“Those days are gone foreverOver a long time ago…”
— “Pretzel Logic,” words and music by Walter Becker and Donald Fagen (Steely Dan)
A woman in her 70s reacted to one of my online essays about the importance of narrative medicine to physicians’ well-being. She said, “[Doctors] can’t be bothered with narration, they can barely be bothered with my finishing a full statement on what brought me into the practice that day.”
It is true that doctors are bombarded with administrative requests that detract from vital time with patients, not least of which are computer orders, lab look-ups, and clinical summary entries. These tasks can be time-consuming and often subtract from the important time that doctors could be spending with their patients. Research has shown that doctors spend nearly two hours on administrative tasks for every hour they spend with patients. This administrative burden not only reduces the quality of care but also contributes to physician burnout. By delegating these tasks to professional assistants – medical scribes, transcriptionists, coders and billers, etc. – doctors can focus more on their primary role, i.e., patient care.
The rise of Nurse Practitioners (NPs) and Physician Assistants (PAs) has been another development in the healthcare industry aimed at easing the administrative and clinical demands of physicians. These professionals have advanced training and education that allow them to diagnose and treat patients, prescribe medications, and manage patient care, thus reducing the workload of physicians. This not only allows doctors to focus on more complex cases but also helps in addressing the physician shortages, particularly in rural and underserved areas.
Furthermore, NPs and PAs play a crucial role in preventive care, patient education, and chronic disease management. Their role has been increasingly recognized and utilized, especially under the patient-centered medical home model and team-based care approach. The coronavirus pandemic underscored the importance of these roles in delivering essential healthcare services. The rise of NPs and PAs represents a transformative shift in the healthcare paradigm, enhancing accessibility and efficiency of care.
What about population health? Have NPs and PAs contributed to the overall improvement of healthcare outcomes? Herein lies the rub, for several studies have shown otherwise, finding that NPs and PAs provide inferior care compared to physicians and increase overall costs. However, the interpretation of these findings is difficult and often depends on the context and specific criteria used to assess quality and cost-effectiveness. It is important to note that the role of NPs and PAs is not to replace physicians, but to complement their work, particularly in areas where there is a shortage of physicians.
Regarding the cost, while the use of NPs and PAs might increase certain aspects of healthcare costs, such as more frequent follow-ups or tests ordered, they may also contribute to cost savings in other areas, such as reducing the need for specialist referrals or hospital admissions.
Quality of care and cost-effectiveness in healthcare are complex issues that depend on many factors. It is crucial that each healthcare provider works within their scope of practice and collaborates effectively with others to ensure the best patient outcomes. The American Medical Association has vowed to fight “scope creep.” As healthcare systems continue to evolve, the roles of NPs, PAs, and other advanced practice providers will likely continue to be refined to optimize patient care and resource utilization.
The preceding discussion underscores how the practice of medicine has changed over time. In the “old” days of medical practice, care was largely delivered by individual physicians, often in solo practices. Physicians were responsible for all aspects of patient care, from diagnosis and treatment to follow-up and administrative tasks. However, as modern medical knowledge and technology, it has become increasingly challenging for one person to manage all aspects of care.
Enter investor or equity-owned healthcare practices. This model has become increasingly prevalent in recent years as many healthcare providers seek to navigate the financial and administrative challenges of modern health care.
On one hand, investor ownership can provide practices with the capital needed to invest in advanced technology, infrastructure, and staff training, potentially improving the quality and efficiency of care. It can also help with back-office tasks, allowing physicians to focus more on patient care.
On the other hand, there are concerns that investor ownership may prioritize profit over patient care, leading to increased costs or decreased quality. For instance, practices may be pressured to see more patients, order more tests, or perform more procedures to generate revenue. Additionally, decisions about patient care could be influenced by individuals without medical training. Nearly half of private equity-owned physician practices are resold within three years – to other private equity firms – creating a “buy to sell” mentality that may not result in any long-term benefits for physician practices and their patients.
Furthermore, the consolidation of practices under investor ownership can reduce competition, potentially leading to higher prices for patients and insurers. Thus, while investor/equity-owned practices can bring benefits, it is crucial to ensure that these arrangements are carefully regulated to prioritize patient care. Both the U.S. Department of Justice and Federal Trade Commission responsible for enforcing U.S. antitrust laws, have emphasized healthcare policy as a top priority. The two federal agencies primarily responsible for enforcing the U.S. antitrust laws – have publicly pronounced that private equity investment and acquisitions are a top priority for the agencies and are setting their sights on health care.
Approximately three-quarters of the U.S. physician workforce are now employed. The Contrasting the ‘old’ days with the modern medical practices of today may have had their merits, such as the close doctor-patient relationships and the continuity of care, but the rise of investor-owned practices coupled with an over-reliance on physician extenders has all but destroyed private practice and perhaps the integrity of the medical profession – and there simply is no going back.
Pretzel logic – twisted reasoning – has won out.
