Re: will primary care survive

[Guest guest]

Here's another thought --

Nurses (not NPs, please take note) conducted these interventions in the U.K., where nurses still have less authority than in the states and nurse practitioners are a new and very undeveloped idea. If you're going to use the literature, you should probably compare apples to apples.

If you really want some literature on the effectiveness of NPs in primary care in the United States, just let me know -- I can bombard you with dozens of studies.

I provide full primary care for my patients. I assume, if you found a patient with liver cancer, you would refer that patient to oncology, would you not? Would you provide their liver transplant yourself? Right, neither would I.

However, I'm perfectly capable of assessing for the presence of liver failure vs. liver cancer, conducting the workup and referring the patient to oncology and gastroenterology. As I did last week.

And if they have uncomplicated congestive heart failure, I will be treating that, but it's likely I won't be doing any cardioversions in my office for their new-onset atrial fibrillation. Do you do that? Or do you send them to cardiology. Right. As I did last week.

And if you find your patient has gallstones, is symptomatic, and needs a cholecystectomy, are you providing those in your office? I hope not. Right. Neither am I.

So, I think your 99% is rather a high estimate, and if it's accurate, there's plenty of studies that show patients do better for some complex diseases when managed by the specialist.

For all the rest that can be managed in this office, I'm doing the same things as an MD, and with my 20 years of patient-care experience, I'm doing it very, very well.

Thanks,

Deanna Tolman, FNP-BC

Head2Toe HealthCare

At the end of the day I think it is all about cost-effectiveness. One of the few recent meta-analysis was published in BMJ, comparing "regular clinics" vs "nurse led clinics".

BMJ 2010; 341:c3995 doi: 10.1136/bmj.c3995 (Published 23 August 2010) Cite this as: BMJ 2010; 341:c3995

Research

Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysisOPEN ACCESS

E , clinical academic fellow, F P , senior clinical research fellow, Rod S , professor in health services research, L , professor of general practice and primary care

Cost and cost effectiveness

Only four studies presented any data. From the United Kingdom one study reported a cost per patient of £434 (€525, $632) over two years to provide additional nurse clinics and support from specialist nurses, representing £28 933 per quality adjusted life year gained19 and another study found that primary care costs were £9.50 per patient compared with £5.08 for usual care.43 In the United States a study reported a 50% higher total cost of staff at $134.68 (£92.65, €111.90) per patient treated in a nurse led clinic compared with $93.70 for usual care,47 but a Mexican study reported $4 (£2.75, €3.32) per patient or $1 per 1 mm Hg reduction of systolic blood pressure.32Also,

Conclusions

Nurse led interventions for hypertension in primary care should include an algorithm to structure care and can deliver greater blood pressure reductions than usual care. There is some evidence of improved outcomes with nurse prescribers, but there is no evidence of good quality from United Kingdom studies of essential hypertension in primary care. Therefore, although this review has found evidence of benefit for nurse led interventions in the management of blood pressure, evidence is insufficient to support the widespread use of nurses in hypertension management within the UK healthcare systems.I don't doubt than any structured intervention can work, but when you factor in that it becomes more expense and the need for regimen algorithms to be followed to achieve results with "Nurse led Clinics" in this limited scope of practice. how many algorithms can you develope for a Primary Care practice? If that was possible a computer could do Primary Care.Other studies that I have quoted at other discussions report the same, midlevels can take care of 80% of the problems out there; even if it is 95% that 5% is what burns all our health care funds today. In my opinion high quality primary care should be delivered by someone that can solve 99% of the patient's problems. It is true that most of my day to day work is mundane but then I get the patient with AS 1.2 cm2 area, AI, MR and TR; that was managed by another provider that uses mid levels. Sure that his BP was controlled on high dose Betablocker and HCTZ and also had some statin on board but he should be on as much ACE-I he could tolerate and as much statin as tolerated. Did the midlevel understand the implications, not likely. I have more examples.Personally, I think we get from the system what we want. In the year 2011 we can choose: (a)Primary Care can mean treatment of sore throats and essential HTN or early DM and referrals to the cardiologist and endocrinologist., or (b)Primary Care can mean treatment of both by the provider without a cardiologist nor endocrinologist plus the treatment for the sore throat. Cost difference: a lot.I strongly believe that there is a place for Mid-Levels in specialty care. Primary Care on the other hand, if you really mean for it to be Primary Care, is just to complicated and vast to be provided efficiently with limited training.Just a thought, from the Barrio



RE "snide comments"

OK, that's very interesting.

