Freedom of Choice

[MOHS_01]

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No, honey, sweet pea is a term of endearment. Dismissing your argument by calling you a stupid **** would be an ad hom. 😀

I hope that you realize you are now drawing things into the discussion that previously only existed in your head.... and Atul G was properly named.... sensationalist propagandizing **** that he is.

 

[MOHS_01]

(But to be fair, I am watching something in Russian, so my English may be a bit more liquid-ey than normal.)

OK -- are you one of those hot Russian babes like on Dancing with the Stars? If so, I take everything back (other than the sweet pea comment)... you can say whatever you wish... and make it look good. 😀

Look it up on Wikipedia

Go Wiki -- FTW!!!!1!!1!!

Then why are state boards and insurance companies so focused on protocols? Why do most state courts have different burden of proof standards for off-label use than FDA approved uses? It's because, legally, it implies misuse.

Again with the poor understanding.... they do it for the very same reason a similar pattern can be found in a variety of fields/sectors -- out of simplicity and/or lack of appropriate knowledge. Why are things simplified in entry level textbooks? Again, for the very same reason -- it is logistically impossible to outline a nuanced approach to complex subjects irreconcilable with yes/no/either/or decision trees.

 

[ReineAshe]

are you one of those hot Russian babes like on Dancing with the Stars?

Don't watch that, so I can't say. Think Milla Jovovich c. 1999. 😉

I hope that you realize you are now drawing things into the discussion that previously only existed in your head.... and Atul G was properly named.... sensationalist propagandizing **** that he is.

🙄

No -- I just know that my Westlaw subscription is, well, a subscription, so I can't link to it.

Again with the poor understanding.... they do it for the very same reason a similar pattern can be found in a variety of fields/sectors -- out of simplicity and/or lack of appropriate knowledge. Why are things simplified in entry level textbooks? Again, for the very same reason -- it is logistically impossible to outline a nuanced approach to complex subjects irreconcilable with yes/no/either/or decision trees.

(1) This has nothing to do with textbooks. Before landing my current bioinformatics gig, I worked for a health law professor.

(2) Unlike medical textbooks, legal casebooks are completely useless.

(3) This is a bit of a strawman.

Re-read my sentence. I didn't say "It is misuse because the burden of proof is on the defence." That would have been a poor understanding due to simplicity and/or lack of knowledge. What I said was "Then why are state boards and insurance companies so focused on protocols? Why do most state courts have different burden of proof standards for off-label use than FDA approved uses? It's because, legally, it implies misuse."

Yes, I know insurers go through a complex CBA risk analysis before requiring their nurses to follow protocols. Yes, I know there are 50 states, plus all of the federal courts applying state law. But restating that would be too much. What I said covers the bases at the correct level of sophistication. It's not automatically misuse in every state -- it's more like a rebuttable presumption in a lot of states.

 

[countingdays]

Who said anything about trying to minimize education? Who said anything about me being an NP or PA?

This thread is about NPs and PAs and patients 'right to choose' them. It is not about ReineAshe and what you read on wikipedia and in Time magazine or JAMA or other rags.

It isn't a straw man argument to argue against a common view amongst NPs and PAs. You think my argument is a straw man because it may not be an argument you make, but it is an argument that nurses make. THIS THREAD IS NOT ABOUT YOU! I could not care less what you think.

PAs have less medical training than MDs. NPs have less MEDICAL training than PAs.

It's true that more training is not always beneficial or necessary. You have to draw the line somewhere or no one would ever finish training, but a trend toward allowing independent practice by lesser and lesser trained individuals reflects poorly on those pushing for lower educational requirements. They don't do so to help patients. They do so to help themselves. It's up to the medical profession to determine the entrance requirements to our profession. It's not for the nursing lobby to bribe their way in using the government.

 

[Stitch]

From a health care policy perspective, med malpractive was effectively America's social safety net. From the average patient's perspective it is now, for all intents and purposes, gone. This is particularly true for drugs. So the more media covers the relationship between docs and Big Pharma, the worse physicians look, particularly for me-too drugs and certain off-label uses. By contrast, NPs and PAs are going to look rosy.

What are you even talking about here? Do you have any hard facts/links to back up this claim at all? Just going to lawyers and settlements, you can see a huge number of drugs which (rightly or wrongly) are areas of litigation. Look at what happened with Celebrex recently. And ask any EM physician about their liability in terms of the 'average patient' you describe. There's no shortage of malpractice.

It's difficult to even tell what you are ranting about here as you keep confusing the issues and seem to fail to understand how anyone actually practices.

 

[hurdlepup]

This thread is about NPs and PAs and patients 'right to choose' them. It is not about ReineAshe and what you read on wikipedia and in Time magazine or JAMA or other rags.

It isn't a straw man argument to argue against a common view amongst NPs and PAs. You think my argument is a straw man because it may not be an argument you make, but it is an argument that nurses make. THIS THREAD IS NOT ABOUT YOU! I could not care less what you think.

PAs have less medical training than MDs. NPs have less MEDICAL training than PAs.

It's true that more training is not always beneficial or necessary. You have to draw the line somewhere or no one would ever finish training, but a trend toward allowing independent practice by lesser and lesser trained individuals reflects poorly on those pushing for lower educational requirements. They don't do so to help patients. They do so to help themselves. It's up to the medical profession to determine the entrance requirements to our profession. It's not for the nursing lobby to bribe their way in using the government.

