Supply and demand 101 continues to work.
You also make rural care viable when you don’t have folks who need to pay off astronomical loans.
Or maybe you do! It’s for your own good.
https://www.ama-assn.org/practice-management/scope-practice/...
(Because the actual answer is “near zero for literally any provider who isn’t completely independent, and almost none of them are, anymore”.)
Or was this just a way to memetically add “enshittification” to a conversation it doesn’t even slightly apply to, but you think that’s currently trendy?
I’ve found that nurses with significant field experience do very well, but there are plenty of courses who will “zero to hero” you fresh out of high school.
Meanwhile, PAs go through a program near as rigorous as medical school and have to have physician supervision while NPs are not subject to oversight.
And, obviously, NPs cover a smaller range of conditions than doctors.
Many colleges offer RN to BSN courses. Some of them can be 12 months (and some less reputable places offer nine months).
Add in a one year graduate nursing degree with some electives and in some states you are now eligible to practice as an ARNP or CRNP.
I’ve personally met several NPs who are 24 years old and are practicing.
The issue is that at that point you are ignorant or often cocky about your knowledge.
Versus premed 4 year degree, med student practice in years 2 and 3 and continued hand holding through residency…? There’s just a little difference.
Sorry, this is fundamentally incorrect. To the point I can only assume you’ve made up every other thing you’ve said. Though I’m fascinated by a paramedic having opinions on someone else’s medical training.
The world would be better if we had less strident opinions on things we know we don’t know anything about.
But if you mean "supervising physician"? Then let's see:
* Alaska - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
* Arizona - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
* Colorado - Full Practice Authority (NPs can perform the full scope of practice without a supervising or collaborating physician.
We're six states in, and half have no requirement for an NP to have any supervision from a physician.
Let's keep going though:
Connecticut, Delaware, DC, Florida, Guam, Hawaii, Idaho... zero supervision required. At this point I couldn't be bothered going through the list. This list, from the AAFP telling physicians about their responsibilities in supervising NPs state by state: https://www.aafp.org/family-physician/practice-and-career/ma...
So to put that back on you, explain my fundamental incorrectness.
And again, if you're talking about DOH oversight, then that seems a little disingenuous, as even the Chief of Medicine at a Level 1 Trauma Center practices under that insight.
I'm very well aware of the limitations of my scope of practice. That's why I operate under online and offline protocols. But hey, maybe I should have done another year or two of school so I could have a "full scope of practice without any need for a supervising physician". Not sure the ad hominem has any relevance.
Or do you just like how the word has shit in the middle of it and are using it incorrectly?
https://pluralistic.net/2024/10/14/pearl-clutching/#this-toi...
Specifically:
> The fact that a neologism is sometimes decoupled from its theoretical underpinnings and is used colloquially is a feature, not a bug. Many people apply the term "enshittification" very loosely indeed, to mean "something that is bad," without bothering to learn – or apply – the theoretical framework. This is good. This is what it means for a term to enter the lexicon: it takes on a life of its own. If 10,000,000 people use "enshittification" loosely and inspire 10% of their number to look up the longer, more theoretical work I've done on it, that is one million normies who have been sucked into a discourse that used to live exclusively in the world of the most wonkish and obscure practitioners. The only way to maintain a precise, theoretically grounded use of a term is to confine its usage to a small group of largely irrelevant insiders. Policing the use of "enshittification" is worse than a self-limiting move – it would be a self-inflicted wound.
In the days before the Internet, there was only space for a 30 second soundbite and that was the level of discourse. These days, we have Twitter and Substack, so there's slightly more nuance available to us (only slightly), and I'd like to think the "normies", as you put it, are smarter than you think, and are capable of nuance.
The healthcare industry is obviously not an online platform. And I would say it's being done to "lower costs" rather than "raise profits" (the two are often related, but not the same). But other than these, it strikes me as the same basic dynamic in a different industry. I spelled it out in a different comment:
> it's part of a continual gradual march down in quality/services to a captive customer base. Basically the opposite environment of innovation aiming to serve customers
The thing with online platforms is that they are new and fresh having been built out of whole cloth by subsidizing investments, allowing for multiple discrete enshittification steps as management focuses on one area after another. Doctorow:
> This is enshittification: surpluses are first directed to users; then, once they're locked in, surpluses go to suppliers; then once they're locked in, the surplus is handed to shareholders and the platform becomes a useless pile of shit.
Whereas the healthcare industry has been turning the screws for years. Now it's just an environment of making things worse wherever new ways to "control costs" can be created.
