Healthcare post COVID-19

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Devil's Advocate
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Healthcare post COVID-19

Post by Devil's Advocate » Mon May 11, 2020 7:42 pm

With the utilization of healthcare significantly diminished in the past 6 weeks I wonder if the healthcare industry has fundamentally changed?

Emergency Medicine census in our midwest state has decreased ~30 to 40%. Will it rebound? I never thought during a pandemic my industry would be threatened so much.

DA

runner3081
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Re: Healthcare post COVID-19

Post by runner3081 » Mon May 11, 2020 9:08 pm

It has changed, in three ways.

1) We have advanced 10 years in the future with video visits, assuming all of the emergency initiatives are rolled back, this will continue to be become more mainstream.
2) there may be more significant health costs/use in the future, many people are deferring care and that will lead to problems later (Coupled with many people who will no longer have insurance after losing their jobs)
3) No one will view that industry as recession proof again

One question... Will mask wearing become the normal just as glove wearing became mandatory after the AIDS discovery?

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Re: Healthcare post COVID-19

Post by Devil's Advocate » Tue May 12, 2020 7:26 am

Thanks runner for the reply.

Surely others have opinions here.

DA

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climber2020
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Re: Healthcare post COVID-19

Post by climber2020 » Tue May 12, 2020 8:20 am

For us, probably not. Can't do surgery over broadband, and even our evaluations are 95% physical exam and 5% history which is different that most other specialties.

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obafgkm
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Re: Healthcare post COVID-19

Post by obafgkm » Tue May 12, 2020 8:21 am

runner3081 wrote:
Mon May 11, 2020 9:08 pm
It has changed, in three ways.

2) .... (Coupled with many people who will no longer have insurance after losing their jobs)
I think that job-based health insurance will not be the major game in town in the not-too-distant future. It will still be a player, but many in the public will push for other options.

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southerndoc
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Re: Healthcare post COVID-19

Post by southerndoc » Tue May 12, 2020 8:23 am

I don't think emergency medicine visits will rebound past 80% of previous volume for a few years.

I think people have realized that not every stomach ache, back strain, etc. needs an ER visit and can either be handled at home, via telemedicine consult, or via urgent care.

People will forget over time and will migrate back to the convenience of 24-hour care. That, plus the population aging and growing, will return us back to 100% volume in 5+ years.

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Re: Healthcare post COVID-19

Post by Devil's Advocate » Tue May 12, 2020 8:42 am

Interesting take southerndoc, thanks.

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Re: Healthcare post COVID-19

Post by southerndoc » Tue May 12, 2020 8:48 am

Sorry, this coming from an emergency physician/administrator. :)

cmr79
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Re: Healthcare post COVID-19

Post by cmr79 » Tue May 12, 2020 12:04 pm

obafgkm wrote:
Tue May 12, 2020 8:21 am
runner3081 wrote:
Mon May 11, 2020 9:08 pm
It has changed, in three ways.

2) .... (Coupled with many people who will no longer have insurance after losing their jobs)
I think that job-based health insurance will not be the major game in town in the not-too-distant future. It will still be a player, but many in the public will push for other options.
Employer-based health insurance, along with employer-based retirement accounts, are in my opinion two of the most backwards parts of the US system. I would welcome that sort of shift.

clip651
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Re: Healthcare post COVID-19

Post by clip651 » Tue May 12, 2020 7:53 pm

As a patient and caregiver for family members with various chronic conditions, I hope that telemedicine visits continue to be widely available where appropriate. I have long been frustrated by only being able to consult with doctors in person - at least in my area, you can never get them on the phone, and nurses relaying a message to the doc, and nurse later telling you a script has been called in isn't a good substitute for an actual conversation and a chance to ask questions in many situations.

Of course, some visits will always continue to need to be in person consults. But telemedicine has the potential to get more care to more people who might otherwise have difficulty getting to all their appointments (e.g. elderly patients in wheelchairs, people with transportation problems, mental health help, etc). And to ease the burden on caregivers, speaking as someone who has loaded family members and their walkers and wheelchairs into cars in bad weather more times than I can count.

