Things Might Not Go As Planned

This:

Can a highly trained nurse deliver anesthetics as well as a physician who has specialized in anesthesiology, or does the nurse require close medical supervision? That issue emerges from two recent studies and from California’s decision last year to join 14 other states in freeing the nurses from a federal requirement that they be supervised by a physician. Colorado seems poised to join the group. The issue is potentially important to patients and to health care reformers seeking to restrain costs and reduce reliance on high-priced medical specialists.

And this:

In a snapshot of systemic waste, researchers have calculated that more than half of the 354 million doctor visits made each year for acute medical care, like for fevers, stomachaches and coughs, are not with a patient’s primary physician, and that more than a quarter take place in hospital emergency rooms.

The authors of the study, which was published Tuesday in the journal Health Affairs, said it highlighted a significant question about the new federal health care law: can access to primary care be maintained, much less improved, when an already inadequate and inefficient system takes on an expected 32 million newly insured customers?

“If history is any guide, things might not go as planned,” they wrote. “If primary care lags behind rising demand, patients will seek care elsewhere.”

I certainly hope patients seek care elsewhere, and I suspect they’re going to insist on it.
Twenty years ago I didn’t have health insurance and I made too much to qualify for Medicaid, and I needed prenatal care. I went here.
It’s a low-cost county clinic, and I got great medical care, although I rarely saw the physician.
We conducted the whole health care debate, Left and Right, on the chosen terms of the opposition, and it became all about loss and fear and scarcity, but it doesn’t have to work that way.
If 32 million new patients (and we’re now calling them “patients” or “customers” instead of “the uninsured”, they magically changed status, apparently) need access to affordable primary care and the medical industry doesn’t respond with more primary care physicians, states are simply going to look to alternatives.
That would be a great result that could speed up changes that benefit everyone.

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69 replies
  1. 1
    John S. says:

    Nurse practitioners seem to be stepping up to fill the void. Throughout my wife’s pregnancy with our 2-month old daughter, she saw the NP far more often than the MD. Even in the hospital during labor and delivery.

  2. 2
    Kay says:

    @John S.:

    30 states now mandate that private insurers cover certified nurse midwives. It’s going to change, with or without the blessing of the medical status quo, because it has to.

  3. 3
    shortstop says:

    I’m one of the lucky ones who’s always had insurance, and I’ve gone to walk-in clinics (doc-in-the-boxes) and paid cash more than once when my primary couldn’t get me in to deal with serious stuff (bad flu on a week when my doc was only practicing in distant suburbs not reachable by public transit) and non-serious but annoying stuff (ears so full of wax my hearing went kaput, and OTC remedies didn’t work).

    I’ve sometimes wondered why larger hospitals don’t set these up as alternatives to the ER for all the non-emergency stuff that comes into the ER.

  4. 4
    El Cid says:

    I know it was pure Soviet British style communismo-laborism, but as a kid I went to community clinics and they were great, in fact I had no idea what it was to have a ‘family doctor’ unless it meant the doctor you were most familiar with at the clinic. Likewise in one of the counties I lived in during college, there was a public dental care clinic, and I got services paid for out of pocket for much cheaper than I would have had to with dental insurance at a private office. I’m not sure but I think I actually did have insurance at the time.

  5. 5
    jibeaux says:

    NP’s are a great source of primary, run-of-the-mill care. My employer (the state), bleeding money every year from health care costs, is starting a pilot program in various locations that basically consists of hiring an NP and converting an unused office somewhere for her, with an 800 number to coordinate appointments for all the different locations. Employees can go there with no co-pay and without using any sick leave if they are enrolled in the pilot program (and enrolling in the pilot program involves getting a general health check and if you have issues such as cholesterol or nicotine or whatever, meeting with a health coach to address them.) The idea is that the overhead should be so low, that even without charging patients the co-pay that the insurer comes out ahead over what they pay for PCP visits. I realize the part where you enroll voluntarily in the program and get your cholesterol checked and so forth to stay in it would give glibertarians fainting spells, but for someone who for years has seen the state try to address health care costs by raising premiums and cutting services, some new damn ideas to lower costs are very welcome.

    Also too, something I read in Half the Sky (I think I have pitched that book a half dozen times by now), is that in many parts of Africa, training doctors doesn’t improve health care because if you’re African, that M.D. is your ticket out of Africa. However, you can train nurses and other paraprofessionals — local women who are tied to their communities and aren’t interested in going anywhere — to great effect. There was even an example of an uneducated, illiterate woman who had been successfully trained to perform a specific type of obstetric surgery (fistula repair) that is commonly needed in Africa. Just involves rethinking what really requires an MD and what might not.

