Scope creep in Canada, NPs are better than GPs, should we prepare for a "turf war"?

[who_knows]

So, check out this article.

https://www.cbc.ca/radio/whitecoat/how-nurse-practitioners-are-bridging-the-gap-between-family-doctors-and-the-er-1.6267206

“…it was an hour visit with her. OK, I hadn't had that much attention ever from a GP," she said. "And from there, she did my entire [medical] history. She was able to get everything down."

As I understand, this was her initial visit with the NP. Almost any first visit takes that long. So there is nothing special about the NP here. But the author deliberately misleads people by suggesting that an hour-long NP appointment is a normal thing.

 

“…Nurse practitioners have "full hospital privileges" in Ontario, Manitoba, B.C., the Northwest Territories and Nunavut”.

Does anyone know how “full hospital privileges” works in reality?

 

“[NPs are] not looking to replace the current primary-care structure in B.C., but rather "addressing a gap" for those who cannot find a family doctor”

Wow, his is straight from the Americans nurse practitioner’s association talking points. “Close gaps”, “increase access”, “rural communities”. In reality, there is extensive research showing that NPs do not decrease healthcare gaps.

 

“Clemens ultimately went with a nurse practitioner… "I thought I'd won the lottery."

What??? This is such overt NP advertising.

So, Clemens has multiple health problems and is considered a “complicated” patient and she entrusted her health to a nurse? What a smart choice!

Overall this reads as propaganda for NPs. Check this out: “Cassie says she feels healthier today”, “her NP provided her with better care than a GP ever has”, “I am living with total joy”, “I really feel that this is a definite way to go”, “nurse practitioners are a solution to the problem”. Can you be more biased?

Ultimately, the conclusion of the article is that family doctors, NPs and other health professionals need to “level out the playing field”. In other words, NPs want to be paid like physicians, ie fee-for-service, so they have an incentive to see more patients and get paid more. But will it not create the same problem (short visits, NPs in a hurry)? The article does not address that because it goes against the narrative that NPs are holier than thou.

I find this very concerning. The article has already mentioned “turf war”. Should we expect a push from NPs for granting them “full practice authority” similar to the American system?

[QueenStan]

Yes. Give an inch take a mile. Same thing that is happening in the US will happen here. Not that it's best for patients.

[Pakoon]

It is way easier to stop it before it happens as opposed to revoking any grounds the NPs make through legislation. The USA is a framework for what will happen. 

I think this is an issue that our American colleges wish they had an opportunity to go back and fix.

[jb24]

The reason why NP's will be successful is because NP's are united and have the power of government perceived cost savings on their side. They are actively lobbying for increased autonomy and abilities to work independently (which is dangerous, but dunning kruger is real). Seems like the media has chosen a certain angle too (CBC article is nauseating to read, especially being post call).

Physicians, have conflicts within their own associations as certain specialties have their own interests in utilization of NP/PA model (specifically surgical specialties, where NP's are advantageous for scut work). It definitely is not good for patient care.

Ultimately, people that can afford care in the US with physicians, will see physicians. However those that don't (probably disproportionately minorities) will get access to inferiorly trained NP's. I would not be surprised if the BC NDP government for example will implement NP's and CRNA's at rapid pace. Take a look at the noctor redd-it for how bad it is over there.

In the US NP's have even co-opted terms from medicine, like NP - "fellows"... They also seem to change specialties as they please, and then call themselves NP specialist in psychiatry for example. 

[Redpill]

The CBC and Toronto Red Star hate doctors, so their slant is unsurprising.

Another factor not discussed is that BC family doctors aren't unified in what they want. Some like the 10 min model where they can quickly churn through patients and make a lot of money. Others would prefer to take a 9 - 5 salary and see fewer patients. The government walks all over doctors because we are shit at negotiating. In turn, they get walked all over by nurses because the NDP loves their unions.

At least this year it looks like the government caved to anesthesiologists, they added 5 more residency spots. We'll see how long it takes for them to switch over to CRNAs...

[shikimate]

The government may be priming the electorate to pay more for healthcare. For example, if you visit a NP clinic you don't pay extra healthcare premium, but when you visit FMD, you have increased healthcare premium. Don't laugh, I think this way they can get a lot more people to pay up for healthcare

It's just like calling your bank's customer hotline. If you have a regular account, you get a robo answer, if you have premium account, you get in line for a real person. If you have a platinum account, you get someone to answer you right away. It's standard in the business world. It's called third degree price discrimination. 