In terms of ER traffic, though, I think when covid settles down, a lot of that will pick up again. Maybe with improved telemedicine triage to help people figure out if they really need to come in. Right now in some places, some people are truly afraid to go into a big medical facility unless it's pretty dire. Images on the local news of nurses threatening to strike due to lack of PPE is one part of that. Hearing they were threatened with discipline or firing for their protests just reinforces that.

lernd
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Re: Healthcare post COVID-19

Post by lernd » Wed May 13, 2020 12:35 pm

EM MD here from southern new england (hit pretty hard with COVID but nowhere near NYC area). Our nadir of ED volume was about 50% of daily volume. We are by no means out of the COVID woods but we are now back up 30-50% above our nadir but still 30% less than average.

People have mentioned reduction in ED visits due to telehealth usage etc. This may apply in certain payor mixes, but depending on patient population, I don't think this really applies. Non-english-speaking, indigent, and self-paying populations are less likely to utilize telehealth options (and urgent care) because they simply are not available to them so they will likely return to the ER. These services often require proof of payment upfront that an ER visit does not impose. Therefore the return of "normal" volume may be hospital dependent based on the surrounding community's demographics.

The ER will still be the place to go to be "medically cleared" for detox/mental health services, sutures and acute injuries. And the ER will always be the place PCPs send patients they don't want to or won't deal with. Anecdotally, these type of patient presentations are starting to "come back."

I do hope that COVID-19 prompts a frank national discussion of appropriate ER usage.

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ram
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Re: Healthcare post COVID-19

Post by ram » Thu May 14, 2020 1:45 pm

The ability of the televideo/ telephone visit volumes to persist post COVID will depend on the willingness of the patient (his/her insurance) to pay for it.

If people like it then they will need to push their insurer to pay for it.
Ram

clip651
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Re: Healthcare post COVID-19

Post by clip651 » Thu May 14, 2020 4:01 pm

ram wrote:
Thu May 14, 2020 1:45 pm
The ability of the televideo/ telephone visit volumes to persist post COVID will depend on the willingness of the patient (his/her insurance) to pay for it.

If people like it then they will need to push their insurer to pay for it.
As an individual patient, I've no leverage whatsoever to push my insurer to do anything. At best, if I am in a position to shop for insurance among choices (sometimes I have choices, sometimes I have to make do with what's available), I can look for the option.

As a patient, I'm willing to pay, and personally would even pay more to have the telehealth option available. (I would pay more in premiums and/or copays for myself and family members if I had the choice.)

It seems to me the doctors as a group are in a better position to encourage insurers to continue to cover it, if their patients are utilizing it and doctors find it effective.

It also seems to be a win/win for everyone - more efficient use of time and resources for the patient. If the system is already up and running now, I don't think it is more difficult for the doctors to continue this, and perhaps might be more efficient. Less risk of passing infections around to staff and amongst patients (even routine infections like colds). Perhaps some visits could continue to be done from the doctors' homes if desired, etc.

rich126
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Re: Healthcare post COVID-19

Post by rich126 » Thu May 14, 2020 11:08 pm

A question would be how this will affect future employment opportunities. Will many people leave healthcare due to their experiences? Does it identify shortages or excesses in certain areas? Are insurance companies losing money and if so will it triggers higher payments, lower payments to doctors? Lots of unknowns.

MSO4PRN
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Re: Healthcare post COVID-19

Post by MSO4PRN » Thu May 14, 2020 11:52 pm

EM will pick back up (slowly). my thoughts->
- states loosening restrictions equals more trauma, etoh related injuries (+ DTs, withdrawals from copious amounts of etoh consumed during "lockdown")
- political suicide to repeal EMTALA
- with increase in tele-health -> PCPs will still refer to ER once a patient says SOB, CP, DOE, (liability buzzwords)
- increase in midlevels in IC/UC still refering to ER
- people are still non compliant (CHF/ESRD/etc)
- everyone still wants full code
- older generation-> more boomers on anticoag falling, increasing health issues (complex) that need inaptient admission

other thoughts on EM
- i think we might see a decrease (possibly) in CMGs/ PE in EM
--- more ppl losing jobs will equal less insurance (plus red states not expanding medicare/medicaid (for now)) less $$$ collected
-- above statement not trying to get political

- i see alot of talk of tele health. ER doesnt really start seeing volume until 1500 -0300 in my experience (academic/community)
---> how many PCPs / tele health providers are gonna be available after 5pm???
--> as someone who has used iPads for pt interaction during Covid (inpatient) -> adults and gero cant (for the most part) use technology, this and tech difficulties, etc. are tough to deal with.

