your local family doctor, pediatrician or internal medicine doc for seeing the same patients. In order to qualify, the clinic -- get the distinction, there, not the doctor, but who ever it is that owns the clinic and contracts with doctors and hires the rest of the staff - must hire at least one "mid level practitioner" to see patients. They can't hire a doctor to do the same work and/or for the same money -- they must hire a Physician Assistant or Nurse Practitioner.

As the article notes, the main reason for the loss of primary care physicians, however, is the low pay for the thinking part of what we do, compared to the procedures of specialists, such as all the varieties of surgeons, urologists, gynecologists and gastroenterologists. We analyze, examine and determine treatment or treatment change, resulting in "Evaluation and Management" visits. Rather than the codes used for procedures, the E&M visits are divided into levels of payment based on a set of check lists and diagnoses. The money from Medicare - followed closely by the insurance companies - has consistently shifted from the office visits toward the procedures.

Needless to say, the smart medical students -- or at least the ones more interested in money than in your family history, living arrangements and whether Junior ate his peas and carrots will become interventional sub-specialists, not a Family Physician or Pediatrician.

A few years ago, Medicare payments increased for home health agencies, which encouraged RN's and LVN's to leave the hospital. Medicare quit paying your family doc to "scrub in" with the general surgeon or orthopedist as an assistant during your gall bladder surgery, colon resection or hip replacement. But, they did pay the surgeon enough to justify the hiring of a nurse practitioner or physician assistant. And studies said there was no difference or even better outcomes, since the "team" worked better in the Operating room and the peri-surgery procedure became more efficient.

(Of course, the NP or PA won't be available to your wife or kids for questions next week, and won't watch the effect of your new level of activity on your blood pressure or diabetes. And your family doctor may no longer even know that she should, since she won't even find out about the surgery until your next visit or hospitalization. But that has nothing to do with the outcome of the surgery, right?)

The increase of Federal funding for Nurse Practitioners has exacerbated the loss of good RN's and LVN's - leading to more of the Federal pie going to nursing schools. And the DrNP will probably have the same effect. The WSJ article mentions the lack of faculty in the nursing schools. The funding will have to come out of the Medicare and Federal "pie."

However, what patients need to consider is whether the DrNP training can truly accomplish the same training in 3 years that our Medical Schools can do in 5 to 7 years. Some have said that mid levels can handle 80% of what doctors do.

It's that 20% that is the difference between knowing what you don't know and planning for the 2 AM crisis.

Medicare Pie Cut Thinner

Think of the money that Medicare pays doctors for seeing patients as though it's a pie called the "Sustainable Growth Rate." This pie is not going to get bigger unless Congress cooks some more pies by New Years. Otherwise, when more patients join Medicare and more pieces are needed next year, we will have to cut the pieces that doctors are paid each time we see a patient into smaller and smaller pieces.

I wimped out: I closed my office in 2003 because I saw the costs of the requirements for medical reporting and "privacy" coming and I figured that I could work part time for other people and make more money than I was making as a solo doc. (And I hate the business part of medicine.) I'm not sure how many others are making the same decision, but we often read about "boutique" practices and docs who won't take Medicare or new Medicare patients. Have you noticed how many doctors in your town are adding things like Botox shots, laser therapy and other cash-pay services?

Medicare will cut doctors' reimbursement by 10% in January if Congress doesn't act before the end of the year. This cut is separate from the Veterans Administration, Medicaid and SCHIP funding and is written into the current law. Since many doctors have contracts with insurance companies that pay based on Medicare, the cuts will go even deeper.

If you don't understand the impact that this cut will have, ask the next person you meet who is over 65 years old whether they had to change doctors when they became Medicare eligible. Ask them whether they have any choice other than to use Medicare and how hard it is to get in to see their doctor.

As I've said before, get ready for it to become even harder.

10 years ago, financial advisers told us that Family Physicians shouldn't have more than 20% of our patient population mix made up of Medicare patients if we wanted to stay in business. Since that time, most doctors have worked harder to be more efficient and have cut out any costs in the office that we don't need. My colleagues cannot afford a 10% cut in pay, while all of our costs continue to go up.

Primary care docs are paid about $160 per hour for office visits by Medicare. We are more likely to see the patients who have 5 or 6 diagnoses, 10 or 12 medicines to straighten out, and who bring in a family member to each visit. These patients take time. If the payment goes down to $155 per hour, most doctors will not be able to afford the cut.

