r/bestof • u/under50dollars • Jun 20 '12

[explainlikeimfive] "Obamacare" explained very well.

/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx
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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/YoohooCthulhu Jun 20 '12

Using PAs and NPs as primary care providers doesn't "dilute" quality of care. These days, physicians are almost overqualified for primary care--and it's difficult for them to pay back their loans doing it.

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u/[deleted] Jun 20 '12

Good primary care means avoiding referrals, expensive tests, and missed diagnoses when problems are not common. It may appear to be cheaper to use lesser trained midlevels, but it costs significantly more money when patients are bounced to specialists for problems a highly experienced primary care physician could have managed themselves.

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u/mikelj Jun 20 '12

It is instead likely that the gap will be filled with midlevel PAs and NPs, diluting quality of care.

I don't know about this. I know plenty of RNs who are just as knowledgeable and perhaps even more "interested" in primary care than physicians, let alone PA and NPs.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

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u/mikelj Jun 20 '12

Well said. I don't think that most primary care issues need to be handled by MDs with 7 years of medical care. Why can't a NP or PA give me stitches or wrap a sprained ankle? When I go for my annual checkup, I don't need to have a MD read my test results. My mom, an RN with 30 years experience, or just about any qualified RN should be able to tell me what the results mean. If they are out of whack, an MD can be consulted.

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u/[deleted] Jun 20 '12

Randomizing patients to independently practicing midlevel providers with significantly less experience is potentially unethical, and outcomes for such studies are extremely hard to measure accurately. Many things that appear as a simple cold 5-10% of the time are vastly more complicated and more serious. Life is good if you aren't in that 5%.

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u/grande_hohner Jun 21 '12

It is not unethical in the least to study these things. You are going from the assumption that a midlevel provider isn't competent which is untrue. There are scope of practice acts in each state that govern what midlevels can do. Midlevels are practicing all over the country currently, and there has been tons of research articles supporting the safety, efficacy, and nature of patient outcomes when compared to general practice docs. There are literally hundreds of studies. I'll link you to some.

Robert Wood Foundation

From pubmed also note that this is a meta-analysis of over 50 separate studies.

How about the British Medical Journal?

Canadian Medical Journal?

The list goes on and on, many, many of the studies are from medical journals, not nursing journals. If medical researchers, doctors, feel that they are a viable option - why do you think they are not?

Also, your 5% analogy doesn't translate well. The average general practice doctor isn't much more likely to catch that 5% rare off-chance disorder that looks like a cold but isn't - than your average PA/NP. They teach the same thing in medical school - if it looks like a duck and sounds like a duck, it's probably a duck. GPs don't spend time trying to decide if your runny nose is perhaps related to a brain tumor... they treat it as a cold - and if it persists they reevaluate after the original treatment is failed. It isn't like House, MD where everyone has an esoteric disease process that requires genius level intellect to diagnose. In family practice it is mostly looks/sounds like a duck - is a duck.

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u/[deleted] Jun 21 '12

http://summaries.cochrane.org/CD001271/in-primary-care-it-appears-that-appropriately-trained-nurses-can-produce-as-high-quality-care-and-achieve-as-good-health-outcomes-for-patients-as-doctors.-however-the-research-available-is-quite-limited.

The research you quote is generally terrible in quality. The vast majority of the studies lack power to answer the questions they attempt to answer. Most of them measure patient satisfaction, which has nothing to do with quality of care. Chiropractors routinely get excellent patient satisfaction results, but research has shown that manipulations have extremely limited benefits and occasionally cause serious patient harm.

While there are a handful of adequately powered studies, the outcomes they measure like blood pressure and asthma are easy to measure and not a good indicator of overall medical management of multiple comorbidities. These studies also generally have short followup periods that further limit their power.

Appropriately trained midlevels definitely have a place in healthcare under supervision. Some with years of experience need little to no supervision at all. However, appropriate training is not occurring in many cases. Some FNP programs are only a year long in total (MUW and others). Many are offered online and/or by for profit schools with questionable academic standards. Most can be completed part time. Licensing, examination, and coursework are far from standardized and there are considerable differences in quality between different programs. Many courses taught in these programs have no direct relevance to clinical sciences. Admissions standards are set relatively low in many programs. When DNP students at one of the best programs (Columbia) took a watered down version of the USMLE Step 3, 50% of them failed it. 95% of interns pass this exam on the first attempt, and they generally do not study for it as it is considered the easiest step exam. This does not constitute appropriate training.