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Re: Healthcare post COVID-19

Post by AlphaLess » Fri May 15, 2020 12:41 am

Devil's Advocate wrote:
Mon May 11, 2020 7:42 pm
With the utilization of healthcare significantly diminished in the past 6 weeks I wonder if the healthcare industry has fundamentally changed?

Emergency Medicine census in our midwest state has decreased ~30 to 40%. Will it rebound? I never thought during a pandemic my industry would be threatened so much.

DA
What do you think the reasons are? I can think of a few:
- people prefer not to go to Emergency Room for the fear of getting COVID,
- there are less emergency situations (less accidents from cars, sports, activity),
- suicides are down,
- etc.

Would be curious to know your thoughts.

Also, it appears that all cause mortality might be down from COVID peak highs, which would be consistent with emergencies having gotten fewer.
"A Republic, if you can keep it". Benjamin Franklin. 1787. | Party affiliation: Vanguard. Religion: low-cost investing.

AlphaLess
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Re: Healthcare post COVID-19

Post by AlphaLess » Fri May 15, 2020 12:44 am

MSO4PRN wrote:
Thu May 14, 2020 11:52 pm
EM will pick back up (slowly). my thoughts->
- states loosening restrictions equals more trauma, etoh related injuries (+ DTs, withdrawals from copious amounts of etoh consumed during "lockdown")
- political suicide to repeal EMTALA
- with increase in tele-health -> PCPs will still refer to ER once a patient says SOB, CP, DOE, (liability buzzwords)
- increase in midlevels in IC/UC still refering to ER
- people are still non compliant (CHF/ESRD/etc)
- everyone still wants full code
- older generation-> more boomers on anticoag falling, increasing health issues (complex) that need inaptient admission

other thoughts on EM
- i think we might see a decrease (possibly) in CMGs/ PE in EM
--- more ppl losing jobs will equal less insurance (plus red states not expanding medicare/medicaid (for now)) less $$$ collected
-- above statement not trying to get political

- i see alot of talk of tele health. ER doesnt really start seeing volume until 1500 -0300 in my experience (academic/community)
---> how many PCPs / tele health providers are gonna be available after 5pm???
--> as someone who has used iPads for pt interaction during Covid (inpatient) -> adults and gero cant (for the most part) use technology, this and tech difficulties, etc. are tough to deal with.
Someone care to translate this?

Really interesting post, but hard to look every other word in google, and trying to interpret.

E.g., Etoh -> ethyl alcohol, but the context used is alcohol abuse.

With respect to telehealth, the biggest issue I see is the examination which requires manual and otherwise close interaction:
- listening to lungs and vitals,
- tapping, pushing, and feeling.

If sufficiently high quality sensors can be made available at home, perhaps telehealth could be more viable.
"A Republic, if you can keep it". Benjamin Franklin. 1787. | Party affiliation: Vanguard. Religion: low-cost investing.

AlphaLess
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Re: Healthcare post COVID-19

Post by AlphaLess » Fri May 15, 2020 12:54 am

cmr79 wrote:
Tue May 12, 2020 12:04 pm
obafgkm wrote:
Tue May 12, 2020 8:21 am
runner3081 wrote:
Mon May 11, 2020 9:08 pm
It has changed, in three ways.

2) .... (Coupled with many people who will no longer have insurance after losing their jobs)
I think that job-based health insurance will not be the major game in town in the not-too-distant future. It will still be a player, but many in the public will push for other options.
Employer-based health insurance, along with employer-based retirement accounts, are in my opinion two of the most backwards parts of the US system. I would welcome that sort of shift.
Interesting comment.

Separate into two slices:
- employer-based health insurance.
- employer-based 401K.

I believe the second is just a tax loop-hole that has been developed. If an unlimited, personal, Traditional or Roth IRA were available, that might be better. Employer-based plans could still compete. One slight advantage to employer plans: it is technically deferred compensation, and you don't own it, yet, and thus, better lawsuit protection.

With respect to health insurance issue. I agree. As a die-hard capitalist, I think that is a huge hinderance to the economic competitiveness. There are already huge barriers to switching employment (sunk cost, relationship, small industry, burning of bridges, etc), and so the last thing we need is another hurdle. Also, when a huge part of your compensation is an insurance premium subsidy, that is not good for price discovery.
"A Republic, if you can keep it". Benjamin Franklin. 1787. | Party affiliation: Vanguard. Religion: low-cost investing.