  6. 6
    WyldPirate says:

    the American Medical Association has been responsible for the shortage of physicians for forever.

    The AMA dictates how many medical schools are that get “accredited”. Through the universities–many whose MD programs are supported by state and federal funds–the AMA colludes to limit the number of students admitted with each class.

    The AMA conspires with teaching hospitals as well so as to limit the number of students in residency training. They keep it just low enough that they have to hire in a bunch of foreign fuckwits every year to fill the residency slots. Most of these poor English speakers–many of them Indian (and yes I’m xenophobic here, most of the times, their English sucks and is unintelligable), get shipped off to the boondocks were there are few physicians.

    There is nothing at all that is “free market” about the supply of MDs in this country. Nothing. IT is a racket that is tightly controlled by the AMA.

    The same thing has happened in the sciences at the PhD level. The number of Americans going into these programs have been stagnant for years. Why, because the pay absolutely sucks. The training is basically slavery and there aren’t any jobs. What did academia do? They recruited from overseas–India, China, etc. And got even more. Now, the bastards are flooding universities, taking the shitty jobs there while unable to even speak intelligible English.

    Corporate America has nothing on academe. They have been ripping off the consumer of their “product” for years and it’s getting worse.

  7. 7
    Kay says:

    @El Cid:

    That’s what made me laugh a little about Obama’s constant refrain of “you can keep your doctor”. I know it was directed at the “medical haves” and not the “have nots”, but still.

    Obama, listen closely: the only people who are really paying desperate attention to this don’t have a doctor. That’s why they’re in the emergency room.

  8. 8

    How about allowing women to give birth at home instead of hospitals and use nurse midwifes and have insurance pay for it? That’s another huge racket which our healthcare gatekeepers deny us access to.

  9. 9
    p.a. says:

    this was a ‘subtextual’ issue during the process of passage. the hope is that eventually, the expanding access to healthcare will decrease the demand for emergency and critical care that is required now for people who have to wait till the last medical minute possible before seeking treatment. ‘eventually’ being the key word. can the system over the next 5 years handle an influx of up to 30 million people who were without healthcare? and given the demographics of an aging population, will the (assumed) increase in ‘healthyness’ affect any long-term decrease in demand, or at least decrease in rate of increase?

  10. 10
    liberal says:

    ..and it became all about loss and fear and scarcity, but it doesn’t have to work that way.

    Yes it does, for how else will MDs collect scarcity rents?

  11. 11
    mistermix says:

    The small town where I grew up, 100 miles from any big hospital, has had a Certified Registered Nurse Anesthetist (CRNA) doing anesthesia at the tiny community hospital for the past 40 years. He’s very good, and also attends for emergency care like trauma, heart attacks, etc. as part of the care team. The hospital couldn’t exist without him, and he’s been the difference between life and death for a lot of people in that town.

    Of course, that hospital is too small to support a MD (Anesthesiologist), so there’s no debate about whether a nurse can do the job. In a bigger hospital, the procedures he performs would be done by an MD at a higher cost for little or no added benefit.

    Makes me chuckle to think that the rest of the US is finally going to clue to the usefulness of CRNAs.

  12. 12
    Corner Stone says:

    We conducted the whole health care debate, Left and Right, on the chosen terms of the opposition, and it became all about loss and fear and scarcity,

    The politicians conducted the “health insurance debate”, not health care, that way, which I found a pathetic capitulation of narrative.
    Some of us discussed it as a moral question. But since that aspect was taken away from the pre-beginning it never had a chance to drive a more powerful refrain.

    edited a little

  13. 13
    Kay says:

    @Corner Stone:

    I’m not talking about a moral question. In my opinion, the moral argument stays within the status quo, and approaches medical care as a fixed resource that has to be parceled out, with “winners and losers”, and that’s the frame the opposition wants.

    We’re all losing, because we’re stuck in a trap. That’s the truth.

    As far as I’m concerned, the moral keening and moaning took us out of the practical and real, and into the abstract, and this belongs in the real world.

    We don’t need permission from the medical gatekeepers to open the gate, and we’re never going to get it. It’s going to happen with or without their consent, because we changed “the uninsured” to “patients”, and they need basic medical care.

  14. 14
    ChrisS says:

    I have one friend that is a registered physician assistant and one that is a RN that specializes in trauma surgery. We all grew up in an impoverished rural area. Now, whenever they’re around, they’re basically on the clock anyway because all the people that think a national healthcare policy is soshulism are asking them questions about their personal health issues because they either don’t have insurance or they don’t want to deal with the hassle that is the modern hospital. Solution, give everyone health insurance and modernize care distribution. Something that won’t be done because controlling supply of care leads to greater profits.

