Everything is changing, so nothing is different.
Trying to contain the excessive cost of American medicine, policymakers are hunting for alternative ways to deliver health care. In particular, nurse practitioners and physicians assistants are cheaper than doctors, so state legislatures are gradually opening the door to independent medical practice by people who don’t have medical degrees. In 2012, “827 scope-of-practice bills were proposed nationwide, with 124 of them passing in 29 states.” California is supposedly in the middle of the pack, allowing nurse practitioners to treat patients with physician oversight, but more about that in a moment. An expanded scope of practice for non-physician providers will, we are promised, make our medical care less costly.
Meanwhile, the independent medical practice is on the way to its eventual extinction, as doctors consolidate and take salaried jobs in health care corporations.
And the effects? The same old shortage of primary care providers, and the same excessive cost. Well, no, not the same costs: As the New York Times recently reported regarding the decline of independent medical practices, “many of the new salaried arrangements have evolved from hospitals looking for new revenues, and could have the opposite effect.”
It would be hard to overstate how badly public policy has gone wrong in the arena of American health care, but here’s a remarkable personal experience to suggest the outlines of the problem. In November, too sick on a Saturday night to wait for Monday, I went to the dreadful emergency room in my own neighborhood. It was my first—and last—visit to the place, and almost nothing at all happened: a nurse practitioner asked some questions, ordered some tests that he told me, as he sent me home, he hadn’t gotten around to reviewing, and suggested that I try to see a doctor on Monday. No diagnosis, no treatment, no doctor.
A month later came the punch line: an EOB to let me know how much of the emergency room physician’s $540 bill my insurance company had paid. The doctor on duty that night in the ER, having never seen me or spoken to me, billed me for her services.
After a fruitless exchange of letters, I called the California Medical Board, traveled around the phone tree, and spoke to a regulator. She explained the rules for billing by a doctor for services provided by a nurse practitioner. The doctor sending a bill has to “supervise” the NP, but doesn’t have to be physically present to do it—not even in the same building—and only needs to review “some percentage” of the NP’s patient charts.
This is a scam, “supervision” without supervision. To be sure, it does cut costs—it cuts the cost for the provider of medical treatment, but without cutting the costs insurers and patients pay for service. It’s a profit-enhancer, not a delivery system for cheaper medicine. A nurse practitioner treats patients, and a doctor who may or may not be in the building sends a bill. State law and regulation cheerfully embraces the practice, and doctors get paid without the unnecessary hassle of actually seeing patients or providing them with medical care.
And we wonder why our health care costs are the highest in the world. Anyway, let’s make everyone pay for this remarkable system, or use the Internal Revenue Service to punish people who opt out. What a great idea.