Well said.

 

[MOHS_01]

Don't watch that, so I can't say. Think Milla Jovovich c. 1999. 😉

🙄

No -- I just know that my Westlaw subscription is, well, a subscription, so I can't link to it.

(1) This has nothing to do with textbooks. Before landing my current bioinformatics gig, I worked for a health law professor.

(2) Unlike medical textbooks, legal casebooks are completely useless.

(3) This is a bit of a strawman.

Let me prioritize. Uh..hmmm.... Sorry that I could not get back to you last night, the "think Milla Jovovich" had me all tore up.... and I could not even remember what we were discussing after that 😉😍

...but now that it is a new day -- I believe the primary problem, at least from the standpoint of the MD, is that you are viewing this through a legal / medmal prism -- one that is perceived as a gross oversimplification -- if not one of frank distortion by most medical professionals. It assumes degrees of rigidity and uniformity that simply do not exist outside of the limited confines of a legal professional's mind. Similarly, another flaw is in the presumption that the legal world's view on medical practice is the correct one; if your "gold standard" is not worthy of a bronze medal, the resulting conclusions will surely be subpar.

...and please stop already with the inappropriate application of the logical fallacies. The textbook example served as a comparison -- an analogy -- not "the" argument. "The" argument is / was the appropriateness and validity of oversimplification.... The ad homs were not ad homs at all -- the above attack on your frame of reference would more closely approximate an ad hom than anything prior, but even this is not a true ad hom as it represents a reasoned explanation for the difference of opinion... even if one side is fundamentally flawed due to an erroneous premise serving as its foundation.

I'm trying to be nice to you because I believe it to be a sin to be mean to pretty ladies

.... and I am of the opinion your conclusions are flawed due primarily to the application of a false "gold standard" rather than some intentionally belligerent and misguided reasoning.

 

[Stitch]

I think a more practical side to this discussion is the question of what are we as physicians doing to address the primary care shortage? FP programs routintely go unfilled. The money isn't in primary care for us, especially with the school debt most of us are burdened with in comparison. Many physicians actively tell students interested in medicine to either pursue other fields or to go to PA school instead. Clearly, we don't want these primary care jobs, or at least not in the numbers needed. I trained in pediatrics but would rather poke out my eyeballs with a soft spoon than work in a primary care clinic. As long as we are doing nothing to address these issues, of course people are going to turn to NPs and PAs in order to fill that gap.

We can sit and talk about how underqualified they are to do so, and (correctly) state that we are more experienced/better trained, but unless we are willing to step up and go into primary care, then it won't amount to much.

 

[doctorperez]

This statement is so evil I can barely stand to respond to it.

A restaurant chain wants to make money. To that end, they need patrons to return to the establishment in the future. They do not generate repeat business by poisoning and killing their customers! Because their survival depends above all else on keeping their food safe, their very existence demands that they MUST police themselves in order to avoid going under.

A mistake of this sort is not made innocently; it reflects a malevolent view of the world and a malevolent view of human beings in general. Your goal is simply to demonize others, not to support a rational conclusion. It disgusts me that there are practicing physicians who actually think like this.

If you really think businesses (e.i. restaurants) will police themselves b/c they are interested in repeat business, then you are sorely deluding yourself, and you need to go visit some third world countries and see what happens when businesses have no one to respond to... 🙄

 

[MOHS_01]

If you really think businesses (e.i. restaurants) will police themselves b/c they are interested in repeat business, then you are sorely deluding yourself, and you need to go visit some third world countries and see what happens when businesses have no one to respond to... 🙄

Do you always have difficulty with rational thought and what constitutes an appropriate comparison? Or just an ignorance of the application and role of the "rule of law"? Governance in general? 😱

 

[doctorperez]

Do you always have difficulty with rational thought and what constitutes an appropriate comparison? Or just an ignorance of the application and role of the "rule of law"? Governance in general? 😱

Not as often as you have titty attacks over your self delusion of rationality 😉

 

[MOHS_01]

Is that like angina of the breasts, Mr(Ms?) Hilton? 😉

 

[ReineAshe]

It isn't a straw man argument to argue against a common view amongst NPs and PAs. You think my argument is a straw man because it may not be an argument you make, but it is an argument that nurses make. THIS THREAD IS NOT ABOUT YOU! I could not care less what you think.

🙄 What revisionist history. Re-read your own posts.

There's quite a range of opinion in the nursing ranks. See, for example, the wide-spread NPR story from a while back: "I'm not an internist. And I tell my patients that. ... I just don't bring the same sophistication that a really skilled internist [does], and I shouldn't. I couldn't." (http://www.npr.org/templates/story/story.php?storyId=129398647)

By painting them with such a broad brush, you're effectively turning them into strawmen.

It's up to the medical profession to determine the entrance requirements to our profession. It's not for the nursing lobby to bribe their way in using the government.

Actually, it's always been up to individual states pursuant to the 10th Amendment's Police Powers. Moreover, the AMA was the first to "bribe their way in using the government." Before then, anyone really could purchase health care from whatever provider they wanted. (Starr, P. Social Transformation of American Medicine: The Rise of a Sovereign Profession And The Making of a Vast Industry. USA: Basic Books; 1982.)

