Primary Care: Time to Reboot
Posted on April 8, 2008
Filed Under New business models for healthcare, Primary Care in America |
American primary care medicine has entered into a period of change. “Change” is perhaps too mild a term; many - especially the primary care practitioners (PCPs) themselves - might call it a period of crisis. In any case it is change so profound that one might be forgiven for thinking Senator Obama is already president.
Consider. PCPs have been hogtied to a dysfunctional reimbursement system that (thanks to the government, the insurers, the AMA, and their own specialist colleagues) has drastically and systematically devalued their training, expertise, and time. The very concept of what a PCP is and does (and indeed, what they should be called - whether PCP, family doctor, general practitioner, gatekeeper, or medical homemaker) seems in constant flux.
Whatever it is PCPs do, the government, the insurance industry, and experts on medical policy have spent years making the primary care job seem, well, easy. Their practices have been reduced to a series of discrete, easily cookbookified tasks. Each of these tasks can be directed by “guidelines” (devised, of course, by non-PCP “experts”), compliance to which can be easily tabulated and monitored, thereby to determine the adequacy of the individual PCP’s performance. And, because their job is now so codified, they are expected to perform it accurately and reproducibly in a matter of minutes (some say 7.5 minutes per patient encounter, though others will allow up to 12.5), just like any other rote industrial process.
To make matters worse, PCPs are slowly awakening to the realization that they are being squeezed out from the bottom. Some of what they do (the really easy stuff) is being corporatized into mini-clinics by the large drug store chains, and the rest is being threatened by newly assertive nurse practitioners and doctor-nurses, who are at least tacitly supported by the insurance industry. (Thanks to Dr. Poses for pointing out the relationship between doctor-nurses and big insurance.)
No wonder PCPs have become so terminally frustrated.
It is natural for PCPs to want to fight the changes that are destroying their profession, and causing their numbers to dwindle. Many have offered ideas. Gain the public’s support by alerting them to the impending and dangerous shortage of PCPs. Improve PCP payment schedules. Forgive the student loans of young doctors who choose primary care. Lobby congress for pro-PCP legislation. Offer novenas.
Some of this (DrRich is thinking the novenas) might hold off the inevitable for a time. But PCPs are fighting more here than just the government, the insurers, their specialist colleagues, and nurses filled with thoughts of vengeance (for 150 years of having to give unquestioning obedience to arrogant, clueless and unfeeling doctors, if you care to ask them). The PCPs are fighting history.
What is happening to PCPs is what happens to many experts whose jobs are fundamentally based on knowledge and/or technology. That is, as knowledge and technology advance, some (and perhaps a lot) of what the experts do can be sufficiently simplified and “democratized” that less well-trained individuals become enabled (or believe they are enabled, which amounts to the same thing) to do it themselves.
This is what the market is telling PCPs has happened to them. A substantial part of what they do indeed has been reduced to guidelines and cookbooks (thanks to remarkable advances in clinical studies and medical technology). The typical patient (note: DrRich said “typical”) with hypertension, diabetes, cholesterol abnormalities, and common infections can be relied upon to respond reasonably well to reasonably standardized therapy. And the market is saying to the PCP: “We can find ways of doing this without you.”
The same thing has happened countless times in history. The 1500-year monopoly enjoyed by the clergy in interpreting the Word of God was completely disrupted by the printing press and by the upstarts who translated scripture into the vernacular. The music industry has been fundamentally disrupted by digital recording software, which enables anyone with a PC to do things that had always required multi-million dollar studios. Ditto for book publishing. Ditto for real estate agents, accountants, car dealers, teachers, newspapers. All are wrestling to one degree or another with the “creative destruction” that is produced by advancing knowledge and/or technology.
For the most part, of course, nobody (except, perhaps, the doctor-nurses) will come right out and tell the PCPs to go away altogether. Instead, they’re telling them to dumb down, to just follow the rules, to stick to the guidelines and be paid to perform (one thinks of trained seals), to become like the lesser-trained practitioners who inevitably will be replacing them over the next decade or so. That’s where the profession is going, they’re being told. Get with the program, adapt to reality - or don’t let the door hit you where you keep your wallet.
