Dollars and Sins
“Concerning trends in primary care physician demand and compensation:
Merritt Hawkins report shows skyrocketing demand for nurse practitioners while the demand for family physicians dropped.
This article summarizes the fact that demand for nurse practitioners(NPs) has increased since the pandemic began. This is based on search engagements conducted by Merrit Hawkins between 4/1/20-3/31/21:
“Nurse practitioners (NPs) topped the list of Merritt Hawkins’ most requested search engagements for the first time, underscoring the accelerating demand for these professionals. In 27 previous years, the top position has always been held by physicians.”
I submit that the demand is not due to patient requests or necessity, but corporate medicine(backed by private equity) preferentially seeking out and hiring cheaper NPs for positions for which they may not be fully or appropriately qualified….all to save costs and increase profits. This blog article further clarifies more reasons why demand may have increased(https://thehealthcareblog.com/blog/2014/09/18/how-to-discourage-a-doctor/)– because the corporate practice of medicine(CPOM) has a specific agenda. The pandemic conveniently provided the CPOM with a Eureka moment; delivering an unexpected opportunity for them to remove physicians from the medical landscape without drawing much attention. Who would question the quality of care for anyone when so many patients with COVID were dying? A great smokescreen for hiding substandard care in other areas. Additionally, COVID led to a financial boon for the CPOM that has persisted for two years, to their delight. It is also my opinion that the significant majority of patients do not demand NPs, as the marketing campaign, “We Choose NPs” by the American Association of Nurse Practitioners(AANP) would have you believe. Patient choice is almost completely removed in today’s health care scenario. Patients are forced, by the corporate practice of medicine and insurance companies, to take what is given to them while they are gouged financially. Being charged the same price they would pay if they had seen an actual physician rather than a facsimile purported to be “equivalent”. Common sense dictates that when given a choice, laypeople will choose physicians, especially if they are being charged the same for the service.
Primary care physicians(Family Medicine, Internal Medicine and Pediatrics) have the most difficult job in medicine because they manage the entire body and all of its systems. When damage is done to children, it is even more reprehensible. Children are not little adults and they are not always “easy”. These con artists do their utmost to convince everyone else that NPP practice is “just as good” as these physicians. Bulls**t. If it were, they would also use NPPs to provide primary care to their families and/or children. They don’t. Their hypocrisy is lost on them. This is the s**t that occurs when ego overrides common sense. When gluttony is prioritized over safety. When one aspires to be a parasitic Pimp or Ho rather than a healthcare professional or executive with integrity. When private equity inserts itself into health care. Bottom line: Primary care physicians are irreplaceable.
As with all businesses, when medicine became corporatized, the expectation was to ensure that profits would be plentiful. The Cartel and Pimps needed it to “rain Benjamins”. The higher the net yield, the happier the shareholders. It never was about quality of care or health care at all. Although unintentional, the “Future of Nursing” campaign, of which Full Practice Authority(FPA) is an integral part, aligned nicely with the goals of the business of medicine. Both entities desired to remove physicians from their natural leadership position in the medical hierarchy. For Pete’s sake, there was ready money to be had. For NPs seeking pay parity and equivalence by professional misappropriation(aka identity theft), physicians were obstructive. In the way. For the corporate practice of medicine, physicians’ pesky ethics not only obstructed their greedy pursuance of financial gain, they were also just too damn expensive. The CPOM had no desire to pay for expertise, their wish was to simply increase the profit margin by any means necessary. So physicians had to go. And go they have. Family Medicine physicians. Internists. Pediatricians. Anesthesiologists. Hospitalists. Dermatologists. Psychiatrists. Emergency Medicine physicians. Replaced by substandard replicas which were NEVER DESIGNED to be substitutes for physicians. They forced a round peg into a square hole and then proceeded to convince the public that the pieces fit by promoting dishonest propaganda and false advertising. Lying comes easy to charlatans. For them, a moral compass is non-existent.