    I don’t understand why walk-in urgent care or routine care clinics aren’t more widespread. A nurse can handle 90% of the caseload without having to even consult with a doctor and for whatever is more complicated than a nasty cold, infection, or minor wound can be referred to the doctor. At my doctor’s, I’ve never had a wait less than 45 minutes past the scheduled appointment and typically the waiting room is full of kids with standard kid illnesses (or old people getting their check-up).

    I’ve never waited a second past my scheduled appointment at my dentist’s office and if I’m early by a few minutes, chances are I get in early. I see my actual dentist for about 30 seconds every 6 months during my cleaning/x-ray. However, I know pretty much everything about my hygienist’s life – past and present.

  15. 15
    Corner Stone says:

    @Kay:

    As far as I’m concerned, the moral keening and moaning took us out of the practical and real, and into the abstract, and this belongs in the real world.

    Once you start from the premise of cost, or cost reduction, or efficiencies as the most important pivot then you have given the opposition what they want.

  16. 16
    Chrisd says:

    So who do patients sue when they get less-than-perfect results from these unsupervised physician extenders?

  17. 17
    ChrisS says:

    fuck, moderation.

  18. 18
    anon says:

    @Corner Stone:

    The politicians conducted the “health insurance debate”, not health care, that way, which I found a pathetic capitulation of narrative.

    Agreed.

  19. 19
    anon says:

    @Chrisd:

    So who do patients sue when they get less-than-perfect results from these unsupervised physician extenders?

    You sue them, the provider. Just like you sue a doctor when she gives you less-than-perfect results.

  20. 20

    Won’t someone think of the cosmetologists!

  21. 21
    Kay says:

    @Corner Stone:

    Once you start from the premise of cost, or cost reduction, or efficiencies as the most important pivot then you have given the opposition what they want.

    We disagree. I listened carefully when the two recommendations came out on PAP testing and mammograms. There was a knee-jerk reaction on the Left that someone or something was denying care, and the Right pointed to it as proof that “Obamacare” was about rationing. They were scientific studies. The mammogram study looked at whether healthy women were being harmed by all those x rays. There was no rational discussion at all. It was all about scarcity and fear.
    I think we’ll get to the point where we can talk about health care, despite the hysteria, but it’s going to take a while.

  22. 22
    liberal says:

    @Corner Stone:

    Once you start from the premise of cost, or cost reduction, or efficiencies as the most important pivot then you have given the opposition what they want.

    That’s not at all clear.

    Like it or not, health care is an economic resource, and as such it’s limited. Thus, the prime questions are: what do we get out of an “investment” in health care? How can we optimize those societal benefits, given a particular level of commitment of resources? And, of course, how much are we willing to pay?

    If you view “cost” as only “how much are we willing to pay?” then you’re right. If you view “cost” as “Christ, we spend at least 16% of GDP on this, and we’re getting mediocre results at best—something is dreadfully wrong here,” then you’re wrong.

  23. 23
    liberal says:

    @Kay:

    There was a knee-jerk reaction on the Left that someone or something was denying care, and the Right pointed to it as proof that “Obamacare” was about rationing. They were scientific studies. The mammogram study looked at whether healthy women were being harmed by all those x rays. There was no rational discussion at all. It was all about scarcity and fear.

    Amen. Amen. Amen. Amen.

    Sometimes “denying care” isn’t denying care, it’s the “option not to treat,” and it results in both less money spent and better outcomes.

    One problem is that a big chunk of the liberal/left has adopted the attitude that the only issue is health insurance. While I agree that single payer is best, health insurance isn’t the only issue—there’s also health care itself. If we were to adopt single payer, and followed the “medical decisions should only be between a patient and her doctor” mantra repeated by many single payer advocates, we could still have a lot of bad and unnecessary medical treatments being administered.

    Not to mention issues like the one the original post pointed out, that another particular problem is economic rent collection by MDs.

  24. 24
    shecky says:

    Do people here really believe this? Last time the idea of relaxing credentialing regulations for providers of services to the public came up, I was one of the few supporters, and was virtually tarred and feathered as a result. Yet, the idea of supporting more nurse practitioners is exactly the same thing. And is also a good idea. Interesting how rent seeking health care gatekeepers get demonized, where their hair cutting counterparts are just doing God’s work.

  25. 25
    Corner Stone says:

    @Kay: To be clear, there is zero wrong with building in efficiency, or reducing costs, or providing better more patient centric care at lower overall cost.
    My point is that when you allow the argument to be started from cost then you have removed the humanity of what we should be talking about.
    HCR should have been an equal rights issue, IMO.