Looking at the situation from this more historical perspective, one can see why it seems futile for PCPs to respond by railing and complaining, by lobbying for the public and the legislatures to understand that they’re actually quite important, by appealing to their specialist colleagues for more than lip-service support, or by trying to convince more medical students to choose a disintegrating profession such as this.
PCPs are in the path of a tidal wave of disruption, triggered by economic realities and enabled by technology. They are unlikely to prevail by a’wishing, and a’hoping, and a’singing, and a’praying.
From the perspective of history, it becomes apparent that what PCPs need to do is reboot. They need to reinvent themselves in a way that is compatible with the new reality. So far, they seem to be seeing only the disruption part of the creative disruption now tearing their profession apart. They need to find the creative part.
From a simple examination of history, two possibilities will immediately come to mind.
1) Just as advancing medical knowledge and technology has made it possible for lesser-trained individuals to encroach on their turf, so have the same advances made it feasible for PCPs to encroach on the turf of their snugger (and smugger) colleagues - the specialists. Observing how some of the bread-and-butter skills of the PCP have been sufficiently reduced to the point that nurses can do it, one finds it inconceivable that similar basic skills now monopolized by specialists haven’t been similarly reduced. It is undeniably true that for a lot of what specialists do, one doesn’t actually need a specialist anymore to do it. (As a cardiologist, DrRich knows for a fact that this is the case, but unfortunately he is bound by blood-oaths extracted by the high priests of his guild - oaths which mortgaged the immortal souls of his progeny down through 10 generations - not to mention the specifics. Sorry.) But look around. You’ll find examples easily enough.
Fundamentally, advancing technology allows individuals to migrate upwards into areas formerly occupied only by more specialized individuals. This is a law of technologically progressive societies. That nurses are aggressively migrating upwards onto the turf of PCPs is merely a case in point. So, rather than fighting a doomed-by-history rear guard action against the advancing army of nurses, why should PCPs not instead launch a blessed-by-history invasion of their own, against the smugocracy (the people whose jobs end in -ologist)? Heck, they’ll even have the insurers and the feds on their side for once (for the same reason the doctor-nurses now do). Wouldn’t that be novel?
2)Another law of technologically progressive societies is that, whenever specialists are displaced by upwardly mobile, technology-enabled non-specialists, there will always be a portion of the customer base that is likewise displaced. That is, the new, less-sophisticated service providers will be able to provide useful services to a majority of customers - but not to all customers. The customers with high-end needs, who are left out under the new regime, present a new business opportunity.
PCPs operate in a world where the majority of their patients probably have relatively common, relatively easily cookbooked medical problems, and most of these patients will do just fine with their new doctor-nurses. But a substantial minority will have high-end needs, either in terms of complex medical problems that cannot be reduced to simple treatment pathways, or in terms of atypical medical problems that are not easily diagnosed.
DB has discussed at some length this “long tail” in the patient population, as defined by some aspect of material complexity in their medical conditions. The long tail simply cannot be served by guideline-directed care, whether administered by doctor-nurses, or by those more malleable (or complexity-averse) PCPs who will simply allow themselves to be absorbed by the new, dumbed-down primary care regime. Long-tail patients, the outliers, will not be small in number. They will comprise an important new business opportunity, “new” because it is a niche that is not recognized today, as it will be when these patients are being systematically (instead of randomly) culled out.
That business opportunity can be filled by many of today’s PCPs. These will be doctors who enjoy puzzling through complex diagnostic problems, and dealing with complex management issues, and have been trained to do so. To DrRich, this spells “internist.” Doctor-nurses can’t do this job. Specialists can’t do it either. This will be a specific niche for internists.
