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Docs disappearing from ER: Calling Phil
[link=https://khn.org/news/article/doctors-are-disappearing-from-emergency-rooms-as-hospitals-look-to-cut-costs/]https://khn.org/news/arti…als-look-to-cut-costs/[/link]
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55 Replies
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Quote from 67ED5CC042435
Doctors are disappearing from healthcare because the executives are hiring NPs and to a lesser extent PAs. Somehow we have had a physician shortage for decades and the short term fix was lets have experienced nurses manage the easier issues. Except over the last ten years the number of NPs exploded and now for many new NPs its a pipeline right out of nursing school. So now we have two problems: not enough doctors and not enough nurses.
The house of cards is bound to collapse.
Re: pipline right of of nursing school, this popped up today:”
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Someone says she doesn’t have enough experience. Her response:
1) I worked as a tech
2) saw critical care while a nursing student.So – there you have it. She thinks that qualifies her.
(incidentally, most of the replies are along the lines of “why is everyone hating on you?? You go girl!!”)
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Again, the greater the gov’t, the greater the crowding out of competence and productivity, the faster you head to decline and collapse.
Everything that enabled the boomers and older to get so entitled now has blown up in their face. Health care and retirement systems are insolvent, the younger people have no future and realize they are the requirement for the old people’s ponzi
It doesn’t have to be a blame game [b]it just is the reality.[/b]-
“greater the gov’t” maybe – but don’t forget that healthcare today is a get rich quick scheme for executives. Hospital systems merge, get rid of a lot of staff and overwhelm those that don’t leave, without a care about competence, quality of care or even safety.
I like where I work, but I don’t know when the next merger will make things intolerable for me. With my spending and savings, I’m continuously operating as if I will leave my job at a moment’s notice.-
These last two posts point out something. When we think about the organization of medicine, there is a tendency to think in a dichotomy:
Single payor (govt) run medicine VS Free market mediicine
This free market medicine has led to mega companies like HCA running large parts of the system, and in some cities (Asheville, NC) they essentially have a monopoly. They have destroyed quietly care in Asheville, NC (Check out the FB page “mountain maladies” what has happened in Asheville is truly tragic, and an important lesson .)
There is a need to think more flexibly. There is a middle ground where perhaps the best answers are. Years ago, there were NO PE groups, no mega hospitals. in my town, Columbus, there were 2 big hospitals – Riverside and University. Then there were two “systems” of two hospitals – Mt Carmel and Doctors (which were the hospitals for DOs). And a couple of medium sized hospitals – grant and St Anthony.
The docs were 95% self employed – sometimes in groups of maybe up to 10 docs, and there were several specialty groups in each hospital.I am sure that there were some problems, no system is perfect, but – the docs had a lot of input into how the hospitals were run. The hospitals actually cooperated on projects – such as helicopter services – to make the whole thing work better. I was even aware of the bigger hospitals in town getting together to prop up St anthony’s with contributions because it was a critical piece. It was in a crime-ridden area – got a lot of trauma, and a lot of patients who couldn’t pay. The other hospitals recognized the importance of this hospital in the entire system, and helped keep it solvent.
Nothing like that happens now.
The govt got into controlling medicine by controlling how it is paid, forcing the hospitals to learn how to game the system, giving rise to mega hospitals and PE running physician groups. -
These last two posts point out something. When we think about the organization of medicine, there is a tendency to think in a dichotomy:
Single payor (govt) run medicine VS Free market mediicine
This free market medicine has led to mega companies like HCA running large parts of the system, and in some cities (Asheville, NC) they essentially have a monopoly. They have destroyed quietly care in Asheville, NC (Check out the FB page “mountain maladies” what has happened in Asheville is truly tragic, and an important lesson .) The disaster in Asheville has caused some to cry out for relief from the only source they can imagine – the govt. People wishing for single payor medicine to replace the mega hospital corporation. So – they are thinking of it as an either/or proposition.
There is a need to think more flexibly. There is a middle ground where perhaps the best answers are. Years ago, there were NO PE groups, no mega hospitals. in my town, Columbus, there were 2 big hospitals – Riverside and University. Then there were two “systems” of two hospitals – Mt Carmel and Doctors (which were the hospitals for DOs). And a couple of medium sized hospitals – grant and St Anthony.