If you read investopedia, there are 3 conditions for price discrimination:

"First, the company needs to have sufficient market power." - duh there's only one provincial insurer for healthcare so no question about this.

"Second, it has to identify differences in demand based on different conditions or customer segments." - most definitely true, there are already private clinics and people flying to Mexico, US for care etc. No shortage of poor people and ultra high net worth people in Canada.

"Third, the firm must have the ability to protect its product from being resold by one consumer group to another." - easy, with provincial insurance you can't hide who's going to which clinic.

 

[zoxy]

24 minutes ago, shikimate said:

The government may be priming the electorate to pay more for healthcare.

IMO, it would be electoral suicide by anyone who would suggest it. The CEO of Bell or RBC don't rely on their customers to remain in their job like a premier would. Besides, doing things differently than the US is how Anglo-Canadians define themselves, with " Free™ " healthcare being the primary differentiator between Anglo-Canadians and Americans. The easiest way to lose an election is to start talking about co-pays, which the opposition will brand as becoming like the US. Anti-Americanism is only getting stronger with the political insanity that goes on in the US. I believe that scope creep is far more likely than the government introducing payment of any sort.

P.S.

I would love to see attacks ads like this one. Might induce me to turn on the TV.

 

[Edict]

I think this is bound to happen, very big difference between NPs managing surgical post-ops compared to true independent practice. The issue though is I have heard of NPs who are seeing the patient's of a family physician, who is out playing golf, and billing for it. I mean, stories like that really don't bode well for doctors as a whole. 

[Financialnoob]

We should be advocating for PAs and get them known....at least they can't practice independently and we have oversight and supervision privileges to help us bill more 

[frenchpress]

1 hour ago, Financialnoob said:

We should be advocating for PAs and get them known....at least they can't practice independently and we have oversight and supervision privileges to help us bill more 

NPs used to require oversight too in many places. It's all scope creep. PAs present a similar problem in the US. 

[Redpill]

12 hours ago, Edict said:

I think this is bound to happen, very big difference between NPs managing surgical post-ops compared to true independent practice. The issue though is I have heard of NPs who are seeing the patient's of a family physician, who is out playing golf, and billing for it. I mean, stories like that really don't bode well for doctors as a whole. 

This is another problem, unfortunately there are enough FPs that abuse the system that it becomes hard to defend. Even if its a small minority you only need a few stories for the CBC and Red Star to run with

[JohnGrisham]

On 12/6/2021 at 3:27 AM, Redpill said:

Another factor not discussed is that BC family doctors aren't unified in what they want. Some like the 10 min model where they can quickly churn through patients and make a lot of money. Others would prefer to take a 9 - 5 salary and see fewer patients. The government walks all over doctors because we are shit at negotiating. In turn, they get walked all over by nurses because the NDP loves their unions.

Its not that everyone loves FFS, its that they aren't many good alternative options that are readily available.  IF you want sessional work or salaried work, that is often only available in certain practice style settings (CHCs, marginalized population focused clinics etc) that are only available in big city cores / academic centres.  The newly implemented New to practice contracts in BC, which are salaried, are lackluster - come with lots of strings attached, and pay MDs less than NPs on a per-patient basis. How is that good faith? After the first few years of practice, and once you know your patients alot better, the math makes more sense for FFS where you can more realistically get away with 10 minute appts like you mention.  

The other main and arguably biggest benefit of FFS, is the ability to be your own boss and modulate hours worked. Some weeks you can work 7 days a week locuming and have full clinic days, others you can drop down to 3-4 days and half days etc.  Salaried models don't come with this benefit, and many would gladly keep taking the pay cut for FFS (remember, locums dont get all the same chronic care premiums that full-scope family docs get, so it truly is a pay cut for locums not wanting the added responsibilty of being MRP), to maintain this benefit of being truly self-employed.

But yet no one says anything about NP salaried contracts, where they arent expected to see patients q10mins to be able to manage their smaller, less complex panel size?

 

[JohnGrisham]

11 hours ago, frenchpress said:

NPs used to require oversight too in many places. It's all scope creep. PAs present a similar problem in the US. 

Exactly. NPs initially were implemented to work ALONGSIDE MDs, but now they can open their own clinics and work independently...not having an MD nearby to help them out when they get over their heads.