The best part is that the feds and the insurers, in selling us on the dumbed-down PCP model, are busily assuring us that there is no substantial need for sophisticated PCPs (hence, the appropriateness of doctor-nurses). And in proving the point they’ll be able to rely on carefully constructed, population-based outcome measures (which, since they speak to the average patient, will look very favorable) to marginalize the complaints of the outlying patients. Having refused to acknowledge the existence of complex patients, they’ll hardly be able to make special provisions for their care.
This leaves the door wide open for internists to establish practices to provide healthcare services to patients with difficult diagnostic or management problems, who are being neglected and mishandled by the “official” healthcare system. (These patients know who they are, and are desperately looking even today for somebody to help them.) And since to insurance companies and the feds these patients don’t exist, these practices will have the opportunity to operate outside the system, as private-pay practices, which will eliminate the demeaning checklists, the one-size-fits all guidelines, and the stifling time limits under which PCPs now must operate. And, like plumbers and electricians, they can get paid for what their time and expertise is worth.
(To those of you who immediately object to such a thing because asking patients to pay themselves for medical care is unethical, DrRich asserts it is indeed possible to do this entirely fairly and ethically, while allowing almost anyone who wants this kind of service to have it, and some day he will describe how. But for now, just celebrate the right of people to spend their own money on their own healthcare even when it’s provided by actual physicians, just as [DrRich suspects] you celebrate their right to spend money on chelationists, homeopaths, or reiki practitioners.)
The bottom line, as DrRich sees it, is that the identity crisis now being experienced by American PCPs, while certainly catalyzed by healthcare economics and politics, is a manifestation of the natural and inevitable disruption produced by advancing knowledge and technology. PCPs may be the first, but all physicians will soon face similar challenges as long as medicine continues to advance.
If the PCPs respond logically to this crisis - that is, instead of fighting it, recognizing the opportunities it presents - their specialist colleagues will soon experience their own “encroachment from below,” which is the hallmark of a mobile, technologically progressive society.
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21 Responses to “Primary Care: Time to Reboot”
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Fascinating analysis, and one I find myself largely agreeing with.
I will have to cogitate on this one a while and perhaps read it again.
Is history squeezing out primary care?…
A unique, and one of the best, takes of the primary care crisis I’ve read:…
Well, option #1 is what a lot of us do in the sense of “having an interest in (–ology)”. However, without the official stamp of having done a fellowship in said specialty, one is set up for liability by pretending to be that which you are not.
That leaves option #2 which is better known as concierge or boutique medicine. As abhorent as I find that option (and not for the usually assumed ethical reasons), it has the advantage that you can choose to suffer financially by ignoring inappropriate pay for performance measures since your patient is supplying your reimbursement. This allows you to BE A DOCTOR and not just function as an automaton.
great post.
However, I think it fails to consider an important factor of generalist care: care of the vague complaint. This is a large part of the value added and something that specialists and/or PAs/NPs are simply not trained for.
If a wise and experienced generalist can efficiently treat or triage or reassure the patient with “side pain” or “breathing troubles” or “pain in my head” or “shooting pain in my leg” or “tired all the time” the system saves money. A lot of money. Keep in mind that even during the guideline driven 10 minute chronic care visit, the vague complaint often rears it’s ugly head.
Having the confidence (earned from rigorous training and experience) to reassure patients much of the time, and judiciously use resources only when necesssary for such complaints is the best way to treat the masses and the multitude of undifferentiated complaints that walk through the door every day. Leaving it to specialists (if you can even figure out which specialist to use for the undifferentiated complaint) will certainly result in more testing, much of which will be overkill. (remember, to a hammer everything is a nail) Midlevels, in general, won’t have the confidence that comes from at least 7 years of training to do the job either. (will likely end up back to the specialists).
This is why the rest of the western world uses a primary care dominated model. Abandon it at your own peril.
Keith,
Nobody said that moving onto the turf of the acknowledged “experts” will be easy or without hazard. The medieval clergy reacted to technology-enabled turf-intrusions by declaring the upstarts to be heretics, and instituting inquisitions and stake-burnings (which, arguably, were even more off-putting than the threat of malpractice suits and specialist-dominated hospital credential committees). This is not something that happens without a fight, sometimes a bloody and painful one, with lots of casualties. Ask a nurse you can trust how easy it’s been to finally begin encroaching on PCPs.