The docs were 95% self employed – sometimes in groups of maybe up to 10 docs, and there were several specialty groups in each hospital.I am sure that there were some problems, no system is perfect, but – the docs had a lot of input into how the hospitals were run. The hospitals actually cooperated on projects – such as helicopter services – to make the whole thing work better. I was even aware of the bigger hospitals in town getting together to prop up St anthony’s with contributions because it was a critical piece. It was in a crime-ridden area – got a lot of trauma, and a lot of patients who couldn’t pay. The other hospitals recognized the importance of this hospital in the entire system, and helped keep it solvent.
Nothing like that happens now.
The govt got into controlling medicine by controlling how it is paid, forcing the hospitals to learn how to game the system, giving rise to mega hospitals and PE running physician groups. Neither govt controlled nor uncontrolled free market health care is the right way.Do I think that someone will discover the right way and do it? no.
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Hospitals love increased utilization !
This will change once ER charges become bundled and the hospital loses money on that chest CT thrown in with the A/P because the mid-level can’t read a CXR.
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That’s a good point. Issue is that medicine of 40 years ago isn’t the medicine of today. Everything costs too much for the old system to work. I don’t know what the answer is, but it starts with cutting administrators (both corporate and gov’t – and this would require both sides ending their incessant micromanagement), putting physicians in leadership roles and not running healthcare like a profit making machine.
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Quote from Phil Shaffer
These last two posts point out something. When we think about the organization of medicine, there is a tendency to think in a dichotomy:
Single payor (govt) run medicine VS Free market mediicine
This free market medicine has led to mega companies like HCA running large parts of the system, and in some cities (Asheville, NC) they essentially have a monopoly. They have destroyed quietly care in Asheville, NC (Check out the FB page “mountain maladies” what has happened in Asheville is truly tragic, and an important lesson .) The disaster in Asheville has caused some to cry out for relief from the only source they can imagine – the govt. People wishing for single payor medicine to replace the mega hospital corporation. So – they are thinking of it as an either/or proposition.
There is a need to think more flexibly. There is a middle ground where perhaps the best answers are. Years ago, there were NO PE groups, no mega hospitals. in my town, Columbus, there were 2 big hospitals – Riverside and University. Then there were two “systems” of two hospitals – Mt Carmel and Doctors (which were the hospitals for DOs). And a couple of medium sized hospitals – grant and St Anthony.
The docs were 95% self employed – sometimes in groups of maybe up to 10 docs, and there were several specialty groups in each hospital.This is too simplistic, always blaming government as if government created all the problem by itself. Years ago is pre-Medicare and very many things were different not just self-employed physicians. You also forget that government intervention has increased the wealth of physicians since the 1950s. And Medicare was specifically created to address issues regarding peoples ability to obtain healthcare, something the free market is not built to address.
And today the primary problem is increasing profits from the system by investors who are creatures of this free market. Labor cost is the investors primary enemy & physicians are merely highly paid labor. Corporate thinking, how to run healthcare like a business built for-profit. Always back to profits as primary with healthcare secondary but as the means for profits.
HCA as well as Tenet have been building themselves as for-profit since the 1960s. Profits are increasing – first responsibility is to investors above everyone else – while asking for more financial assistance while cutting back on labor, whether physicians or nurses. Because remember, nurses went on strike recently in order to address corporates reduction nursing workforce increasing patient loads on nurses in critical areas.
Its never been only physicians who are being cut. Its not nurses, PAs & NPs who are the enemy, theyre just taking jobs with higher opportunities.
This is the perfect divide & conquer strategy, pitting physicians against nurses & others.[link=https://www.fiercehealthcare.com/providers/kff-profit-hospital-system-margins-surge-past-pre-pandemic-levels]https://www.fiercehealthcare.com/providers/kff-profit-hospital-system-margins-surge-past-pre-pandemic-levels[/link]
[link=https://www.realclearpolicy.com/articles/2022/04/11/hospitals_make_120_billion_while_skirting_federal_transparency_law_826022.html#!]https://www.realclearpolicy.com/articles/2022/04/11/hospitals_make_120_billion_while_skirting_federal_transparency_law_826022.html#![/link]
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. Years ago, there were NO PE groups, no mega hospitals. in my town, Columbus, there were 2 big hospitals – Riverside and University. Then there were two “systems” of two hospitals – Mt Carmel and Doctors (which were the hospitals for DOs). And a couple of medium sized hospitals – grant and St Anthony.
The docs were 95% self employed – sometimes in groups of maybe up to 10 docs, and there were several specialty groups in each hospital.…
Nothing like that happens now.
The govt got into controlling medicine by controlling how it is paid, forcing the hospitals to learn how to game the system, giving rise to mega hospitals and PE running physician groups. Neither govt controlled nor uncontrolled free market health care is the right way.
