ERs are hiring fewer doctors to save money | Hacker News Reader

ERs are hiring fewer doctors to save money

npr.org

56 pointst23109 comments

> 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.

We need to outlaw for profit anything with healthcare. The incentives are misaligned with society’s needs.

I'm not sure about that. Private health care is largely beneficial in countries with strong socialized health care. I'm definitely no expert on financial regulation, but I see the practice of "flipping" businesses as the real problem. Where I live, we've recently introduced a "house flipping tax" (which doesn't go far enough, in my opinion, but that's another conversation). A similar approach could be taken to private sales of businesses: if you buy and sell a company in a relatively short period of time, the gains (from the sale, from income, etc) should be taxed at a steeply elevated rate.

Yeah, private healthcare can always be a valid addition, but access to "strong socialized healthcare" should be a relatively good minimum floor — something many countries do not have.

All humans need health maintenance, it doesn't need to be a "can I afford it" value proposition. I know friends currently living without it because they can't, even with subsidized social options... this is endemic to the problem of "socializing" a private healthcare system, where $ comes first.

Absolutely. The US creates particularly perverse incentives. In countries with strong socialized healthcare, private offerings must be better than the public service to be worthwhile. In the US, private healthcare needs to be better than literally nothing when a big player buys up the competition.

A lot of people are perfectly happy with private healthcare. I happen to be one of them. But I'm also not opposed to my tax money funding the county hospital either. We can have both.

Private is not the same thing as for profit. A non-profit is a private entity. They are not part of the public sector.

In fact, much healthcare was delivered like so pre-WW2. Still today, Kaiser and Cleveland Clinic are non-profit.

I'm happy with my private, for-profit healthcare. But I'm also glad to support public healthcare services with taxes. It's not just one or the other, we can have both of them.

Probably because you are generally healthy...

I will mention again for the fun of it, that private healthcare for profit works very fine in other places, like Switzerland for which I can vouch. There might be a lesson somewhere, maybe?

The overwhelming majority of hospitals are nonprofit.

The overwhelming majority of prisons are run by the state.

The overwhelming majority of higher education is nonprofit.

The Catcholic church circa 1500 was nominally nonprofit.

PE probably does turn everything to shit but acting like not having shareholders or owners who are looking to wring every cent out so they can get the fattest check will solve the problem seems naive at best.

Non profit is a tax designation and that's it. Non profits, especially healthcare, still pay their execs and c suite multiple times *more* than physicians and staff, and cut corners and costs in many areas. Non profit status doesn't mean shit.

Having a non-majority of something doesn't make it "not true" or "not matter".

Why in the world would you include a statistic about the Catholic church in this conversation? Are you insinuating something? You can do better.

You really need to put more context around your last comment. It's confusing at best.

I think the problem here is that "profit motive" is reduced to capitalism. For politicians profit is votes so under funding hospitals and prisons to spend in high profile pork projects (can even be tax cuts) is still profit motive. It's a rational choice if they think they can get more votes, more bang for their buck, by spending it elsewhere. This isn't traditionally seen as "profit motive", but really it is because it was done for the private benefit instead of over arching ethical deliberations or calculations for net good etc.

Boy you people really love banning things don't you. Why on earth would you _outlaw_ people from being able to see their private, for-profit family doctor.

I’m not sure who “you people” are. Doesn’t feel like that’s adding much to the conversation, nor does it incline me to participate.

Why only healthcare specifically?

We’ve seen that having a profit motive is, to a point, generally good in many areas of commercial life.

Healthcare is not one of these areas.

I'm asking why the difference? Why is it good for society sometimes, and sometimes terribly wrong, in your view?

Externalities of the absence of something can be small, large, positive or negative.

What do you think are the externalities of _not_ having healthcare available to majority of your population ?

You rephrased the question

Inelastic demand is one oft cited trait.

Let's do the same for housing

Because there shouldn't be a variety of price points, and innovation should not be hoarded. Healthcare should be uniformly the best it can be.

Agree but the question is why specifically only healthcare

Sadly this probably means no covid vaccine and few advancements. It's easy to spread out what we have; it's hard to run an engine of care and innovation at the same time. Choose hard.

I appreciate that R&D funding requires investment, but that doesn't have much to do with hospital reimbursement rates -- especially when the alternative of a more European-style healthcare system comes along with a German company inventing one of the two Covid vaccines (https://en.wikipedia.org/wiki/BioNTech)..

European drugs are often funded by their profits from America.

