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  • #16
    Originally posted by Notsobad View Post
    I hope physican PCP do not disappear. As a specialist, I can tell who the good primary care providers are.
    Please banish this phrase. The more appropriate term is primary care physician.

    There’s a world of difference between someone who can get into and through a U.S. med school and residency vs. someone who has eight cereal box tops and enough shipping and handling money to pay for an online NP degree. Even if it’s a “DNP”, complete with white coat and clipboard.

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    • #17
      Originally posted by Hank View Post

      Please banish this phrase. The more appropriate term is primary care physician.

      There’s a world of difference between someone who can get into and through a U.S. med school and residency vs. someone who has eight cereal box tops and enough shipping and handling money to pay for an online NP degree. Even if it’s a “DNP”, complete with white coat and clipboard.
      But. But. Team player. Synergy. Inclusion!!!!!

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      • #18
        I’m not sure anyone has actually answered the OP’s question from a business angle. I kind of wish we had more MBA’s and health care administrators on the forum so we understood the way the system worked.

        If mid levels are cheaper and generate similar revenue, why haven’t they just replaced all (or at least the vast majority) of us yet? Especially if they’re independent. And why do they really pay us more? We know it’s not because they feel sorry for us because we have higher student loan debts and because they’re intimidated by our degrees.

        Do they think it’s important enough to payers to justify the premiums? Is it because of Medicare requirements? Is it because they just think docs are easier to push around, groom for leadership, and because they’re the only ones who will take overnight call and work weekends?

        I know we’re focusing on primary care, but the same question applies to my specialty.

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        • #19
          MD/DO PCPs have so much value to me. It’s a great opportunity for MD to start concierge practice. This will create a new tier and hopefully a profitable one for doctors.
          I know plenty, including myself, would feel more comfortable with a MD/DO. And I’ll gladly pay if I have to for concierge if it goes that way.

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          • #20
            Originally posted by Lithium View Post
            I’m not sure anyone has actually answered the OP’s question from a business angle. I kind of wish we had more MBA’s and health care administrators on the forum so we understood the way the system worked.

            If mid levels are cheaper and generate similar revenue, why haven’t they just replaced all (or at least the vast majority) of us yet? Especially if they’re independent. And why do they really pay us more? We know it’s not because they feel sorry for us because we have higher student loan debts and because they’re intimidated by our degrees.

            Do they think it’s important enough to payers to justify the premiums? Is it because of Medicare requirements? Is it because they just think docs are easier to push around, groom for leadership, and because they’re the only ones who will take overnight call and work weekends?

            I know we’re focusing on primary care, but the same question applies to my specialty.
            Yes that’s exactly what I was alluding to
            How can we keep ourselves relevant strictly from a business perspective

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            • #21
              Originally posted by HikingDO View Post
              From a purely financial standpoint, it doesn’t. We’re a dying breed.
              So why isn’t this happening faster ?
              in future will we need to put compete with midlevels by agreeing to less pay ?

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              • #22
                Originally posted by Savedfpdoc View Post
                Im fm, work with 2 mid Levels(don’t supervise either). One of them has 20yrs experience and I’d see him as my pcp. The other has 5yrs and over orders test/referrals….so much so that mgmt had to ask the float ma to help w her bucket. My bucket stays around 50, but my ma doesn’t get help bc “I don’t order a lot”….go figure.

                as far as the original post..I see Mds in primary care being obsolete in 10-20yrs…it’s already going that way. Just look at the new primary care clinic owned by a large corporation in town…they hired 3 midlevels first, still looking for a doc to supervise them, tells u alot. Atleast for now patients still need me to sign thur diabetic shoe orders, food stamps documents, electric bill assistance forms, and there still a few surgeons who require an MD sign the Oreos clearance. Atleast for now
                Yes but question is for how long ? And what factors are preventing big organizations from scrapping MDs altogether?

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                • #23
                  Originally posted by gap55u View Post
                  If and only if value based care and population health starts to matter — then docs will show value compared to mid levels. A specialist friend goes crazy because an NP sees a patient with chronic cough and refers to allergy pulmonary and ENT at same visit (true case). C-suite sees $$$. I’m afraid for primary care— and by extension for our health care system — we will end up with yet worse health outcomes at higher overall expense
                  Do midlevels exist in Europe Australia and japan ?

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                  • #24
                    Originally posted by nastle View Post
                    What is stopping all the bighealthcare companies from replacing primary care doctors wholesale with mid levels ?
                    This is not another mid level bashing thread , let’s keep it focused on a single issue
                    How does it make sense financially for a organization to hire one MD rather than 2 midlevels ?
                    Why would this be primary care specific? I booked a hand appointment the other day for my daughter. Guess who saw her? Guess who does all the procedures in IR? There are now APC only EDs. This trend (including the online NP school phenomenon you've likely noticed) has nothing to do with primary care and everything to do with economics.

                    It's beyond me why an insurance company or any other payer would pay the same rate to an APC (with a chart signed later by a doc) as a doc, but until that changes, you're right. Medicare only pays 85% of what it pays a doc if you are only seen by an APC, but I don't think that premium is high enough. When a hospital/clinic etc is paid 50% for an APC visit, there will no longer be the economic incentive to use APCs that exists now. Then they'll only be in places that can't recruit a doc, which is how independent practice is generally sold to state legislatures.
                    Helping those who wear the white coat get a fair shake on Wall Street since 2011

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                    • #25
                      I think you are right about the physician / APC premium and I am sure that will change in the future.

