Freeing Primary Care with New Skill Mixes, Technology and Scope of Practice Laws
welcome to the foresight Health Roundup podcast foresight Health podcast series for healthcare revolutionaries outcomes matter customers count and value rules hello again everyone this is Dave baa news editor foresight Health it is Thursday October 5th our fall decorations are out and there's a bag of freshly picked Macintosh apples on the counter in the kitchen what could be better they say an apple a day keeps the doctor away but what about physician assistants or nurse practitioners or does that require the American Medical Association and that's what we're going to talk about on today's show new research that shows that more Pas and NPS are providing Primary Care to patients to tell us what this trend means for the health care market and for healthc care consumers are Dave Johnson founder and CEO foresight health and Julie merchon partner at transformation Capital hi Dave hi Julie how are you guys doing this morning Dave you know Dave you're talking about fall decorations but I just can't believe how hot it's been they cancelled the Twin Cities and Milwaukee marathons last week due to excessive heat I still haven't put away my shorts for the winter and that this rate of climate change who really needs Florida right yeah it was in the mid 80s this week pretty crazy for October Julie how are you I had the same experience I was in San Francisco for the week and it was 85 yesterday and I was not prepared so coming back to Seattle I put my puffy on to get off the plane thinking oh it's going to be cold here and it was hot in Seattle it's weird I will say that shorts in Chicago are not a barometer of temperature I'll just say there's very little correlation so they aren't for you they aren't for me yeah exactly now before we talk about this new report and all the scope of practice disputes taking place across the country let's talk about your experiences with physician assistants and nurse practitioners Dave have you ever been treated by a PA or MP and if so what was your experience I fell while running a couple years ago uh when I got up my left pinky was at a 90 degree angle ouch yeah I tried to pop it back into place but it was still crooked a nurse practitioner at a nearby urgent care clinic fixed the problem for me he took an x-ray saw there were no fractures and realign the finger joint basically by pulling it and putting it back in place I did chuckle when the bill described this activity as surgery insurance covered every penny can you imagine what this would have cost if I'd gone to either an orthopedic specialist or an emergency room yeah sounds like it all worked out and there's a a pull your finger joke in there somewhere that we could talk about offline Julie how about you has a has a PA or MP ever taken your blood pressure or checked your heartbeat yeah well an NP fired me from my oby office after I had kids and I've been seeing her for a couple years and she sat me down one day and said you don't really need to keep coming here anymore it's nice to see you but you can just go back to your PCP and I thought my gosh you just fired me she was great so yes oh yeah I've been fired I don't think I ever heard that one before that's that's too bad I saw a nurse practitioner instead of my cardiologist for my annual heart checkup after he cancelled that the last minute and she was terrific and I've seen a physician assistant in Urgent Care when I have about about a bronchitis you know I need an inhaler and some steroids and I'm good to go even I know that but you can't get them without a prescription okay let's talk about this new study in the British medical journal that everyone else is talking about researchers from the Harvard Medical School looked at 276 million visits by Medicare patients in outpatient clinics and skilled nursing facilities from 2013 through 2019 the percentage of evaluation and management visits which basically are primary care visits delivered by Pas and MPS Rose from 14% in 2013 to almost 2 6% in 2019 for physician assistance it Rose from 5.1% to 88.4% and for nurse practitioners it Rose from 88.9% to 17.3% over the same period the percentage of visits done by primary care physicians dropped from 42.4% to
33% and the percentage done by Medical Specialists dropped from 43.7% to 41.3% it all adds up to 100% each year I checked Dave at the end of last week show you challenge the notion that the only way to cut anesthesia cost was to cut down on anesthesia you suggested that certified nurs anesthetist could do it better and cheaper I know you've got a thing about this scof of practice issue what do you think about the study findings is this trend a good thing or bad thing for the healthcare Market and is it a good thing or bad thing for healthcare consumers good thing this is a great thing for the HealthCare Marketplace and for healthc care consumers you know Dave if I could wave a magic wand and do one thing in US Healthcare I'd eliminate the indirect billing provision that requires all medical bills to be submitted under the direction of a supervising physician such a waste of time energy and money no wonder Physicians believe and act like they're captains of the ship service provision and billing should align around outcomes you know best result at the lowest cost not process Mechanics for example why do I need a licensed dermatologist to conduct my annual body scan for Troublesome gross a nurse or even a machine could be just as effective or even more effective at doing this really basic task the only reason it happens this way is they can build more money for it you're right that this scope of practice issue is the one right now that's making my head explode uh not that I've moved on from revenue cycle management I haven't but this latest one started in August when I spent a couple hours in the simulation lab sawing bones threading catheters and doing internal suturing with a da Vinci machine at the Mayo Clinic and as I moved from Station to Station I was just struck at how routine and mechanical all these procedures were and every time I got to a new station I asked the doctor supervising it why do we need doctors to do this looks pretty straightforward and I always got the same answer we're here in case something goes wrong all surgeons in the United States regardless of the type of surgery they do usually require 13 years of training four years of college four years of medical school three years of residency and two