Valuethinker
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Re: Healthcare post COVID-19

Post by Valuethinker » Fri May 15, 2020 3:54 am

runner3081 wrote:
Mon May 11, 2020 9:08 pm


One question... Will mask wearing become the normal just as glove wearing became mandatory after the AIDS discovery?
I am guessing you mean in the medical field?

Mask wearing is a general, societal thing. I have lived (or spent a lot of time in) 3 of the highest incidence AIDS cities in the developed world (including London) and it made no difference to how I carried out my life. I've also been to Africa, which is on another planet in terms of AIDS.

Whereas Covid-19? Official UK government advice is now to mask your face when interacting with others. It's a weird feeling talking to someone through a bandanna. So Covid-19 is causing a complete change in public manners and mores, for the forseeable future.

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Re: Healthcare post COVID-19

Post by Devil's Advocate » Fri May 15, 2020 6:00 am

MSO4PRN wrote:
Thu May 14, 2020 11:52 pm
EM will pick back up (slowly). my thoughts->
- states loosening restrictions equals more trauma, etoh related injuries (+ DTs, withdrawals from copious amounts of etoh consumed during "lockdown")
- political suicide to repeal EMTALA
- with increase in tele-health -> PCPs will still refer to ER once a patient says SOB, CP, DOE, (liability buzzwords)
- increase in midlevels in IC/UC still refering to ER
- people are still non compliant (CHF/ESRD/etc)
- everyone still wants full code
- older generation-> more boomers on anticoag falling, increasing health issues (complex) that need inaptient admission

other thoughts on EM
- i think we might see a decrease (possibly) in CMGs/ PE in EM
--- more ppl losing jobs will equal less insurance (plus red states not expanding medicare/medicaid (for now)) less $$$ collected
-- above statement not trying to get political

- i see alot of talk of tele health. ER doesnt really start seeing volume until 1500 -0300 in my experience (academic/community)
---> how many PCPs / tele health providers are gonna be available after 5pm???
--> as someone who has used iPads for pt interaction during Covid (inpatient) -> adults and gero cant (for the most part) use technology, this and tech difficulties, etc. are tough to deal with.
Thanks Morphine,

Very thoughtful post. I just wonder how quickly business will pick up. Our shop is an independent group and the pain is substantial. Cutting attending and APP hours. Next step will be cutting benefits if things don't go back to "normal" soon.

DA

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Re: Healthcare post COVID-19

Post by Devil's Advocate » Fri May 15, 2020 6:03 am

AlphaLess wrote:
Fri May 15, 2020 12:41 am
Devil's Advocate wrote:
Mon May 11, 2020 7:42 pm
With the utilization of healthcare significantly diminished in the past 6 weeks I wonder if the healthcare industry has fundamentally changed?

Emergency Medicine census in our midwest state has decreased ~30 to 40%. Will it rebound? I never thought during a pandemic my industry would be threatened so much.

DA
What do you think the reasons are? I can think of a few:
- people prefer not to go to Emergency Room for the fear of getting COVID,
- there are less emergency situations (less accidents from cars, sports, activity),
- suicides are down,
- etc.

Would be curious to know your thoughts.

Also, it appears that all cause mortality might be down from COVID peak highs, which would be consistent with emergencies having gotten fewer.
I think your list is a reasonable one. I suspect the first reason is the big one. Whether suicides are down I wouldn't know.

DA

cnblure
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Re: Healthcare post COVID-19

Post by cnblure » Fri May 15, 2020 6:34 am

I'm hoping Amazon or another company with the means breaks into the health insurance game. If they came out with something like a $200 a month $3000 deductible plan that was as easy to purchase as anything else online, wouldn't this be a viable option for a lot of people? And if they were successful, maybe actual health insurance companies would be more motivated to be competitive and accessible.

nobleMemo
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Re: Healthcare post COVID-19

Post by nobleMemo » Fri May 15, 2020 8:25 am

Devil's Advocate wrote:
Mon May 11, 2020 7:42 pm
With the utilization of healthcare significantly diminished in the past 6 weeks I wonder if the healthcare industry has fundamentally changed?