State LAs probably follow the advice of national medical NGOs for the same reasons that their predecessors followed the advice of the ALI and NCCUSL to create the UCC. Moreover, I'm willing to bet that there are still some state law variations, with the most notable pertaining to Louisiana and licensing physicians with DUIs.

 

[ReineAshe]

I think a more practical side to this discussion is the question of what are we as physicians doing to address the primary care shortage? FP programs routintely go unfilled. The money isn't in primary care for us, especially with the school debt most of us are burdened with in comparison. Many physicians actively tell students interested in medicine to either pursue other fields or to go to PA school instead. Clearly, we don't want these primary care jobs, or at least not in the numbers needed. I trained in pediatrics but would rather poke out my eyeballs with a soft spoon than work in a primary care clinic. As long as we are doing nothing to address these issues, of course people are going to turn to NPs and PAs in order to fill that gap.

We can sit and talk about how underqualified they are to do so, and (correctly) state that we are more experienced/better trained, but unless we are willing to step up and go into primary care, then it won't amount to much.

As I PM'd someone else earlier:

This is the credited response.

 

[ReineAshe]

What are you even talking about here? Do you have any hard facts/links to back up this claim at all?

If you have a Westlaw account, yes. If you don't, no. The legal profession is absurdly proprietary.

Just going to lawyers and settlements, you can see a huge number of drugs which (rightly or wrongly) are areas of litigation.

🙄 You're kidding, right?

Everyone goes to ATL, Volokh Conspiracy, and sometimes that dude from UT/Chicago. If you're in health law, you get RSS feeds from the FDA. If you have a question about a specific drug, you run a specific query in Westlaw.

Look at what happened with Celebrex recently. And ask any EM physician about their liability in terms of the 'average patient' you describe. There's no shortage of malpractice.

Read Baker on that one.

Attorneys weed out cases so that on average only 1/4 of those cases actually get to you -- and most of the time, your peers think you should have lost the case. Peters PG. Doctors & Juries. Michigan Law Rev. 2007;105: (7):1454-1495.

It's difficult to even tell what you are ranting about here as you keep confusing the issues and seem to fail to understand how anyone actually practices.

1) Ad hom. 🙄

I was citing a prof who claimed that medmal was America's defacto disability safetynet. He argues that if you want medmal to go down you should: (1) make Social Security disability benefits easier to obtain after medical mistakes and (2) make benefits comparable to what they are in the EU and Canada.

2) Your position is both wrong and flawed, though.

For someone without a legal background, I'd start with the Medical Malpractice Myth by T. Baker. It's one of the very few legal academic texts that's an enjoyable read.

 

[ReineAshe]

Let me prioritize. Uh..hmmm.... Sorry that I could not get back to you last night, the "think Milla Jovovich" had me all tore up.... and I could not even remember what we were discussing after that 😉😍

...but now that it is a new day -- I believe the primary problem, at least from the standpoint of the MD, is that you are viewing this through a legal / medmal prism -- one that is perceived as a gross oversimplification -- if not one of frank distortion by most medical professionals. It assumes degrees of rigidity and uniformity that simply do not exist outside of the limited confines of a legal professional's mind. Similarly, another flaw is in the presumption that the legal world's view on medical practice is the correct one; if your "gold standard" is not worthy of a bronze medal, the resulting conclusions will surely be subpar.

...and please stop already with the inappropriate application of the logical fallacies. The textbook example served as a comparison -- an analogy -- not "the" argument. "The" argument is / was the appropriateness and validity of oversimplification.... The ad homs were not ad homs at all -- the above attack on your frame of reference would more closely approximate an ad hom than anything prior, but even this is not a true ad hom as it represents a reasoned explanation for the difference of opinion... even if one side is fundamentally flawed due to an erroneous premise serving as its foundation.

I'm trying to be nice to you because I believe it to be a sin to be mean to pretty ladies

.... and I am of the opinion your conclusions are flawed due primarily to the application of a false "gold standard" rather than some intentionally belligerent and misguided reasoning.

So you really can't think of a legit response to my comments?

Good to know.

 

[countingdays]

I'm curious as to why so many people in this forum are opposed to a patients right to choose who they will receive care or health related information from. If people decide they want to receive their care from an NP or PA as opposed to an FP, should that not be a choice they are allowed to make? In every other area of life people are allowed to make choices about what kind of services they wish to receive and who they wish to receive them from. Why should the same not be true of healthcare?

Is it fair for me to assume that your questions indicate that you believe NPs and PAs should have independent practice rights?
I would hate to be accused of making a straw man argument by responding to the obvious implication of your questions. Sometimes people like to avoid the truth by rambling on and on about irrelevant points.

 

[Stitch]

1) Ad hom. 🙄

That word that you use. I do not think it means what you think it means...

So you really can't think of a legit response to my comments?

Again, I'm not sure you've made any arguments. All you've done is respond with a single citation and made several vague references to sources or authors that only you can readily evaluate. What exactly is your point? Malpractice is 'dying'? That's laughable. Drug companies are immune from law suits? I doubt it. No one should precribe any off label drugs? 😕

I think it's very clear that your perspective is very far removed from the actual practice of medicine.

