> 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.
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)
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.
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.
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?
Most hospitals are already losing money or close to losing money. Taking away profit motive from them e.g. by subsidizing operation would only increase cost of care, because the incentive to run lean/efficiently goes away.
The insurance system and perverse incentives embedded in it is the primary reason healthcare is expensive here. Also many countries have price controls on drugs, and US does not (thus subsidizing RoW in regards to new drug research).
The uk National Health Service is free at the point of use, and is a completely government run, non-profit service. That model doesn’t seem to be working either:
I think only allowing nonprofit hospitals would be worse than the current state of affairs. You'd still be asking private organizations to be responsible for ensuring we have adequate medical treatment available, but you'd very literally be relying on the charity of strangers to ensure that. For-profit medicine at least provides excellent incentives for corporations to spend the enormous sums of money needed to set up and run hospitals.
If you're against hospitals being for-profit businesses (which I think is a perfectly reasonable stance), it seems to me the real alternative would be government-run hospitals. Then you'd have a centralized, well-resourced organization that is generally incentivized to keep people healthy running things, rather than just hoping that enough non-profits get involved to serve the medical needs of the country.
Almost every hospital organization is actually a non-profit.
However non-profit does not mean non-revenue.
Hospitals have real costs, and it is entirely possible the emergency department was a money sink. No one can be turned away, so it is used as the healthcare of last resort for those without other access, who, almost by definition, cannot pay.
> 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.
The reason for this is opiates. Any time any place in the US sets up free or low cost shelter, the dope addicts move in.
Other industrialized nations don't seem to have as many addicts as the US, or maybe they still have real heroine instead of fentanyl.
> 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.
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.
In the ER, though -- I can see the case for experienced MDs making a big difference in outcomes.
I strong disagree. From the hospital perspective, NPs and PAs are cannon fodder thrown on the line.
My sister in law is a NP who quit the ER. She worked as an RN in an ER for a decade and knew that she lacked the training and skills to be doing some of the stuff she was forced to do.
Patient lives and her license were at risk every day.
> The part I didn't like was how they made me get out a credit card while they we're treating me.
Yes, I recently had to visit urgent care after probably ~8 years of staying out of the hospital. To be allowed in the door of the building I was required to swipe a credit card (literally 5 feet inside the front door, "we need you to authorize a charge on your card for this visit to proceed") and then they had credit card readers inside the patient rooms attached to the EMR computers for "charge as you go" medical care.
I was having a minor anaphylactic reaction to something - not enough to restrict my breathing or make me want to use my epipen yet - but I experienced the same thing. Went to the ER, face red and swelling, lips starting to tingle, the whole 9 yards. They had me enter all my personal info, name, address, insurance card, etc. Then swipe for my $250 ER copay all before seeing anybody competent. The worker at the desk didn't understand what I meant when I said "anaphylactic reaction" I had to gesture at my face and say "allergic reaction" ffs!
At least my reaction wasn't as bad the first time. That time was pre-covid and they had somebody with experience and functioning brain cells at the check-in and they brought me right in and started taking vitals and did an IV literally right on the other side of the check-in desk. On that visit they had the payment person come around hours later while I was recovering in a bed on a different unit for monitoring while I was coming down off of the meds they pumped me full of.
All businesses are like this - it saves them money on collections. If your insurance refuses to pay up -- or you refuse to pay up -- or you decide to pay your car payment instead of the medical bill -- they lose out.
It might be a bit distasteful to do it in proximity to medical care.
But just tell them that they can bill you, make up an excuse if you need to.
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 told 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.
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?
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.
The AMA probably isn't the best source for that type of data.
The little throwaway lines in that review are funny; "Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety."
Weird because the study they're talking about didn't say a word about patient safety.
Their metrics are weird too - it's looking at hospital spend "per member per month" which was higher with the non-physician staff but I'd be curious if the $30 difference was more or less than the difference in salaries between the two groups.
Is it though? There are quite a few people who lack access to the normal healthcare system and use the ER as primary care of last resort because no one is turned away. PAs and NPs would be perfect for those patients.
I can tell you from personal experience that hospital funding priorities are wild. It's an ongoing turf war between hospitals.
* 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.
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.
Don’t ER docs have to work odd hours and see patients without any prep or background? I get the docs have the same education, but I can see taking half pay for a more predictable schedule and patient load, along with lots of time before hand to figure things out. They are different jobs, supply and demand probably sets one to be higher paid than the other.
> 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."
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.
This is not the right way to keep humans running well, for both the sick and 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.
Note that the term "Medical Assistants" in the US generally refers to the folks who are able to take vitals and minimal-complexity care. They're not given anywhere near the responsibility of an RN let alone an NP.
Check out https://www.reddit.com/r/nursing/ 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".
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.
Moreover, despite being overworked and literally caring for people's lives nurses are severely underappreciated. Because people are rude and needy especially 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.
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.
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.
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.
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.
Everyone in healthcare is overworked - but at least in the US people have the choice to move to a better-paying employer. I work in Northern california with a nurse who lives in Florida and flies out for a bunch of shifts, then takes a few weeks off. In the UK where I originally trained, the pay is shockingly low compared to the US, due to lack of competition IMO:
+1. Without citing sources, I will also say I think hospital admins, directors, execs, etc. are constantly looking for ways to cut costs, while the top execs take home millions in pay. Even in nonprofits that haven't been touched by private equity. They don't value the providers, nurses, doctors, or PAs.
[+] [-] klyrs|3 years ago|reply
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.
[+] [-] azinman2|3 years ago|reply
[+] [-] ganlaw|3 years ago|reply
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.
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.
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?
