> Private equity companies pool money from wealthy investors to buy their way into various industries, often slashing spending and seeking to flip businesses in three to seven years.<p>The focus of the article is on physicians vs. NPs and PAs, but the real driver of the enshittification is, yet again, private equity firms extracting short-term profits, to hell with long-term outcomes.
Hospitals shouldn't be a profitable business. The primary goal of a hospital should be serving patients sickness. (Easier said than done)<p>My partner is a physician at a hospital in NYC, and something that they are struggling with now is lack of social services for patients to get them out of hospital beds and into homes/rehabs.<p>As a immigrant in this country, I am constantly flabbergasted by the state of healthcare here and people's willingness to accept hospitals as profit seeking businesses the same as a fortune 500.<p>Obviously if the law allows these hospitals to seek profits, they will. So the question is, how do we change the law? And why don't people want to change it?
> While diagnosing and treating patients was once doctors' domain, they are increasingly being replaced by nurse practitioners and physician assistants, collectively known as "midlevel practitioners," who can perform many of the same duties and generate much of the same revenue for less than half the pay.<p>IMO, PAs and NPs are a good idea for medicine overall. Especially since lots of folks who would consider a career in medicine are turned off by residency.<p>In the ER, though -- I can see the case for experienced MDs making a big difference in outcomes.<p>Disclosure: my wife is a PA.
My last ER visit I was seen by a PA, which is fine. They're more than competent.<p>The part I didn't like was how they made me get out a credit card <i>while</i> they we're treating me.<p>Which, according to a story by the NY Times, is a common thing. Send a nurse around with a swipeable tablet to ask how you'd like to pay.<p><a href="https://www.nytimes.com/2023/01/25/podcasts/the-daily/nonprofit-hospitals-investigation.html" rel="nofollow">https://www.nytimes.com/2023/01/25/podcasts/the-daily/nonpro...</a>
The example of the woman who went three times before seeing a doctor and having a diagnosis made is a little silly - regardless of who sees the patient, it often takes repeat 1-2 repeat blood tests every 48 hours to figure out if the patient’s HCG level is rising enough or falling which is needed to help figure out whats going on [1]. The patient is often <i>told</i> to return to the ED for those return visits because its almost impossible to get seen by an Ob-Gyn in that timescale, and the main concern is to not miss a life-threatening ectopic pregnancy.<p>[1] <a href="https://wikem.org/wiki/Ectopic_pregnancy" rel="nofollow">https://wikem.org/wiki/Ectopic_pregnancy</a>
There is some evidence in the primary care world that going to a NP for primary care costs more than going to a doctor: <a href="https://www.ama-assn.org/practice-management/scope-practice/amid-doctor-shortage-nps-and-pas-seemed-fix-data-s-nope" rel="nofollow">https://www.ama-assn.org/practice-management/scope-practice/...</a>. In short, NPs order more tests without improving patient outcomes.<p>I have no doubt that it's the same in the ER. It takes training and knowledge to know what test you don't have to order. Do you really need a CT scan for your diarrhea?<p>That being said, I think there is definitely a role for NPs : low complexity and/or non-acute highly specialized care. The emergency department is not the environment for that.
I can tell you from personal experience that hospital funding priorities are wild. It's an ongoing turf war between hospitals.<p><pre><code> * Buying up private practices
* Remodels so the hospital has a more pleasant ambiance
* Having an excessive amount of cash on hand to signal various things to various parties
* Working out the cost schedules with insurance companies
* Audits for a certifications outside of regulatory requirements that are useless on the nursing floor (lean/six sigma/etc)
* Adding new types of facilities outside the core competencies of the organization such as gyms or specialized satellite facilities.
</code></pre>
Really, healthcare is a cutthroat industry that's all about signaling.