Just a completely evidence-free claim that's repeated ad nauseam. The big European pharmas (along with the big US ones) are repurchasing shares on the order of tens of billions of dollars per year. If they're so reliant on excess profits to fund R&D, maybe they should have held onto those funds?

Go look at Pfizer revenue from US vs Europe. Europe has more people, but less than half the revenue in a typical year.

Americans are indeed subsidizing new drugs for the entire world.

Presenting Pfizer as if it's primarily serving the German market is silly. Pfizer by revenue is primarily in the US market.

https://www.statista.com/statistics/267877/revenues-of-pfize...

It's not evidence free. One of the things single payer does is negotiate discounts based on their whole country's population. That's going to fund ops and a bit of profit, not R&D.

> If they're so reliant on excess profits to fund R&D

R&D money comes from profits. It's not specific to the pharma industry. They just have particularly enormous R&D costs.

"European-style" isn't so much of a thing. There are all sorts of models. BioNTech is a public listed for-profit company that partnered with Pfizer, a public listed for-profit company, to develop that vaccine.

There needs to be lots of profit in healthcare for anyone to do anything, or even to be in a position to do anything.

Of course there's a European style in contrast to the American style.. Single payer coverage governed by a government/quasi-government body with no profit taking and rates for drugs and care negotiated by the payer. Some have free point-of-service care, some have copayments, some have private insurance or supplemental insurance but the contours are the same.

There are dozens of huge pharma companies in Europe inventing life-saving drugs with plenty of profits to go around, this conceit that we need to price gouge Americans to pay for Research while the same firms spend more on marketing than R&D is just the dumbest thing.

mRNA vaccine research was funded in large part by DARPA grants in the USA.

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).

https://www.chiefhealthcareexecutive.com/view/hospitals-losi...

> 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

If I had the choice between system A with excellent community health outcomes, but didn't turn a profit, was heavily subsidized, and ran with operational bloat, versus system B which ran lean/efficiently but produced poor health outcomes I would choose A every single time and I imagine most people would

Currently in the US we have neither. We have a bloated/inefficient system that also produces poor community health outcomes. But at least a few private equity firms might turn a profit, so at least there's that??

"Also many countries have price controls on drugs, and US does not (thus subsidizing RoW in regards to new drug research)"

I think this line is BS propaganda by the pharmaceutical industry. I am 100% sure the US would be way better off if they controlled prices and then subsidized research directly instead of paying outrageous prices.

As far as hospitals losing money, this doesn't mean that they are using their money efficiently. My ex used to do auditing of hospitals and a lot of them showed a circle of friends consisting of local construction company, architects, business consultants, doctors and others. They all lived well on charging a lot of money to the hospitals and the hospital execs didn't check because they were all buddies.

> 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.

This comes up in every thread about healthcare and it's just plain wrong/backwards.

The reason they appear to be losing money or close to losing money is by design, because of the incentive to be inefficient. It's a way to balloon the "costs" in their accounting and demonstrate to the outside observers that they are "oh so poor" and need help, whereas in reality, they charge exorbitant amounts for procedures and then mark it off as "losses" when consumers can't pay.

If you look at Hospital REITs, the majority of the systems have low rent coverage on a cash flow basis. Look at the distribution yields/low multiples applied to hospital real estate... many are priced with high tenant default/bankruptcy risk.

e.g. MPW

Hospitals are not the same as Medical Office, which tend to be more profitable. Where are the facts to corroborate your statement?

But... if they're already losing money because they're inefficient, with a 'profit motive' in place... it's obviously not enough of a motive to be efficient. They may be losing money not because of inefficiency anyway, but assuming so... existence of 'profit motive' coupled with inefficiency should be evidence enough that they're not linked.

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:

https://www.cnn.com/2023/01/23/uk/uk-nhs-crisis-falling-apar...

> That model doesn’t seem to be working either

The model works just fine. The reason the NHS isn't working is because the Conservative government has intentionally underfunded it (UK per capita spending on healthcare is significantly lower than other European countries).

That, plus the CNN article shared above can’t simply be reduced to failure of “the model”:

> Explanations for the current crisis “have to start with a consideration of Covid-19,” Ben Zaranko, an economist at the Institute for Fiscal Studies (IFS) whose work focuses on Britain’s health care system, told CNN. “There’s the simple fact that there are beds in hospitals occupied by Covid patients, which means those beds can’t be used for other things.”

Same as Canadian. It took me 7 months to get an endocrinologist appointment. Luckily I was in traveling in Mexico and saw one there. If I had waited for my Canadian appointment, i would have lost all my hair and over 30kgs by that time. (It was a harmone related problem).

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.