                      As an organization we track all physicians and APCs for value , as an individual and a group. It is easy to see who adds "value" and who spends alot ordering tests and referrals. Since a significant portion of our group and individual income depends on these metrics, the whole idea of nonsensical referrals and Cat Scanning the whole body directly affects one's individual income down the the APC level. So you can actually track that one APC who has a significantly higher rate of referrals for acute sinusitis. I can see which Cardiologist has the highest episode of care for chest pain diagnosis. In the past, the motto was the more tests and referrals the merrier , but when an individual physician or APC sees a direct hit to the income , it usually changes behavior. In the past , the bonus or value payment was slim , but now it can be close to 1/3 of income.

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                      • #26
                        Originally posted by nastle View Post
                        Yes but question is for how long ? And what factors are preventing big organizations from scrapping MDs altogether?
                        Right..10-20yrs not sure. At that point I’ll start a homestead

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                        • #27
                          Originally posted by The White Coat Investor View Post

                          Why would this be primary care specific? I booked a hand appointment the other day for my daughter. Guess who saw her? Guess who does all the procedures in IR? There are now APC only EDs. This trend (including the online NP school phenomenon you've likely noticed) has nothing to do with primary care and everything to do with economics.

                          It's beyond me why an insurance company or any other payer would pay the same rate to an APC (with a chart signed later by a doc) as a doc, but until that changes, you're right. Medicare only pays 85% of what it pays a doc if you are only seen by an APC, but I don't think that premium is high enough. When a hospital/clinic etc is paid 50% for an APC visit, there will no longer be the economic incentive to use APCs that exists now. Then they'll only be in places that can't recruit a doc, which is how independent practice is generally sold to state legislatures.
                          There is a basic problem going on. Medicine is very silo-ed. One field or area of the hospital has no clue about what is happening in other fields. Before I became an active forum reader I had no clue that other specialities no longer perform any sort of physical exam. This would be impossible in OB/GYN. Also I was surprised at how many IM fields do not do basic things that I learned as a medical student like LPs, thoracentesis, etc. I feel this opened the door for APCs. Now everyone wants to practice at the top of the license and let others do the easy stuff. The more APCs are allowed to practice doing procedures the more the general public views them as doctor replacements. I am still unclear who is responsible in a malpractice case. The largest insurer in my state for years would not reimburse midwife deliveries which limited them here. Now that is changing too. Scope of practice legislation is very important. A bill just passed in my state allowing optometrists to some eye cases for example. It is very hard to fight these types of changes when a hospital is your employer.

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                          • #28
                            What's really scary to me is feeling like you have no choice to see a physician even if you want to. At this point whenever my parents go to the "doctor" i make sure that they're seeing an actual physician. But when my dad had an acute event and went to the hospital who the heck was taking care of him? Not like we had any choice in the matter and you look like a jerk if you make a stink about being treated by midlevels.

                            And this is someone who has extremely high medical literacy. The rest of the public are being completely taken for a ride

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                            • #29
                              I think PCP will still exist but in greatly reduced numbers. mainly to supervise the mid levels and see some complex patients. This also applies to many specialists, as their numbers needed will be less. They will be paid more, but th overall numbers will be far fewer than today.

                              As to NP practicing independently, a few do. But most don't want the hassle. They like to punt the responsibility and risk to someone higher. They might get paid only 100-150K compared to a PCP who might make 250K, but they don't compare their salary to a M..D. They compare it to their former self, a R.N., who gets paid only 50-60K and does hard work will less status.

                              In Oncology you see a minimum of one NP to an oncologist. I think the trend is now to have 2 to a physician. Soon the oncologist will only be seeing initial consult of complex cases and few tricky follow ups. The rest of the work, including putting in orders for chemo, follow up and all other grunt work will be done by mid levels.

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                              • #30
                                Originally posted by Hatton View Post

                                I was surprised at how many IM fields do not do basic things that I learned as a medical student like LPs, thoracentesis, etc. I feel this opened the door for APCs.
                                Hem/Onc do only only one procedure on a regular basis and that is a bone marrow exam. Thirty years ago every hem/onc did it on his own. Then insurers reduced the payment to a pitiable $50-100 and even bundled it with the cost of the kit. The price of the kit rose to $50. So physicians punted it to their mid-levels and used that 1 hour to see consults or write more chemo orders.

                                Funny thing of economics happened next. The hem/onc practice managers felt that their mid-levels were not adequately reimbursed for that procedure. They punted that to radiology to do it under fluoroscopic guidance. The IR physician can use that accessory and increase the charge of the procedure from $50 to $500. Soon 80 lb patients with their iliac crests jutting out in the back were wheeled in from the floor to the radiology department to have the procedure done by IR physician.

                                The final nail in the coffin was that the IR radiologist felt that the procedure was not worth his time when he could do more complex IR procedure. So there is now a PA in the IR department who does the bone marrow on cachectic oncology patients, when it should have been reserved for the truly obese patients.

                                The perverse skewed end results of insurance economics where a underpaid $50 procedure becomes a $500 procedure done by a midlevel with an useless radiology assistance. I am still the only onc in town who does my own bone marrows. When I retire, there will be no hem/onc in town who will be doing that basic procedure on a regular basis.
                                Last edited by Kamban; 03-18-2022, 08:52 AM.

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