    And the narrative that focused on care, and better outcomes could have also definitely included reports on efficiency.
    But we did not have that discussion. We talked exclusively about cost, and that prescribes that we are guaranteed to talk only about “winners and losers”.
    We talked about “health insurance”, not “health care”.

    I have no issue with the examples you cite above in the FP post.

    ETA – And also @liberal: since it seems my brief prior post was not clear to some degree.

  26. 26

    The thing is, the entire healthcare debate we were never discussing our choice of doctors or care we were offered a choice of INSURANCE PLANS.

    And fuck it all, I don’t want a choice of insurance plans. I don’t want to wade through all of that crap and figure out “which plan is right for me.” Sometimes all this glorifying of consumer choice is just amazing to me. Choice? I hear Big Huge Fucking Hassle to wade through the gobbledy gook when all I want is to GO TO MY DOCTOR and not get reamed in the pocketbook for the privilege.

    Seriously, we’ve been drinking this free market Kool Aid so long we’ve internalized the argument and don’t even recognize that SOME shit shouldn’t have to be treated like oranges or laundry detergent.

    Sorry to get all shouty and stabby but the entire healthcare system in this country is so obviously a moneymaking enterprise that serves no one but the elites and it still pisses me off that we aren’t allowed to talk about that.

  27. 27
    Mark says:

    @SouthernBeale

    Giving birth at home is for the insane. There are so many babies who need to be resuscitated, and midwives don’t have the skills or the equipment. You’ve generally got less than five minutes to save these kids and you can’t drive to a hospital and get admitted that quickly.

    And remember – just because you know 10, 20 or even 50 people who’ve had a home birth with a midwife, it doesn’t mean it’s anywhere near as effective as a hospital delivery. Mortality rates are low, so it takes a large sample to see a midwife’s effectiveness.

  28. 28
    Chrisd says:

    @anon:
    Their malpractice coverage will match their reduced salary. This is de facto tort reform. Is the malpractice industry okay with this?

  29. 29

    Might not go as planned?

    No battle plan survives contact with the enemy. [Clauswitz]

    We have to adjust and adapt as we go along.

  30. 30
    CA Doc says:

    Ahem, family physician who has busted tail for past 2+ yrs to see healthcare reform pass, chiming in here. Sure, our system needs to do a better job of using teams to leverage everyone’s skills to maximize access. Community clinics are a great model for this, and one of the fights in the primary care community is to change medical education payments so that young doctors can train there and be inspired to stay. But to think that this country can fix its huge primary care problem with some NP’s in retail clinics is crazy. Primary care is ongoing prevention, diagnosis of new problems, coordination of specialist care and end of life care. You get the most cost savings when this is provided in the context of a long term relationship, because the power of trust and familiarity goes a long way towards healing and preventing waste and duplication of services.
    The money to be made in healthcare right now is in specialty services, not in primary care. So just like physicians, a huge chunk of NP’s and PA’s are working in specialty settings. People follow the money, so until the payment structure changes, we remain with an expensive, upside down system with way too many specialists and too few primary care docs.

  31. 31

    @shecky:

    Yet, the idea of supporting more nurse practitioners is exactly the same thing. And is also a good idea. Interesting how rent seeking health care gatekeepers get demonized, where their hair cutting counterparts are just doing God’s work.

    Orders of magnitude difference, shecky – on all ends of the equation.

    Get back to me the next time you and your insurance pay $20,000 for a dye treatment or you want to have your significant other perform a laproscopy.

  32. 32
    Kay says:

    @liberal:

    One problem is that a big chunk of the liberal/left has adopted the attitude that the only issue is health insurance.

    They’re not totally to blame for that. I think that was deliberate, for political reasons, because 85% of people have health insurance, and the people who don’t, don’t vote.
    Democrats focused on health insurance because to focus on health care is too scary for people, and most people have adequate health care. Republicans focus on health insurance because they have no intention of changing the status quo regarding delivery or cost of care.
    I think we get there, but maybe not in the way we planned, which is okay by me, as long as we get there. And we have to. It costs too much.

  33. 33
    Steve LaBonne says:

    Absolutely, positively, the “normal” family practice model should be one MD backing up a group of advanced practice nurses and physicians assistants. Paying for an MD to treat the sniffles or do a routine physical is ludicrous. And in fact resistance will be overcome simply because there will be no other way to meet the demand.

    To Mark, NURSE midwife != just plain midwife- not by a long shot. Nurse midwives, like other APNs, are highly trained professionals.

  34. 34
    RalfW says:

    My ex saw a nurse practitioner for several years as his primary care person and adored her.