It would take a rethinking of how the government would run the medical systems though. For example, the Veterans Administration hospital system is now a mix of Govt. and Referrals to for profit because the Govt. run hospitals have failed to meet standards / needs consistently. The health care has always been deemed pretty subpar / inadequate as well.

I'm not opposed to a government system, but it needs to be a redesign and re-haul of everything we've done so far and the reality is that it's just not likely to happen.

There are some exceptions to quality at the VA, notably when the VA is co-located with a school such as Stanford in Palo Alto. There they often have great medical providers and support.

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.

Profit is a strong incentive to optimize. non-profit organizations are under different incentives. They both have pitfalls, they both have advantages.

Profit is a strong incentive when there's active competition. When there's not competition, for-profit business turn to extracting rents on captive customers.

Health care larger is not a competitive market. Lots of customers only have limited options (i.e. rural hospitals) and the urgency of some purchases don't support competition (i.e. ER visits)

I agree its not a competitive market. Rural areas suffer in all areas of limited markets, medical isn't special. Government involvement (including, but not limited to limiting licensing). insurance clouds the market as well (both how we procure insurance and government limitations of insurance).

> Profit is a strong incentive to optimize.

Optimize what? Certainly not costs, since for-profit hospitals have every incentive to push for unneeded expensive operations.

Maybe you’re mistaking healthcare for a market where meaningful competition and information symmetry exists?

> 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.

Non profit, publicly owned hospitals can be just as bad- https://www.vox.com/policy-and-politics/2019/1/7/18137967/er...

Aren’t most hospitals in the states non-profit? But all those doctors and administrators want money, so it hardly matters.

Hospitals shouldn't be a profitable business.

Then elide "profitable" since that is the goal of every business.

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.

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.

Counterpoint: You can go read the “Noctor” subreddit or ask any practicing physician why it’s bad for patient outcome.

Ultimately we need more doctors and less hospital administrators.

Man, that subreddit reads like the most massive case of sour grapes imaginable.

It's just people (presumably a lot of physicians / med students?) griping about how NPs and PAs are acting too good for their titles. All the actual stories are, like, one-off anecdotes about how some NP made some medical mistake. As if MDs don't make a massive amount of mistakes, I guess?

Edit: lol, reading more, and I have seen multiple posters and commenters directly reference how much less "intelligent" NPs and PAs are. This whooooole sub is just a massive superiority complex

Edit2: There's a moderator bot that automatically responds with a list of rebuttals, which includes this beauty:

> You're just sexist. Ad hominem noted.

They covered that one already:

https://www.reddit.com/r/Noctor/comments/yf3ajr/updated_fpa_...

> Arguments Not Allowed

...

> Doctors make mistakes too. Yes, they do. Why should someone with less training be allowed to practice independently? Discussions on quality of mistake comparisons will be allowed.

If we need more doctors then it's time for doctors to rectify that themselves. Doctors and dentists both gatekeep their professions because of money, not because of talent.

I know plenty of "practicing physicians" that speak highly of midlevels. Comparing tenured doctors to the student-filled shit factory that is "noctor" is either extremely disingenuous or extremely ignorant.

> You can go read the “Noctor” subreddit

There's just no way I would take medical advice (like which provider to choose from) from a site that's basically anonymous creative writing.

And let's be frank: just browsing this subreddit, it reeks of sexism and racism (it's no coincidence that the demographics for nurses are different than doctors). There's also not a single verifiable claim or study that would prove their point. And a lot of comments about IQ that sounds eerily similar to the current discourse of "race realists"...

> Ultimately we need more doctors and less hospital administrators.

I guess I tend to agree but you can't just conjure them up. You can set policies to encourage physicians to emigrate to the US and make it easier for students to pay for med school, but in the end only so many people are going to want to become doctors.

Doctors say we need more of them and their high pay?

I'm sure the high paid software engineers at boeing said something similar when jobs were being outsourced "we need more US engineers". Look at the software problems they had and tell me they were wrong.

Just like software engineers are best qualified to evaluate software quality, doctors know medicine better than anyone else. Just because they are incentivized to protect their job doesn't mean they are wrong.

> Just like software engineers are best qualified to evaluate software quality, doctors know medicine better than anyone else. Just because they are incentivized to protect their job doesn't mean they are wrong.

It was rather trivial for Boeing engineers to show, without a doubt, that the cheap offshored programmers didn't write software as good as they did. The design simply spoke for itself and didn't perform to spec.

Why not simply have doctors do the same? If their fellow medical workers can't deliver the same quality of care at the same speed and cost, then it should be trivial to show.