That “years ago” scenario was also in a US medical system in which government controlled payments.
The changes at play are simply free market labor forces finally finding their way into healthcare where they had been surprisingly muted for many years.
And today the primary problem is increasing profits from the system by investors who are creatures of this free market. [b]Labor cost is the investor’s primary enemy & physicians are merely highly paid labor.[/b] Corporate thinking, how to run healthcare like a business built for-profit.
This. Corporatism has come to medicine. And there is no putting the toothpaste back in the tube.
Years ago, there were NO PE groups, no mega hospitals. in my town, Columbus, there were 2 big hospitals – Riverside and University. Then there were two “systems” of two hospitals – Mt Carmel and Doctors (which were the hospitals for DOs). And a couple of medium sized hospitals – grant and St Anthony.
The docs were 95% self employed – sometimes in groups of maybe up to 10 docs, and there were several specialty groups in each hospital.
That world is not coming back. I know there are some people on this board who pine for the days of pre-consolidation or who have wishful thinking about the return of the 8 man traditional generalist radiology private practice contracted to one single hospital.
The percentage of doctors working under that model is shrinking and I don’t see anything on the horizon to alter that dynamic.
Market forces in labor are driving the use of midlevels. Market forces in consolidation, market share, negotiation leverage with insurers etc, are driving consolidation.
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Docs *might* be able to staunch some of the bleeding with successful lobbying to get strict scope of practice regs in place … but honestly, with the labor shortage and aging population needing more care I don’t see those efforts as likely to see a large amount of success.
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Quote from dergon
The changes at play are simply free market labor forces finally finding their way into healthcare where they had been surprisingly muted for many years.
The only disagreement I have with your post, dergon, is “surprisingly muted for many years.”
It’s not been muted, it was building and growing. I was aware of for-profits and labor and costs back in the late 1970’s or early 1980’s.
This is now the model that everyone’s adopted to stay competitive. Unfortunately in this sort of environment, the investors/business class have all the cards with small exceptions like striking nurses. Everyone else is divided into groups who compete with each other for their piece of the pies offered by the investors who are calling the shots.-
There was a great article on JACR about the history of radiology compensation that clears up some misconceptions that some of these replies are displaying about the “good old days.”
[link=https://www.jacr.org/article/S1546-1440(20)30173-3/fulltext]https://www.jacr.org/arti…40(20)30173-3/fulltext[/link] -
Quote from Frumious
Quote from dergon
The changes at play are simply free market labor forces finally finding their way into healthcare where they had been surprisingly muted for many years.
The only disagreement I have with your post, dergon, is “surprisingly muted for many years.”
It’s not been muted, it was building and growing. I was aware of for-profits and labor and costs back in the late 1970’s or early 1980’s.
This is now the model that everyone’s adopted to stay competitive. Unfortunately in this sort of environment, the investors/business class have all the cards with small exceptions like striking nurses. Everyone else is divided into groups who compete with each other for their piece of the pies offered by the investors who are calling the shots.
I suppose that’s fair.
But the current labor shortage combined with financial strains on hospital systems has really put it into overdrive in the last couple of years.
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Including all the factors over time is way beyond AM posts. You are correct. And yet with financial strains on hospitals, they are also seeing high profits.
I don’t see a fundamental disagreement in our posts.
UncleMinnie’s post intrigued me to do a search of my own regarding the “good old days” of regulation and physician income, not specifically radiologist income.
[link=https://www.kevinmd.com/2012/09/doctors-complain-history-physician-income.html]https://www.kevinmd.com/2012/09/doctors-complain-history-physician-income.html[/link]
[link=https://journalofethics.ama-assn.org/article/us-health-care-non-system-1908-2008/2008-05]https://journalofethics.ama-assn.org/article/us-health-care-non-system-1908-2008/2008-05[/link] -
Quote from Frumious
Including all the factors over time is way beyond AM posts. You are correct. And yet with financial strains on hospitals, they are also seeing high profits.
We mostly agree … but point of clarification …
Hospitals are not seeing “high profits”
[link=https://www.fiercehealthcare.com/providers/unsustainable-losses-are-forcing-hospitals-make-heart-wrenching-cuts-and-closures-leaders]https://www.fiercehealthc…s-and-closures-leaders[/link]
Anywhere from 53% to 68% of the nations hospitals will end 2022 with their operations in the red versus the 34% reported in 2019, according to new industry projections released Thursday by Kaufman Hall on behalf of the American Hospital Association (AHA).
