Monday, May 30, 2011

Medical Care - Payment and Practice

There has been a major change in how medicine is being practiced in the United States - at least in the state of Maine. The New York Times described how Maine's physicians have seemingly moved further to the "left" politically as the manner of medical practice changes in the state. With the number of female physicians now approaching 50% - women who wish to combine medicine with mothering are opting for salaried hospital positions with defined hours, instead of opening practices. This refashioning of how medicine is being practiced is occurring nationwide, I believe. More and more physicians, male as well as female, are opting for a lifestyle-alteration, allowing more time for family and fun. As a general rule, such salaried positions are not as remunerative as are incomes from private practice - one way that will help in controlling soaring medical costs.

Some other ideas:

1) Limit, or eliminate, reimbursement for procedures and treatments for which there is no documented benefit, e.g. routine mammography before age 50, routine colonoscopy after age 75, certain cancer treatments.
2) License nurse practitioners and other similarly trained medical personnel (e.g. physician-assistants) to practice medicine - independently and without supervision by a physician.
There are 158,348 licensed nurse-practitioners in the United States (American College of Nurse Practitioners, 2008). Just imagine the increase in the availability of medical practitioners if even 50% of them would open family practices, supplementing the present number of family practitioners (95,075 in 2009, according to the American Association of Family Practitioners). Nurse practitioners (see Blog July 16, 2008) are perfectly capable of handling the vast majority of medical issues (I would guesstimate some 95%) for which patients visit physicians.
3) Implement a Ryan-Rivlin type plan (such a plan was advocated by the Simpson-Bowles Committee) which would include a limit on Medigap coverage as well as some form of defined-contribution plan for contributors prior to retirement.
4) Raise the eligibility age for Medicare. The Medicare plan did not anticipate life expectancy to reach 80 (77 for men, 82 for women) by 2011. As the number of aged Americans is increasing, the number of employed Americans contributing to the Medicare pool is decreasing.
5) Medicare supports the post-graduate training of physicians with substantial capitation grants to the medical institutions that carry out the training. Eliminate these programs from the general Medicare budget and assign them elsewhere, so that cost for education and cost for care are separated.

Of these, the one that would include no additional significant cost, yet provide meaningful benefit, is the licensing of non-physician personnel to practice medicine. Remember, the EMT that responds to emergencies and the medic treating field injuries in combat - people to whom we entrust out lives - are not physicians! Don't worry about a properly trained nurse practitioner making errors in clinical judgment. They rarely will, believe me! Being a physician is great - we are well-trained, intelligent, and knowledgable. But as competent as we MD's are, there are quite a number of judgement errors for which we've been responsible.

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