mid-level creep: current status in canada

[hanoori]

oh wow i didn't realize how much the creep is happening here and from what you guys have written, more creep seems unavoidable.

i really hate how the government looks at fam physicians as expensive when they do so so much and reduce unnecessary referrals to specialists. the fact that BC pays NPs more per patient than fam docs is a huge slap to the face for fam docs (and all docs in general really). 

that being said, i do agree that evidence and data should drive our decisions going forward: do NPs provide similar quality of care in canada? are they actually more expensive in the long term? I don't think canada's government will ever do anything about it unless theyre shown to be more costly than fam docs, regardless if fam docs provide a better quality of care to their patients. hope to see actual data soon but this outlook feels very demoralizing for those looking to go into family medicine and, if nurse anesthetists are mass hired, those gunning for anesthesiology

13 hours ago, ChemPetE said:

I can dig up the retrospective study list if you like. Book cost for sure they’re less. The problem is the downstream costs - you have to remember the US is incentivized for interventions; healthcare systems get reimbursed percentages of costs for tests, consults, etc. whereas here it just comes out of the healthcare budget. That’s why insurance companies and hospitals in the private system will try and maximize OR and surgeon efficiency for example, it’s a money maker. Here, ORs cost the system money and so the resources are rationed instead. The NPs ordering pan scans and inappropriate blood work will feedback money to their employers as well. What I’ve heard mentioned and have not seen is alleged Ontario data saying that they are more expensive.

Edit: directly copied from the bastion of the noctor sub forum, only as an example of the above

Resident teams are economically more efficient than MLP teams and have higher patient satisfaction. https://www.ncbi.nlm.nih.gov/m/pubmed/26217425/
Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. https://www.ncbi.nlm.nih.gov/pubmed/29710082
Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
Nonphysician clinicians were more likely to prescribe antibiotics than practicing physicians in outpatient settings, and resident physicians were less likely to prescribe antibiotics. https://www.ncbi.nlm.nih.gov/pubmed/15922696
The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation. https://www.mayoclinicproceedings.org/article/S0025-6196(13)00732-5/abstract00732-5/abstract)
Further research is needed to understand the impact of differences in NP and PCP patient populations on provider prescribing, such as the higher number of prescriptions issued by NPs for beneficiaries in moderate and high comorbidity groups and the implications of the duration of prescriptions for clinical outcomes, patient-provider rapport, costs, and potential gaps in medication coverage. https://www.journalofnursingregulation.com/article/S2155-8256(17)30071-6/fulltext30071-6/fulltext)
Antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047413/
NPs, relative to physicians, have taken an increasing role in prescribing psychotropic medications for Medicaid-insured youths. The quality of NP prescribing practices deserves further attention. https://www.ncbi.nlm.nih.gov/m/pubmed/29641238/
(CRNA) We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. https://www.ncbi.nlm.nih.gov/pubmed/22305625
NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. https://pubmed.ncbi.nlm.nih.gov/32333312/
Both 30-day mortality rate and mortality rate after complications (failure-to-rescue) were lower when anesthesiologists directed anesthesia care. https://pubmed.ncbi.nlm.nih.gov/10861159/
Only 25% of all NPs in Oregon, an independent practice state, practiced in primary care settings. https://oregoncenterfornursing.org/wp-content/uploads/2020/03/2020_PrimaryCareWorkforceCrisis_Report_Web.pdf
96% of NPs had regular contact with pharmaceutical representatives. 48% stated that they were more likely to prescribe a drug that was highlighted during a lunch or dinner event. https://pubmed.ncbi.nlm.nih.gov/21291293/
85.02% of malpractice cases against NPs were due to diagnosis (41.46%), treatment (30.79%) and medication errors (12.77%). The malpractice cases due to diagnosing errors was further stratified into failure to diagnose (64.13%), delay to diagnose (27.29%), and misdiagnosis (7.59%). https://pubmed.ncbi.nlm.nih.gov/28734486/
Advanced practice clinicians and PCPs ordered imaging in 2.8% and 1.9% episodes of care, respectively. Advanced practice clinicians are associated with more imaging services than PCPs for similar patients during E&M office visits .While increased use of imaging appears modest for individual patients, this increase may have ramifications on care and overall costs at the population level. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1939374
APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED‐day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = −0.15 to −0.10) and lower RVUs/clinician hour by 0.4 (95% CI = −0.5 to −0.3). Increasing APP staffing may not lower staffing costs. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14077
When caring for patients with DM, NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21–1.37), endocrinologists (OR = 1.64, 95% CI = 1.48–1.82), and nephrologists (OR = 1.90, 95% CI = 1.67–2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01–1.12) https://onlinelibrary.wiley.com/doi/10.1111/jgs.13662
Ambulatory visits between 2006 and 2011 involving NPs and PAs more frequently resulted in an antibiotic prescription compared with physician-only visits (17% for visits involving NPs and PAs vs 12% for physician-only visits; P < .0001) https://academic.oup.com/ofid/article/3/3/ofw168/2593319
More claims naming PAs and APRNs were paid on behalf of the hospital/practice (38% and 32%, respectively) compared with physicians (8%, P < 0.001) and payment was more likely when APRNs were defendants (1.82, 1.09-3.03) https://pubmed.ncbi.nlm.nih.gov/32362078/
There was a 50.9% increase in the proportion of psychotropic medications prescribed by psychiatric NPs (from 5.9% to 8.8%) and a 28.6% proportional increase by non-psychiatric NPs (from 4.9% to 6.3%). By contrast, the proportion of psychotropic medications prescribed by psychiatrists and by non-psychiatric physicians declined (56.9%-53.0% and 32.3%-31.8%, respectively) https://pubmed.ncbi.nlm.nih.gov/29641238/
Most articles about the role of APRNs do not explicitly define the autonomy of the nurses, compare non-autonomous nurses with physicians, or evaluate nurse-direct protocol-driven care for patients with specific conditions. However, studies like these are often cited in support of the claim that APRNs practicing autonomously provide the same quality of primary care as medical doctors. https://pubmed.ncbi.nlm.nih.gov/27606392/
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Although evidence-based healthcare results in improved patient outcomes and reduced costs, nurses do not consistently implement evidence based best practices. https://pubmed.ncbi.nlm.nih.gov/22922750/

 

 

this is legitimately insane 

[Arztin]

Also, don't NPs have a pension? When taking the pension into account, are NPs really less expensive? Someone would need to crunch the numbers.