This is why groups usually mobilize to push their “superiors” off their turf only when they themselves are being pushed. Ask the Goths (the ones who finally pushed south to sack Rome), all about the Huns. Their choices (similar to the PCPs) were: be annihilated, be absorbed, or move on to greener pastures currently occupied by somebody else.
The way I see it:
Huns = nurses
Goths = PCPs
Fat, effete, overpriviledged Romans = specialists
Rich
pcb,
I failed to mention your point (the post is too long already), but did not fail to consider it.
Determining which vague complaints are likely to indicate pathology and which can be reassured into acceptabilty is indeed a service that can be provided by the internists I’m talking about. And you may be right that the doctor-nurses will respond as many PCPs do today when faced with complaints they cannot characterize - and fire the patient off to one or more specialists, who will react by performing whichever expensive tests are in their repertoire, whether likely to be of use or not. If so, expenses will be very high.
And if so, the insurance companies won’t have gained much by driving away PCPs. But that’s not their plan.
So (in the spirit of tying everything to covert rationing) I’m guessing that the doctor-nurses will be directed by (and fully protected by) handed-down guidelines. So, for instance, the 70-year-old woman with a complaint of “weak and dizzy” will be given a CBC, lytes and an ECG, and if all looks reasonably OK, a pamphlet on coping with the ravages of aging. There will be no concern here except for following the guidelines. The patient will probably be fine. If it turns out she has something serious, nobody’s at fault. When her underlying disorder finally manifests, odds are reasonable that overall expenditures will not be much greater than if an early diagnosis had been made - and may be substantially less. I’m postulating, in other words, that the economics of such a scenario would be favorable to the “system.”
Under my proposal, on the other hand, that 70-year-old would at least have the option of going to a doctor (a good general internist) who can really evaluate her symptoms. And because the internist is interested in pursuing complex diagnoses, really wants to help the patient, and is BEING PAID for time and effort, will try her hardest to do a good job, as economically as possible, and resolve the issue for the patient.
The fact that the doctor-nurses won’t do a good job with this patient is irrelevant to the system. The only question is: how much money will be spent? And once you move the doctors out of the picture, and replace them with a new kind of professional whose self-definition has been fundamentally centered on the vital importance to public health of following the guidelines and pathways, this is something that becomes much easier to control.
Rich
Dr. Rich,
I’m a little less confident in the ability of the covert rationers to apply guidelines to undifferentiated complaints. A guideline cannot take a thorough history, ask the right questions, decide on how to focus an exam, and then judiciously order further studies, modifying a differential each step along the way, then applying judgment and patient values and preferences into the mix before deciding on a course of action. (Especially in patients with comorbidities and polypharmacy.) For that, you need a doctor.
The biggest rationers, less covert of course, are the centralized systems in other western countries, and they seem to recognize that generalists are fundamental to controlling costs. Keeping patients away from specialists (appropriately of course
) is a key to resource utilization. Any good rationer knows that.
One would think we would inevitably come to similar conclusions here.
pcb,
I hope you’re right. But covert rationing has nothing whatever to do with what works, or what’s fair, or what’s efficient, or what’s right - and everything to do with what you can get away with. How well the guidelines actually help patients (under my scenario) is ultimately irrelevant. It’s whether you can get away with promulgating guidelines that reduce dollars spent (whatever the “cost” to the patients themselves).
I believe the payers think (or hope) they can get away with eliminating (or at least greatly diminishing), the physician’s role as the point of entry into the healthcare system, and replace them with less independent, more malleable professionals.
The ultimate malleability of doctor-nurses remains to be seen. One suspects they will be “infected” by professional pride themselves, and will want to think for themselves and actually help patients. The ultimate gullibility of patients in subjecting themselves to one-size-fits-all pathways, likewise, remains to be seen.
