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Future physician supply amidst the growing ranks of NP’s and PA’s


An article in NEJM Catalyst looks at future  physician supply in relation to increased use of nurse practitioners and physician assistants.

The writers conclude:

“It is unlikely that the physician supply will grow more rapidly than we project: the AAMC projects even slower growth, the number of GME slots is constrained, and even an immediate expansion of medical school capacity and training opportunities wouldn’t substantially affect the physician supply for many years. Growth in the NP and PA workforces is more uncertain. Although shorter, more flexible training requirements for these providers have facilitated an unprecedented increase in new entrants, growth rates could fall if demand for nonphysician providers is lower than anticipated and job-market prospects worsen. Major changes are unlikely, however, given the expected increases in demand for care, growing use of team-based and interprofessional practice, and the fact that NPs disproportionately serve rural and underserved populations, whose needs would otherwise go unmet.”

To read read the article, please hit this link.

Physician warns of undertrained NPs and PAs


In a Medical Economics piece, Rebekah Bernard, M.D., asserts that  undertrained nurse practitioners and physician assistants, whom states have been  giving more physician-like authority, are jeopardizing U.S. healthcare.

Among her observations:

“Unfortunately, this lower quality of training and clinical experience is beginning to become apparent. New studies are demonstrating that removing standardized curriculum and physician supervision from nurse practitioner training and practice is impacting the quality of patient care, including poorer quality referrals to specialists compared to primary care physicians, more unnecessary skin biopsies, than physicians, increased diagnostic imagingincreased prescriptions, including increased antibiotic prescribing[v] and higher opioid prescribing shown in the states of Connecticut and New Hampshire. Payouts for malpractice claims against NPs are also on the rise, as are claims for the improper prescribing and management of controlled substances. With training programs churning out NPs at a rate of 23,000 per year, compared to about 19,000 physicians graduating from medical school per year, we may see these trends grow.


To read her whole piece, please hit this link.

Not too few physicians but bad distribution, not enough non-physician clinicians

It’s sort of a cliche to say that America has a  dangerous shortage of physicians. But a New York Times story challenges that.

It says, among other things:

“Some people think there’s no shortage at all — just a poor distribution of the doctors we have.”

“Adding data to this argument, the United States has fewer practicing physicians per 1,000 people than 23 of the 28 countries that reported data in 2013 (among nations in the Organization for Economic Cooperation and Development).”

“But there is strong evidence that we are thinking about this the wrong way. In 2014, the Institute of Medicine released a thorough analysis on graduate medical education that argued there was no doctor shortage, and that we didn’t really need to invest more in new physicians.

“The system isn’t undermanned, it said: It’s inefficient. We rely too heavily on physicians and not enough on midlevel practitioners, like physician assistants and nurse practitioners, especially because evidence supports they are just as effective in primary care settings. We don’t account for advances in technology, like telehealth and new drugs and devices that lessen the burden on physician visits to maintain health.”

“And we fail to recognize that what we really have is a distribution problem. Parts of this country have lots of doctors, perhaps too many. These are mostly in cities, especially in cities where it seems desirable to live. The problem is made worse by the ways we reimburse for care. Medicare, for instance, pays more to doctors who live in places that are more expensive. The argument for this is that the cost of living is higher, so reimbursements must be, too. But that also means that doctors can earn more in places where they already might want to live. A result is that many rural areas, and less popular cities, experience more of a doctor shortage than others.”

“The other distribution issue is in specialization. When it comes to generalists, we ranked 24th of 28 countries in doctors per 1,000 people. Specialists are a different story. There, we were 11th. This is an important fact about the American health care system. We sometimes hear that we have too many specialists and too few generalists. That’s not necessarily the case. We have an average number of specialists compared with other advanced countries, and even shortages in some specialties. It’s the ratio of specialists to generalists that’s the problem. …”

To read the full Times story, please hit this link.

The still modest lure of physician unionization


“Strike action” (1879), by Theodor Kittelsen

More physicians are considering joining unions.

One  well-known supporter of unionization is David M. Schwartz, M.D., president of a union local that represents 27 hospitalists at PeaceHealth Sacred Heart Medical Center at RiverBend, in Springfield, Ore.

“The biggest challenge for employed physicians is going to be the realization that they’re no longer part of an autonomous profession,” he told Medscape. “They work for people who no longer respect their autonomy.”

The publication reported that his group “is thought to be the first doctors’ local limited to just one specialty. The National Labor Relations Board now lets “micro-units” of employees to join unions, which could boost the  overall unionization of physicians.  It is easier to sign up a small group, such as hospitalists, than to recruit the entire physician workforce in a hospital.

But don’t expect a  rush of hospital-employed physicians to join unions, although things may change as healthcare’s reimbursement revolution accelerates.

Howard Forman, M.D., a radiologist who teaches healthcare economics at Yale, noted that unhappy employed physicians generally have many jobs they can move to — and hospitals’ C-suites’ knowledge of that would tend to prevent unpopular moves that would lead many physicians to quit.

“A few physicians able to move ‘should provide a meaningful lever to change compensation and work requirements for all,’ ‘ Dr Forman told Medscape. For most doctors to agree to strike, ”the times would have to be more desperate than they are now”.

Still, the move to hire cheaper clinicians such as nurse practitioners and physician assistants to perform many of the tasks traditionally performed by physicians, and especially by internists, pediatricians and hospitalists, may soon reduce  the number of physicians’ greener pastures elsewhere.