    When I had knee surgery, the PA handled most of the pre- and post-op stuff, and was right there with the Orthopod during the 2 hour procedure that was supposed to be a 30 minute slam-dunk.

    I admit I was slow to warm to having a PA do most of the visits, so I do relate emotionally to the fears of many. But I got over it by, tah dah, exposure to it just being that way, and now I look back on the total experience and am satisfied.

  35. 35
    Wag says:

    Can a highly trained nurse deliver anesthetics as well as a physician who has specialized in anesthesiology

    Yes, without a doubt a CRNA can deliver the same high quality care, if not higher quality care, than an MD. And I hope that Gov. Ritter makes the right decision and opts out.

    Trivia-Bill Clinton’s mother was a CRNA.

  36. 36
    suzanne says:

    @shortstop:

    and I’ve gone to walk-in clinics (doc-in-the-boxes)

    When I use this term, I’m referring to something completely different.

  37. 37
    WereBear says:

    Only a hundred+ years ago, physicians were diagnostic wizards; because there was little they could do to actually cure people.

    Now, we have the opposite problem; we cure so many things, so easily, that most doctors run down the most likely and off you go with a prescription. I don’t think this needs particular expertise; heck, I could do it and be right 90% of the time.

    I think we would do better with a lot more nurse practitioners, and then see a doctor if “by the numbers” isn’t working. That’s when we need diagnostic wizards; and then they would be more likely to be diagnostic wizards.

  38. 38
    Felonious Wench says:

    I have good insurance. I’m fortunate.

    However, for the colds, flu, strep throat, etc. that a family with two kids and one teacher gets, I rarely go to the doctor. I go to our clinic down the street. It’s more convenient, they have great hours, and the nurse has become part of the family. She knows us all, takes her time, she’s just great. I go to our doctor for more serious issues, which are rare.

    My family has had better medical care than we have in years, because I can get in to see her as soon as an illness starts. She checks us, gets us meds if we actually need them, and sends us on our way.

    You will pry my local clinic, staffed by a wonderful nurse, when you pry it from my cold, dead hands.

    FW

  39. 39
    MikeTheZ says:

    Wait wait wait…

    A larger supply means a demand for more doctors…

    And the Worshipers at the Alter of the Free Market think the laws of economics CAN’T solve this?

  40. 40
    merrinc says:

    @suzanne:

    Same here. Last time I went to a Doctors Urgent Care, I had pneumonia (for the second time in 18 months) and no health insurance. They wanted $175 just to see me – and that didn’t include the cost of x-rays, meds, etc. It was Sunday so I just decided to wait until the next day when the practice I regularly go to would be open. (Because what the hell, I was only suffering intense pain when I tried to BREATHE.)

    My doc has always cut me a break by coding the exam as less intensive and the practice gives a 20% discount for payment in full at time of exam. So even with paying out of pocket for a prescription, it cost less than the doc in the box place.

    First thing I did when I got insurance was get the goddamn pneumonia vaccine. It’s typically recommended for 65 and older and I still have plenty of fifties left but I would have trampled some senior citizens to get that vaccine.

  41. 41
    Cain says:

    It’s a low-cost county clinic, and I got great medical care, although I rarely saw the physician.

    This is pretty much why health care in urban cities in India is so cheap. You can throw a stone and hit a clinic. We don’t have healthcare insurance in India (or maybe we don’t use it.. I dunno) It seems better just to have clinics plentiful. The doctors are sometimes a crapshoot but most of the time they are pretty reasonable. Much cheaper than the American system (is it safe that our system is the most expensive?)

    The right always argues that health care is expensive due to lawsuits and what not. We’re going through a frivolous one right now and it’s an emotional rollercoaster.

    cain

  42. 42
    liberal says:

    @Kay:
    I pretty much agree. OTOH, a lot of people (patients/health care consumers/whatever) have unreasonable attitudes about medicine, like the idea that more is always better.

  43. 43
    liberal says:

    @Steve LaBonne:

    Absolutely, positively, the “normal” family practice model should be one MD backing up a group of advanced practice nurses and physicians assistants. Paying for an MD to treat the sniffles or do a routine physical is ludicrous.

    Yes, it’s totally absurd.

    Another thing I don’t get is why it’s economically efficient for MDs to organize themselves into these fairly tiny groups. There’s no economies of scale? I suspect the rent collection opportunities are greater when the practice is smaller.

  44. 44
    CA Doc says:

    @ Liberal
    It isn’t economically efficient and the overall trend is away from small practices. However in big chunks of the country, a small rural population can’t support a larger group. Also, many physicians love the fantasy that they can only fully advocate for their patients by being fiercely independent. I don’t happen to buy that, but it is a strong part of physician culture.