 

[MOHS_01]

So you really can't think of a legit response to my comments?

Good to know.

🙁 Sidebar -- have you, perchance, seen the motivational poster re: "no matter how hot she is...."?

....

Re-read my sentence. I didn't say "It is misuse because the burden of proof is on the defence." That would have been a poor understanding due to simplicity and/or lack of knowledge. What I said was "Then why are state boards and insurance companies so focused on protocols? Why do most state courts have different burden of proof standards for off-label use than FDA approved uses? It's because, legally, it implies misuse."

Yes, I know insurers go through a complex CBA risk analysis before requiring their nurses to follow protocols. Yes, I know there are 50 states, plus all of the federal courts applying state law. But restating that would be too much. What I said covers the bases at the correct level of sophistication. It's not automatically misuse in every state -- it's more like a rebuttable presumption in a lot of states.

OK -- here you go: state boards, as far as I am aware, do not issue treatment protocols for the purposes of guiding treatment; the impetus behind the creation of these protocols is to provide legal cover for those practicing under their jurisdiction. These protocols represent a sampling of the most commonly employed options available for any given disease -- not the hierarchal cardinal rank order for treatment. Likewise, the legal impetus behind these protocols should be readily apparent given the disease states most often chosen... Insurance carriers, on the other hand, focus on protocols for cost containment primarily; they are done in an effort to mitigate the losses associated with potential fraudulent acts as well as to simplify things to a level that the less initiated can understand.

Let me ask you this -- what should happen when these (quite) finite state sanctioned cookbook medicine protocols have been exhausted and have failed to achieve the desired ends? What if the protocol does not exist? Should we simply tell the patient, "Well, according to the State of XXXX and BCBS you are now officially SOL -- take it up with the FDA?" or "Sorry, Charlie, but I'm afraid that we are awaiting approval of..... at the request of our (former guardian of the social safety net 🙄) medmal overlord."

Venturing away from FDA approved indications may imply misuse in the minds of the legal establishment, but it most certainly does not (by definition) in the medical world. You continue to inappropriately conflate the two.

 

[deepdish83]

Actually, it's you who's using poor examples. When you're providing medical care, you're putting others at risk. When you decide to eat raw food, you're putting only yourself at risk. There's a big difference there. When you decide to provide medical care for others without adequate training, you are knowingly putting others at risk. And you yourself say you don't support knowingly putting others at risk. So, I guess we agree then.

No the key is being able to distinguish between a voluntary transaction between people and an involuntary one. I am opposed to people using force in violation of my rights. When you punch someone in the face, you are doing so against their will. In this example both parties have not voluntarily agreed to the transaction (the punch), and therefore this example has nothing to do with the freedom to choose.

When I order a rare steak at a restaurant, it also is a transaction which involves two parties (myself and the restaurant owner), however in this case it is an entirely voluntary transaction. No one is forcing me to patronize the restraunt much as no one is forcing the owner to prepare the food in any specific way.

 

[deepdish83]

I don't believe that the government should regulate all activities that may cause people harm. I do believe that the someone should regulate activities that have the potential to cause harm to others (not yourself). I don't care if you choose to punch yourself in the face all day. I do care if you decide to punch someone else in the face. That's when I want someone stepping in.

Bad example there. You can choose to eat unhealthy if you want because you're only hurting yourself there, not others. However, when you start practicing voodoo medicine, you put others at risk. There's a big difference there. Choose to harm yourself all you want. But the moment you start to knowingly put others at risk (due to lack of training), I think someone needs to step in to regulate.

Actually if I start practicing voodoo medicine it doesn't put anyone at risk. If I open a voodoo medicine office near a burger king, a motorcycle shop, and a high thrills adventure company that offers services like skydiving lessons, who exactly is being put a risk??? You act as though people are being forced in at gun point. If I decide to patronize burger king, they are putting me at risk for all the diseases associated with eat fast food. If I buy a motorcycle, they are putting me at risk, as motocycles are a much more dangerous (and unnecessary) form of transportation then a car. If I decide to spend my weekend skydiving as opposed to sitting on my couch they are putting me at risk as well. I hope you understand that consumers put themselves at risk all time by purchasing goods and services from other people.



Also I really have no interest in debating individual studies in this thread. If you want I can start another thread on the merits of NP vs MD studies. I do want to make sure you realize that you have a bad habit of taking what I say totally out of context.

Here you say:

I'm guessing you're referring to the Mundinger study that nursing midlevels seem to think is the greatest thing on earth:

Then later you make this claim:

It's a pretty poorly designed study and the fact that you posted it thinking it proved equal outcomes shows that you don't understand how studies are designed or interpreted. I recommend that you learn to do this rather than depend on other people to tell you what the results of a study are.

First I never posted this study. Second I most certainly never stated that this study proved equal outcomes. I merely said their is a fairly substantial body of work that deals with equal outcomes between midlevels and doctors in the field of primary care. I also noted that in this entire body of work there is not a single publication that indicates better outcomes from the MD side. I never claimed equivalence, nor have I ever claimed to have read every single paper published on the subject





You also make this statement. I completely agree with with your second sentence by the way:

Many nursing midleves cite studies without having read anything further than the abstract. Unfortunately, the abstract doesn't tell you much about methodology.