To read the Medscape piece, please hit this link.

Emergency in Vt.? Link up with an S.D. physician


Mt. Ascutney, the subject of many celebrated painters over the years.

Hospitals & Health Networks reports:

“The emergency department at Mt. Ascutney Hospital and Health Center, a 25-bed critical access hospital in Windsor, Vt., is staffed by physician assistants, with an emergency physician on backup. But if they need more immediate help, the push of a button will summon emergency medicine specialists — from South Dakota.

“A two-way, high-definition video/audio link connects two Mt. Ascutney Hospital emergency bays to Sioux Falls, S.D.-based Avera Health, a leading provider of tele-emergency services, through an arrangement with the Dartmouth-Hitchcock Center for Telehealth. Mt. Ascutney Hospital is an affiliate of Dartmouth-Hitchcock {Medical Center, based in Lebanon, N.H., and   the Geisel School of Medicine at Dartmouth College.)

The controversial role of NPs and PAs



Nurse practitioner at U.S. naval base in Japan.

This article from Physicians Practice looks at the expanding but controversial status of nurse practitioners and physician assistants in U.S. healthcare.

Regulators and insurers seek to boost their role as part of an effort to curb costs  and expand healthcare access in the world’s most expensive healthcare system. But many physicians think that these nonphysician clinicians are inadequately trained for expanded roles and fear that they will cut into physicians’ incomes.

Rural areas well positioned to lure primary-care physicians


“Morning in the Woods,” by Currier & Ives.

The Medicus Firm, a  healthcare staffing company, reports that primary-care physicians might want to consider looking in a rural area for a new job. Not only do many rural areas have significant need for PCPs, but they may also offer the biggest compensation packages.

The Medicus Firm compiled data based on its placements of PCPs and physician assistants made with more than 250 hospitals, health systems and medical groups in 2015.

Here are six takeaways on PCP and PA compensation based on its findings, as summarized by Becker’s Hospital Review:

1. “Internal-medicine physicians bring home higher salaries on average than family practice physicians. Based on data provided by The Medicus Firm, the average family practice physician salary was $210,192 in 2015. Comparatively, the average internal medicine salary was $238,975 in 2015 or about 14 percent more than family practice.”

2. “By average placement salary, rural settings are the most lucrative for both internal medicine physicians and family practice physicians. The average placement salary for family practitioners in rural areas was $227,261 — 16 percent more than the average urban salary and nearly 10 percent more than the average salary in a mid-sized community. For internal medicine physicians the average rural placement salary of $256,667 is 13 percent greater than its urban equivalent and 10 percent greater than the mid-sized community average.”

3. “Average signing bonuses across both family practice and internal medicine seem to follow the trend of greater awards in rural areas. The average primary care signing bonus is $19,714, according to the The Medicus Firm. However, broken down by family practice and internal medicine physicians,the signing bonus data shows no clear trend.”

4. “Average total compensation — including both salary and signing bonus — got larger as community size got smaller. Despite the range of signing bonuses, total compensation, like average salary trends, shows a negative correlation between total compensation and population size.”

5. “{B}oth average salary and average total compensation was highest in the Central U.S./Upper Midwest and the South/Southwest.”

6. “PAs earned an average salary of $112,680 and an average signing bonus of $6,250 in 2015. About one-third were paid relocation bonuses ranging from $5,000 to $15,000, averaging about $8,751. PAs were the fourth most-placed clinician in 2015, according to The Medicus Firm. Salary and compensation data by community size and region was not available.”

Median salary rises to nearly $100,000 for PAs


With the aging of the population and Medicaid and other health-insurance expansion under the Affordable Care Act,  U.S. physician assistant compensation has risen to a median of almost $100,000 on average across the U.S. amid a nationwide shortage of physicians.

A new state-by-state statistical profile of the profession from the National Commission on Certification of Physician Assistants  found that the median PA salary was $95,000 for 2014, the most recent  full year that such information is available.

Forbes noted that the salaries ”are rising even faster in certain areas of the U.S. for physician assistants, known in the industry, according to the commission, which certifies physician assistants. PAs in California, Connecticut, Minnesota, Arizona and Alaska have a median salary of $105,000.

Open your mouth for the dental therapists


Text and WGBH podcast:

What has been happening with  the rise of such non-physician clinicians as nurse practitioners and physician assistants is now  happening in dental care, too, with the appearance of “dental therapists”. They work in the space between dentists and dental hygienists.

It’s a matter of healthcare access and cost.

Many middle-class patients forgo dental care because it is very expensive, in part because dentists have demanded and gotten very high incomes. Consider that the average net income for a general dentist exceeds $180,000 — more than the average of around $170,000 for primary-care physicians. In some places poorer people on Medicaid can get dental care, though such access can vary quite a bit across America.

Further hurting access is that dental insurance, if you have it, usually provides very skimpy coverage, forcing most patients to make very large out-of-pocket payments. It’s enough to scare a lot of people away from getting the treatment they need. And course poor dental care can lead to other health problems, including heart disease.

So  some states,  although often opposed by dentist organizations fearful of reduced incomes for their members, are authorizing a new classification called “dental therapists” to provide routine care at considerably lower prices than those charged by dentists.

We’d bet that pressure from payers will lead to a rapid expansion in the number of this new kind of dental practitioner. We may even see them soon in retail clinics run by CVS and other drugstore chains.


Video: Key role of PAs and APNs in population health


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