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<p>Exactly. Until we reach a crisis point in funding healthcare (and we are almost there - it will happen as the mass of baby boomers move into Medicare), it’s going to be really hard to get buy-in on changing our system. I see small, incremental steps taking place under healthcare reform but if we have a change of administration next year, it could get overturned.</p>
<p>I don’t even know where to begin to respond to this assertion. One of the first few sentences compares the medical industry to the finance sector…throwing money at uninsured pts. No, not comparable. These are peoples lives not mortgages.</p>
<p>Despite deep cuts in Medicaid /Medicare reimbursement, the ltc, snf facility I am employed we are hiring like crazy. We have enormous turnover with nursing assts. And difficulty finding RN’s. I am the RN supervisor of the skilled unit but we have seen a dramatic increase in hospice pts. this year. I have knee and hip sx along side metastatic ca pts. </p>
<p>I see universal healthcare becoming a reality eventually but as far as a bubble…I don’t think it would ever be as severe as housing, dot com etc…</p>
<p>It is very stressful work and we work with a lot less staff than we used.to when I first started in 1999. Nurse aids wages are pathetic in our area, about $10/hr. Many work part time not because full time isn’t available but to qualify for Medicaid for at least their kids. No way most of them can afford deductibles and copays. </p>
<p>One thing I do appreciate about my job is the ability to work part time and still have good wages. Because of the stress and short staffing, I couldn’t comprehend a typical 5 day work week. And that is another reason you see so many part timers. Plus, most hospitals offer decent benefits starting at 24 hrs/week.</p>
<p>“The health care job bubble has already burst. Nursing schools are churning out new nurses who can’t find job.”</p>
<p>Send them our way. We’ll take as many as we can get, and even pay a bounty. And this is a capital city, with low housing costs, fantastic environment, and great place to raise kids. </p>
<p>The new Accountable Care Organizations springing up everywhere will lessen the demand for docs, and massively increase the demand for nurses, and nurse managers.</p>
<p>(Career Builder currently lists 43 PAGES of openings for nurses in New York - though not all in NYC. And yes, as in most careers, they’d prefer ones with experience.)</p>
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<p>Why would ACO’s decrease the demand for docs?</p>
<p>I also believe ‘networking’ and contacts play a significant role in landing a job,particularly your 1st job…fortunately,we have some in nursing and healthcare…</p>
<p>@GTalum… the concept behind ACOs is bundled payment–receiving one lump sum for the provision of care to a defined population (such as medicare seniors in a city, or to take care of a specific employer group, etc.) from soup to nuts. Whoever is receiving the bundled payment has to figure out how to get the best possible outcomes and the lowest possible cost (in order to pay everyone who touches the patient and still pocket profit.) In this scenario, using doctors as the centerpiece (the quarterback) of care planning makes sense…but in order to pocket more dollars, that doctor (or whoever is receiving the bundled payment, it can be a hosptial system, a physician group, an insurer…anyone who steps up, negotiates it, and then negotiates with the other providers they need ) is trying to use the most efficient and most economical care deliverers while still getting that outcome. So the use of more nurses, more technicians, throughout the care continuum (and less specialists. only when needed,) actually is the way to go. So the primary care physicians of the future actually take on the most important role, and the specialist physicians–while still darned important–are tapped into only when needed. In todays world, where there isn’t quite the same rationing and quarterbacking of care, has extensive use of specialists when it really isnt value added. Have an
ingrown toe nail? No heck no you dont need an ortho doctor. You need a Phys Asst. </p>
<p>A simplistic example yes–but you get the gist.</p>
<p>^I totally agree with ProudMomofS’s assessment of how an ACO will work. We are beginning to take on risk using the ACO model. I do believe you will see a steep increase in the use of mid-level providers (NPs, PAs, midwives, etc). Those will be great health care career paths, btw. We already don’t have enough mid-level providers. However, I don’t think that’s going to translate into an excess supply of physicians across the board. We are about to see a shortage of physicians, particularly primary care physicians, at exactly the time when baby boomers are hitting peak health care usage. The infrastructure for educating physicians in this country hasn’t kept up with the impending demand. There will definitely be certain physician specialties that will be in overabundance. We are already seeing that with cardiologists/ CT surgeons/ Vascular surgeons. We’ve done so well with treating and preventing heart disease that we now have too many physicians in this specialty in many markets. I’m getting ready to start a project assessing how many physicians in each specialty we will need in our market under an ACO model. Should be fun.</p>
<p>In the new ACOs, screening for “behavioral health conditions” (substance abuse/mental health) will all likely be done by nurses, under the supervision of nurse care managers. The incentives in the ACOs will be heavy (as they have been in some HMOs for the past 20 years), to keep patients away from physician specialists. The care managers might even be paid bonuses for doing so (as they are in some HMOs now) Primary care will be delivered by physician assistants and ARNPs. So while in theory the demand of primary care docs would go up (as need for specialists goes down), the reality is that not many of them will be needed either. </p>
<p>Where I live, many of the BSNs are, almost by definition, younger and have less experience (generally speaking, though not necessarily in nursing) than the two-year RNs, and many of them went to the four-year schools because they couldn’t get into the two-year ones. The only places here where the four-year degree is required is school nursing (and many schools are getting rid of them), and public health nursing (which is laying folks off left and right). The employers would much prefer two-year RNs with some experience (either in nursing, or just of the world) than 21-year old BSNs without it.</p>
<p>My wife’s practice is desperately short of nurses with any geriatric experience, or at least the psychological wherewithal to deal with dying patients and their families. I don’t know of many 21-year-olds who could easily cut it - simply not enough life experience.</p>
