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Delivering Health
Doctors Should Do Less Work

One way to help lower the cost of health care delivery is for doctors to work less. The WSJ has a trend story on the increasing prominence of “team-based” care. In this model, nurse practitioners, physician assistants, and clinical pharmacists do more of the day-to-day basic care under doctor supervision. The doctor is called in for higher-level decisions or procedures.

We’d like to believe that doctors are delegating more of their routine work to other professionals. It’s cheaper for all of us when they do (how care is delivered does ultimately affect how much insurers pay for it). But there is very stiff resistance to this trend:

 A 2012 survey of more than 1,000 low-income people in California by the Blue Shield of California Foundation found that the majority preferred to be seen by doctors. About 1 in 4 of the respondents already had team-based care, and 94% of them said they liked it. Among those who didn’t have team-based care, 81% said they were willing to try it.

Doctors may resist being part of a team and ceding care of their patients, studies have found. Experts in health-care delivery also caution that team members must coordinate care and delegate clearly to avoid anything falling through the cracks.

This resistance persists even though many individual doctors think team-based models will free them up to do the kind of care they got into medicine to do in the first place. One test for whether doctors are delegating more care is the success of scope-of-practice bills. These bills allow nurse practitioners to perform more medical tasks autonomously—for example, prescribing drugs. One bill of this kind just passed in Kentucky, and two are pending in Florida and West Virginia. Doctor’s groups have staunchly opposed the Florida bill. It is up for vote today, and the result will help us understand just how much momentum models like team-based care will have.

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  • Andrew Allison

    “One way to help lower the cost of health care delivery is for doctors to work less.” seems hardly likely to endear the concept to Doctors who, at least in private practice, get paid per capita. A more enticing sales pitch might be that it allows them to see a larger number of patients who actually need their skills.

  • Boritz

    Watch the pricing model. Prediction: There may be a cost break in the beginning but one day you will wake up and find you are paying as much (or more) to see an ancillary team-member as you once paid to see a doctor. There will be studies to determine whether quality of care has suffered as a result of the new model. These studies will show whatever those who ordered them want them to show. Will my dog still get to see the guy with 8 years of college? How about going to see the doctor means going to see the doctor.

    • qet

      Yes, I agree with this, especially in the context of the gradual absorption of doctors into hospital corporations as salaried employees as described in a Via Meadia post from last week. The hospital corporations will acquire all medical service providers eventually, and the costs savings to them from paying non-MDs less than MDs to provide care will be retained by their executive administrations and not passed along to consumers. See Colleges & Universities, US.

      • Andrew Allison

        I think that the issue of doctors moving to salaried positions within hospital corporations needs more study. We’ve had doctors working as salaried employees at, e.g. HMOs, in parallel with private practice for a very long time.

        Doctors are abandoning private practice, at least in part, because of the overhead. Making their work environment more satisfying (by letting others to routine work) would mitigate this.

  • mgoodfel

    As someone with chronic medical problems (paraplegic), there are times I just want routine care and would take it from a nurse-practitioner without complaint. There are other times when I want a doctor. I really don’t want a system where you get the NP all the time, and have to escalate problems to the doctor.

    From the doctor’s point of view, there are two problems. Will the NP know when they are in over their heads? And will they spot that rare symptom which indicates trouble?

    I also think it will be difficult to get good at being a primary care doctor if you only get the hard cases, or only spend your time reviewing test results. Experience with routine problems seems necessary if you want to distinguish those from the complex cases.

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