One of the consequences of unsupervised(or poorly supervised) NPP practice is that malpractice claims and payouts are increasing, for NPs in particular and the physicians and hospital systems for which they work. One such case is the tragic story of Alexus Ochoa. The attorneys acting on behalf of her family sued the hospital and ED medical director for permitting an unqualified NP to work, unsupervised, in an ED where supervision was required. The following link is a podcast of “Patients At Risk”, with one of the attorneys from the law group representing the Ochoa family. For the record, the NP was also named as a defendant, BY HER EMPLOYER, and was held accountable as well. What happens when hospitals replace physicians with NPs? – Attorney Travis Dunn (Part 1)
It is my contention that the “trend” mentioned in the article is unsustainable. Why? Because one cannot “fake it until you make it” in medicine. The art and science of medicine is simply too complex, as is the human body. The deficits in fundamental medical knowledge eventually manifest in poorly managed patients, suffering from medical errors that no physician would make. Can’t sweep humans under a rug, so the damage inevitably becomes visible. I fully expect that much like the housing crash of 2008, this medical bubble will also collapse, with a trail leading directly to the culprits who caused the fiasco. U.S. “hellcare” is a fragile, unstable, unscrupulous system propagated by rapacity. It is not too big to fail and when it does, I predict the fall will be catastrophic. To whom will everyone turn to repair the resultant clinical devastation precipitated by the current system? Physicians. That’s who.
“Healthcare is neither a right nor a privilege. In a civilized society, it is a necessity. The corporate practice of medicine is directly antithetical to that need and its power must be abrogated.”–N. Newman, MD
I am on disability that began with weird headaches. I have been stable with my current treatment for 5 or more years. Due to my mistake in scheduling I “had” to see the “neurology” NP instead of the MD for my once a year medicare required visit. I did not tell her I was a physician. I try not to. She wanted to change my treatment. Argued when I wanted to talk about why it wasn’t a good thing because of side effects etc. At the end of the visit she said I should see her now. I told her as an MD I would be seeing the MD. Her face went blank. My MD appointment is coming up soon. I will find out why she has a NP now.
In reviewing the discussion above – once again, we must make the distinction between PA philosophy and training and NP philosophy and training. PA training has always been closely aligned with medicine and PA education emphasizes team care with physicians. There are no PAs who are pushing for “independent practice”. Nursing leadership, going back to the 1950’s has been threatened by physician involvement in nursing education and it is nursing that is pushing for “independent practice” – they have succeeded in 26 states so far. They are typically vague about “independent practice of exactly what – “nursing” or “medicine” in some cases try to slip in the back door by using the term “primary care”. Most practicing NPs do not want to be independent from doctors but rather enjoy working with doctors. I could write a lot more and have over the past fifty years but my main point today is to separate the PAs from the NP discussion – two completely different philosophies and leadership. Of course the corporate practice of medicine is the biggest outrage of all (big pharma and insurance companies who have shareholders to please over patients).
Happy Holidays 🙏
Fred
Alfred M. Sadler Jr. MD FACP
With all due respect Dr. Adler, I never make commentary about anything for which I cannot provide evidence.
