Wednesday, May 17, 2006
Quicker Than I Thought
by Tom Bozzo
Like Ezra, I have nothing in principle against the concept of having NPs deliver some basic care at something like half the price of a physician taking a two-minute peek at a patient. I also agree with him that continuity of care is a concern, though to the extent that the next best alternatives for the clinics' target market are some combination of prayer and ER visits, the concern may well be secondary.
It's not too hard to imagine everyone being pushed into variations on these services for primary care — the next step for insurers would be tiered office visit co-payments and co-insurance. Conventional medical practices might respond by hiring more NPs of their own or by cutting their prices (to some insurance companies) on physician services if they needed to retain price-sensitive patients. Anyone whose tiered prescription drug insurance has followed the standard trajectory would expect insurers to inexorably increase the incentive to choose the lower-cost mode of care. The effect is to reduce the demand for (and hence compensation of) some physician specialties.
Via Ezra Klein, I see that in speculating on the ability of corporate health care to cut some physicians out of the care delivery loop, I'd missed Exhibit A: small clinics co-located with chain drug stores and big-box discounters, using nurse practicioners to administer some primary care services at $49 or $59 a pop. That's about half the price via MDs, based on the insurance paperwork we see for our pediatric visits.
Like Ezra, I have nothing in principle against the concept of having NPs deliver some basic care at something like half the price of a physician taking a two-minute peek at a patient. I also agree with him that continuity of care is a concern, though to the extent that the next best alternatives for the clinics' target market are some combination of prayer and ER visits, the concern may well be secondary.
It's not too hard to imagine everyone being pushed into variations on these services for primary care — the next step for insurers would be tiered office visit co-payments and co-insurance. Conventional medical practices might respond by hiring more NPs of their own or by cutting their prices (to some insurance companies) on physician services if they needed to retain price-sensitive patients. Anyone whose tiered prescription drug insurance has followed the standard trajectory would expect insurers to inexorably increase the incentive to choose the lower-cost mode of care. The effect is to reduce the demand for (and hence compensation of) some physician specialties.
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A limiting condition for this will be the supply of NPs. It's not like there's an abundance to go around, or that massively expanding that number would be an easy institutional accomplishment.
That's true in the near term. Given that there are already something like six RNs for every physician in a primary care field, it's less obvious that nimbler parts of the educational establishment couldn't produce a lot more NPs -- at least relative to current numbers -- on the time scale of, say, producing new physicians from scratch. But you are well-positioned to point me to evidence that might convince me otherwise.
There has been the idea for a long time that the number of NPs per MD should be higher. Two problems are that MDs run medical schools and are not necessarily excited about anything that may compromise their compensation and, perhaps more importantly, it's not clear what kind of educational incentive structure would result in the proper number of appropriately talented people getting NP certification and not wanting to go for their MD.
A possible structure of future health care would be something where the NP/PCP distinction becomes minimized, and MDs are basically all specialists.
A possible structure of future health care would be something where the NP/PCP distinction becomes minimized, and MDs are basically all specialists.
Tom: "small clinics co-located with chain drug stores and big-box discounters, using nurse practicioners to administer some primary care services at $49 or $59 a pop. That's about half the price via MDs, based on the insurance paperwork we see for our pediatric visits."
Ken: Actually, my old insurer used to pay the pediatrician $41. Add in my $15 copay and the total is $56, which is well within that range.
Ken: Actually, my old insurer used to pay the pediatrician $41. Add in my $15 copay and the total is $56, which is well within that range.
I vaguely recall from my diss that NPs also control their own licensing criteria. (I could very well be wrong, though -- it's been a while!) Interests being what they are, it's not al all clear that NPs have an interest in being a dime a dozen.
If history is any guide, standards for NPs will go up just about the time an influx of newly-minted graduates from NP programs show signs of meeting the old criteria. And, a few "sunset laws" notwithstanding, state legislatures have been remarkably unwilling to eliminate occupational licenses, especially in the realm of health and medicine where the public and political costs of quackery are high.
Ah, market imperfections: the bane of economists, the bread-and-butter of sociologists.
If history is any guide, standards for NPs will go up just about the time an influx of newly-minted graduates from NP programs show signs of meeting the old criteria. And, a few "sunset laws" notwithstanding, state legislatures have been remarkably unwilling to eliminate occupational licenses, especially in the realm of health and medicine where the public and political costs of quackery are high.
Ah, market imperfections: the bane of economists, the bread-and-butter of sociologists.
No, no, Kim. "Market imperfections" are not the bane of economists--they are what is used to argue why the theory didn't work as claimed, and therefore why it should be applied again.
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