[hanoori]

1 hour ago, Arztin said:

Also, don't NPs have a pension? When taking the pension into account, are NPs really less expensive? Someone would need to crunch the numbers.

do they actually? damn i might have chose the wrong career

 

(jk i swear but still i wish we had a pension of some sort, pathology looking mighty fine with theirs )

[ChemPetE]

14 minutes ago, hanoori said:

do they actually? damn i might have chose the wrong career

 

(jk i swear but still i wish we had a pension of some sort, pathology looking mighty fine with theirs )

My specialty has the option of employed + pension at reduced salary vs contract. They’re close in overall compensation, with some edges in some aspects to one vs the other, but contractor at higher pay rate might still win out overall.

[Snowmen]

On 9/24/2021 at 2:27 PM, Arztin said:

Also, don't NPs have a pension? When taking the pension into account, are NPs really less expensive? Someone would need to crunch the numbers.

I remember doing the calculation a few years ago. When you add in their benefits, NPs earn about 90$/hour in Quebec whereas an FP earns about 105$/hour once you remove expenses. When you consider that FPs see more patients per hour and more complicated cases... Yeah. And let's not even mention the downstream costs.

[indefatigable]

Perception creates reality in politics

If the public thinks NPs "care" more (spend more time with their patients) and the governments pay "less" (since benefit and overhead costs are often not properly/fully accounted for as they fall in different buckets) then NPs will continue to gain traction.  Higher patient volumes of MDs can be perceived as cold business logic and any higher downstream costs of NPs explained away as health care is expensive (esp. MDs).  

OTOH the public will often see gross billing information for MDs which confirms their suspicion that doctors are overpaid without accounting for overhead or lack of benefits not to mention increasingly high educational costs with high debt loads.  MDs for are often reluctant to disclose their actual take home pay and even on this forum gross billings are conflated with the term salary (which usually implies benefits as well).  This is without getting into the urban preferences for MDs who often come from high SES backgrounds.  

The opportunity cost alone of spending years accumulating debt vs earning money as a nurse means that if the numbers are that close, then at the moment it's probably a better financial choice to become a NP vs FP - even if the work may end up being more limited.

MDs, esp FPs, like others have mentioned, should ocnsider trying to promote a narrative of high-quality and cost-efficient care.  I believe that divulging more of the actual take home pay along with "projections" of what benefits (pension esp) cost with debt loads would give a better perception of doctor's actual earnings.  At this point the "cat's out of the bag" for many MDs billings so I think controlling the narrative a little more could be beneficial.    

[hanoori]

21 hours ago, Snowmen said:

I remember doing the calculation a few years ago. When you add in their benefits, NPs earn about 90$/hour in Quebec whereas an FP earns about 105$/hour once you remove expenses. When you consider that FPs see more patients per hour and more complicated cases... Yeah. And let's not even mention the downstream costs.

wowza talk about a problem waiting to happen (or in this case, downstream costs exploding as NPs gain more traction)

 

4 hours ago, indefatigable said:

Perception creates reality in politics

If the public thinks NPs "care" more (spend more time with their patients) and the governments pay "less" (since benefit and overhead costs are often not properly/fully accounted for as they fall in different buckets) then NPs will continue to gain traction.  Higher patient volumes of MDs can be perceived as cold business logic and any higher downstream costs of NPs explained away as health care is expensive (esp. MDs).  

OTOH the public will often see gross billing information for MDs which confirms their suspicion that doctors are overpaid without accounting for overhead or lack of benefits not to mention increasingly high educational costs with high debt loads.  MDs for are often reluctant to disclose their actual take home pay and even on this forum gross billings are conflated with the term salary (which usually implies benefits as well).  This is without getting into the urban preferences for MDs who often come from high SES backgrounds.  

The opportunity cost alone of spending years accumulating debt vs earning money as a nurse means that if the numbers are that close, then at the moment it's probably a better financial choice to become a NP vs FP - even if the work may end up being more limited.

MDs, esp FPs, like others have mentioned, should ocnsider trying to promote a narrative of high-quality and cost-efficient care.  I believe that divulging more of the actual take home pay along with "projections" of what benefits (pension esp) cost with debt loads would give a better perception of doctor's actual earnings.  At this point the "cat's out of the bag" for many MDs billings so I think controlling the narrative a little more could be beneficial.    

100% agree. someone else said it in this thread, but docs dont stick by each other enough whereas nurse unions are ready to go to great lengths to promote the nurses image. Mind you, i do agree with many of the nurse union's actions, our colleagues deserve good pay - its just the NP situation just feels like so many are overstepping their positions, especially the governments that have this really short term perspective with lack of insight.

on another note, its very ironic that we belittle america for letting their insurance companies make healthcare decisions as opposed to the doctors and now we are in the same boat at times with our insurers, the governments haha