I did say, PAs and NPs that are in close agreements and support with physicians.

I have worked with both -- those that I am most comfortable with ANY decisions, and those that seem to go off on a tangent and have difficulties.

Just because you are independent doesn't mean you are an island -- I don't do brain surgery either.

Depends on your comfort zone -- being a full solo is a different kind of decision maker. In my state, NPs and PAs cannot be solo without a collaborative agreement. Having said that, until about 5 years ago, the state said that a doc had to see the pt every 3rd visit, and sign off on notes. Now it is sign off a "selection of notes" every 2 weeks, and limited but almost full prescription authority.

If you're up to being on your own, independent in your state, good for you -- snarky or not, choose your credentials and be up front.

I know you're sensitive about this...I am too.

Matt in Western PA

IMP article in Medical EconomicsTo: Date: Sunday, February 27, 2011, 12:37 PM

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics http://bit.ly/hUawDzGordon

[Guest guest]

Here's another thought --

Nurses (not NPs, please take note) conducted these interventions in the U.K., where nurses still have less authority than in the states and nurse practitioners are a new and very undeveloped idea. If you're going to use the literature, you should probably compare apples to apples.

If you really want some literature on the effectiveness of NPs in primary care in the United States, just let me know -- I can bombard you with dozens of studies.

I provide full primary care for my patients. I assume, if you found a patient with liver cancer, you would refer that patient to oncology, would you not? Would you provide their liver transplant yourself? Right, neither would I.

However, I'm perfectly capable of assessing for the presence of liver failure vs. liver cancer, conducting the workup and referring the patient to oncology and gastroenterology. As I did last week.

And if they have uncomplicated congestive heart failure, I will be treating that, but it's likely I won't be doing any cardioversions in my office for their new-onset atrial fibrillation. Do you do that? Or do you send them to cardiology. Right. As I did last week.

And if you find your patient has gallstones, is symptomatic, and needs a cholecystectomy, are you providing those in your office? I hope not. Right. Neither am I.

So, I think your 99% is rather a high estimate, and if it's accurate, there's plenty of studies that show patients do better for some complex diseases when managed by the specialist.

For all the rest that can be managed in this office, I'm doing the same things as an MD, and with my 20 years of patient-care experience, I'm doing it very, very well.

Thanks,

Deanna Tolman, FNP-BC

Head2Toe HealthCare

At the end of the day I think it is all about cost-effectiveness. One of the few recent meta-analysis was published in BMJ, comparing "regular clinics" vs "nurse led clinics".

BMJ 2010; 341:c3995 doi: 10.1136/bmj.c3995 (Published 23 August 2010) Cite this as: BMJ 2010; 341:c3995

Research

Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysisOPEN ACCESS

E , clinical academic fellow, F P , senior clinical research fellow, Rod S , professor in health services research, L , professor of general practice and primary care

Cost and cost effectiveness

Only four studies presented any data. From the United Kingdom one study reported a cost per patient of £434 (€525, $632) over two years to provide additional nurse clinics and support from specialist nurses, representing £28 933 per quality adjusted life year gained19 and another study found that primary care costs were £9.50 per patient compared with £5.08 for usual care.43 In the United States a study reported a 50% higher total cost of staff at $134.68 (£92.65, €111.90) per patient treated in a nurse led clinic compared with $93.70 for usual care,47 but a Mexican study reported $4 (£2.75, €3.32) per patient or $1 per 1 mm Hg reduction of systolic blood pressure.32Also,