In order to earn that money, we need the office and furniture, utilities, supplies for the patient room and office staff, at least a couple of staff members to check patients in and assist us, someone to answer the phones, those phones, refrigerators for medications, someone to handle the billing and banking, and all of the fees and insurance that normal businesses handle, like property taxes, slip and fall insurance, fire insurance, employee tax to the State, property tax on the building, furniture and supplies, and unemployment insurance, etc.


Then, we have malpractice insurance, professional dues to the County Medical Society and most likely our State and national AMA dues in order to remain "Board Certified," State licensing fees, DEA licenses from both the State and Federal systems, hazardous waste disposal fees, CLIA (office lab) fees, and the fees to keep our computer systems that are increasingly mandated by law if we want to be paid the full $160. The new electronic medical records can cost as much as $30-$40,000 per doctor up front and several hundreds to thousands per month.

In addition to these costs, Medicare requires the highest level of reporting, risk and red-tape. This year, there was a planned delay of payment from the Federal government for 2 weeks at the end of October built into the Federal budget to make it appear balanced. There were also unplanned delays when doctors began using the new National Provider Numbers phased in this year as part of the Medicare laws. (A lot of that expensive computer software in the office, at the insurance companies, and at the Center for Medicare and Medicaid Services couldn't handle the numbers.)

Now do you see why I hate business?

For more information and history, read this article or watch this video from the Texas Academy of Family Physicians.

Please consider calling your Representative to the House, your two State Senators, and the White House and ask them to protect Medicare payments to doctors.

Varied and deep rooted (cost of health care)

I'd just add a few observations to the New York Times editorial (free registration required) on the cost of health care in the US.

I'm a big proponent of making patients responsible for more of their health care costs. Health Savings Accounts, long term care insurance, and even deductibles are good ideas. I would also add that the vast majority of the people on Medicaid and public assistance could do some sort of public service work in payment for their health care. (Medicare, disability, and veteran's health care has been paid for already.)


I especially like the idea that primary care should be emphasized. How about *paying* doctors to do it instead of ensuring that we lose money for every Medicaid and Medicare patient we see?

And they don't mention some of the problems that I see:

1. Over the counter medicines that probably aren't needed in the first place and don't do what they are believed to do. Did anyone notice that the baby cold medicines are not useful and no longer standard of care? And please don't get me started on homeopathy - I'll irritate a couple of million of my readers if I go on about the useless idea that a substance diluted millions of times in water can't do anything.

2. Botox, cosmetic surgery, and beauty treatments - Do these services, when provided by a physician go into that giant number?

3. The hidden costs of school-based health care and the need for "notes" from doctors for school and work. I doubt that many people are aware of how much of Medicaid money is spent on "mainstreaming" and on learning disabilities in our school systems. I'm sure that few would understand the pressures that doctors face to provide the testing, medications, and follow up required to get mom back to work after the baby is too sick for daycare or school, for the note for the Tuesday patient who says they had food poisoning on Monday, or for the demand from a school or from the parents to get the 7 year old tested for a learning disability for all sorts of reasons.

4. Salaries and perks for insurance big wigs that could pay for the healthcare system of a couple of nations. United Healthcare, which threatens to swallow up every insurance company in the nation, has paid at least $120 Million dollars to its CEO for at least 10 years.

5. I don't want it to go away -- but -- Medicare pays for quite a bit of the research and medical education in the country. We need to see this research and the doctors, medicines and treatments that come from these funds as the valuable commodity they are and quit dinging "health care costs" for it.

Privacy, politics, and medical records

The editors and pseudoeditors of the American Journal of Bioethics blog are talking about all the people who accessed the hospital records of George Clooney after his motorcycle accident.

Somehow, according to the author of the post, it's all President Bush's fault.

In light of the news and comments on the latest iteration of SCHIP and Hillary Clinton's health care plan, I've been doing a little research. We ought to learn and remember the history of the privacy laws, the push for electronic records. But we certainly can't claim that the problem began in January 2001.

HIPAA began the whole electronic record push and originated in 1996. It's about anything but "privacy." See the records available on line, here.

The Privacy Rule, a later part of the Act (the Summary is 25 pages), specifically mandates full disclosure to the Secretary of Health and Human Services, or any agent of the Secretary, of all information in any facility that participates in any way (or ever hopes to do so) with Medicare. It also allowed those entities to make copies to take out of the office and to write their own subpoenas that need to be vetted by a judge after the fact. Attorney General Janet Reno advocated the use of the technology to track down Medicare fraud and abuse back in 2000.

The first big influences toward electronic medical records (EMR) and digital imaging are even older. Back in the late '80's, when I was in medical school, the Veterans Administration pioneered the EMR. (I used to practice diagnosing patients from their list of medications and procedures, the first elements of the record, before our notes could be entered.)In the early '90's, radiologists discovered the benefit of taking call from home while being able to read emergency head CT's and other images.