I too am not gainfully employed by the healthcare industry. I have just advocated many times for multiple family members. With the reflective hacker/systems mindset I've become painfully aware of the system's patterns of failure.
I guess not much at this point where PCPs don't seem to do much beyond use rubrics, prescribe, and refer. Which is why I used the word enshittification - it's part of a continual gradual march down in quality/services to a captive customer base. Basically the opposite environment of innovation aiming to serve customers.
> How much time, in a day, do you think doctors are spending on “insurance”,
I'd say at least half their time, if not much more. They certainly aren't scheduling these 10-15 minute appointments back to back all day. By "insurance" I am of course including all of the extra documentation and runaround they have to do simply to satisfy the third party beancounters' demands. I'd say this even includes a good number of patient visits themselves.
https://www.astralcodexten.com/p/what-your-doctor-spends-80-...
https://siderea.dreamwidth.org/1182366.html
Observations in my personal experience line up with this:
- Number of signs at my primary care office about their procedures for providing/processing referrals, like this is the majority of their work
- The numerous questionnaires every office makes you fill out ahead of every appointment, that they themselves never actually read
- Experience with a not-terribly-large specialist office who employed an entire full time "nurse navigator" whose job it was to help doctors prepare documentation for "prior approvals"
- The multiple times I've seen a doctor personally step in to grease the system for something way way below their pay grade, because it was the only way to provide appropriate health care
I'm sure I'm forgetting plenty too. Frankly I don't know how one could step into any moderately sized medical provider and not perceive the entrenched corporate government tentacles in every facet.
Being HN, we're talking about systems and cohorts, not individuals. I've had some great individual NPs that were more actively engaged than most doctors. PAs as well. And I've had plenty of crappy MDs just phoning it in. But none of that is really relevant to the system meeting higher demand by simply lowering its standards rather than actually being reformed.
5 years could be plenty?
Dozens (I gave up counting) of states have absolutely no supervision for NPs: https://www.aafp.org/family-physician/practice-and-career/ma... - they have full autonomy as providers.
https://web.archive.org/web/20200501175120/https://www.balti...
Kenneth Arrow famously analyzed the healthcare market and made the above insight: https://assets.aeaweb.org/asset-server/files/9442.pdf
I know he was a Nobel Laureate but not sure if this is the work that won him the Nobel.
Updated: I should qualify my statement by pointing out this is for the US healthcare system.
Counterfactual: patients in India routinely shop around for second opinions and negotiate fees.
In addition, doctors aren't the only cost centers in health care either. Even if they're free, which is sort of already the case or fairly inexpensive for the insured in the US, the overall cost of healthcare will still be high.
Plus if you want completely free clinics (everything from doctors to medicine, etc), then you're not talking about a market solution to the issue, which is completely fair too. No one said you have to use a free market solution for this problem.
My point is that we can't expect a free market to solve this issue. It isn't as simple as supply and demand.
It really is that simple.
Giving people insurance without actually increasing the supply of doctors or clinics increases the number of people willing and able to seek treatment. It does nothing for lowering costs of said treatment. Per basic economics, that’s shifting the demand curve (i.e., increasing demand).
With no changes to supply that leads to higher prices. So every time the government makes a new program or expands anny existing one that provides insurance coverage, costs for everyone will go up.
In contrast, my proposal for explicitly bringing in doctors and creating clinics increases supply. People who would have gone to see a doctor elsewhere may now choose to go to this new free clinic.
The demand curve itself would not change, though with the lower cost due to the supply curve shift you would have a larger overall market.
This is clearly oversimplified. There’s some second order effects where if primary care market increases, you’ll need more X-rays and CAT scans. So there could be an increase in those prices. But that’s could be solved in the same way too.
I think in countries where the health care costs aren't as astronomically high as the US there is some form of government intervention to distort the market. And the original post is more or less arguing for a market distortion that doesn't rely on simple price signals to bring costs under control. But that is very different than what has happened in Denver's housing market.
If that expenditure does impact health insurance costs, then the rebuttal given above about increasing the supply of doctors not improving affordability fails.
If you google [National Health Expenditure spreadsheet], there's an annual spreadsheet that has includes an incredible amount of detail about where we spend money, broken down in a variety of different ways.
I think we are talking past each other. My argument is not that lower prices for medical services wouldn’t lead to lower insurance costs. My argument is specifically that increasing supply doesn’t necessarily lead to lower prices for medical services. It would be quite a finding if US cities with more doctors per capita have cheaper medical services but if anything the opposite is true
For instance, if there's a lot more doctors, the payer may be able to negotiate lower prices. We already have insurance mechanisms that drive patients to the providers that the insurer has negotiated with...