I have been an EM physician for nearly 27 years, part of that time was spent in the Army where PAs are well-trained and plentiful. I am also actively involved in the opposition to independent practice so trust me when I tell you that I fully understand the difference between NPs and PAs. I do not conflate their education or clinical practices. However, I absolutely do conflate their push for independent practice. Most of my articles have been about FPA. Most physicians are unaware of the movement of Optimal Team Practice(OTP) for PAs which is promoted by the American Academy of Physician Assistants(AAPA). It is the equivalent of FPA and they have managed to achieve it in a few select states. I have always acknowledged that it was a response to them being pushed out of the medical landscape by NPs because they have FPA. I’ve also stated that I believe it to be a mistake by the AAPA to force this agenda because they lost the support of physicians like myself who up to that point, had absolutely no issue with PAs. The AAPA claims OTP does not place physicians at legal risk. That is incorrect. Not one OTP bill indemnifies physicians, thus docs are at more risk with the newfangled “Practice Agreement” than they were with the original Delegation of Services Agreement(DSA). In addition, during the first wave of the pandemic, both the American Association of Nurse Practitioners(AANP) and the AAPA attempted to obtain independent practice by going to President Trump and requesting that he grant independent practice, carte blanche, in all 50 states. Both organizations accused physicians of interfering with their ability to assist in the pandemic, which was a lie but an effective marketing ploy because they achieved success in few states. Whether or not individual PAs support independent practice is irrelevant if they do nothing to oppose OTP. To date, I have yet to see one state PA organization or group of PAs LOBBY at the state or federal level against OTP.
For the record, in 2017, a select group of PAs in WA and TN attempted to seek the ability to independently practice primary care in underserved areas provided they obtained a Doctorate of Medical Science(DMSc)–which sounds very much like “Doctor of Medicine”. It is an online doctorate equivalent to the sham DNP degree for NPs. Fortunately, the bill in WA was withdrawn and the one in TN failed. Neither bill was supported by their respective PA state chapters. In March 2021, the PAs in TN again attempted to convince legislators to pass a bill for independent practice. Members of Physicians for Patient Protection(PPP), of which I am a member, vigorously opposed the proposed bill through mass phone calls and letter writing campaigns to each legislator in the Senate and House. In addition, it is important to note that the Physician Assistant Education Association(PAEA), the organization which represents physician assistant education in the United States, concluded in their 2017 Task Force report that current PA programs DID NOT prepare PAs to practice independently.
“The results of PAEA’s program director, past president, and medical director surveys are unambiguous. PA programs do not currently train students for OTP. This new practice model proposed by the JTF would require essentially a new paradigm for PA education. Unintended consequences of OTP for PA programs could include increased program content, length, and costs; and increased health care experience requirements for applicants to PA programs, which would likely reduce applicant and student diversity. The already critical shortage of clinical training sites in many parts of the country would make it problematic — if not impossible — for many programs to accommodate expansion of their clinical curricula. And finally, PA programs may need to explore awarding a clinical doctorate, with uncertain implications for the professional practice environment of all PAs.
Accordingly, PAEA cannot support the optimal team practice provisions (lines 122-163) of resolution 2017-A-07-HO, eliminating a legal relationship between PAs and physicians. We ask the HOD to strike this language and retain the Collaboration section (lines 94-121) until a greater understanding of the benefits and challenges for PA education, and for new graduates, are fully explored by AAPA, PAEA, ARC-PA, and NCCPA as part of an inclusive joint task force.”
Therefore Dr. Adler, in stating that “there are no PAs who are pushing for “independent practice””, you are incorrect.
Hi Natalie – let’s be on a first name basis – you are absolutely correct when I said that no PAs have pushed for independent practice. Thank you for describing some specific situations. I should have said “few” – certainly when compared to organized nursing. It was essentially a typo on my part as I am sure it was when you called me Dr. Adler twice. No harm, no foul.
The pandemic had a lot of people clamoring to help out – from medical students acting as doctors in New York to EMT’s elsewhere. I think that most were probably well intentioned, to deal with hospitals that simply were overwhelmed.
I have been involved with PA Education since 1968 and was the first President of PAEA (called APAP back then) in 1972. I cofounded the PA Program at Yale Medical School on 1971. Here is a link to the first book on PAs that is free to upload:
https://pahx.org/wp-content/uploads/ 2016/11/Sadler_Sadler_Bliss_2nd_Edition.pdf.
After leaving academic medicine, as a general internist practicing primary care, it has been a pleasure to precept PA and NP students in Monterey County California.