None of this ought to give current PCPs any comfort. If they don’t reinvent themselves, then even if you are correct and the system inevitably realizes that PCPs (in their current incarnation) are needed, by that time irreversible damage will have been done to their profession. That, of course, is happening right now.
One of the most intelligent treatments of the primary care collapse I have seen, but I beg to differ on a few points. Dr. Rich describes a process which evolves in a medically and economically rational way. However, the process in many ways is being dictated by medically and economically ignorant bureaucrats and politicians. Practices outside of our current reimbursement system are not viable for most doctors. Patients simply won’t go. A number of physicians have tried this. Most have failed. Wouldn’t physicians abandon the obnoxious third party payors en mass if this were possible?
And it’s a great idea for an internist to tackle complex problems not easily managed by protocols, but our current system won’t pay for it. And imagine the resistance from specialists if PCPs were to encroach on their turf. Since specialists run organized medicine and its lobbies (i.e. AMA), PCPs would likely lose this battle, too.
I’m not as optimistic as Dr. Rich, although I am open-minded and willing to be persuaded otherwise. The federal government’s deathlock on our health care system will only increase, at least in our lifetimes. Only when the consequences of government-run healthcare become truly awful and apparent to everyone, as in the UK, will the pendulum swing away from federal control.
Sincerely,
Brian Carty, MD, MSPH
Even more than usual a great posting and great answer to some of the comments made as well,particularly the 5:21 PM reply. I am less optimistic about the likelihood of the general internist being able to re-tool in a professionally and economically meaningful way.The “midlevels” represent a threat from below mainly because the third parties believe that will save money.I don’t see how the general internists’ interest coincide to that degree with the third party payers.But I can hope.
As a family medicine resident finishing up her training, I’m starting to wonder how I’m different from these PAs and NPs and future doctor-nurses? I have more years of training and substantially more debt, but if I’m providing exactly the same service to exactly the same people as they are, what’s the point? I’d love to hear what encouragement some of the more seasoned PCPs out there can offer me.
Drs. Carty and Gault,
Thanks for your kind comments about my post. Much appreciated.
The suggestion you both made that I am perhaps being overly optimistic, however, makes me realize that I must not have expressed myself adequately on this point. So, I soon will address this matter in a new post.
Let me just say for now, though, that when it comes to the prospects of PCPs, I am not, in fact, overly optimistic.
Rich
Sharon,
While we wait for some encouragement from those “more seasoned PCPs,” let me make a couple of observations.
First, I am often wrong about stuff, even important stuff like this. So, maybe things will be just fine for PCPs, and they will regain the honorable position (and the pay) they truly deserve. That is, it’s possible I am way off base here.
Second, it is unlikely that even doctor-nurses will ever gain absolute equivalence with real physicians who are practicing primary care, whether in the eyes of the insurance companies, the feds or the public. There will probably always be some differential in prestige and in pay. The displacement of PCPs by midlevels will likely be relative, not absolute.
Third, keep in mind that displaced workers are a natural fact of life in a dynamic society. When I was young there were still doctors who “specialized” in polio and tuberculosis. They eventually had to move on to something else. (The TB guys, if they weren’t nonagenarians, would now begin to find work again.) HIV-aids specialists, God willing, may some day be in a similar position. I come from a family of steel workers whose entire way of life disappeared between 1970 - 1985. The advantage you have over the typical displaced worker (should you choose to become one - it will, after all, be a matter of choice, since some semblance PCP practice will likely always to be available), is that you are a physician, and there will be great need for physicians no matter who gets elected.
Fourth - and this is the real point of my post - every societal upheaval creates opportunities for those who are insightful enough to see them and bold enough to reach for them.