<p>Can you imagine how many people will lose their jobs when technology like this comes out very soon:</p>
<p>[Programmable</a> Bio-Nano-Chips: First Viable Medical Lab on a Chip? | Singularity Hub](<a href=“http://singularityhub.com/2011/02/16/programmable-bio-nano-chips-the-first-viable-medical-lab-on-a-chip/]Programmable”>Programmable Bio-Nano-Chips: First Viable Medical Lab on a Chip?)</p>
<p>relax and stop panicking. prison doctors (and nurses) are in high demand in some states. high stress and inherently dangerous depending on the facility, but the jobs are there and the pay is excellent.</p>
<p>“The delivery system is going to have to change …”</p>
<p>Simple changes in this area would help enormously. A prescription in order to get basic antibiotics? An eye exam within 6 months to re-order contacts? A doctor’s order if you want a standard blood panel? $15K for standard pre-natal care and delivery?</p>
<p>The other thing I should have mentioned about nurses, and I don’t know whether this is universally true: where I live, the two-year RNs almost all become LPNs after their first year, and immediately begin working. So, in addition to more life experience, they come out of nursing school with at least a year of nursing experience. I don’t think that is true of the four-year nurses.</p>
<p>Well, sure insurers and Obamacare will try very hard to get Americans to accept nurses as the medical decision makers in terms of diagnosis and treatment strategies. Does anyone actually think this will play? Everyone knows a nursing degree is about 1/10 the time, effort and IQ requirement of the MD degree. Everyone will demand an MD overseeing their care. </p>
<p>In the end – Americans and everyone on the planet wants most to (1) stay alive, and (2) feel good. </p>
<p>Best thing to be through the good times, bad times and all times unless you’re a truly gifted (and lucky) entrepreneur is a doc.</p>
<p>Hey, mini, doesn’t your wife teach nurses or something?</p>
<p>Hey I’ve got a question … will the price of an MRI go down once the nurse can order it? If nurse practitioners get authorized to deliver babies, will they still be exempt from carrying malpractice insurance? (Well OK, I guess that’s two questions.)</p>
<p>I’ll probably get flamed for my sentence on nurses needing 1/10 the IQ of docs. Okay, so maybe not the IQ part but the amount of education and time I think are pretty obvious. </p>
<p>I mean, at this point, docs are having to see a gazillion patients per day to make the same income they were making five yeas ago so I guess they are spread so thin that they are as useful as a nurse.</p>
<p>Yeah! Isn’t it great to have cheap healthcare?</p>
<p>Anyone read “Your money or your life?”</p>
<p>America – and most of the world – likes to buy stuff but not to spend on staying alive and feeling good. They think that is a right. Well, if they persist that view then they will get the healthcare they have coming to them.</p>
<p>Sewhappy,</p>
<p>You are correct. The American people will get a taste of non-physician care and reject it. I am a specialist and I have already seen many instances of mismanagement of patients by these providers. Because they don’t have the training they order too many tests and consults. I have seen them miss physical findings. I have seen them tell patients untruths about their medications. They are inadequately trained in so many aspects of quality patient care and disease management that it is truly frightening. The patients are becoming aware and asking to see physicians. </p>
<p>Their role, in my opinion, is in following a plan of care set forth after a diagnosis is made in conjuction with a physician. For example my son was diagnosed with a cholesteatoma (ear tumor) during a routine physical by his pediatrician. If not caught early and treated surgically, he would be deaf in that ear. I highly doubt an NP/PA would have found this subtle abnormality-when he showed it to me I could barely see it!</p>
<p>Thanks for the primer on ACOs. I’m used to thinking of it as a quality of care or pay for performance model as opposed to a capitated system. </p>
<p>NewHope - NPs are not exempt from carrying malpractice insurance and many are trained to deliver babies. You can be assured that the cost of the MRI is the same. The NP performs the same assessment and diagnostic process as a physician would and if she/he determines you need an MRI, why would you pay less. </p>
<p>Mini - there is nothing about having an MD after your name that guarantees quality of care. In my practice, the PA and NP meet quality of care indicators about 90% of the time with the physicians being around 50-60%</p>
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Not a flame, just a measured observation that it was 1. wrong; 2. unkind; and 3. potentially inflammatory. Glad to see you corrected yourself by saying that “maybe” you’re incorrect on the IQ requirement.</p>
<p>I’m sitting in the same room with an MD who has to see those gazillion patients to make less than he made five years ago (I like to keep one around in case of an emergency). When I read him your post he laughed and said he hopes you’ll never need to go to a hospital, because when you need help in the middle of the night it’s the nurse who’s going to call the doctor. Also offered that you’re off on the amount of education and training. And his entailed 4 years of med school, 3 years of residency, and a 3-year fellowship.</p>
<p>There are ways to communicate unhappiness with our health system without insulting an entire profession.</p>
<p>Sewhappy,</p>
<p>You are correct. The American people will get a taste of non-physician care and reject it. I am a specialist and I have already seen many instances of mismanagement of patients by these providers. Because they don’t have the training they order too many tests and consults. I have seen them miss physical findings. I have seen them tell patients untruths about their medications. They are inadequately trained in so many aspects of quality patient care and disease management that it is truly frightening. The patients are becoming aware and asking to see physicians. I won’t say there are not exceptions but in general this is what I and others are experiencing.</p>
<p>Their role, in my opinion, is in following a plan of care set forth after a diagnosis is made in conjuction with a physician. For example my son was diagnosed with a cholesteatoma (ear tumor) during a routine physical by his pediatrician. If not caught early and treated surgically, he would be deaf in that ear. I highly doubt an NP/PA would have found this subtle abnormality-when he showed it to me I could barely see it!</p>
<p>The best GP i have ever had was a nurse practioner…every single MD i’ve eve had ,couldn’t hold a candle to her?..as a matter of fact one of the GP’s in practice left to become an administrator at a hospital</p>