There are five PA organizations and AAPA “represents” the practicing PAs. Unfortunately their House of Delegates has been taken over by a militant group who fear that NPs are surpassing them. The great majority of the 150,000 certified PA’s in practice are not for independent practice.
I was very involved five years ago in the Optimal team Practice discussion (please see my response to the then President of AAPA – Sadler, A.M., Jr.: “Optimal Team Practice: How to Get There,” Journal of the American Academy of Physician Assistants, 30: 8–9 (2017).
Regarding the doctoral degree, that is primarily reserved for PAs in Academic who need a doctorate to get tenure and be allowed to run programs. It is not required for practice. AAPA and PAEA sponsored a summit meeting in 2009 to decide what the terminal degrees for PAs should be at the Master’s Degree was overwhelmingly voted in. This is in contrast to PT, OT and Pharmacy who have all gone to the doctorate as the entry level degree. The of course there is the Doctor of Nursing Practice (DNP) which you have described so eloquently in past writings. A classic example of what many have called “degree creep”.
You might enjoy checking out the PA History Society’s website at pahx.org to learn more about PA history.
Please feel free to write me directly at [email protected]. I would would enjoy discussing these vital issues with you in greater detail, if you like. Maybe we can even zoom.
All the best and Merry Christmas 🎄
Fred
Alfred M. Sadler MD FACP
Dr. Sadler, I will contact you privately–the history you provide is invaluable. It is my habit to use titles out of respect. I sincerely want to apologize to you, publicly, for referring to you by the incorrect name which is actually the name of my former director with whom I have had recent contact.
Hi Natalie, I received your message this morning but before I could respond it disappeared from my inbox. As an 80 year old, I swear there must be a gremlin in my computer that likes to misbehave from time to time. Please resend. I very much look forward to further direct communication. Best regards, Fred
email – [email protected]
Beautifully and powerfully written!
It’s easy to express an opinion, it’s another to substantiate. I’d like to see the malpractice data you reference. It’s great to sit and pass judgement on another profession and completely ignore the incompetence of your own. The tragic case described in “patients at risk” is no more or less so than the physician who misdiagnosing ‘Migraine’ in 20 y/o female presenting w/post-coital “worse headache in my life, who died after 3 successive office visits with the same complaint seen by the same MD…my supervising physician. SAH.
I do understand and agree with the many issues you have with NPs. They should not be practicing medicine independently. At the same time, I object to the propensity of physicians to conflate PAs w/NPs. For the past 50 years (yes, it’s been that long), we (PAs) were born, bred, educated (indoctrinated) to be team players. We fully appreciate the education, knowledge and dedication of physicians. There is a synergy to a good Physician/PA practice that can only benefit the people we serve: our patients. I’ve been a PA for 40 years and have no regrets. I’ve had the privilege of working many outstanding physician mentors over my career and thank them for all their support and encouragement.
Nurses are the most trust health care “provider” today. Hero’s to the public in general. Huge lobby and the support of millions of grateful patients. I predict independent practice for NPs on all 50 states within 10 years, the PA will become an idea that failed, and physicians will still be lamenting their loss of influence to the detriment of all.
You can oppose NPs, PAs, RAs, other heath care professions until the cows come home. Unless and until you can supply the manpower to meet the demand, we are here to stay.
1. I’ve shared the malpractice data in a PPP podcast and a multitude of articles that I have written. I will not be redundant by adding it to this article.
2. I have no issues with NPs or PAs and whether they stay or go is of no relevance to me. I have an issue with NPs/PAs practicing medicine w/o a medical license or physician supervision. They are not qualified to do so. Period. You need not extrapolate or make any other presumptions from that statement.
3. Physicians can be incompetent in medicine, NPPs cannot. If one is not formally or appropriately trained in medicine, no presumption can be made that they are competent. Therefore they cannot be deemed incompetent. NPPs are not incompetent to practice medicine, they are unqualified. Huge difference.