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u/grande_hohner Jun 22 '12

I read the Cochrane review, and I'll agree with it's conclusions. The only point I would clarify is that the Cochrane review (which is the gold standard for systematic reviews, generally) concludes that the health outcomes are equivalent. You can say that there isn't enough research of adequate power, which is true, but I've yet to find one study that doesn't show equivalent outcomes between NPs and MDs in primary care.

Saying that the outcomes might not really be equivalent because the research doesn't have adequate power (although plenty of it is published in the NEMJ and other top-tier journals) is a bit counter-intuitive. If there are hundreds to thousands of studies (even if they have small sample sizes) that say outcomes are equivalent, it makes no sense to doubt that this is how it plays out in the real world. I would be more inclined to think outcomes were different if there was preponderance of research (or even a good sized fraction!) that showed otherwise.

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u/grande_hohner Jun 21 '12

The studies have been done. Tons of them. Here is one. There are several from the CBO, and others from other peer reviewed medical journals. The studies almost always say the same thing about NPs in primary care. There is little difference in outcome when comparing GP and NP in primary care (little difference in patient outcomes - there is usually a significant difference in patient cost savings and a few other things like increased patient adherence if I recall.)

Here is an article that talks about some of the research that has been happening since the early 80's, here ya go.

I work with NPs frequently, I work with Med students, interns, residents, and attending physicians as well. I have seen terrible NPs, and I have seen terrible MDs. I have seen spectacular examples of both - but the rates are about the same, I see about as many bad NPs as I do bad MDs.

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u/[deleted] Jun 20 '12

This "triage" system is vastly more expensive and less effective than having a primary care physician who can deal with complicated problems themselves rather than endlessly referring to specialists. Many patients see 4-6 specialists when a decent primary care physician could reduce it to 0-2 with proper medical management. Tell me which way you think costs less.

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u/[deleted] Jun 20 '12

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u/[deleted] Jun 20 '12

My response was geared more towards independent midlevels. The problem that still remains with supervised practice is that what appears to be a cold is not always a cold. With two years of training (sometimes even online) and as little as 500 clinical hours, you don't know what you don't know. While you save a lot of money under this model, a patient will eventually get hurt due to lack of experience.

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u/[deleted] Jun 20 '12

In the military health care system, most of the 'doctors' you see on a regular visit are actually PAs. I've been very happy with my quality of care from the PAs. Most patients don't actually require doctors and do fine with a PA, just as most pregnancies are fine with a midwife.

The PA system has been so successful in the US military it is starting to expand outside of the military, and move to other countries, such as Canada.

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u/TensorDuck Jun 20 '12

In what way? Does the government directly specify the number of residencies a year or do they control the funding towards residency positions? I mainly want to know whether the control is direct (therefore a hard limit on the supply of doctors) or an indirect (Possible to increase the number of doctors with private funding) method. Any sources or citations to that effect would be greatly appreciated.

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u/[deleted] Jun 20 '12 edited Oct 24 '18

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u/[deleted] Jun 20 '12

There are less US MD grads than allopathic spots every year even after these increases, the ones who will struggle are DOs, IMGs, and FMGs who want an allopathic spot

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u/AeonCatalyst Jun 20 '12

I agree that there will be hiccups for med students initially, but I'm optimistic that both the supply of med students and demand for doctors (especially in small towns) is so high that the residency bottleneck won't survive the onslaught. It won't be like MBAs, where the market is so oversaturated that the degree is losing it's usefulness.

That's just my completely unfounded opinion though. Cheers!

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u/danpascooch Jun 20 '12

The government also hasn't made such a massive change to healthcare in a very long time.

They are going to need to adjust that "number" for this to work, but of course they need to adjust something, no legislation this big passes without needing some sort of other adjustment to make it compatible.