  45. 45
    Louise says:

    NPR did an entire week on this issue last month. See the summary of the series here.

  46. 46
    liberal says:

    @CA Doc:

    But to think that this country can fix its huge primary care problem with some NP’s in retail clinics is crazy. Primary care is ongoing prevention, diagnosis of new problems, coordination of specialist care and end of life care. You get the most cost savings when this is provided in the context of a long term relationship, because the power of trust and familiarity goes a long way towards healing and preventing waste and duplication of services.

    Yes, but why not have larger clinics with larger NP:MD ratios? The current system simply isn’t rational.

    The money to be made in healthcare right now is in specialty services, not in primary care.

    Seems that way, because it seems like the choices for PCP with my insurance (very large carrier) is pretty limited, but specialists are not.

    People follow the money, so until the payment structure changes, we remain with an expensive, upside down system with way too many specialists and too few primary care docs.

    Yes, the payment structure has to change, but the entire medical industry is completely irrational. The fact is that there are multiple market failures in medicine, so the only way to get anything resembling a rational cost/benefit is to have top-down control.

    A lot of that will involve curtailing physician freedom. (Example: doing away with most spinal fusion surgeries, which the evidence says is a total waste of money—IIRC tens of $B/yr.) Relatively high physician autonomy, coupled with physician rent seeking in the form of tight controls on MD slots in med schools and MD immigration as well as inevitable patient ignorance (tremendous information asymetry), is the perfect recipe for exploding costs.

  47. 47
    liberal says:

    @CA Doc:

    It isn’t economically efficient and the overall trend is away from small practices.

    I live in a pretty densely settled suburban region of the Wash DC metro area, and I see no evidence of such a trend.

    Went to a PCP a couple days ago (family medicine MD): maybe two or three MDs at that office. In a building with lots of tiny practices. Got referred to a cardiologist. Two of them in that office, with the same last name.

  48. 48
    liberal says:

    @Felonious Wench:

    However, for the colds, flu, strep throat, etc. that a family with two kids and one teacher gets, I rarely go to the doctor. I go to our clinic down the street.

    Why go anywhere with colds or flu, as they’re not treatable if they’re viral? (Well, I guess we can treat viruses now, but in most cases there’s no point.)

    Strep is another matter.

  49. 49
    aimai says:

    @Mark:

    So how and why does Holland do it so successfully? The notion that tons of babies need to be resucitated at birth–or that that resuscitation depends on some magical “doctor” skill not possessed by midwives, is just absurd. The vast majority of births are pretty uneventful–so uneventful that hospitals prevent you from coming in until you are already in labor–or long predicted to have problems. That is, close monitoring before the labor indicates the majority of problems that will occur for a high risk pregnancy.

    I had both a hospital birth and an at home midwife birth. The very nice suburban hospital where I had my first child was so abusive to the delivering mothers that they were unable to supply us with (for example) vaseline for our dry lips–that was on another floor and not to be accessed. Every change in shift meant a change in attitude/rules from the nursing staff. The doctors only show up in the last fifteen minutes anyway. If there had been a problem with the birth they would have whipped me off to an operating room and I can assure you, given the rest of the treatment, it would have taken more than fifteen minutes. At my home birth, since I’m five minutes from a hospital, I would have been in the same operating room in fifteen minutes with the same call ahead to schedule it.

    aimai

  50. 50
    CA Doc says:

    @Liberal
    I totally agree with you that team practice, with MD’s providing the care that needs a medical degree and delegating what doesn’t, is the way we need to move. But care currently is paid for only with face to face visits. Until we change that paradigm it is hard to change the structure of practice.
    The very strong wave of change provided by managed care in the 80’s and 90’s swept a lot of small practices away in California, but other parts of the country were not as affected. The emphasis in the ACA on innovation in measuring quality and paying for value is a start in redesigning the system. But it may be too little too late for our primary care infrastructure.

  51. 51
    catclub says:

    @WyldPirate:

    You had me up until this part:
    “The same thing has happened in the sciences at the PhD level. The number of Americans going into these programs have been stagnant for years. Why, because the pay absolutely sucks. The training is basically slavery and there aren’t any jobs.”

    I would argue that restricting supply of MD’s and getting very large salaries out of it for the limited number of MD’s is definitely NOT ‘the same thing’
    as low supply of job seekers for jobs where the pay sucks and the training is basically slavery and there are no jobs.

  52. 52
    Mark says:

    @aimai: Europe has a totally different attitude to infant mortality. They punt on a lot of kids who get resuscitated here. Just look at the standard for premature babies – the American standard for viability is several weeks younger than in Europe.