Interestingly enough in the thread Article: "Nurse Practitioner Or Doctor: What's The Difference?" Answer: Nothing!, a poster asked for proof to back up the claim that physician led care teams have better outcomes.

You replied by posting an abstract that mentioned physician leadership. I've added your full quote below from the thread.

"Efforts to improve efficiency without physician leadership and buy-in have been unsuccessful...Physician leadership, interdisciplinary team dynamics, and standardization of practice play crucial roles in reducing length of stay."

One of the first results that came up on a PubMed search. Seems like physician leadership plays an important role in efficient care of CHF patients. I will admit that I did not read the study beyond the abstract though. So I don't know of any flaws in methodology. However, it seems like a ton of articles popped up when searching for physician leadership on PubMed. Seems like there's a decent bit of evidence for it.

Double standard anyone?

 

[dynx]

Actually if I start practicing voodoo medicine it doesn't put anyone at risk. If I open a voodoo medicine office near a burger king, a motorcycle shop, and a high thrills adventure company that offers services like skydiving lessons, who exactly is being put a risk??? You act as though people are being forced in at gun point. If I decide to patronize burger king, they are putting me at risk for all the diseases associated with eat fast food. If I buy a motorcycle, they are putting me at risk, as motocycles are a much more dangerous (and unnecessary) form of transportation then a car. If I decide to spend my weekend skydiving as opposed to sitting on my couch they are putting me at risk as well. I hope you understand that consumers put themselves at risk all time by purchasing goods and services from other people.



Also I really have no interest in debating individual studies in this thread. If you want I can start another thread on the merits of NP vs MD studies. I do want to make sure you realize that you have a bad habit of taking what I say totally out of context.

Here you say:



Then later you make this claim:



First I never posted this study. Second I most certainly never stated that this study proved equal outcomes. I merely said their is a fairly substantial body of work that deals with equal outcomes between midlevels and doctors in the field of primary care. I also noted that in this entire body of work there is not a single publication that indicates better outcomes from the MD side. I never claimed equivalence, nor have I ever claimed to have read every single paper published on the subject





You also make this statement. I completely agree with with your second sentence by the way:



Interestingly enough in the thread Article: "Nurse Practitioner Or Doctor: What's The Difference?" Answer: Nothing!, a poster asked for proof to back up the claim that physician led care teams have better outcomes.

You replied by posting an abstract that mentioned physician leadership. I've added your full quote below from the thread.




Double standard anyone?

While others may argue with you I agree 100%
Let patients make the choice, its freedom.
Meanwhile...let me charge whatever I want for my services...Also in the name of freedom! let the market decide. You've got an appendicitis in rural mississippi? you better pay up sucker! Thats a nice car you pulled up in! I'll take that as payment...or you can try your luck driving it 100 miles to the next provider that can take your appendix out (wait to see what he charges when you get there in even worse shape!). Free market my friend, works both ways.

Glad someone out there understands these things. Don't let these other *****s get you down.

 

[JaggerPlate]

While others may argue with you I agree 100%
Let patients make the choice, its freedom.
Meanwhile...let me charge whatever I want for my services...Also in the name of freedom! let the market decide. You've got an appendicitis in rural mississippi? you better pay up sucker! Thats a nice car you pulled up in! I'll take that as payment...or you can try your luck driving it 100 miles to the next provider that can take your appendix out (wait to see what he charges when you get there in even worse shape!). Free market my friend, works both ways.

Glad someone out there understands these things. Don't let these other *****s get you down.

Technically, couldn't you not accept any insurance (assuming you aren't in EM) and try to charge whatever you can get away with? Is there really a reason this concierge model couldn't be applied to other fields (legally I mean). Malpractice?

In reality though, I think you'd have a very hard time getting enough appendicitis patients at 2k when the hospital down the street with remove it for a $200 PPO co-pay.

With the exception of a few fields: elective procedures, small, small market for concierge PC, etc, the insurance industry keeps medicine out of the realm of free market/basic economic principles. I mean, all I hear about is two things: 1. The primary care 'shortage' and 2. Crashing salaries in primary care ... doesn't quite compute, you know??

 

[dynx]

Technically, couldn't you not accept any insurance (assuming you aren't in EM) and try to charge whatever you can get away with? Is there really a reason this concierge model couldn't be applied to other fields (legally I mean). Malpractice?

In reality though, I think you'd have a very hard time getting enough appendicitis patients at 2k when the hospital down the street with remove it for a $200 PPO co-pay.

With the exception of a few fields: elective procedures, small, small market for concierge PC, etc, the insurance industry keeps medicine out of the realm of free market/basic economic principles. I mean, all I hear about is two things: 1. The primary care 'shortage' and 2. Crashing salaries in primary care ... doesn't quite compute, you know??

No. If I was a surgeon in a rural area with an ER and I refused to treat an emergency case because they wouldnt meet my price I'd lose my practice and a lot of money. And my example was an area without a hospital down the street. Some folks live and work in all that flat **** you fly over when you visit NY from LA.

 

[MOHS_01]

Technically, couldn't you not accept any insurance (assuming you aren't in EM) and try to charge whatever you can get away with? Is there really a reason this concierge model couldn't be applied to other fields (legally I mean). Malpractice?

