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Comment by mikeyouse | Hacker News Reader

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.

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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.

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/

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.

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