With the Boeing engineers the outsourcing wasn't obviously an issue to individuals outside the system until the 737 MAX was grounded and 346 people were dead. Requiring such a sentinel event before the value of US engineering was known to the public suggests to me that it was not trivial for the Boeing engineers to prove their value.

Doctors are at a greater disadvantage as there is not likely to be a sentinel event that kills 189 people at once. Nothing about the US medical system is trivial.

Consider the private equity run emergency department in the article, I am sure that they could make more profit off of NPs and that doctors wouldn't save private equity costs. The article suggests that NPs are saving private equity money while costing patients and taxpayers more. Speaking of quality, why should private equity care about quality if it doesn't effect their bottom line?

That's correct but I believe their bias makes them a untrustworthy worthy source

My last ER visit I was seen by a PA, which is fine. They're more than competent.

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...

> 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.

The whole thing made me sick to my stomach.

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.

Same thing happened to me in Canada.

Did they tell you how much the charge would be?

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.

[1] https://wikem.org/wiki/Ectopic_pregnancy

There is some evidence in the primary care world that going to a NP for primary care costs more than going to a doctor: https://www.ama-assn.org/practice-management/scope-practice/.... In short, NPs order more tests without improving patient outcomes.

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.

The AMA obviously has an agenda, but that doesn't that change the fact that non-physicians cost patients and taxpayers more money, hard to argue with the cms data.

Who cares if your doctor gets paid more if he is saving you and the taxpayers money. I guess it might make business sense from a hospital perspective, because physicians are more expensive to employee than NPs and hospitals don't have a business reason to save taxpayers or patients money.

Claiming as a fact that non-physicians cost more money based on the back of one random study from a Mississippi health system might be a bit rash. Especially since almost every other bit of research has shown the opposite;

"Overall, the average PCMD cost of care is 34% higher than PCNP care in the low-risk stratum, and 28% and 21% higher in the medium-risk and high-risk stratum" - https://journals.lww.com/lww-medicalcare/Fulltext/2021/02000...

"Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care." - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559935/

For a few examples from the past couple years.

Truly it's a nuanced topic and you cannot say that across the board NPs cost more than physicians. I have no doubt that NPs and PAs can be cost saving when employed appropriately.

An issue with your first study is that some NP care was attributed to physicians (as a result of NPs billing under a physicians NPI), hence decision making that was done by an NP is being analyzed as if it was done by a physician. In the study I linked that wasn't have been an issue as they could see which patients were on which providers panel.

The study you linked on PAs is interesting, although it's an international one and ~24% of included studies were of PAs who did only one procedure (not really applicable to the discussion here). If you bring a PA into your practice to do only one procedure it's hard to envision that being much of an issue.

The NPR article itself links to a study that shows NPs cost more than physicians (in the emergency department), so it's not just one random study that shows they can cost more.

I think we could both post studies back and forth all day, maybe it makes more sense to look at things from first principles. If your ED visit is billed the same whether you are seen by an MD or NP, how would an NP go about saving you money? I hope that we can agree they will have less medical knowledge, so I don't see how they could order fewer studies / tests safely.

Trying to apply "first principles" approaches to something as complicated as medical billing and reimbursement is a fools' errand. As a quick example before I move onto more pressing things, you ask, "If your ED visit is billed the same whether you're seen by an MD or NP, how would an NP go about saving you money?"

It'd be helpful to know that they aren't billed the same!

From CMS:

> When an emergency department E/M is shared between a physician and a PA or NP from the same group practice and the physician provides the substantive portion of the E/M encounter with the patient, then the service may be billed under either the physician's or the PA's or NP’s UPIN/PIN number. If the physician does not provide the substantive portion of the encounter even if the physician participated in the service by reviewing the patient’s medical record, then the service may only be billed under the PA's or NP’s UPIN/PIN. In this scenario payment will be made at 85 percent of the Medicare physician fee schedule.

Please correct me if I'm wrong here: You save $45 on the professional services, but you still pay the same facility fee (~$1000), the CT scan still costs the same (~$5000), labs are still the same (~$110)... etc. So maybe you have saved ~1% seeing an NP, hence why I said "billed the same", although you are correct that they are not the exact same. Now imagine that a NP orders a CT scan that was unneeded 1% more often than a physician, at this point it costs more on average to see the NP.

Again - this is far too complex to "first principles" your way out of. You need to be clear who you're talking about when you talk about savings (savings to the patient?, to the private insurer?, to medicare/medicaid?,to the hospital?, to the taxpayer if it's a public health system?) and even still, it will vary massively given that much of our care is state-driven.