In reality though, I think you'd have a very hard time getting enough appendicitis patients at 2k when the hospital down the street with remove it for a $200 PPO co-pay.

With the exception of a few fields: elective procedures, small, small market for concierge PC, etc, the insurance industry keeps medicine out of the realm of free market/basic economic principles. I mean, all I hear about is two things: 1. The primary care 'shortage' and 2. Crashing salaries in primary care ... doesn't quite compute, you know??

There is a lot of truth located in this post. Rightly or wrongly, patients consider their healthcare "already paid for" via their health insurance premiums; as such they will choose to "not pay double" by performing end runs around the confines of their insurance benefits. You also make an argument that I have made many, many times on here to no avail -- the cash FFS market is far more constrained than many would like to admit. The population of people willing to pay out of pocket for concierge services is very finite and simply does not exist in either great enough concentration or numbers for this to be a viable alternative for many. A similar argument can be easily made for cosmetic services. Likewise your point on the pricing for procedural or intensive services is similarly true; their RVU determined valuations are such that massive contraction would result if folks had to pony up those numbers directly.

 

[cpants]

So why have any medical professional whatsoever standing between the public and the pharmacopoeia? Surely you don't believe that patients should be able to walk into a pharmacy and buy Xanax or penicillin without a prescription.

So therefore, there are necessary limits on the choices a person has in the healthcare they can purchase. Someone with appropriate training needs to be the gatekeeper to certain treatments. Society and government decide the standards which define who is able to be that gatekeeper. This just isn't a role which the market can take on. You are welcome to consult and even pay an RN or an uncle for a cold remedy, just don't expect that remedy to be a cephalosporin, and for good reason.

 

[JaggerPlate]

There is a lot of truth located in this post. Rightly or wrongly, patients consider their healthcare "already paid for" via their health insurance premiums; as such they will choose to "not pay double" by performing end runs around the confines of their insurance benefits. You also make an argument that I have made many, many times on here to no avail -- the cash FFS market is far more constrained than many would like to admit. The population of people willing to pay out of pocket for concierge services is very finite and simply does not exist in either great enough concentration or numbers for this to be a viable alternative for many. A similar argument can be easily made for cosmetic services. Likewise your point on the pricing for procedural or intensive services is similarly true; their RVU determined valuations are such that massive contraction would result if folks had to pony up those numbers directly.

👍

Also, just as an aside ...

I believe there is still much more viability/realism in cosmetics when compared to concierge medicine, but that the key to success is finding a unique niche, becoming the "expert" for that specific area, and sticking with it until it's no longer viable? Any thoughts (as someone who I believe used to do a bit of cosmetics/has knowledge in the area). I say this because two of the most successful guys in cosmetics I know found a unique new therapy (when it was just on the brink of becoming the next big thing), devoted their practice to it, and now only practice that/are the "go to guy" because they've done it so many times and for so long

 

[MOHS_01]

So why have any medical professional whatsoever standing between the public and the pharmacopoeia? Surely you don't believe that patients should be able to walk into a pharmacy and buy Xanax or penicillin without a prescription.

So therefore, there are necessary limits on the choices a person has in the healthcare they can purchase. Someone with appropriate training needs to be the gatekeeper to certain treatments. Society and government decide the standards which define who is able to be that gatekeeper. This just isn't a role which the market can take on. You are welcome to consult and even pay an RN or an uncle for a cold remedy, just don't expect that remedy to be a cephalosporin, and for good reason.

Without giving it a great deal of thought, I actually would not have a problem with some prescription drugs being available without prescription...and why should I? Why do you? Outside of protectionism, of course.... They get the same pharmacologic effect of Xanax with alcohol every day of the week. OTC antibiotics are a bit more problematic, however, as a very good case can be made for the perils of resistance that would most likely result.... and they fall under the the greater domain of public health, a rightful case for regulation and government intervention.

 

[MOHS_01]

👍

Also, just as an aside ...

I believe there is still much more viability/realism in cosmetics when compared to concierge medicine, but that the key to success is finding a unique niche, becoming the "expert" for that specific area, and sticking with it until it's no longer viable? Any thoughts (as someone who I believe used to do a bit of cosmetics/has knowledge in the area). I say this because two of the most successful guys in cosmetics I know found a unique new therapy (when it was just on the brink of becoming the next big thing), devoted their practice to it, and now only practice that/are the "go to guy" because they've done it so many times and for so long

Potentially... and I agree that there should always be a measurable advantage in being "the" guy for any given procedure, but there are so many things in play that it is incredibly difficult to predict with any degree of certainty. In the past two decades cosmetic surgery has been a decent gig; there have been three big factors, two of which I believe to be fairly unique and not likely to repeat or persist, feeding into this (at least from my way of thinking). The first is a relatively low level of competition despite the "cutthroat" competitive environment spoken about within the field -- and I would point to the high price level for any given service even in the most "competitive" of environments as evidence. No industry consisting of numerous independent producers can maintain high margin pricing levels in a truly competitive environment. Part of this low competition is due to the limited numbers of training positions in the involved specialties, but a good portion has to be related to the fact that the pricing level in "real" medicine has remained high enough to keep most potential competitors in that rather than venturing into the cosmetic world (at a price advantage). This is why I walked away from cosmetic medicine in large part -- I could earn similarly performing my mix of general and surgical dermatology without incurring the cost, risk, and expense associated with a cosmetic practice (not to mention the intangibles that I deplored...). The next reason is one of demographic trends -- the largest segment of the population was in their years of declining physical appearance -- and peak earnings.... earnings that were grossly overstated and inflated. Last was a larger macroeconomic setting that was artificial and unlikely to be repeated any time soon. Everyone believed they were wealthier than they actually were. They watched the value of their major assets and retirement "grow" without additional input of labor. Less and less (as a percentage) of their income was required to service daily sustenance, leaving more for discretionary spending. Savings rate was negative and there was far too much comfort with debt. The "era of great moderation" lulled the masses into believing that the good times were indefinite; collective memory was short and few people remembered what truly hard times were like.