All this leads to, is more inappropriate lab investigation, more unnecessary specialist referrals etc, aka more costs that are not captured at a surface level.

[Redpill]

18 hours ago, JohnGrisham said:

Its not that everyone loves FFS, its that they aren't many good alternative options that are readily available.  IF you want sessional work or salaried work, that is often only available in certain practice style settings (CHCs, marginalized population focused clinics etc) that are only available in big city cores / academic centres.  The newly implemented New to practice contracts in BC, which are salaried, are lackluster - come with lots of strings attached, and pay MDs less than NPs on a per-patient basis. How is that good faith? After the first few years of practice, and once you know your patients alot better, the math makes more sense for FFS where you can more realistically get away with 10 minute appts like you mention.  

The other main and arguably biggest benefit of FFS, is the ability to be your own boss and modulate hours worked. Some weeks you can work 7 days a week locuming and have full clinic days, others you can drop down to 3-4 days and half days etc.  Salaried models don't come with this benefit, and many would gladly keep taking the pay cut for FFS (remember, locums dont get all the same chronic care premiums that full-scope family docs get, so it truly is a pay cut for locums not wanting the added responsibilty of being MRP), to maintain this benefit of being truly self-employed.

But yet no one says anything about NP salaried contracts, where they arent expected to see patients q10mins to be able to manage their smaller, less complex panel size?

 

To be clear I'm not bashing FFS, I do think the model provides a lot of value to the system, especially for its ability to see a large volume of patients quickly. My point was that different doctors want different things and as a result we are not united. I have spoken to people who have seen these negotiations done at arms length, and their observation was the NP groups are better able to lobby government with clear messaging of what they want.. and so they are able to achieve their goals. 

The BC government is going to chase all the family doctors away from full-servce primary care, then use that as the rationale for expanding NP services in the province. And I just don't see doctor groups doing enough to stop this.

[JohnGrisham]

8 hours ago, Redpill said:

The BC government is going to chase all the family doctors away from full-servce primary care, then use that as the rationale for expanding NP services in the province. And I just don't see doctor groups doing enough to stop this.

Agreed on this, that as far as the govt is concerned MD = NP in primary care, even if NPs will actually cost a lot more.  

 

[GeriGIM]

Training in America. NP teams are the norm on the wards and in the ICU.  It’s hard for payers (governments, health systems) to see the difference in care provided by an NP v physician. The NPs know there’s a difference. The physicians know there’s a difference. But that difference is hard to measure. 

It’s easy to measure the difference in labor cost, however. American Inpatient NPs earn about $150k CAD. Inpatient IM about $350-400k. Imagine you’re a healthcare executive trying to cut costs — how do you not replace docs with NPs?  Scope creep is inevitable if doctors don’t protect their profession. 

Edited January 13, 2022 by GeriGIM

[Edict]

22 hours ago, GeriGIM said:

Training in America. NP teams are the norm on the wards and in the ICU.  It’s hard for payers (governments, health systems) to see the difference in care provided by an NP v physician. The NPs know there’s a difference. The physicians know there’s a difference. But that difference is hard to measure. 

It’s easy to measure the difference in labor cost, however. American Inpatient NPs earn about $150k CAD. Inpatient IM about $350-400k. Imagine you’re a healthcare executive trying to cut costs — how do you not replace docs with NPs?  Scope creep is inevitable if doctors don’t protect their profession. 

Some of it is inevitable, certainly with increasing amounts of electronic documentation and a lot of protocolized medicine, a lot of the skill based practice of medicine has decreased. Unless you can prove that physicians order less unnecessary testing (which we all know is true) and that the unnecessary testing is more value than their salary, you'll find it hard to justify not bringing in NPs. 

[jb24]

On 12/8/2021 at 4:58 AM, Redpill said:

To be clear I'm not bashing FFS, I do think the model provides a lot of value to the system, especially for its ability to see a large volume of patients quickly. My point was that different doctors want different things and as a result we are not united. I have spoken to people who have seen these negotiations done at arms length, and their observation was the NP groups are better able to lobby government with clear messaging of what they want.. and so they are able to achieve their goals. 

The BC government is going to chase all the family doctors away from full-servce primary care, then use that as the rationale for expanding NP services in the province. And I just don't see doctor groups doing enough to stop this.

I agree wholeheartedly with this. It's very dangerous.