Conclusions

Nurse led interventions for hypertension in primary care should include an algorithm to structure care and can deliver greater blood pressure reductions than usual care. There is some evidence of improved outcomes with nurse prescribers, but there is no evidence of good quality from United Kingdom studies of essential hypertension in primary care. Therefore, although this review has found evidence of benefit for nurse led interventions in the management of blood pressure, evidence is insufficient to support the widespread use of nurses in hypertension management within the UK healthcare systems.I don't doubt than any structured intervention can work, but when you factor in that it becomes more expense and the need for regimen algorithms to be followed to achieve results with "Nurse led Clinics" in this limited scope of practice. how many algorithms can you develope for a Primary Care practice? If that was possible a computer could do Primary Care.Other studies that I have quoted at other discussions report the same, midlevels can take care of 80% of the problems out there; even if it is 95% that 5% is what burns all our health care funds today. In my opinion high quality primary care should be delivered by someone that can solve 99% of the patient's problems. It is true that most of my day to day work is mundane but then I get the patient with AS 1.2 cm2 area, AI, MR and TR; that was managed by another provider that uses mid levels. Sure that his BP was controlled on high dose Betablocker and HCTZ and also had some statin on board but he should be on as much ACE-I he could tolerate and as much statin as tolerated. Did the midlevel understand the implications, not likely. I have more examples.Personally, I think we get from the system what we want. In the year 2011 we can choose: (a)Primary Care can mean treatment of sore throats and essential HTN or early DM and referrals to the cardiologist and endocrinologist., or (b)Primary Care can mean treatment of both by the provider without a cardiologist nor endocrinologist plus the treatment for the sore throat. Cost difference: a lot.I strongly believe that there is a place for Mid-Levels in specialty care. Primary Care on the other hand, if you really mean for it to be Primary Care, is just to complicated and vast to be provided efficiently with limited training.Just a thought, from the Barrio



RE "snide comments"

OK, that's very interesting.

I did say, PAs and NPs that are in close agreements and support with physicians.

I have worked with both -- those that I am most comfortable with ANY decisions, and those that seem to go off on a tangent and have difficulties.

Just because you are independent doesn't mean you are an island -- I don't do brain surgery either.

Depends on your comfort zone -- being a full solo is a different kind of decision maker. In my state, NPs and PAs cannot be solo without a collaborative agreement. Having said that, until about 5 years ago, the state said that a doc had to see the pt every 3rd visit, and sign off on notes. Now it is sign off a "selection of notes" every 2 weeks, and limited but almost full prescription authority.

If you're up to being on your own, independent in your state, good for you -- snarky or not, choose your credentials and be up front.

I know you're sensitive about this...I am too.

Matt in Western PA

IMP article in Medical EconomicsTo: Date: Sunday, February 27, 2011, 12:37 PM

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics http://bit.ly/hUawDzGordon

[Guest guest]

Exactly, and I agree with you. Critical thinking is both a skill that can be learned and a basic way of looking at the world, but in either case, it takes time.

Perhaps you should look at hiring an experienced NP instead of a protocol-driven PA, and then just be sure there's plenty of time to do the critical thinking that's necessary.

Last Friday I saw a patient for the 3rd time. She is 60, has HTN, obesity, depression, knee pain, ?carpal tunnel, and now shoulder pain. Did an exam -- no obvious trauma or reason for this very painful shoulder, and I'm ready to send her off for some imaging when she says, "And do you know what this red stuff is on my face?" and points to her cheeks. I tell her I think that's rosacea, and I can prescribe some things that will help that. She says, "Well, at least it's not psoriasis, like these other areas," and shows me a few places where she's been diligently peeling off the plaques as they form, so of course I hadn't seen them. I ask her if anyone else in her family has this, and she says, "Yes, all my sisters, and my dad, too." And then the light goes on for the shoulder pain, ulnar wrist pain and swelling, and knee pain, and I said, "Oh my gosh, I'll be darned if you don't have psoriatic arthritis." Labs are pending.

It took three relaxed visits for her to get to the end of the list of complaints to tell me about the little areas of psoriasis. She's never had anyone take so much time, and let her tell the whole story. Before this, it was always "treat to the urgent."

Yup, I'm not getting paid enough from Medicaid for this, but boy is it satisfying.

Deanna, FNP

Having recently hired a very experienced PA to help in my practice I want to weigh in on this, and also tell what the local big boxes, and Urgent cares are doing.