Your figures e.g. for a CT scan are wildly wrong if you're talking about anything government-paid. The reimbursement for a differential chest CT to the facility is closer to $150 from the government (https://www.cms.gov/medicare/physician-fee-schedule/search?Y...) but again, that varies depending on a million other things.

So making some claim like the 15% savings from an NP reimbursement is only 1% of the total cost of a visit needs a heck of a lot more specificity than your gut feeling on what things might cost.

I care about savings to the patient and taxpayer if that's helpful. I just googled "average cost of emergency department CT scan", I agree that is not what Medicare would reimburse.

It is a bit rash, but it’s the exact same study trotted out literally thousands of times by disgruntled residents on Reddit, fuming that there exists a profession that can practice medicine without years of humiliating residency. Whenever someone uses that study as a citation, it’s immediate reason to discredit anything else they’re going to say. Just spend a few minutes looking at that “Noctor” subreddit the guy shared. It makes me disguised with MDs in general just reading it, until I remind myself that most of the posters there are just inexperienced students or residents. I do feel bad for the suckers that take its content at face value though.

Truly reddit is a place full of idiots on all sides, do you have specific criticisms of the study I posted though? Or specific criticisms of the study in the NPR article?

https://xkcd.com/882/

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.

Right - and the risk is much greater seeing “unfiltered” emergency patients, compared to a patient who has had a full assessment in the ED, had surgical issues ruled out, etc and was then admitted to the internal medicine service.

What risk? Malpractice coverage is provided by the hospital, or more typically, the private equity group that owns the ER physician practice. Last I looked, independent ER docs pay something like $15k more per year than IM docs for solo coverage... there's still quite a ways to go to make up that other quarter million dollars.

I don't think the average person realizes that Blackstone is one of the largest employers of ER docs... it's not "supply and demand" that's increasing ER salaries, it's a private equity cartel that aggressively upcodes routine treatment and then sues hospitals to increase their reimburesment rates.

https://en.wikipedia.org/wiki/TeamHealth

https://tennesseelookout.com/2022/05/09/tennessee-health-bil...

> What risk? Malpractice coverage is provided by the hospital, or more typically, the private equity group that owns the ER physician practice.

Stress isn't alleviated just by insurance. Sometimes people care about doing their job right and "winning". ER docs are just put on the spot constantly.

> I don't think the average person realizes that Blackstone is one of the largest employers of ER docs...

It doesn't really matter, unless you want to claim that they employ more ER docs than the other systems put together, which I doubt they are even close to that. If Blackstone had a lock up on ER services, you would think they would not pay their ER docs as much to stick around since they would have fewer places else to go.

The popular conception of an ER doc is completely divorced from the day-to-day reality.. This isn't House, they're not "put on the spot" constantly like they're on some island. They are part of a care team and they call for IM/ID/Cardio/Radiology consults when they have any question about a diagnosis. They certainly have stressful jobs but no moreso than the floor physicians or other providers who work the same shifts and who take the critically ill patients when they need care beyond the capabilities of the ER.

If being an ER doctor is such a cushy deal for more money, doctors who would otherwise choose internal medicine would just choose that. There is plenty of variation in medical specialties, but, at least for people who are going to medical school today, I'm sure they are well informed what is in demand and what isn't. At least in this case, I don't see non-market forces at work (whereas medicine has plenty of those in other places).

because besides money, maybe some human doctors find it emotionally difficult to tell someone their family member died because we made the wrong diagnosis, or took too long to make the correct diagnosis?

By analogy, if you have home insurance, you don’t mind if your house burns down? Seems unlikely…

I think a dual system is necessary, due to the US’ reluctance on relying heavily on government (on paper).

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.

> 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.

Ama also keeps supply of doctors down too. That's why all these medschools have such low acceptance rates.

If you are an Indian and have a 3.8 gpa you still might not get into medschools which is pretty absurd.

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.

Yeah I was actually thinking of Physician Assistant

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:

https://www.salary.com/research/salary/alternate/registered-... https://www.payscale.com/research/UK/Job=Registered_Nurse_(R...

+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.

The thing is, I think a big part of solving the crisis is cutting costs and improving efficiency, and also advertising and lobbying to get more income. Because healthcare is intrinsically expensive. So I get why admins are important.

That being said, even with no experience or understanding of admin myself, I can still see that they are doing a really bad job. Because they are "taking home millions in pay"; because there are simple things like increasing nurses' pay (when the alternative is hiring traveling nurses for even more!) and actually listening to their feedback; because even to the unknowing public there should be some support, yet I've never heard anything good about admin except when they don't take excess pay and implement the obvious.

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