The groups optimistic projections place 2022s hospital margins 37% lower than what it recorded in 2019. Its pessimistic prediction sees that margin decline plummet to 133%.
In either case, hospitals stand to lose billions of dollars in 2022, Lisa Goldstein, senior vice president at Kaufman Hall, said Thursday during an AHA press call discussing the report. It will be the worst year since the start of the pandemic.
Much of the damage comes from expenses anticipated to continue rising through the end of the year to nearly $135 million more than 2021, according to the report.
About $86 billion of that expected increase is tied to labor, which traditionally encompasses about half of a hospitals total expenses, Kaufman Hall wrote. Contract labor that normally constitutes about 10% of a hospitals salary and wages budget was responsible for a third of the increase, Goldstein said. Contract labor remains in elevated demand as hospitals across the country contend with a workforce shortage.the two large systems in community are each hundreds of millions of dollars in the red coming out of 2022.
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When the hospitals start cutting the $XMillion salaries of their multiple administrators, then I will believe they are struggling financially.
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That never happens. It doesnt happen in corporate America in wont happen in corporatized American healthcare.
High level management salaries hold all the way up to bankruptcy and beyond
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Hospitals are not seeing “high profits”
[link=https://www.fiercehealthcare.com/providers/unsustainable-losses-are-forcing-hospitals-make-heart-wrenching-cuts-and-closures-leaders]https://www.fiercehealthc…s-and-closures-leaders[/link]
Anywhere from 53% to 68% of the nations hospitals will end 2022 with their operations in the red versus the 34% reported in 2019, according to new industry projections released Thursday by Kaufman Hall on behalf of the American Hospital Association (AHA).
The groups optimistic projections place 2022s hospital margins 37% lower than what it recorded in 2019. Its pessimistic prediction sees that margin decline plummet to 133%.
In either case, hospitals stand to lose billions of dollars in 2022, Lisa Goldstein, senior vice president at Kaufman Hall, said Thursday during an AHA press call discussing the report. It will be the worst year since the start of the pandemic.
Much of the damage comes from expenses anticipated to continue rising through the end of the year to nearly $135 million more than 2021, according to the report.
About $86 billion of that expected increase is tied to labor, which traditionally encompasses about half of a hospitals total expenses, Kaufman Hall wrote. Contract labor that normally constitutes about 10% of a hospitals salary and wages budget was responsible for a third of the increase, Goldstein said. Contract labor remains in elevated demand as hospitals across the country contend with a workforce shortage.
the two large systems in community are each hundreds of millions of dollars in the red coming out of 2022.
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Caution here. Losses are being widely publicized but aren’t half the story.
True, most hospital systems have lost $ in the past few years. It’s also true their losses are very, very small when compared with overall revenue (this point is rarely discussed).
More important, ask why we’re hearing so much about their losses? During years they made obscene profits we never heard much, if anything, about the profits.
They’re using these relatively small losses for their PR benefit to decry staffing costs and justify future cuts (primarily by replacing MDs with mid-levels, bill 85% of MD while paying mid-levels 35% of MD salary, and pocket the difference). -
Bingo.
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Quote from UncleMinnie
“greater the gov’t” maybe – but don’t forget that healthcare today is a get rich quick scheme for executives. Hospital systems merge, get rid of a lot of staff and overwhelm those that don’t leave, without a care about competence, quality of care or even safety.
I like where I work, but I don’t know when the next merger will make things intolerable for me. With my spending and savings, I’m continuously operating as if I will leave my job at a moment’s notice.
Yes, the point is (along with Phil’s dichotomy) that you have an in betweener that is subsidized by the gov’t who can print money, or borrow ad infinitum, seemingly. That means the grift of the middle man (your execs) is huge and the government and other third party payers are the mirage or sinkhole for so may of the dollars.
Free market would be the most efficient but emotions and propaganda get in the away (bad things happen and people act like they shouldn’t have, but overall medical costs are crazy low)
Gov’t/single payer would be least efficient but certain costs would be curtailed, the issue is that the bureaucracy gets paid big for being lazy – but corps/execs of the hybrid system aren’t parasitizing things
Pick your poison-
I feel bad for ER docs and anesthesiologists. Fields got decimated by corporate AND Midlevels.
At Least FP / IM docs have an opportunity to open up a clinic and some entrepreneurial venues…if you’re anes, youre essentially stuck with a corporate low paying job making 30% more than a CRNA, unless you live somewhere undesirable, or are extremely lucky. And you get stuck with the harder cases and call.
