4.5 - Controversial Stuff

Important Questions

What is the impact of APPs on physicians

Salary & Job Prospects

Autonomy

Esteem

Semantics vs Real consequences

Stop labeling physicians as providers

Impact on Care

Impact on Cost

NP Training Adequate?

What is the impact of APPs on physicians

What is the impact of APPs on physicians

Salary & Job Prospects

Wisconsin Hospital Replaces All Anesthesiologists With CRNAs

15 Docs Fired From Illinois Health System to Be Replaced With NPs

Autonomy & Job Satisfaction

My BIAS the following is a WRONG way of looking at things. Lets discuss:

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Esteem

Corollary of why the term "provider" grates. Our job is not to shovel healthcare. We provide our patients expertise, advice, and care. — Jeff Linder MD

"Assigning the 'provider' designation to primary care health professionals also risks deprofessionalizing them." —  Allan H. Goroll, MD

Semantics vs Real consequences

First - False Equivalence

the word implies that physicians and other health care professionals are interchangeable, rendering a commoditized, untailored service

Second - Depersonalization & Deprofessionalizing

feelings of powerlessness in increasingly consolidated, hierarchical health care organizations, which can lead to worse patient care

Third - Degrades both “no provider school”

downgrading physicians to “provider,” while seemingly minor, is cumulatively invalidating; it dishonors physicians' intensive training and weighty responsibility for others' welfare and ignores doctors' inherent role: docere, “to teach.”

Forth - Primary Care “Providers”

Acceptance  “provider” may represent implicit bias within medicine and may disproportionately harm primary care residents as they form professional identities.

Erlich and Gravel 2021 - Professional Identity Misformation and Burnout - A Call for Graduate Medical Education to Reject “Provider”.pdf150.8KB

Impact on Care - Is there a difference in Care provided?

Regardless of provider role, patients reported receiving more therapeutic or preventive care from NPs but more diagnostic care and biomedical treatments from physicians

NPs and physicians providing different care when serving in the same role. Findings can inform policy-makers as they develop policies for serving patients and utilizing the relevant expertise of NPs and physicians

Lets talk Cost, Value

Defining FTE: Full Time Employment

2,087 hours per year calculate for 40 hr/week

How Many Hours Per Week Do Doctors Work?

2672 hours per year 51.40 hours per week

Cost

Physician 2672 X 100 = 267200

APP 2087 X 55 = 114785

Patient Load Average

Physician: 18- 22 (~20)

APP Outpatient: 12-16 (~14)

APP Inpatient: 8-12 (~10)

Ambulatory Cost - Per Patient

Physician = 51 $ per patient

APP = 31$ per patient

Time per Patient

Physician: 20 Patient in 8 hours = 24 Mins per patient

APP: 10 Patient in 8 hours = 34 Mins per patient

Untitled

DaysHoursTotal HoursPay RateTotal CostPt/DayT/PatientCost per patient
Physician
262
12
2672
100
267200
20
5240
51
APP
262
12
2087
55
114785
14
3668
31

Inpatient Cost

Physician = 90 $ per patient

APP = 66 $ per patient

Physician vs APP

WeeksDaysHoursTotal HoursPay RateTotal CostPt/DayT/PatientCost per patient
Physician
26
182
12
2184
150
327600
20
3640
90
APP
26
182
12
2184
55
120120
10
1820
66

Real World Much More complicated

Physician Only Model vs Physician + APP model is nearly equivalent in Cost

It about about Extending service

Physician Model

20 Patient per Physician

Physician + APP Model

20 Patient Per Physician

10 Patient Per APP x 2 = 20

Total Coverage per Physician (+ Extenders) = 40

Other Factors in Inpatient Setting

Nights Calls

Weekend Calls

Holiday Calls

Complex Patient

Admission vs Followup

Acute vs Chronic Care

12 vs 8 Hours Shift

Should Physicians be compensated for Supervising APPs?

It is all about Liability

Impact on Cost - Chronic Care

Utilization And Costs For Complex Patients

We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.

Primary And Specialized Ambulatory Care: Systematic Review

Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study

Impact on Cost - Acute Care

In acute care it is more about improving access then cost savings

Generally Employed physician models are subsidized by hospitals with downstream revenue

With addition of NP they may or may not break even

However, solve the critical problem of availability & moral injury

Cost of Education

Untitled

PrivatePublicAverage
PA
91630
50289
63000
NP
30000
60,000
44000
MD
278,455
207,866
250000
While the cost of medical school in and of itself is certainly high, the true cost of becoming a doctor is in years and years of your life
The total cost of attending med school including lost opportunity is around $800,000
$75,000 functions as a threshold over which increased earnings do not alter happiness

Training Requirements is Adequate?

Required Clinical Hours in Training

Untitled

RequiredTypicalResidencyFellowshipTotal
NP
500
1500
0
0
1000-1500
PA
2000
2000
0
0
2000
Physician
6000
6000
10000
4000
20000

Length of Education

Untitled

UndergraduateGraduateResidencyFellowshipAverage
NP
4
2
0
0
6
PA
4
2
0
0
6
Physician
4
4
3-5
1-3
14

Independent NPs: What's the Evidence?

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What does the Future Hold?

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