Probably more than you were looking for.....

 

[deepdish83]

There is a lot of truth located in this post. Rightly or wrongly, patients consider their healthcare "already paid for" via their health insurance premiums; as such they will choose to "not pay double" by performing end runs around the confines of their insurance benefits. You also make an argument that I have made many, many times on here to no avail -- the cash FFS market is far more constrained than many would like to admit. The population of people willing to pay out of pocket for concierge services is very finite and simply does not exist in either great enough concentration or numbers for this to be a viable alternative for many. A similar argument can be easily made for cosmetic services. Likewise your point on the pricing for procedural or intensive services is similarly true; their RVU determined valuations are such that massive contraction would result if folks had to pony up those numbers directly.

This would not be the case if people were provided with greater choice in their selection of insurance. The reality is that fee for service is the most efficient and effective way to deliver most services and goods. The basic idea of insurance, pooling resources to deal with a low probability but high risk event, is corrupted when it is used for high probability low risk events.

Health insurance companies, depending on the state, are mandated to cover expenses that really should be only FFS. There is absolutely no reason that insurance should be forced to cover things like IVF or even routine check ups. If I know that I need a mammogram every year it is silly to have insurance cover this expense.

 

[JaggerPlate]

Probably more than you were looking for.....

Wow. Hahaha, not at all! Thank you for that analysis. 👍

 

[QuizzicalApe]

I have a hard time understanding the allure of this "open the market so people can see anyone, without this degree and license business getting in the way" position.

It seems to presume that every person is an informed consumer that won't be led away from perfect objective rationality by advertisement, the demands of one's own time, the immediacy of an emergency situation, laziness, and unsubstantiated anecdotes. An utterly free market is not a panacea, nor is it in itself some sort of supreme moral good such that implementing it is worth any consequences, no matter how dire.

A system where the utterly unqualified are driven out of business because too many people have died is not to be preferred over one where they weren't allowed to perform open heart surgery to begin with.

 

[cpants]

Without giving it a great deal of thought, I actually would not have a problem with some prescription drugs being available without prescription...and why should I? Why do you? Outside of protectionism, of course.... They get the same pharmacologic effect of Xanax with alcohol every day of the week. OTC antibiotics are a bit more problematic, however, as a very good case can be made for the perils of resistance that would most likely result.... and they fall under the the greater domain of public health, a rightful case for regulation and government intervention.

Having worked extensively with benzo addicts, I have to disagree that they should be available at will to the public. That could get very ugly, very fast. Antibiotics, certainly not. I agree that certain drugs could be safely used OTC by the public, and there is already a system in that place for that to happen. Prescription antihistamines for allergy relief comes to mind as a recent example. However, that was only possible after extensive safety and efficacy data were available from years of physician-prescribed experience. My point was not really about drugs in specific but rather that there are treatments out there that have the potential to cause significant harm and those are necessarily regulated by government. In general I am very libertarian, but I feel that this arena is an appropriate use of government to protect the public. It's not that I think the market couldn't effectively weed out poor practitioners, it's that waiting for the body count to get high enough for the public to avoid a doctor is not an acceptable method of regulation.

 

[MOHS_01]

I have a hard time understanding the allure of this "open the market so people can see anyone, without this degree and license business getting in the way" position.

It seems to presume that every person is an informed consumer that won't be led away from perfect objective rationality by advertisement, the demands of one's own time, the immediacy of an emergency situation, laziness, and unsubstantiated anecdotes. An utterly free market is not a panacea, nor is it in itself some sort of supreme moral good such that implementing it is worth any consequences, no matter how dire.

A system where the utterly unqualified are driven out of business because too many people have died is not to be preferred over one where they weren't allowed to perform open heart surgery to begin with.

Perhaps your "hard time in understanding the allure" is because you are asking the wrong question -- or approaching from the wrong angle -- from the outset. I agree that an intelligent and informed consumer would go to the most reputable provider more often than not, but neither degree nor pedigree =/= competence.... and I have met many Mayo and Harvard trained students, residents, and physicians who commanded mediocre skill at best -- so that metric is flawed from the outset. Then there are the more fundamental questions of whether people should be protected from their own willful decisions, resources should be seized from some to reward others (the inevitable outcome of any state sanctioned -- and funded -- monopolistic right), etc. The system that you seemingly prefer is a technocratic one whereby "expert" decision makers usurp the authority over choice and dictate from their surrogate role; if this system were half as good as many intellectuals like to believe the USSR would have mopped the floor with us (as was widely predicted by these "elites" throughout a good portion of the 20th century)... which obviously did not happen. Surrogate decision making ultimately fails because the surrogate lacks the necessary level of consequential knowledge in any particular situation; while it may be appealing in the abstract, we do not live our lives in the abstract.

