Replacing Doctors With Midlevels?

SOMETIMES "BEING CHEAP IS VERY EXPENSIVE."

Written by Dr. Dina Strachan, MD

Editor Note: If you are lucky, being “cheap” might cost you time and money. If you are unlucky, it might cost you your life.

The use of midlevel providers, physician assistants and nurse practitioners, as replacements for actual doctors, was once again in the news last week. Edward-Elmhurst Hospital, a Chicago area health institution, fired 15 physicians stating in an e-mail that "Patients have made it very clear that they want less costly care and convenient access for lower-acuity issues (sore throats, rashes, earaches), which are the vast majority of cases we treat in our Immediate Cares.” The assumption is that midlevel providers provide the same service as board-certified doctors for a reduced cost to the system--but it that true? Salaries offered to midlevel providers may be lower than that of physicians, but are they able to provide the same quality of healthcare at a lower cost to patients? Is convenient access to a midlevel provider, rather than an actual doctor, really what the public is looking for?

As a board-certified dermatologist in the competitive Manhattan marketplace, I’ve observed a number of examples of lower quality, less efficient and more expensive care for patients who finally make their way to my office after making choices based on ostensible “conveniences,” and cost savings alone, or thinking that something is just being “a rash” that anyone could treat. What is ironic about this is that in a crowded marketplace the consumer is expected to be able to get better service because of competition. It appears that that theory is not true. That is the problem when patients are thought of as "consumers" and not patients.

A few weeks ago, a long-time patient of mine came back to see me. “You’re gonna be mad at me,” she confessed. “Why would you think that?” I asked. She had developed a rash on her face over a month prior. In fact, it was a condition I had treated her for in the past. She says she didn’t come to me because there were “no appointments” (not true) so she went to an urgent care near her. She saw a primary care doctor who wasn’t sure what she had, but who gave her an oral antibiotic in case it was an infection. This was not the right diagnosis. The medication didn’t work. Next, she went to a private-equity backed dermatology practice mostly staffed by physician assistants. The diagnosis she was given was, oddly, even less accurate, despite this being a specialty office. The physician assistant treated her for the incorrect diagnosis, shingles, with the correct medication but at the wrong dose. The dose is super standard and easily available on the internet—so this was odd. Again, this oral medication didn’t work. So she found herself returning to someone who might have been a little less convenient to see, but who had the expertise to correctly diagnose her in a few minutes.

Was going to someone other than an actual specialist more convenient and cheaper? No. She had to go to three visits when she could have gone to one. She had to pay three consultation copays when she could have paid one. The insurance provider had to pay out more, too. She paid for three prescriptions when she could have paid for one. Let us not forget that she also ingested 3 drugs that could have caused side effects or antibiotic resistance—a public health problem—and that two of them provided no benefit to her.

Once travelling in Mexico I heard a local person comment about street food, “sometimes being cheap is very expensive.” The cheap meal gets you sick. You miss work. You have to buy medicine. And none of this is convenient.

It will be interesting to see for whom replacing doctors with people with lesser training is cheaper and more convenient. From what I can tell, it won’t be cheaper for the patients. 1

Dr. Dina Strachan is an internationally recognized, Harvard and Yale educated, board-certified dermatologist, entrepreneur, consultant, speaker and best-selling author of Moxie Mindset: Secrets of Building a Profitable, Independent Physicians Practice in a Competitive Market. Learn more at www.drdinamd.com. Follow her @drdinamd

Editor Note: If you are lucky, being “cheap” might cost you time and money. If you are unlucky, it might cost you your life.

The use of midlevel providers, physician assistants and nurse practitioners, as replacements for actual doctors, was once again in the news last week. Edward- Elmhurst Hospital, a Chicago area health institution, fired 15 physicians stating in an e-mail that "Patients have made it very clear that they want less costly care and convenient access for lower-acuity issues (sore throats, rashes, earaches), which are the vast majority of cases we treat in our Immediate Cares.” The assumption is that midlevel providers provide the same service as board-certified doctors for a reduced cost to the system--but it that true? Salaries offered to midlevel providers may be lower than that of physicians, but are they able to provide the same quality of healthcare at a lower cost to patients? Is convenient access to a midlevel provider, rather than an actual doctor, really what the public is looking for?