4. The Alexa Ochoa case is not about incompetence, it is about a NP who was unqualified to practice emergency medicine. It does not take a physician 11 hours, even an incompetent one, to diagnose a CLASSIC PE. However, it is the type of error that is predictable from one untrained, unlicensed and unqualified to practice medicine. As far as your analogy, you have amplified the point that if a highly trained physician can make a mistake, then it is absurd to believe an individual with less medical education and training would be less likely to misdiagnose.
5. I doubt NPs or PAs will be practicing unsupervised in all 50 states in 10 years for the reasons stated in the last paragraph. That kind of “health care” is unsustainable. Increasing morbidity and mortality rates occurring as a result of unqualified HCPs managing patients w/o supervision will expose the deficits themselves. Physicians won’t have to say a word. However, they will be expected to correct the damage. Mark my words.
An ugly likelihood in America is that we have ceased to have the prosperity needed for First-World medicine except for the vlasti like the Kardashians. There is no longer enough for the poor to have doctors-or nurse practitioners. Look at old Soviet medicine-to see a doctor within six months cost you a bribe, get your penicillin on the black market, and becoming a “top Soviet physician” meant how wormy you were, not how skilled. The rich had a special plan – go to America for your care. What will we do?
We absolutely do have the prosperity for first-world medicine in this country.
It’s just that we’ve decided to put the money into private insurer profits, PBMs, etc.
Revolution follows the same theme. Wait for an opportunity to smash – a famine or pestilence. That is the hammer stage, and everyone has a hammer. Next, the sickle. But very few have the sickle. Slash and terrify. No more praise for NP’s or PA’s or independent practice EMT-practitioners. Do your job for a pittance and shut up while you’re at it.
Your essays are always so pertinent as my field is forever hounded by questionably trained optometrists seeking to cash in on a referral kickback and simultaneously trying to sneek in surgical/laser babysteps through the state legislature which have the potential to harm patients and the medical bottom line…..an in office laser can and has been used in my field to “print” money……(example is laser treatment for glaucoma- does the patient really have glaucoma- so many times the diagnosis is questionable- and how many times can to you laser the patient if he/she does in fact have the disease…..all open to “medical” interpretation, correct? Actually the answer is as often as you wish- setting the power low makes this a harmless placebo-
I need not recite the multiple factors leading to a shortage of physicians, nurses, and other health care/ home care workers. I pray my family and I will not suffer from this situation as I am entering the golden years. The generations following us will have to stand up for themselves. In my rural area, too many of my personal patients have a midlevel PCP (the last P is for for provider). Their primary care physician has introduced his stable patients to the midlevel, as we all know that the easiest way to make money is to have someone else make it for you and the word “supervision’ is so loosely defined. Think positive-80% of all patients get well no matter what you do to them. So many people nowadays are empowered and can seek care for themselves. They can use Google or follow in the footsteps of Steve Jobs
The P/E firms are all the same- seek short term profits and minimize liability to themselves….that is how successful businesses work- forgive me I am jaded.
The court case you cite is recent and it will take years for enough cases to accumulate before our legislators feel like stepping in- and all the while they will be receiving lobbying money……so while I do financially support our “Surgical Scope’ fund, I doubt I will be around when the massive class action suit finally comes around and a whistleblower comes out to admit the he was pressured to cut costs or risk being blackballed. The powers in charge are obviously putting one foot after the other as they enter the door while we can only simply observe this travesty.
The ‘who is really in charge” issue is an entertaining mental exercise. NP in ER calls NA on call in OR about a hot abdomen……..get the robot ready!
Life is so scary nowadays. In my time, it was watch out for the July doctors- the new grads. Now the world is upsiide down.
In April 2021, Physicians for Patient Protection(PPP) highlighted this very issue(scope creep by optometrists) in an article by an opthalmologist.
https://www.physiciansforpatientprotection.org/only-eye-surgeons-should-perform-eye-surgery/