Fellowship years this is the equivalent of training bicycle mechanics with the same intensity that we train Mechanics for airplanes or nuclear power stations it's just a crazy system why not align training with the particular surgery particularly for routine procedures like angioplasty you know as I sat there and thought about it afterward why don't we have the equivalent in Medicine of surgical mechanics what I'm about to say is absolutely sacrilege in medicine but I'm not even sure these surgical mechanics would need to attend college you know drone operators don't need to know how to fly airplanes near as I can tell all they have to do is be good at video games the current system takes very talented people sends them to medical school gives them an excruciatingly Long training period loads them up with debt so they can become drum roll please surgical mechanics than to limit Supply and inflate compensation does this system make any sense you know thank God we don't send plumbers and electricians through a similar training and credentialing process they'd cost even more than they already do so surgical mechanics let's look at all these regulations and credentialing processes and let's have them make sense these contradictions or this misalignment between surgical task training and cening are only going to get greater as the machines become a bigger bigger part of our lives so you asked doctors at the Mayo Clinic why we need doctors and they let you go you got guts Dave I'll give you that I was having this conversation with Molly Koy the other day and she told me I needed to hire full-time protection as I start walking around the country that might be actually exactly Julie any questions for Dave well Dave I saw an interesting article about an uprise among veterinarians so we love to ask you what do you think veterinarians and doctors have in common well the most obvious thing is they're both increasingly owned by private Equity right that's probably why they're having the uprising tou you know for over 30 years we've taken our cats to Blum Animal Hospital which is right here in our neighborhood in Lake View and Blum has been just a terrific place it's it's where Oprah used to take her pets you know the Chicago standard for high quality whatever Oprah does the rest of us should do too so when I was writing my first book Market versus medicine I actually had a segment in the book that made the statement that our two cats at the time Baxter and Bailey got better primary and Specialty Care than Terry and I did you know they had a medical home which was Lum Animal Hospital Dr Dan our vet cordinated all the Care Baxter had hypertropic cardiomyopathy so he had his own cardi ologist so yeah he actually probably extended Baxter's Life by by at least 10 years I mean actually pretty remarkable but the care was always coordinated they shared medical records there was transparent pricing everything went through Dr Dan so I wrote this passage and I gave Dr Dan a copy of the book and you know highlighted the page and he had it on display in his office right up until the time he retired about three or four years ago but boy has the world changed since 2015 2016 private Equity bought Blum we now have pet insurance we're constantly on the lookout for overtreatment prices have skyrocketed and we are now in the same kind of battles with the insurance company over what they'll pay and not pay for and so in that regard Julie to your question it feels like pet care which used to be superior to human care has become more in line with human care and that is not a good thing so Dave do you think you know vets fighting against non vets doing some of the things you described kind of parallels what's happening with medical doctors and MPS and physician assistants I'm not expert on the area Dave so I'll just go completely into the realm of speculation which you know I'm very comfortable doing but I think lots of the professions are trying to hold on to whatever sort of credibility and responsibility they can have for procedures that can be done in better faster cheaper ways so it wouldn't surprise me at all if vets are you know rallying against these new and improved ways of doing things in the same way that doctors and nurses are thanks Dave Julie it's your turn uh what's your reaction to the study findings and what Innovations or Technologies are you seeing in your part of the world that would push these percentages higher or even Place most clinicians for Primary Care well I was working with community health centers 20 years ago and they had team based care down and they had to because with their reimbursement structure they had to provide access at the lowest cost possible begging borrowing and stealing so everyone they have was practicing at the top of the license like you know so they had this down and now today fast forward it is interesting you're seeing it in a lot of commercial models I will say some of the models that are doctor created tend to become very doctor Centric whereas some of the models that you know some are doctor created but some are entrepreneur you know non-physician Credence are really using NPS and PAs a lot more opery Health one of our companies practices Advanced primary care and uses incredible mix of MDS and MPS and by the way integrates Behavioral Health and us as coaches I mean they're managing the whole person right that's what Dave cats expect right right I was just talking to Blue Cross Shield of Arizona yesterday and they launched their pra model which is their Advanced Primary Care model using a lot of mixed clinicians in their model Village MD calls their NPS and PAs their advanced practice providers and claims that they are champions for their patients I mean there's a lot of buildup going on of some of the vent models to really make this class of clinicians feel like they are you know one of the most important partners for their patients so this is a big wave you know beyond just a small Trend another tip that I found which I thought was really interesting is cararo which is a company we're related to from one of the companies that it bought and they talk about how physici assistants have the ideal skill set to lead EHR and informatics projects because they're more more facilitators in the practice and there are really excellent translators between nurses Physicians patients and other caregivers and it makes them kind of more uniquely equipped to translate what's needed in the EHR and what's needed in workflow to actually