[+] [-] adam_arthur|3 years ago|reply
The insurance system and perverse incentives embedded in it is the primary reason healthcare is expensive here. Also many countries have price controls on drugs, and US does not (thus subsidizing RoW in regards to new drug research).
https://www.chiefhealthcareexecutive.com/view/hospitals-losi...
[+] [-] ghufran_syed|3 years ago|reply
https://www.cnn.com/2023/01/23/uk/uk-nhs-crisis-falling-apar...
[+] [-] idopmstuff|3 years ago|reply
If you're against hospitals being for-profit businesses (which I think is a perfectly reasonable stance), it seems to me the real alternative would be government-run hospitals. Then you'd have a centralized, well-resourced organization that is generally incentivized to keep people healthy running things, rather than just hoping that enough non-profits get involved to serve the medical needs of the country.
[+] [-] tyoma|3 years ago|reply
However non-profit does not mean non-revenue.
Hospitals have real costs, and it is entirely possible the emergency department was a money sink. No one can be turned away, so it is used as the healthcare of last resort for those without other access, who, almost by definition, cannot pay.
[+] [-] abfan1127|3 years ago|reply
[+] [-] linuxftw|3 years ago|reply
The reason for this is opiates. Any time any place in the US sets up free or low cost shelter, the dope addicts move in.
Other industrialized nations don't seem to have as many addicts as the US, or maybe they still have real heroine instead of fentanyl.
[+] [-] klooney|3 years ago|reply
[+] [-] seanmcdirmid|3 years ago|reply
[+] [-] throwawaysalome|3 years ago|reply
Then elide "profitable" since that is the goal of every business.
[+] [-] unknown|3 years ago|reply
[deleted]
[+] [-] unknown|3 years ago|reply
[deleted]
[+] [-] wyldfire|3 years ago|reply
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.
In the ER, though -- I can see the case for experienced MDs making a big difference in outcomes.
Disclosure: my wife is a PA.
[+] [-] Spooky23|3 years ago|reply
My sister in law is a NP who quit the ER. She worked as an RN in an ER for a decade and knew that she lacked the training and skills to be doing some of the stuff she was forced to do.
Patient lives and her license were at risk every day.
[+] [-] shiftpgdn|3 years ago|reply
Ultimately we need more doctors and less hospital administrators.
[+] [-] ourmandave|3 years ago|reply
The part I didn't like was how they made me get out a credit card while they we're treating me.
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.
https://www.nytimes.com/2023/01/25/podcasts/the-daily/nonpro...
[+] [-] quasse|3 years ago|reply
Yes, I recently had to visit urgent care after probably ~8 years of staying out of the hospital. To be allowed in the door of the building I was required to swipe a credit card (literally 5 feet inside the front door, "we need you to authorize a charge on your card for this visit to proceed") and then they had credit card readers inside the patient rooms attached to the EMR computers for "charge as you go" medical care.
The whole thing made me sick to my stomach.
[+] [-] bluesquared|3 years ago|reply
At least my reaction wasn't as bad the first time. That time was pre-covid and they had somebody with experience and functioning brain cells at the check-in and they brought me right in and started taking vitals and did an IV literally right on the other side of the check-in desk. On that visit they had the payment person come around hours later while I was recovering in a bed on a different unit for monitoring while I was coming down off of the meds they pumped me full of.
[+] [-] wyldfire|3 years ago|reply
It might be a bit distasteful to do it in proximity to medical care. But just tell them that they can bill you, make up an excuse if you need to.
[+] [-] azinman2|3 years ago|reply
[+] [-] schemescape|3 years ago|reply
[+] [-] ghufran_syed|3 years ago|reply
[1] https://wikem.org/wiki/Ectopic_pregnancy
[+] [-] oaktrout|3 years ago|reply
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?
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.
[+] [-] mikeyouse|3 years ago|reply
The little throwaway lines in that review are funny; "Patients deserve care led by physicians—the most highly educated, trained and skilled health care professionals. Through research, advocacy and education, the AMA vigorously defends the practice of medicine against scope-of-practice expansions that threaten patient safety."
Weird because the study they're talking about didn't say a word about patient safety.
Their metrics are weird too - it's looking at hospital spend "per member per month" which was higher with the non-physician staff but I'd be curious if the $30 difference was more or less than the difference in salaries between the two groups.
[+] [-] tyoma|3 years ago|reply
[+] [-] mattpallissard|3 years ago|reply
[+] [-] mikeyouse|3 years ago|reply
[+] [-] seanmcdirmid|3 years ago|reply
[+] [-] nobodyandproud|3 years ago|reply
https://en.m.wikipedia.org/wiki/Healthcare_in_South_Korea
https://en.m.wikipedia.org/wiki/Healthcare_in_Taiwan
Both countries are market based societies, each have taken a somewhat different approach to the problem, yet both systems are quite efficient.
[+] [-] cptcobalt|3 years ago|reply
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.
This is not the right way to keep humans running well, for both the sick and the docs.
[+] [-] VWWHFSfQ|3 years ago|reply
[+] [-] magic_man|3 years ago|reply
If you are an Indian and have a 3.8 gpa you still might not get into medschools which is pretty absurd.
[+] [-] wyldfire|3 years ago|reply
[+] [-] unknown|3 years ago|reply
[deleted]
[+] [-] armchairhacker|3 years ago|reply
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.
Moreover, despite being overworked and literally caring for people's lives nurses are severely underappreciated. Because people are rude and needy especially 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.
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.
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.
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.
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.
[+] [-] ghufran_syed|3 years ago|reply
https://www.salary.com/research/salary/alternate/registered-... https://www.payscale.com/research/UK/Job=Registered_Nurse_(R...
[+] [-] oneepic|3 years ago|reply