ER is the same. See the sickest patients…but at least compensated 2-3X of a ER PA or NP, for now.-
Have you talked to anesthesiologists? It seems like the market is extremely hot with compensation very high as well.
I would certainly rather be an anesthesiologist than an EM doc right now-
I work in a small town and I would say that about 60% of the “providers” in our ER are midlevels. Any patient with a possible fall or MVC gets at least 7 CTs (CT Head, CT face, Cspine, Chest, Tspine, AP, Lspine)+ extremity xrays. Any patient who comes in with nonspecific headache gets stroke protocol with full workup including CT head, CTA head+Neck, and MRI Brain. They order MSK MRI to “r/o occult fracture” in a patient with chronic pain. Every patient with low back pain is “r/o cauda equina”. I lose so much time reading these non-indicated studies.
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Quote from boggles
Have you talked to anesthesiologists? It seems like the market is extremely hot with compensation very high as well.
I would certainly rather be an anesthesiologist than an EM doc right now
Yeah. My dad’s an anesthesiologist. I did 2 years of anesthesiology residency before switching.
Trust me, unless you’re in the midwest ( NOT chicago ) – its pretty crappy. CRNA’s are proliferating. They recently changed their name to ‘nurse anesthesiologist’ and are referring to themselves as ‘dr.’ now because they are required to get a online nursing doctorate degree. This is not a joke.
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Quote from ar123
At Least FP / IM docs have an opportunity to open up a clinic and some entrepreneurial venues…if you’re anes, youre essentially stuck with a corporate low paying job making 30% more than a CRNA, unless you live somewhere undesirable, or are extremely lucky. And you get stuck with the harder cases and call.
You can do independent anesthesia. Lots of endoscopy and ASC work to go around. The hospitals are locked down by the corporates, if you prefer 7-4 on your own schedule with no call, you can be independent.
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Thanks for the tag….
Yeah this is just the beginning. I have been thinking for 3 years, that this is a dramatic change in health care in the US and no one is watching. I have thought there is a pulitzer prize in this for some journalist, but when approached they say things like “i am too busy with covid”, etc.
Note the citation of the Radiology paper. Showed 5.3% increase in ER imaging. I am skeptical. I feel it is greater than that. Particularly when a similar paper from Mayo showed 59% of all midlevel consults to other services were unnecessary. Similar dynamic.
Companies like APP (and University of Pennsylvania) are changing our medical care permanently and are very busy trying to hide what they are really doing.
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I’m not surprised. Once everyone in the ER started getting CT for diagnosis you really don’t need many ER doctors if trauma handles the major incoming trauma patients.
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Quote from RadCog
I’m not surprised. Once everyone in the ER started getting CT for diagnosis you really don’t need many ER doctors if trauma handles the major incoming trauma patients.
unfortunately, it seems that you really do ….
as noted in the OP’s link
{T}reatment by a nurse practitioner resulted on average in a 7% increase in cost of care and an 11% increase in length of stay, extending patients time in the ER by minutes for minor visits and hours for longer ones. These gaps widened among patients with more severe diagnoses, the study said, but could be somewhat mitigated by nurse practitioners with more experience.
The study also found that ER patients treated by a nurse practitioner were 20% more likely to be readmitted to the hospital for a preventable reason within 30 days, although the overall risk of readmission remained very small.
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Quote from dergon
Quote from RadCog
I’m not surprised. Once everyone in the ER started getting CT for diagnosis you really don’t need many ER doctors if trauma handles the major incoming trauma patients.
unfortunately, it seems that you really do ….
as noted in the OP’s link
{T}reatment by a nurse practitioner resulted on average in a 7% increase in cost of care and an 11% increase in length of stay, extending patients time in the ER by minutes for minor visits and hours for longer ones. These gaps widened among patients with more severe diagnoses, the study said, but could be somewhat mitigated by nurse practitioners with more experience.
The study also found that ER patients treated by a nurse practitioner were 20% more likely to be readmitted to the hospital for a preventable reason within 30 days, although the overall risk of readmission remained very small.
If you are replaced and the main side effect is an 11% increased length of stay you are replaceable. That’s like pointing to report turn around time as a legit quality metric. -
The question is WHY are hospitals reporting losses & what hospitals, where.
Rural hospitals are & have pretty always been in danger on major losses threatening closures. And they are also much more sensitive to any change & competition for staffing.
The 2 paragraphs in Fiercehealth article give a major reason, labor competition due to burnout of nurses while trying to replace them with traveling and contract nurses as 1 major reason.Much of the damage comes from expenses anticipated to continue rising through the end of the year to nearly $135 million more than 2021, according to the report.