Emergency Medicine census in our midwest state has decreased ~30 to 40%. Will it rebound? I never thought during a pandemic my industry would be threatened so much.

DA
The fact that the ED census has dropped by so much should prompt us all to reflect on whether the census now is close to what it actually should be. I imagine you didn't go into EM to be a PCP, but how much of your job was PCP work pre-pandemic?

I can tell you from the imaging side of things my experience with ED patients has been night and day. Pre-pandemic a majority of exams I interpreted were negative. Intra-pandemic a majority are positive. Volumes, of course, are down.

runner3081
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Re: Healthcare post COVID-19

Post by runner3081 » Fri May 15, 2020 8:32 am

Valuethinker wrote:
Fri May 15, 2020 3:54 am
runner3081 wrote:
Mon May 11, 2020 9:08 pm


One question... Will mask wearing become the normal just as glove wearing became mandatory after the AIDS discovery?
I am guessing you mean in the medical field?

Mask wearing is a general, societal thing. I have lived (or spent a lot of time in) 3 of the highest incidence AIDS cities in the developed world (including London) and it made no difference to how I carried out my life. I've also been to Africa, which is on another planet in terms of AIDS.

Whereas Covid-19? Official UK government advice is now to mask your face when interacting with others. It's a weird feeling talking to someone through a bandanna. So Covid-19 is causing a complete change in public manners and mores, for the forseeable future.
Yes, in healthcare. I suspect we will end up with both masks and eye protection, moving forward.

runner540
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Re: Healthcare post COVID-19

Post by runner540 » Fri May 15, 2020 8:39 am

obafgkm wrote:
Tue May 12, 2020 8:21 am
runner3081 wrote:
Mon May 11, 2020 9:08 pm
It has changed, in three ways.

2) .... (Coupled with many people who will no longer have insurance after losing their jobs)
I think that job-based health insurance will not be the major game in town in the not-too-distant future. It will still be a player, but many in the public will push for other options.
Agree that will be a coming change. Another that might happen is shifting away from fee for service to a capitated model.
4 min video with a healthcare economist about the levers:

https://www.wsj.com/video/why-the-healt ... B7B44.html

https://www.dallasnews.com/business/hea ... he-future/

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btq96r
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Re: Healthcare post COVID-19

Post by btq96r » Fri May 15, 2020 9:46 am

One aspect of healthcare that's already changing and will so long as COVID-19 restrictions are in play...throughput.

Healthcare is (rightly or wrongly) a business, and optimized as such. A lot of providers are figuring out how the profit margin looks when you have to reduce available slots per day (ie: chances to make money), so you can space out patients to make sure the waiting room accommodates social distancing. Plus there is the fact that a lot of healthcare "customers" will be out of work, and out of insurance. Someone who had Blue Cross two months ago, and is suddenly on a state level Medicaid plan basically means the fee for service collected is a fraction of what it used to be, so you're providing the same services for a notably reduced compensation.
Moderation is for Canadians.

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firebirdparts
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Re: Healthcare post COVID-19

Post by firebirdparts » Fri May 15, 2020 10:37 am

cnblure wrote:
Fri May 15, 2020 6:34 am
I'm hoping Amazon or another company with the means breaks into the health insurance game. If they came out with something like a $200 a month $3000 deductible plan that was as easy to purchase as anything else online, wouldn't this be a viable option for a lot of people? And if they were successful, maybe actual health insurance companies would be more motivated to be competitive and accessible.
Insurance is a mathematical product. You can't just give it away. If you want to cheapen it, you have to have some way to stop people from spending the money.

But anyway, my wife went to the ER just yesterday, and it's not crowded, of course, and they wouldn't let me in. Win/win for the customer, FWIW. My wife didn't want to go, more than usual, so that's also a positive. I didn't have to leave work to take her, because I wasn't at work. The pandemic seems to be all positives so far. There was no one in the hospital with the disease, so there wasn't much risk to offset all these positives.