    Seriously, I think you’re engaging in anti-intellectualism here. Doctors may be pricks with no social skills, but they’re generally smart people (smarter than midwives) who’ve seen a lot more complications and have a better idea what to do with them. Why you would want to use a less-educated person to deliver a baby in an environment with a higher mortality rate is beyond me.

    For a while, I dated a pediatrician who was doing her residency in a serious teaching hospital. There is no question in my mind that when you’ve got a baby who’s not breathing – and that’s a lot of them – you want her on the job and not a midwife who pretends that she can handle complications as well as a hospital can.

  53. 53
    Mark says:

    Btw, it amazes me that we have a society where people won’t vaccinate their kids because Jenny McCarthy says not to, but they advocate taking known risks with childbirth.

  54. 54
    kay says:

    @Cain:

    This is pretty much why health care in urban cities in India is so cheap. You can throw a stone and hit a clinic. We don’t have healthcare insurance in India (or maybe we don’t use it.. I dunno) It seems better just to have clinics plentiful. The doctors are sometimes a crapshoot but most of the time they are pretty reasonable. Much cheaper than the American system (is it safe that our system is the most expensive?)

    This is the other thing I don’t get. I would think rural areas would be thrilled to look at options, because we have no choice. We have a single (private) medical group that offers access in two counties. One “choice”. I have to drive 40 miles if I want to go to a public clinic, and, you know, I do, even though I now have health insurance. Since poor people have 1. unreliable transportation and 2. rural areas don’t have public transportation poor people go to the local (private) emergency room or else they don’t go.
    Conservative states are getting screwed the worst, yet they’re the most resistant to reform.

  55. 55
    Joe Buck says:

    Nurse practitioners can do a lot, and can deal with someone who has common cold or flu symptoms, or a muscle strain, just fine.

    But anesthesia? One of the most common reasons for dying in surgery is the anesthesia: too much and you’re dead, too little and you may have PTSD for the rest of your life, remembering how it was when you couldn’t move but you could feel the knife cut into you. It’s insane to move this job to untrained people.

  56. 56
    kay says:

    @Joe Buck:

    There’s stats in the article that would go against that. I know, I always heard that too, but apparently it is no longer true.

    I think “untrained” is wildly inaccurate, too. They get plenty of training. They’re well compensated, too. It’s not bargain basement at all, it’s just half the cost of the MD.

  57. 57
    WyldPirate says:

    catclub@52:

    You know, catclub, after re-reading it, I see you’re right. They’re not really the same thing at all.

    Could we agree that both of the situations I described are pretty slimy practices?

  58. 58
    thalarctos says:

    @liberal: Often you can’t tell the difference just from symptoms without having a culture taken. It very often turns out in hindsight that it was indeed viral, and can only be treated symptomatically, but expecting people to be able to distinguish between them beforehand from the symptoms, especially with non-verbal infants or with toddlers who can’t accurately describe how they’re feeling, really isn’t practical.

  59. 59
    Mark says:

    What surprises is that no one is seriously talking about cutting doctor pay. Dermatologists and radiologists don’t need to make $350k for 40-hour a week jobs.

    But we have a government that has decided that a few professions – medicine and finance – must continue to make a lot of money because…Well, I don’t know what we would lose if finance was merely as well-compensated as law or engineering…

  60. 60
    Kay says:

    @Corner Stone:

    To be clear, there is zero wrong with building in efficiency, or reducing costs, or providing better more patient centric care at lower overall cost.
    My point is that when you allow the argument to be started from cost then you have removed the humanity of what we should be talking about.
    HCR should have been an equal rights issue, IMO.

    I disagree with that. Talking about health care without talking about how much it costs or why it costs so much is cowardly. It avoids the whole issue, and deludes people into thinking they can maintain the status quo if we just shift costs, to insurance companies, to government, to someone else. We can’t. It costs too much, but talking about that means you have to to take it out of the moral realm and get hard-headed, and we weren’t ready to do that, mostly because most of us have insurance so don’t have to worry about it.

  61. 61
    EFroh says:

    HEEEEYYYY Lucas County!!!

    *bred, born and raised in Maumee* :)

  62. 62
    Corner Stone says:

    @Kay: Again, you avoid reading what I wrote.
    Talking about cost is good, efficiency good, better patient outcomes good. Not “avoiding” anything or leaving part of the issue out.
    But when that is the starting point you’ve lost. Your “hard headed” realm is going to get you nothing but a bunch of demagoguery about how we’uns is paying for them shiftless lazy bums! That’s all that was talked about. Not how to make care better. How to antagonize angry white middle class people.
    You will never, ever have the discussion you keep saying you want if you start or focus on the cost side.