About $86 billion of that expected increase is tied to labor, which traditionally encompasses about half of a hospitals total expenses, Kaufman Hall wrote. Contract labor that normally constitutes about 10% of a hospitals salary and wages budget was responsible for a third of the increase, Goldstein said. Contract labor remains in elevated demand as hospitals across the country contend with a workforce shortage.
Healthcare labor is adjusting to same pressures as the labor market in general, high demand, low supplies pushing higher wages & labor costs. When McDonalds is cited as a competition for healthcare labor because it both pays better with less stress, you know we are in deep trouble.
At best, profit losses or reduction in profits is a mixed message.
[link=https://www.bloomberg.com/news/articles/2022-09-15/us-hospitals-to-face-heart-wrenching-decisions-as-losses-mount]https://www.bloomberg.com/news/articles/2022-09-15/us-hospitals-to-face-heart-wrenching-decisions-as-losses-mount[/link]
[link=https://www.npr.org/sections/health-shots/2022/09/28/1125176699/some-hospitals-rake-in-high-profits-while-their-patients-are-loaded-with-medical]https://www.npr.org/sections/health-shots/2022/09/28/1125176699/some-hospitals-rake-in-high-profits-while-their-patients-are-loaded-with-medical[/link]
[link=https://www.nbcnews.com/health/health-news/workers-us-hospital-giant-hca-say-puts-profits-patient-care-rcna64122]https://www.nbcnews.com/health/health-news/workers-us-hospital-giant-hca-say-puts-profits-patient-care-rcna64122[/link]
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Would love to insert some quotes but this 403 FORBIDDEN error raises its head so often & the only way to get rid of it is to delete things until it goes through.
Whats this about?-
Quote from Frumious
Would love to insert some quotes but this 403 FORBIDDEN error raises its head so often & the only way to get rid of it is to delete things until it goes through.
Whats this about?
It’s an error on the AM side that just needs to be fixed. Similar to the mobile formatting, the ease at which spammers create new threads, the toleration of sock puppets, etc, etc.
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Its intermittent, whats the triggers?
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An article on one hospital not swimming in money, but a major one in NYC.
Not sure what to make of the article & the campaigns purposes but neither does the article outside of apparent staffing issues that plague most everyone today.
[link=https://www.nytimes.com/2023/02/26/nyregion/maimonides-medical-center-brooklyn-hospital.html]https://www.nytimes.com/2023/02/26/nyregion/maimonides-medical-center-brooklyn-hospital.html[/link]-
Regarding private investors riding in on their black horses to save the day, and run healthcare, like a business, a comment on the article describes private investors actual goal, stripping the carcass for money.
Edward Freeman
Holyoke, MAThere was a hospital in Fairmont, WV, about 30 minutes south of Morgantown where I lived. It was struggling. When word got out that the hospital was going to be purchased, the staff celebrated. At last the hospital would be we well managed, run like a business. And it was. Things got worse in every way. The private sector heroes road into town and stole the place blind. When there was nothing left to steal, they closed the hospital. It had a level 2 trauma center. Another victory for neoliberals. Around the same time, two hospitals closed in Ohio.
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NP chart shows how NP training equivalent to MD
[link=https://twitter.com/ENPDoc/status/1645840473796521984]https://twitter.com/ENPDo…us/1645840473796521984[/link]
**eyeroll emoji**-
Midlevels are not trained to bear ultimate responsibility for medical decision making. So whenever they perform a medical workup which their supervising physician deems to be laking (Why didn’t you order this test?), they learn to avoid such unpleasant interactions in the future by ordering every possible test, to appease the physician. Thus we get the CT of the mid-humeral, mildly comminuted, mildly displaced diaphyseal fracture, easily diagnosed on plain film by a first year resident. All because some doc hut their feelings in the past.
This is how we have shifted from a 2% per year volume growth trajectory to a 5+% growth trajectory. It is unsustainable, and something in our field will break in the next decade. I’m glad I can read my own scans, for when I need medical care in the future, my scans may not be read for weeks, and will be interpreted by a midlevel right out of online school.
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Quote from Dumb Luck
Midlevels are not trained to bear ultimate responsibility for medical decision making. So whenever they perform a medical workup which their supervising physician deems to be laking (Why didn’t you order this test?), they learn to avoid such unpleasant interactions in the future by ordering every possible test, to appease the physician. Thus we get the CT of the mid-humeral, mildly comminuted, mildly displaced diaphyseal fracture, easily diagnosed on plain film by a first year resident. All because some doc hut their feelings in the past.
