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Public beware of changing care paradigms

By Rafael Fernandez, Jr., MD

The corporate takeover of medicine continues to accelerate at an alarming rate. According to a study conducted by the Physicians Advocacy Institute and Avalere Health, more than 75% of doctors are now employed by hospitals, health systems and other companies. The recent announcement of Amazon’s purchase of One Medical for $3.9 billion is perhaps the most glaring example of this paradigm shift.

In Florida, the takeover was aided by Tallahassee policymakers who expanded the role of non-physician practitioners in recent years, including providing independent practice for advanced practice nurse practitioners and increasing the number of nurse practitioners to 10. medical assistants that a doctor can supervise.

Make no mistake, while these non-physician practitioners have applauded their expanded role in care delivery, it is corporate interests that provide the muscle behind these efforts. The equation is simple, doctors are more expensive and difficult to replace than mid-level providers. But this calculation will only work if more dispatched supervised or independent mid-level practitioners can produce with the same efficiency and effectiveness as physicians.

The training and skills that physicians and mid-levels bring to the table are not comparable.

Physicians are not permitted to independently diagnose, treat, or prescribe until they have logged 15,000 to 16,000 clinical hours. While nurse practitioner organizations promote that NPs are ready to independently diagnose and prescribe after logging between 500 and 1,500 clinical hours.

And some early performance data shows the efficiencies not materializing.

According to an article from the American Medical Association, “CMS 2017-2019 cost data for Medicare patients without end-stage renal disease who were not in a nursing home showed that spending per member and per months were $43 higher for patients whose primary healthcare professional was a non-physician instead of a physician.This could translate to $10.3 million in additional spending per year if all patients were followed by PPAs, according to the analysis.When risk-adjusted for patient complexity, the difference was $119 per limb, per month, or $28.5 million per year.

The Dade County Medical Association has always maintained that a physician-led team is the best way to improve quality and appropriate utilization of health care services. Unfortunately, as more physicians become middle managers in a growing army of mid-level providers, their decision-making is more often compromised by limited time and dictated influences from above. The reality of this shifting care paradigm should worry patients, policymakers, and those purchasing health insurance for themselves, their constituents, or their employees.

Dr. Rafael Fernandez, Jr. is president of the Dade County Medical Association.



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