Rich
sharon,
check out this post to give you some optimism that the last 7 years may be worth it in the long run.
http://blogs.wsj.com/health/2008/04/10/medicare-advisors-pay-more-for-primary-care-less-for-procedures/?mod=WSJBlog#comments
DrRich: Excellent post and discussion
Sharon: Don’t despair. There is currently great demand for F.P. and you should value yourself and compare opportunities to find a practice and colleagues you like. Do not go into private practice or you will be unhappy and underpaid. Learn and do as many procedures as possible. Once you build up a loyal patient base, if you are underpaid and undervalued, you can start a concierge practice and patients will pay you for your expertise and time. The three A’s of success still apply: Ability, Affability, Availability. Good luck
Some of my fellow residents and I are always joking about opening a Botox clinic that we each work at one day a week. That would pay back my loans pretty quickly…
A brilliant analysis. Fascinating to read about the parallel universe of American health care. As a student I had a time attached to a family practice residency in Chicago. At that time, the generalist family docs- to-be were bullish about the future. In the UK, the Family doc, or GP, has always had a more entrenched position than in the USA.
But the same “dumbing down” process is happening here. The nurse-specialists are on the skills escalator taking a upward ride to demonstrate the everlasting truth of the Peter principle. The UK “internist”, the old fashioned general physician has disappeared. They are all sub-specialists now. No longer do we have that most wonderful of all doctors, the general physician, who took a holistic view of the patient, and took ownership of his “problem” and not of the organ system in which the sub-specialist specialises.
Enter the Gypsies. Well, the GPwSIs - the GPs “with a special interest.” They too are on a skills escalator with their nurse colleagues, pretending that their “interest” in, say, cardiology makes them cardiologists. It doesn’t.
I think our generation of doctors are the last of the old school.
Maybe this is progress. Maybe not. I dread getting ill!
John
John,
Thanks for your note.
I am a long term optimist, and believe that technological advances will ultimately bring great improvements to healthcare. I spend my time nowadays consulting in research and development with start-ups that are trying to harness this new technology to improve people’s health, and I assert that some of this stuff is going to be truly remarkable to behold.
Unfortunately, under a dysfunctional system based on covert rationing (which absolutely requires complexity, obfuscation and illogic in order to function), bringing such helpful technologies to market is a daunting and often impossible prospect - even if it improves outcomes and saves money.
This partially explains why I am a short term pessimist, and believe that the healthcare upheavals we are now facing will cause lots and lots of disruption, heartache, and even injury and death before things get a lot better.
The industrial revolution (in my opinion) turned out to be a good thing for mankind, but as it began it was accompanied by generations of downtrodden, oppressed, exploited masses who were powerless to help themselves. I fear for how long we will be in this destructive phase of healthcare. Certainly, I think, for the remainder of my lifetime.
I like to think that my grandchildren will have a fighting chance, though.
Rich
The Uk issue is, at its base, a fight between the British Medical Association and the government for control of the system. Because of the funding system the governemtn has little or no financial leverage to change it.
While little was asked of, or expected of the NHS, these two organization sat rather uneasily together having the occasional argument. The last time they clashed on the scale that is being seen today, and with the venom that is being experienced today, was when the Labour party created the NHS in 1948. Then, 89% of British Physicians swore they would never work for, or have anything to do with the NHS. Today, they are it’s biggest group of defenders. Why? Simply, because defending the 1948 ideal allows them not to have to change, adopt new ways of working, begin to put the patients needs before the system and it’s employees and contractors. Just as in 1948 declaring they would never work for it was a way to try and stave off change.
We Brits love to point across the Atlantic and ask “do you want your system to be like the American one where 40 million people don’t have healthcare insurance”? The clear unspoken intent is to say the US has a two tier system where 40 million people can’t access healthcare at all. It makes us feel better. The reality is that the British system is also two tiered. The 8% of the population who have private health insurance get treated in clean hospitals by cheerful physicians and nursing staff. Interestingly, they are the same staff who work in the NHS. These patients are the ones who have paid to jump the Que (line). The majority unfortunately are subjected to a post code lottery, must wait months for treatment, lie in their own feces because staff are too lazy to clean them or help them with their needs when in hospital, are treated in filthy hospitals, and generally ignored or seen to be a problem by those working in the NHS. A system that tolerates surgeons who give all the patients to be seen in a particular surgery an 8 am appointment, and then work through these patients, so the doctor won’t be inconvenienced, with the unlucky patients being forced to wait the entire day until 5 or later. There is a 1950’s arrogance still present in British medicine where the “care givers” are far more concerned for their comfort and the maintenance of the status quo than the patient. NHS employees and doctors would scream that these are harsh words, but of course, they are not the ones dying on waiting lists.