This is how we have shifted from a 2% per year volume growth trajectory to a 5+% growth trajectory. It is unsustainable, and something in our field will break in the next decade. I’m glad I can read my own scans, for when I need medical care in the future, my scans may not be read for weeks, and will be interpreted by a midlevel right out of online school.
If you had to guess top 2 things that might “break” or cause the eventualy break or larger problems, what would they be?-
The first thing to break will be overnight coverage. The acceptance of teleradiology daytime workers in traditional private practices during this tight hiring market will draw radiologists away from night work. Those hospitals that lose overnight telerad coverage will demand that the existing group cover their own overnights, which will poison such groups and make it impossible for them to hire. People will also leave those groups for daytime only jobs. Then such hospitals will be left with a dysfunctional group and will have no viable bids in an RFP. At some point in the next 5-10 years, there will be hospitals with NO radiology coverage at night if things don’t change.
The silver lining is that healthy groups will then be able to extract stipends from hospitals!-
Quote from Dumb Luck
The first thing to break will be overnight coverage. The acceptance of teleradiology daytime workers in traditional private practices during this tight hiring market will draw radiologists away from night work. Those hospitals that lose overnight telerad coverage will demand that the existing group cover their own overnights, which will poison such groups and make it impossible for them to hire. People will also leave those groups for daytime only jobs. Then such hospitals will be left with a dysfunctional group and will have no viable bids in an RFP. At some point in the next 5-10 years, there will be hospitals with NO radiology coverage at night if things don’t change.
The silver lining is that healthy groups will then be able to extract stipends from hospitals!
And that provides the opportunity for lower cost (read mid-levels) to enter into the world of imaging interpretationit is going to be a tough needle to thread
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Quote from Checkpoint Inhibitor
Quote from Dumb Luck
The first thing to break will be overnight coverage. The acceptance of teleradiology daytime workers in traditional private practices during this tight hiring market will draw radiologists away from night work. Those hospitals that lose overnight telerad coverage will demand that the existing group cover their own overnights, which will poison such groups and make it impossible for them to hire. People will also leave those groups for daytime only jobs. Then such hospitals will be left with a dysfunctional group and will have no viable bids in an RFP. At some point in the next 5-10 years, there will be hospitals with NO radiology coverage at night if things don’t change.
The silver lining is that healthy groups will then be able to extract stipends from hospitals!
And that provides the opportunity for lower cost (read mid-levels) to enter into the world of imaging interpretationit is going to be a tough needle to thread
or….
AI could be advanced enough by this time to wet read nighttime images equal to or better than a mid-level. All that is needed is a mid-level to supervise the ED.
AI will determine what to order from the triage assessment based on profit and risk. From the results it will either order more tests or diagnose.
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Do you think hospitals will hire “mercenary rads” to read at night and pay them well above market and let that eat into their technical fee pie?
Quote from Dumb Luck
The first thing to break will be overnight coverage. The acceptance of teleradiology daytime workers in traditional private practices during this tight hiring market will draw radiologists away from night work. Those hospitals that lose overnight telerad coverage will demand that the existing group cover their own overnights, which will poison such groups and make it impossible for them to hire. People will also leave those groups for daytime only jobs. Then such hospitals will be left with a dysfunctional group and will have no viable bids in an RFP. At some point in the next 5-10 years, there will be hospitals with NO radiology coverage at night if things don’t change.
The silver lining is that healthy groups will then be able to extract stipends from hospitals!
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Quote from PPRad
Do you think hospitals will hire “mercenary rads” to read at night and pay them well above market and let that eat into their technical fee pie?
Quote from Dumb Luck
The first thing to break will be overnight coverage. The acceptance of teleradiology daytime workers in traditional private practices during this tight hiring market will draw radiologists away from night work. Those hospitals that lose overnight telerad coverage will demand that the existing group cover their own overnights, which will poison such groups and make it impossible for them to hire. People will also leave those groups for daytime only jobs. Then such hospitals will be left with a dysfunctional group and will have no viable bids in an RFP. At some point in the next 5-10 years, there will be hospitals with NO radiology coverage at night if things don’t change.
The silver lining is that healthy groups will then be able to extract stipends from hospitals!
This is what always had to happen. And where you get guys like me saying, you’d have to pay me a million dollars to do it. And we aren’t kidding.