Yet another point that needs to be made is the consumer/market effects that your presumed superior system promotes, which are gross distortions in the pricing mechanism. It is not wrong to state that much of outpatient medicine does not require MD level training; many, if not most routine follow-ups for chronic conditions do not. Many low acuity encounters do not. The real trick is in the delineation of what does -- and that is what often requires higher levels of cognition (which added training benefits). Take derm for example; it does not take a blooming genius to manage a small child with typical eczema, a teenager with mild acne, or an adult with limited psoriasis. It really does not take an MD to evaluate these patients in follow-up to monitor for response or adverse effects of medications, yet that is the system we employ today. It drives up the cost for those services which could be provided on a lower cost basis and diverts funds from those services which entail a higher level of risk or require greater input costs. If someone could legitimately provide these service at 1/2X, yet, through your regulatory protectionist hurdles are forbidden from doing so, you have then stolen 1/2X from that person in no less of way than if you had reached in their pocket and forcefully taken it. By the same token, you have also stolen from the imaginary provider who never had the opportunity to offer the similar service at the lower cost....

 

[MOHS_01]

Having worked extensively with benzo addicts, I have to disagree that they should be available at will to the public. That could get very ugly, very fast. Antibiotics, certainly not. I agree that certain drugs could be safely used OTC by the public, and there is already a system in that place for that to happen. Prescription antihistamines for allergy relief comes to mind as a recent example. However, that was only possible after extensive safety and efficacy data were available from years of physician-prescribed experience. My point was not really about drugs in specific but rather that there are treatments out there that have the potential to cause significant harm and those are necessarily regulated by government. In general I am very libertarian, but I feel that this arena is an appropriate use of government to protect the public. It's not that I think the market couldn't effectively weed out poor practitioners, it's that waiting for the body count to get high enough for the public to avoid a doctor is not an acceptable method of regulation.

In my mind benzos=boos, so I do not see the difference. Those who would self medicate to the point of abuse already enjoy sufficient legal avenues to do so... and I was not placed on this earth to live other's lives' for them. If they want to piss it away, fine by me -- just don't ask me to pay for it.

You're thinking far too narrowly on the topic of the efficacy, justifiability, and ultimately the need for state sponsored accreditation; if a single entity was chosen as the preferred method for "guaranteeing safety" why would something akin to Underwriter Laboratories not suffice? Why would personal and business reputation not suffice? Sure, it has its downside for the new entrant into the field who is "nudged" into going into a group with an already existing good reputation... but the very same drawback exists already in large degree, and would only be temporary as reputation (and thus, a practice) builds relatively quickly.

If we could only remove the socialization of the costs and let people bear the burden of their poor choices this would be a much easier argument to make.

 

[QuizzicalApe]

I'd argue that there are situations where it is beneficial to society and the vast majority of individuals to have people with expertise in the field decide what is an acceptable baseline level of expertise or safety. Medical care is one of those, food is another, vaccine production, etc.

While individual skill varies from that baseline, if you think too many people are slipping under acceptable limits then I'd find it reasonable to push for raising the bar rather than razing the system.

I agree with you, though, that the standard of training doesn't have to be equivalent for every treatment and service. It is reasonable to suggest that different standards of training could be set for something more or less complex - but it is equally reasonable to expect that if there is a reasonable expectation of danger that we have a system in place such that the patient will know that their care provider is qualified.

 

[MOHS_01]

I'd argue that there are situations where it is beneficial to society and the vast majority of individuals to have people with expertise in the field decide what is an acceptable baseline level of expertise or safety. Medical care is one of those, food is another, vaccine production, etc.

Some of the worst atrocities in the history of mankind were applauded by the intellectuals, experts, and elites of their day... so if that truly is your argument -- and you want to apply force against any contrarian view -- you may either wish to reconsider or at least beef it up a bit. 😉 The next question would have to be, "Who is this 'society'? For I have yet to see him or her walk through my door." Healthcare involves the treatment of individuals, not the treatment of groups or some statistical class... and I would love to hear the argument that says $100 of lower cost (and more often than not) reasonable care by a lesser trained provider is worse for the individual who can afford to pay no more than the $100 than the level of "no care" rendered by the highly trained professional. Just like with minimum wage laws and various other intrusions -- the group of people hit hardest are those who we claim to look out for the most.

I agree with you, though, that the standard of training doesn't have to be equivalent for every treatment and service. It is reasonable to suggest that different standards of training could be set for something more or less complex - but it is equally reasonable to expect that if there is a reasonable expectation of danger that we have a system in place such that the patient will know that their care provider is qualified.

Do they really know that now? What constitutes qualified? It should be determined by the measure of results achieved and by no other metric... yet we receive our stamps of approval long before taking solo flight for any length of time.... What percentage of cases involving true negligence do you believe are performed by BC/BE physicians vs non-BC/BE physicians? Does our current system really work as the proponents claim? What percentage of docs reach the status of BC/BE? Do you honestly believe that we have a fabulous system when virtually everyone is labeled as a (pre-meltdown) Tiger Woods or Michael Jordan?