The electronic medical record and digital storage of images is a good thing - but like all tools needs to be used properly.

The whole coding and reporting of medical care has grown into the usual government "leviathan" (to use Ira Magaziner's defense to the lawsuit against him and Hillary Clinton for the unknown status of the consultants on their 1993 Health Care Task Force).

We still hope that the EMR will help us do better than we have in the past. Although I believe that most clinicians will disagree with the the "quality" markers used, see today's NEJM article about child health care.

However, I don't think that the incident involving Mr. Clooney's records proved anything about electronic records other than the hospital had the ability to monitor who accessed the records - and that human beings are curious about celebrities.

In the meantime, Texas seems to be volunteering to be a lab for privacy issues with the correlation of drivers, insurance, and cars as well as photographing and surveying the people who use US IH 35. Car 54 can run your license plate at a red light or while you're driving down the highway and then cite you if you're uninsured. My taxes should definitely go down if these tactics can be used to generate revenue.

More on Clinton Health Plan

After my review about some of the news coverage of Hillary Clinton's proposed government healthcare plan, I did some more digging. The Kaisernetwork.org review is here. A Wall Street Journal editorial is here.

The proposed Clinton plan mandates coverage and depends on 1/3 of its revenue from "$35 billion in savings to the government through a more efficient health system." (I wonder who will be considered less "efficient" - doctors or very sick patients?) And mandates that insurance premiums remain below a certain percentage of household income and that tax rates increase in households above $250,000.

All of which, the history of HMO's, capitated plans, and most especially government funding tells us, will result in restrictions in services, long waiting times, and less convenience combined with loud demands for more.

I know it seems a cliché, but how does government "efficiency" work at the Post Office? Fed-ex, UPS and DHL don't have nearly the restrictions medical care does: They charge according to weight, size and distance, but the customer and the recipient decide the contents of the package and the destination. I've never heard of Fed-Ex telling a customer that their package wasn't necessary or couldn't be moved because some Ph.D. (Doctor of Packing handling) had set a formulary - or that they'll take the package 100 miles and no farther. The biggest difference is convenience and the variety of options offered. Although they are able to compete financially and functionally with the US Postal Service, the lines aren't as long and the system is built to handle the unusual. The unusual is a large part of our business in Family Medicine.

The US First Class stamp is great for letters that don't need to be delivered for a day or two. Maybe the government should cover preventive health and let insurance cover sick people.

Mandates don't guarantee coverage. In Texas, we have to show our insurance card when we register the car, get our license renewed and each year when we have the car inspected. The uninsured rate is estimated to be around 24% (anywhere from 20 to 60%, according to the numbers of tickets issued in the big cities). In Colorado, it may be as high as 35%. (More here.) To compensate, Texas will soon begin correlating driver's licenses, car registration and insurance by a data bank accessible to the police car behind you in traffic. Wait 'till Bubba catches wind of this.


A little bit for everyone from the first dollar that cuts off above a certain level is dangerous. I know Medicare eligible patients who had great drug benefits through their retirement plans. They were forced to go to one of the "donut hole" plans, and now pay more out of pocket than before. We now have a good indication that the "donut hole" in the Medicare Part D drug plan leads to an increase in hospitalizations.

However, while researching all this, I did read about one plan that seemed to make sense to me. I've copied, pasted, and changed the name to "the Plan."

The Plan Gives All Americans The Same Tax Breaks For Health Insurance And Helps States Make Affordable Private Health Insurance Available To Their Citizens.

1. The Plan Will Help More Americans Afford Health Insurance By Reforming The Tax Code With A Standard Deduction For Health Insurance – Like The Standard Deduction For Dependents. The primary goal is to make health insurance more affordable, allowing more Americans to purchase coverage. The Plan levels the playing field for Americans who purchase health insurance on their own rather than through their employers, providing a substantial tax benefit for all those who now have health insurance purchased on the individual market. It also lowers taxes for all currently uninsured Americans who decide to purchase health insurance – making insurance more affordable and providing a significant incentive to all working Americans to purchase coverage, thereby reducing the number of uninsured Americans.

* Under the Plan, Families With Health Insurance Will Not Pay Income Or Payroll Taxes On The First $15,000 In Compensation And Singles Will Not Pay Income Or Payroll Taxes On The First $7,500.
o At the same time, health insurance would be considered taxable income. This is a change for those who now have health insurance through their jobs.
o The Plan will result in lower taxes for about 80 percent of employer-provided policies.
o Those with more generous policies (20 percent) will have the option to adjust their compensation to have lower premiums and higher wages to offset the tax change.