  63. 63
    Kay says:

    @Corner Stone:

    We focused on health insurance because that made it easier to pretend nothing else had to change. All we needed was single payer or a public option, and we’d all get elaborate, equitable care at low, low prices. We’d have an “equal right” to health care.

    It’s nonsense, Cornerstone. Health care is 1/6th of the economy. Like it or not, it’s also a shit-load of middle class jobs. Pretending you can shift costs and never address what it costs and the repercussions of any change there is a fantasy.

    Not what health insurance costs. What health care costs.

    Still, liberals are light years ahead of conservatives, who simply restrict access and deny care to cut costs, and natter on about “selling insurance across state lines”, which is yet another pain-free “solution” that does next to nothing. Conservatives haven’t even addressed health insurance costs. We’ll die waiting for them to man up enough to address what health care costs.

  64. 64
    Corner Stone says:

    @Kay: If you can’t read it’s not my problem.

  65. 65
    Kay says:

    @Corner Stone:

    You have an almost child-like faith in the power of narrative to change reality.
    I’m not talking about denying costs or pretending they don’t exist, to pursue some higher-plane moral discussion. I’m talking about speaking about this in a way that doesn’t reinforce the conventional wisdom that we are powerless to have any effect on our own medical care system, and we have to bash our heads against the wall to prop it up. We don’t. We can look at alternatives, without being so fearful.
    I don’t think it matters, ultimately, as I said. I think it changes whether interested parties like it or consent to it or not. I think it changes faster with millions of new patients.

  66. 66
    Felonious Wench says:

    @liberal:

    Why go anywhere with colds or flu, as they’re not treatable if they’re viral?

    That’s why I said in my post: “She checks us, gets us meds if we actually need them, and sends us on our way.”

    Note the “If we actually need them.”

  67. 67
    Tom Levenson says:

    @Mark: More w. Mark than my sometimes co-conspirator Aimai here. Just came off brunch with my niece, who is in the midst of her OB/Gyn residency in a very big city. Home midwifery is not a bad idea at all for pregnancies that have been fully medicalized throughout — all the diagnostics monitoring etc. — and that are known to be of low risk, and for which plan B is clearly worked out ahead of time (Doc on call, hospital identified and in the loop and so on.)

    But, as described by my niece (among others, and yes, I know that anecdotes ain’t data) there are in fact important things that doctors actually know and do, and there are plenty of births that call on those skills, and the most frustrating experience my niece has had is explaining to folks who have had wholly unnatural pregnancies — bunches of IVF, miscarriages, this and that — that a “natural” childbirth poses real risks for mother and child.

    I’m completely down with the idea that there are lots of contacts with the medical system that don’t need to go through the hands and minds of MDs; but it is important to pay attention to the events that do, or that often do.

    Also, FWIW — I’m getting my care through a practice that seems to approximate what the sense of the thread requires: I have a great primary care doc (we followed her, and paid more for the privilege, from my institution’s captive HMO to a larger NFP one, and will follow again, and pay more, next year, when my employer drops HMO (1) in favor of more restricted choices). She works in a large practice affiliated with a big bad tertiary care hospital (the Brigham, as it’s affectionally known round here, part of the Partner’s megalith that is the source of a fair amount of health care inflation in these parts). I see her once a year for my physical, and if needed at other times, but for routine or occasional complaints, I see the NP with whom she works. My doc reviews my file and responds to the system imperatives (emailing prescription approval to my PT, e.g.) but she does not take the time, nor need she, for most of what I need right now from a health care provider.

    It can be made to work in other words: I have a very good doc, and because of the economics of her practice and the use of appropriate caregivers, she is able to see me and my family and many more folks than she would if she were compelled to handle the strained ligaments and scrapes and pains of 50ish existence. Good for us, good for her employer, good for the system.

  68. 68
    Corner Stone says:

    @Kay: If you can’t read it’s not my problem.

  69. 69
    Mark says:

    @Tom Levenson: Not sure if you’re agreeing with me or not. I’m not opposed to a midwife delivering a baby in a hospital…I just can’t believe people who worry about 1-in-a-million freak accidents would put themselves at risk of being among the 1-in-1000 home deliveries with serious complications.

    Maybe I’m mis-perceiving this thread, but it seems to bring out a lot of anti-education/anti-scientific attitudes. You can’t have it both ways – if republicans are morons because they don’t believe in evolution, then you can’t cling to your fantasies about organic food, cell phone towers, vaccines, chiropractors and homeopathic medicine. Science is all-in – either you’re willing to examine the evidence in all cases, or you don’t get it.

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