The PA I hired is highly skilled, worked at the UW in teaching part time for years, currently serves on the Pharmacy and Therapeutics committee, is 10 yr my senior, and worked independently (sp) for 5 yr in a local hospital owned clinic until they deemed it wasn't making enough money last July. He did Medicare, Medicaid, and L & I. I think he is great, but he runs completely on protocol for most things, I definately don't. He doesn't believe in pain medications, so my 5 chronic pain patients have to see me, at least until the WA rules changes and it's even to complicated for me. He hasn't had any training or experience with ADD, so all my ADD patients also have to see me. He buys the university line that all sinus infections will clear eventually, so they don't need antibiotics. Personally, the people who've already had at least one sinus surgery or failed surgery, or have asthma, I throw the antibiotics, because my clinical experience tells me they will be back, worse, and irritated. And so they have been, for me to see. My point is, he is very capable, but still can't or won't be able to see and manage all the things I do. He also seems to order way more tests than I do, personally after so many years of doing this, I'd think he'd order less, but he doesn't have the training I do or maybe the "balls". So that is where the higher cost of care comes in, ordering more tests, if you do, and seeing things back, that you should have pre-empted in the first place.

Now to the local scene. I have 2 Urgent cares less than 10 min away, and 3 ER's within 30 min each. All the UC are completely staffed by PA's, no ARNP's, no MD's. Also all on protocol. The PA's may only RX Amoxicillin or Augmentin 875 for infections, unless there is an allergy. So the kids who have recurrent otitis, and eat Amox for breakfast, end up with failed treatment back in my office, again increased cost to the system. Most times unless there is a documented strep positive they get nothing anyway, it's less expensive, and data wise, may be better if viral.

The local ER's are staffed by both PA's and MD's and I'm sure the MD's only see the harder/more serious stuff. But today I did a f/u on one of my regular patients with Myasthenia gravis, back pain, and asthma. Went to ER yesterday for asthma flare, last time she had one she ended up in hospital with respiratory failure, d/t her myasthenia, couldn't continue the work of breathing. Now even though she saw a MD, there was a flow sheet, with 20 different conditions, Asthma, CP, HTN, Fever, Fracture, with the mandatory protocol all written out. So he doen't even get to think, he has his protocol, no less, no more. He got the CXR, pulse ox and peak flow, knew about the MG, ( now back on meds, before off), gave her one neb, a Zpac and sent her out. IN my office today, her peak flow is 160, with no breath sounds, too tight for that. I had to do his job, epi, and 3 nebs back to back, and steroids. Again this should have all happened yesterday. So even the MD's are being forced to do suboptimal care, by some bean counter's study, about what should work. Excuse me, she was even admitted to that hospital for the resp failure, 4 months ago, did you bother to pull the records?

So anyone can be made to work too fast, not do the right thing, and it is already happening. I do believe that PA's and ARNP's can see many things, maybe most, but not 90%, and I do believe that in some instances they only can because they work on a protocol, then it is just is it a good or bad protocol?

Cote' MD

IMP article in Medical EconomicsTo: Date: Sunday, February 27, 2011, 12:37 PM

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics http://bit.ly/hUawDzGordon

[Guest guest]



I'm glad you're committed for Medicaid...think you're being taken advantage of...

IMP article in Medical EconomicsTo: Date: Sunday, February 27, 2011, 12:37 PM

Dreaming of the ideal practice - IMP article in Feb 10 Medical Economics http://bit.ly/hUawDzGordon

[Guest guest]