The reimbursements for ER doctors are incredibly out of wack with the training and responsibilities compared to similar physicians, and especially with advanced practice nurses/PAs. In some places, it's not uncommon to have ER docs making over $500k while the internal medicine docs that they turn their sickest patients over to will make less than half of that. The non-physician staff performing the same will see less still. Compared to the IM docs, they have the same educational requirements, same residency length, they work at the same hospitals, but the ER docs just rake it in.
I think a dual system is necessary, due to the US’ reluctance on relying heavily on government (on paper).<p><a href="https://en.m.wikipedia.org/wiki/Healthcare_in_South_Korea" rel="nofollow">https://en.m.wikipedia.org/wiki/Healthcare_in_South_Korea</a><p><a href="https://en.m.wikipedia.org/wiki/Healthcare_in_Taiwan" rel="nofollow">https://en.m.wikipedia.org/wiki/Healthcare_in_Taiwan</a><p>Both countries are market based societies, each have taken a somewhat different approach to the problem, yet both systems are quite efficient.
> While diagnosing and treating patients was once doctors' domain, they are increasingly being replaced by nurse practitioners and physician assistants, collectively known as "midlevel practitioners," who can perform many of the same duties and generate much of the same revenue for less than half the pay. [...] In a statement to KHN, American Physician Partners said this strategy is a way to ensure all ERs remain fully staffed, calling it a "blended model" that allows doctors, nurse practitioners and physician assistants "to provide care to their fullest potential."<p>This seems like you're expecting your ER docs to handle the worst of the worst for days on end, rather than a good blend of patients. Seeing a "routine" ER patient may offer a mental break between a more critical patient. It truly seems like an actively shitty work environment to always walk into have the worst of the worst cases—because going to the ER is already a worst case.<p>This is not the right way to keep humans running well, for both the sick <i>and</i> the docs.
While also giving Nurse Practitioners and Physicians Assistants more responsibilities while paying them far less than an MD. Just the same as attorneys are expensive, so you just give everything that lawyers used to do to paralegals and pay them 1/4 as much.
Check out <a href="https://www.reddit.com/r/nursing/" rel="nofollow">https://www.reddit.com/r/nursing/</a> to get a glimpse of the modern US healthcare system (Canada and EU are similar). I don't really know what else to call it than "shitshow".<p>In an effort to cut costs hospitals severely overwork their doctors and nurses. It's endemic, anyone who knows anything about healthcare understands that people work >12hour shifts where they are always busy and you can see the constant chaos in any ER.<p>Moreover, despite being overworked and literally caring for people's lives nurses are severely underappreciated. Because people are rude and needy <i>especially</i> when they are sick or their loved one is sick, and a lot of people just don't realize what nurses have to deal with.<p>Though some nurses really are terrible at their jobs: nurses who are externally apathetic or downright sadistic or dangerously incompetent. But that too leads back to healthcare being mismanaged and underfunded, because proper management and funding is required to find and fire these nurses and or prevent them from being hired.<p>Also, environments in many healthcare orgs are toxic. Probably because of all the stress that working >12 hour shifts and seeing people severely sick. The drama and absurd rules go beyond anything I've ever heard about in any tech company, things are normalized that in a software job nobody would tolerate.<p>To say it's "a complex/hard problem" is an understatement. Healthcare is one of the biggest expenses of any country. It really does require tons of resources to diagnose and treat a sick patient: there are only so many surgeons and drug manufacturers and MRI machines, and the same symptoms can be from 1000 different diseases and the same disease can present different symptoms in 1000 patients. In first-world countries we expect to provide quality care to anyone rich or poor, because to deny care is very wrong, but in practice that means we have over 400 million people that need specialized visits and treatment.<p>But at the least people need to understand, and governments need to stop funding other various things when what we really need is more hospitals and salaries for more healthcare workers. It seems every day I hear about Canada cutting or ignoring healthcare costs or US fighting over funding and whether insurance should be private. As a tech worker I think doctors and nurses should be payed more than tech workers, because what I do is very important, but what they do is moreso because they are literally saving people's health.