The problem is, getting paid a cool mil means you are getting taxed crazy amounts on the last several hundred grand … another issue in general with American commie creep and .gov lunacy-
Cash balance plan
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Quote from sandeep panga
Cash balance plan
Yuuuup-
This is already happening. Nights need to be covered, and practices have to pay a premium to do so.
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Quote from sandeep panga
Cash balance plan
The problem is that this is just another gov’t held and confiscatable/taxable delayed/forced savings. Not only will the USD not be maintained, they will take it from you “rich people” when the collapse comes. And if that’s not in 3 years, it’ll be by 2030 for shizzle-
Had a PA order concurrent CT AP and RUQ US in ED last night. Pt was really sick, just kind of a panicked order it all frenzy. Talked her down. Also talked her out of the US after my CT report with Gall bladder distention with no stones or sludge, no biliary dilatation, no wall thickening or pericholecystic fluid or induration. Patient had been vomiting for two days, I surmised had probably not been eating much and offered may be due to relative fasting state, does not appear inflammatory . That was not enough without me calling to ask what the US might show that would be of use to her. She said the report says its dilated. I pointed out that the report reasonably accounts for that and provides at least five pertinent negatives and a declaration that it doesnt appear inflamed. I asked if he was tender there, and she wasnt sure. She called back in two minutes to cancel and even thanked me.
They have no earned confidence, so they skip basic physical examination, and dont have enough critical thinking skill derived from the combination of intensive classroom tempered by many thousands of clinical hours, to even interpret a report that is making every effort to spoon feed .
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Cash balance is overrrated. Gonna have to pay tax on that big boy sooner or later. Taxes will probably never be less than they are now. My opinion is that its better to pay your taxes now. Taxes will soon resort to increased levels in 2025 I believe with sunset of the previous legislation. And they will only go up from there. Imagine if dems get a supermajority in both house and senate plus win presidency. They may create a top tax rate of 50%+ plus.
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It doesnt matter if taxes just “go up”, it matters that they go up enough that the taxes youre paying the money out on are higher than the marginal tax break your getting putting it in. that is not going to be true for the vast, vast majority of people, especially physicians. It’s dumb to pay 40+% taxes now so you dont pay in the 20s in retirement.
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Quote from boggles
It doesnt matter if taxes just “go up”, it matters that they go up enough that the taxes youre paying the money out on are higher than the marginal tax break your getting putting it in. that is not going to be true for the vast, vast majority of people, especially physicians. It’s dumb to pay 40+% taxes now so you dont pay in the 20s in retirement.
You are underestimating the degree to which taxes will go up in the future, and inflation to boot. Just wait til 2025, you’ll see. -
Even Biden uses 400, as some arbitrary measure for where he wants to keep taxes the same. and thats for earned income. Theres no way that taxes at <2-300k with the ability to control your tax rates through taxable and roth are higher than making >5-600k W2 now.
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[link=https://www.dmagazine.com/healthcare-business/2023/04/texas-nurse-practitioners-want-to-be-free/]https://www.dmagazine.com…oners-want-to-be-free/[/link]
[b]Texas Nurse Practitioners Want to Be Free[/b]
Most states in the country allow nurse practitioners to work independently, but Texas still requires oversight.A group called the Coalition for Healthcare Access is supporting a pair of bills in the Texas Legislature that would remove the mandate for NPs to be supervised by physicians and place regulatory authority for NPs under the Texas Board of Nursing. Amazon, the Texas Association of Health Plans, Texas 2036, the Texas State Chamber of Commerce, AARP, the Texas Organization of Rural and Community Hospitals, and many others have all signed on as supporters of the legislation that would end the practice that costs NPs thousands of dollars a month for oversight from an MD.
Two bills have been introduced toward removing the delegation requirement. Senate Bill 1700s author is Sen. Cesar Blanco of El Paso, and House Bill 4071 is from Fort Worths own Stephanie Klick, a nurse who has been [link=https://www.dmagazine.com/healthcare-business/2023/04/texas-is-likely-to-expand-medicinal-marijuana-laws-but-access-is-still-an-issue/]responsible[/link] for Texas medical cannabis legislation and is chair of the public health committee in the House. The two bills are nearly identical and allow NPs to diagnose and treat patients, prescribe drugs, including controlled substances and devices, and serve as the primary care clinician of record.
The Texas Medical Association, which represents physicians and medical students in Texas with 57,000 members, has defeated similar bills in past legislative sessions and aims to do so again this year.-
Reading that Amazon sponsors these bills puts the recent Amazon clinic spam emails I’ve received in perspective.
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