When I ponder about this, the future looks murky. Over the past 8 years of having an IMP, I have become certain that the whole medical system is on the verge of collapse--that we may only have 4 or 5 years to save primary care or it will go the way of the dodo. Then, a few months later, I realize that I was just focusing on a small piece without seeing the whole. Some things I think are truths:1) We need high quality primary care in order to have a reasonable shot of having a functional health care system.2) The current system is toxic and most (>50%) of primary care physicians would retire tomorrow if they became independently wealthy.3) Our country’s health “system†costs twice as much as the systems in other industrialized nations and performs much worse.4) Current projections show that our system is financially unsustainable.5) We have a distribution problem of primary care providers (notice I do not say we have a looming primary care crisis—if you do the math 300,000,000 people divided by 340,000 providers (120,000 FP, 50,000 IM, 50,000 Peds, 100,000 NPs, 20,000 PAs) equals 882 patients/provider. The problem is that many primary care providers are doing other things (due to the toxic conditions) and insurances force providers to discriminate against certain subsets of patients (due to payment models). So although we do have a looming problem of matching demand with supply, this is philosophically different than arguing that we just don’t have enough primary care providers).6) The true joy of primary care for both the patient and the doctor lies in a strong relationship forged over time.7) The patients are the ones with the diseases and therefore the system needs to be changed to address their needs.We all know about the reasons to be glum about the future, but there are bright signs in an otherwise desolate picture:1) Although most non-IMP practice management types would call us insane, the IMP movement continues to grow and many of our practices are finally reaching “financial maturity†and doing just fine.2) Well thought out people at high levels do understand the pressures and problems with the current system and are looking for “different†solutions. As we continue to prove our worth, we can hopefully have a place at that table.3) All around the nation, small businesses are sprouting up pushed by a movement toward a more sustainable, healthy community and world. Generally, they all follow the mantra “Let the big box stores do their thing. I think I can achieve sustainability through healthy relationships.†So I say, let the hospitals do what they want with their primary care practices, I can and do offer something better. So who knows. Maybe the future is terrible and we will all either have to choose to be assimilated or annihilated. Then again, maybe we are already on the cusp of something wonderful and just have to wait for others to catch up. From: [mailto: ] On Behalf Of magnetdoctor@...Sent: Monday, February 28, 2011 3:37 PMTo: Subject: Re: will primary care survive I completely agree with this view point. I think in 5 yr we will all be some type of Conceirge higher end service, or you will be working for the big system. It will take some time for that to happen, and some time for it to become obvious that that system isn't viable either. Better to prepare now. There won't be a middle, like we are in now. So either find another type of career or make plans to be in the high end, like we are now, only we don't get paid for it. Cote' will primary care surviveTo: Date: Sunday, February 27, 2011, 4:19 PM  RE can there be a model that works?

[Guest guest]

My experience of 5 yrs of having a FNP as a partner was a bit different.

PA and NP training/ed is different. NPs work independently in OR, but

not PAs who more often work in surgery, though sometimes in

subspecialties. My FNP partner was generally a good clinician at

uncomplicated care. He was not good at recognizing when someone was more

complicated. He only asked for my help on a few occasions and that made

me concerned about what he was not asking me about. He said he had done

some hospital call in a small town but he did not know how to utilize

the hospital system. He did much fewer consults than I did I think

because he didn't know how to ask for them and even more importantly, he

often didn't know when he needed to ask for them.

Everyone needs to know their limits--primary care docs, surgeons,

cardiologists, CEOs, Presidents. Aside from the issues of medical care

by protocol, some NPs and PAs think they are as knowledgable as MDs, or

perhaps even better. Many are good at what they do but none are as fully

trained as MDs. When an NP or PA is fully comfortable with his/her

limits, that's great, and I'm happy to work with them and I have. But

that is not always the case. My mother saw a NP in a small town ER who

totally missed her mucositis(caused by having taken too large a does of

Methotrexate). I insisted she get herself to her BU-affiliated hospital

ER. She was found to be pancytopenic and had to be treated with Nupogen.

A NP in an office I worked in 10 yrs ago asked me to listen to the heart

of a pt she was treating for bronchitis. She was just curious what kind

of murmur he had. It was a severe MR murmur and he didn't have

bronchitis. We was on the verge of mitral valve failure and full heart

failure. He was in the OR by end of wk. I'm sorry if I offend any of the

NPs in this list serve. I agree with Gordon, we have to work together.

But we also need to address such problems.

Ellen son, MD

>

> Having recently hired a very experienced PA to help in my practice I

> want to weigh in on this, and also tell what the local big boxes, and

> Urgent cares are doing.