2. The Affordable Choices Initiative Will Help States Make Basic Private Health Insurance Available And Will Provide Additional Help To Americans Who Cannot Afford Insurance Or Who Have Persistently High Medical Expenses. For States that provide their citizens with access to basic, affordable private health insurance, the Plan's Affordable Choices Initiative will direct Federal funding to assist States in helping their poor and hard-to-insure citizens afford private insurance. By allocating current Federal health care funding more effectively, the Plan accomplishes this goal without creating a new Federal entitlement or new Federal spending.

There's no list of covered benefits, no mandates. However, each family would choose how much and what kind of coverage to buy. The current system of larger tax breaks to employers for more expensive health insurance and smaller breaks for less expensive coverage would disappear. Tax breaks for insurance would no longer be tied exclusively to a given job. Government subsidies would only be necessary for the indigent and those "hard-to-insure."

The plan was proposed by President Bush in his 2007 State of the Union address and is outlined here.

Government mandated healthcare is government-controlled healthcare

According to this article from the Associated Press, Hillary Clinton envisions a day when you will have to show proof of insurance to your employer prior to being hired for a job.

By BETH FOUHY, Associated Press Writer Tue Sep 18, 12:59 PM ET

WASHINGTON - Democrat Hillary Rodham Clinton said Tuesday that a mandate requiring every American to purchase health insurance was the only way to achieve universal health care but she rejected the notion of punitive measures to force individuals into the health care system.
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"At this point, we don't have anything punitive that we have proposed," the presidential candidate said in an interview with The Associated Press. "We're providing incentives and tax credits which we think will be very attractive to the vast majority of Americans."

She said she could envision a day when "you have to show proof to your employer that you're insured as a part of the job interview — like when your kid goes to school and has to show proof of vaccination," but said such details would be worked out through negotiations with Congress.

Coincidentally this month, we read about a man in the UK who is being refused surgery by National Health Service docs because he won't quit smoking - although he did cut back to 10 cigarettes a week. And there's the woman who was required to cover her hair or risk being turned away by an NHS dentist.

Here in the US, beginning in 1996, there was a push to punish Medicare recipients who went to docs who charged more that the Medicare allowable. As it is, docs have to "opt out" officially if they want to do a cash-only practice - cheaper or higher - and are not allowed to charge Medicare, Medicaid, or any Government insurance for at least 24 months. This pretty much locked all Medicare eligible patients into the system - they must see a doc who plays the ICD, CPT game or all procedures, hospitalizations will mean going to another physician who has not opted out.

However, back in 1997 and 1998, there were some opinions given by the Clinton administration that Medicare eligible patients were themselves breaking the law if they chose to go out side the system.

Of course, that was just at the time that the E&M codes and all the Uber-reporting rules came into force due to the Balanced Budget Act of 1997. Here's a page full of stories covering that period.


It was also about the time that the Office of the Inspector General started making armed raids on hospitals and Reno, Shalala, and Freeh held rallies in football stadiums to teach Medicare recipients to turn their docs and hospitals in for fraud and abuse and $1000 reward.

Medicare fees tied to reporting

"Pay for Performance" (P4P, sometimes called "Pay for Play" by some of us who aren't fond of the scheme) just got a huge boost from Congress. Expect to see more docs carrying computers equiped to run an "electronic medical record" (EMR) around the office.

And don't be surprised to see more solo and small group practices withdraw from participation with Medicare and insurance companies, merge with ever-bigger groups or close down completely as the docs find other ways to make a living.

The current lines of EMR cost $50,000 per doc or "provider" to start, and can cost $8000 or so each year for up keep. (I have no idea why, but that's what I hear.) And EMR's will be necessary in order to charge for the work that the doc does in the near future.

Initially, the scheme will measure the doc's ability to report data, more than any health benefits. From today's Wall Street Journal, subscription only:

This is clearest in Medicare, the federal health program that covers more than 40 million elderly and disabled people. Congress agreed to erase a scheduled reduction in payments to physicians, but it made a 1.5% bonus payment available only to physicians who report to Medicare how they perform on certain specified barometers of health-care quality. Initially, the payments will be based on whether the physician reports the data, but the system lays the groundwork for higher payments to better-performing physicians.

Among the information Medicare officials will collect: whether doctors provide aspirin and beta blockers to patients having heart attacks, and whether elderly patients are screened for their risk of falls. These practices are considered indicators of good patient care.