support more than just the doctor patient interaction so Kio is talking about how Pas could really develop their careers into more of the EHR and other digital Health implementation and design frankly which I think is actually pretty interesting when you think about the need for that in the industry and my last example is EC consults Dave you've heard of e-consults of course right yep Arista MD Rubicon MD Picasso MD I mean these models are kind of game changers for primary care because they connect whether you're a primary care provider a physician or a nurse or an MP PA they connect all those categories of clinicians to Specialists even you're if you're a specialist and you need a specialty consult they're providing real time clinical decision support a lot of them are providing referrals and scheduling support and care coordination as well and they're helping you know create the right path for patients who are seeing someone in the primary care realm so this means that with these kinds of Technologies I mean you can have you don't necessarily need the physician you can have a nurse with that patient in a rural setting right so honestly the future is going to be defined by a number of things but a few key vectors certainly is all the technology I just talked about plus AI I mean just going to self-care going to Virtual self-care but oriented care as your first line is definitely the first factor of change the second I think which is much more human is you know when you start to see chief medical officers at these Ambulatory Care practices in acute care settings who are NPS Pas or do's and not MDS you're going to see a lot more change because there's still a Control Function at that level just like the Control Function I talked about with ph created you know Innovative models that are so pretty do Centric that's going to open up a whole new world of how the humans think about who the humans need to be I love the irony of moving away from MDS ultimately is better for patients yeah that's something most people think about thanks Julie that was excellent I'm not sure it's ironic Dave yeah yeah yeah right right it's true right right Dave any questions for Julie well Julie that was fantastic and I just steep back and sort of look at everything you just said and project forward a little bit with AI and expanded capabilities among non-physician Primary Care practitioners does this country really confront a massive physician shortage as is so widely reported you know I have been saying this for I'm gonna say six or seven years now and I used to say it pretty boldly and then I got a lot of s eyes and then I started to sort of whisper a little bit more I don't know why I got so Meek but we are not looking at the facts of where AI I don't going to say AI just technology and just proper connections and better use of our capacity in this country on just a physician level is one set of changes and all the other clinical levels can help support I mean I don't think that we have a physician shortage in the way that people talk about we may have a lot of capacity misalignment there is no doubt about that we don't have the right types of Physicians or the right types of caregivers in the right geographies or you know always in the right care settings but at the end of the day if we did a better job of utilizing all those folks through some of the Technologies I just talked about we I think would have a much smaller concern about our problem but I think frankly the only people who are probably still concerned are the yeah that's interesting here here's my million dooll idea and it kind of dovetails with what you just said I'm going to invent an online symptom tractor that after you answer all the questions and no matter how you answer the questions it says there's nothing wrong with you go to bed right yes that's it first Do no harm right you because every symptom tracker I've ever used says it could be a sign of something serious go see your doctor just in case right that's how they all end and that's if you can get an appointment like you said Julie fantastic now let's briefly talk about other news that happened this week it wasn't all bad was it Julie anything else worth noting today I have a really fun little tidbit and it's really interesting when you think about it I read this week you know you know the company toast which is the restaurant management app if you've ever ordered something online for pickup or delivery you you may have used the toast app and some Wall Street analysts looked at toast and this is like a a bigger macro like healthc Care's impact on fintech so Wall Street analysts looked at some longer term impacts on their stock and they actually Revis numbers down because they're expecting that the appetite suppressant from again the glp1 drugs like gmic and wovi will have impacts on the volumes at restaurants as fewer customers order via tote so toast will make less money wow yeah talk about a ripple effect in the market juicy yeah that's a good one Dave what else was in the news that caught your eye so Julie's headline is toast is toast good Dave I like it is there a song in there somewhere could be could be oh don't start don't no no no please please well i' I've been getting into some good good trouble as former Congressman John Lewis used to say in Minnesota Governor Waltz there has created a very high-profile task force that launches this week to study the University of Minnesota's Professional healthc Care training and education program and this is all tied up with the 's multi-billion dollar funding request from the state to revitalize its academic clinical Enterprise which I think is among the most ludicrous in the world that somehow this is going to lead to Better Health in the state so I'm really watching this task force to see whether they come down on the side of more health or more health care and by the way this is not the first time we're going to confront this issue of Public Funding to prop up financially struggling clinical and academic Enterprises y shiny new patient Towers that's great Dave thank you and thank you Julie that is all the time we have for today if you'd like to learn more about the topics we discussed on today's show please visit our website at foresight health.com and don't forget to tell a
friend about the foresight Health Roundup podcast subscribe now and don't miss another segment of the best 20 minutes in healthcare thanks for listening I'm Dave baa for foresight [Music] health
2023-10-13 00:21