>

> The PA I hired is highly skilled, worked at the UW in teaching part

> time for years, currently serves on the Pharmacy and Therapeutics

> committee, is 10 yr my senior, and worked independently (sp) for 5 yr

> in a local hospital owned clinic until they deemed it wasn't making

> enough money last July. He did Medicare, Medicaid, and L & I. I think he

> is great, but he runs completely on protocol for most things, I

> definately don't. He doesn't believe in pain medications, so my 5

> chronic pain patients have to see me, at least until the WA rules

> changes and it's even to complicated for me. He hasn't had any

> training or experience with ADD, so all my ADD patients also have to

> see me. He buys the university line that all sinus infections will

> clear eventually, so they don't need antibiotics. Personally, the

> people who've already had at least one sinus surgery or failed

> surgery, or have asthma, I throw the antibiotics, because my clinical

> experience tells me they will be back, worse, and irritated. And so

> they have been, for me to see. My point is, he is very capable, but

> still can't or won't be able to see and manage all the things I do. He

> also seems to order way more tests than I do, personally after so many

> years of doing this, I'd think he'd order less, but he doesn't have

> the training I do or maybe the " balls " . So that is where the higher

> cost of care comes in, ordering more tests, if you do, and seeing

> things back, that you should have pre-empted in the first place.

>

> Now to the local scene. I have 2 Urgent cares less than 10 min away,

> and 3 ER's within 30 min each. All the UC are completely staffed by

> PA's, no ARNP's, no MD's. Also all on protocol. The PA's may only RX

> Amoxicillin or Augmentin 875 for infections, unless there is an

> allergy. So the kids who have recurrent otitis, and eat Amox for

> breakfast, end up with failed treatment back in my office, again

> increased cost to the system. Most times unless there is a documented

> strep positive they get nothing anyway, it's less expensive, and data

> wise, may be better if viral.

>

> The local ER's are staffed by both PA's and MD's and I'm sure the MD's

> only see the harder/more serious stuff. But today I did a f/u on one

> of my regular patients with Myasthenia gravis, back pain, and asthma.

> Went to ER yesterday for asthma flare, last time she had one she ended

> up in hospital with respiratory failure, d/t her myasthenia, couldn't

> continue the work of breathing. Now even though she saw a MD, there

> was a flow sheet, with 20 different conditions, Asthma, CP, HTN,

> Fever, Fracture, with the mandatory protocol all written out. So he

> doen't even get to think, he has his protocol, no less, no more. He

> got the CXR, pulse ox and peak flow, knew about the MG, ( now back on

> meds, before off), gave her one neb, a Zpac and sent her out. IN my

> office today, her peak flow is 160, with no breath sounds, too tight

> for that. I had to do his job, epi, and 3 nebs back to back, and

> steroids. Again this should have all happened yesterday. So even the

> MD's are being forced to do suboptimal care, by some bean counter's

> study, about what should work. Excuse me, she was even admitted to

> that hospital for the resp failure, 4 months ago, did you bother to

> pull the records?

>

> So anyone can be made to work too fast, not do the right thing, and it

> is already happening. I do believe that PA's and ARNP's can see many

> things, maybe most, but not 90%, and I do believe that in some

> instances they only can because they work on a protocol, then it is

> just is it a good or bad protocol?

>

> Cote' MD

>

> IMP article in

> Medical Economics

> To:

> Date: Sunday, February 27, 2011, 12:37 PM

>

> Dreaming of the ideal practice - IMP article in

> Feb 10 Medical Economics

> http://bit.ly/hUawDz

> Gordon

>

>

>

Attachment: vcard [not shown]

[Guest guest]

very good points ellen.

i totally agree.

i have 2 nurse practitioners in my practice hence im really not IMP.

they think im very smart.

and i think they're both very smart.

i think the best part of this set up is i have company. i think it best to have

somebody to bounce off of... ie peer review. if i keep on telling myself all of

what i do is best practice... ill end up believing it sooner or later.

grace

> >

> >

> >

> > Subject: IMP article in

> > Medical Economics

> > To:

> > Date: Sunday, February 27, 2011, 12:37 PM

> >

> > Dreaming of the ideal practice - IMP article in

> > Feb 10 Medical Economics

> > http://bit.ly/hUawDz

> > Gordon

> >

> >

> >

>