Why is the system like this? Simply because there isn’t any competition. There isn’t a fear among GP’s that patients will go to another practice if they close at 5, open at 9 and ignore the needs of the modern world. The GP surgery down the street operates in exactly the same way. They own their patients. Since the surgeons make 7 to 10 times their NHS salaries and the nursing population supplements their income from private practice of medicine, there isn’t any incentive to improve throughput levels and quality of care in NHS facilities. It is very lucrative for a UK surgeon to move an NHS patient onto his private list.
The current battle between the BMA (the doctors union) and the government is being fought by the BMA on a platform of no change what-so-ever. They maintain the system is one of the best in the world, patients don’t want better access just a good doctor. The WHO data that shows the UK at the bottom of the European league tables for outcomes, is quickly swept under the rug by placing the blame on red tape and government targets. There is never any suggestion that antiquated ideas and techniques and a rabid hatred of reform by BMA members might be one of the largest contributing factors.
Returning to my first assertion that the funding mechanism is the problem one must first understand that UK GP’s are not some of, but are the best paid GP’s on the planet. The average pay is $240,000, with many making $500,000 annually. This represents a 58% pay increase over the past 2 years, and yet in those two years, productivity has dropped some 2% in each year. Hours worked when compared to 1992 have dropped 7 hours per week. UK spend on healthcare is now at 10% of GDP which is comparable to most other modern European countries with far better outcomes than ours. So, even a marginally intelligent person must conclude the payment mechanism is broken and competition along with a social insurance payment system have to be introduced if any of these trends are to be reversed.
The UK system gives us the American system turned on it’s head. We have apparently come to the conclusion that we will tolerate 8% of our population getting reasonable and fast care, while the rest of us will have to put up with something that is not too far off systems seen in the third world. The UK government has no real leverage points to change what is an antiquated broken and failing system.
The most frequent statement made by both the BMA and the government is that the NHS is a gift to the British people because it is “free at the point of delivery and accessible to all”. This is also the problem with the NHS. Since it is seen as a free good people don’t value it, the staff don’t value the patients, and people are expected not to complain about the massive lack of quality of care and access.
There is much written about the US system that is disparaging, much of it understandable, and yet, I would much rather try and solve your problem. I have had numerous American friends over the years who have come to the UK to work for 3 to 4 years. The ones who have needed other than minor treatment have always returned to the US for care having not wanted to chance dying in the UK health system.
My prediction is that the NHS won’t exist in 10 years. As disposable incomes in the UK increase and people become more aware of their options, they too will avoid the NHS like the plague. It will reamin a poor system, but only used by poor people.
I will leave you with this; as politicians turn towards Europe and point to the Uk system as an exemplar, remember, this is the system with some of the worst outcomes in the western world, where healthcare rationing is rampant even though we spend a stated 10% of GDP (when pensions and state aid are added in, fair comparisons to the US system would put the number north of 13%) and people with experience of other systems including not just Americans but other Europeans return to their own countries for care.
QUOTE-”Midlevels, in general, won’t have the confidence that comes from at least 7 years of training to do the job either”
They probably will after spending 7 years on the job with a supurb MD/DO mentor. Are you saying that a “mid-level” will never reach the critical thinking/decision making ability of an MD/DO simply because they didn’t experience a formal residency?
I am a PCP, and in my experience, NPs actually cost more. They order more tests and consultations that I do because their training does not allow them to think from basic principles. They need “clinical pharmacologists” to help them because they don’t really understand pharmacologists and they rely to a great extent on detailing from the pharmaceutical industry and jump on the bandwagon with new drugs.
They are also used to a more 9-5, no call, type of job and will never do more than that while physicians go the extra mile. They also consider themselves “preventive” but don’t really have the knowledge base to back this up in clinical practice.