I don't know what people will do in the future. I guess they'll act like they always did at such time that they don't see a risk from catching anything, for whatever reason.
A fool and your money are soon partners

stoptothink
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Re: Healthcare post COVID-19

Post by stoptothink » Fri May 15, 2020 10:47 am

firebirdparts wrote:
Fri May 15, 2020 10:37 am
cnblure wrote:
Fri May 15, 2020 6:34 am
I'm hoping Amazon or another company with the means breaks into the health insurance game. If they came out with something like a $200 a month $3000 deductible plan that was as easy to purchase as anything else online, wouldn't this be a viable option for a lot of people? And if they were successful, maybe actual health insurance companies would be more motivated to be competitive and accessible.
Insurance is a mathematical product. You can't just give it away. If you want to cheapen it, you have to have some way to stop people from spending the money.

But anyway, my wife went to the ER just yesterday, and it's not crowded, of course, and they wouldn't let me in. Win/win for the customer, FWIW. My wife didn't want to go, more than usual, so that's also a positive. I didn't have to leave work to take her, because I wasn't at work. The pandemic seems to be all positives so far. There was no one in the hospital with the disease, so there wasn't much risk to offset all these positives.

I don't know what people will do in the future. I guess they'll act like they always did at such time that they don't see a risk from catching anything, for whatever reason.
MY ER doc friend said he has yet to treat a single COVID patient and that his facility has been absolutely dead. People are not coming in unless it is literally an emergency. They have not let anybody go yet, but it is probably just a matter of time. In my clinic (owned by my employer, I sit on the board), we have had 23 positive tests but zero hospitalizations. Traffic is way down (telemedicine is slightly up), but as the facility's primary purpose is to be the medical home for the employees of the company (although it is open to the public) we are doing OK and in fact have hired two new providers in the last few weeks.

MSO4PRN
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Re: Healthcare post COVID-19

Post by MSO4PRN » Fri May 15, 2020 10:58 am

cnblure wrote:
Fri May 15, 2020 6:34 am
I'm hoping Amazon or another company with the means breaks into the health insurance game. If they came out with something like a $200 a month $3000 deductible plan that was as easy to purchase as anything else online, wouldn't this be a viable option for a lot of people? And if they were successful, maybe actual health insurance companies would be more motivated to be competitive and accessible.

amazon and JPM and BRK are trying this -> haven is what its called

their CEO just stepped down
- i believe his quote was sometime like healthcare is too complicated / has too many regulations

illumination
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Re: Healthcare post COVID-19

Post by illumination » Fri May 15, 2020 11:10 am

southerndoc wrote:
Tue May 12, 2020 8:23 am
I don't think emergency medicine visits will rebound past 80% of previous volume for a few years.

I think people have realized that not every stomach ache, back strain, etc. needs an ER visit and can either be handled at home, via telemedicine consult, or via urgent care.


I hope this is a long term trend.

JPM
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Re: Healthcare post COVID-19

Post by JPM » Fri May 15, 2020 11:12 am

We have to suspect that many primary care practices with 50-60+% overhead costs will fail financially in the next few years unless the regulatory burdens are lifted rapidly or we get medicare for everybody sooner than I expect. Some medical subspecialties will fail as well. Twenty percent unemployment for a couple of years will cut the insured full-freight population by a lot. Established surgeons may do well enough by virtue of higher top lines, but it may be more difficult for newbies to get a start except in employed positions. If financially well managed, the large integrated groups in urban and suburban and prosperous exurban locations may prosper at the expense of struggling independents squeezed between falling top lines and unavoidable expenses occasioned by regulatory compliance. Practices in rural or unprosperous exurban communities will often struggle. Many docs in these situations will retire if they can.

mega317
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Re: Healthcare post COVID-19

Post by mega317 » Fri May 15, 2020 5:00 pm

MSO4PRN wrote:
Thu May 14, 2020 11:52 pm
etoh
Alcohol
EMTALA
Requires ERs to treat anyone who comes in regardless of insurance/payment ability.
SOB, CP, DOE
shortness of breath, chest pain, dyspnea on exertion
CHF/ESRD
congestive heart failure, end stage renal disease
full code
resuscitate, as opposed to DNR, DNAR, AND, etc
boomers
born in the post WWII baby boom


I have no data but I would be extremely shocked if suicides are down significantly.
https://www.bogleheads.org/forum/viewtopic.php?t=6212

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LilyFleur
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Re: Healthcare post COVID-19

Post by LilyFleur » Fri May 15, 2020 5:03 pm

cmr79 wrote:
Tue May 12, 2020 12:04 pm
obafgkm wrote:
Tue May 12, 2020 8:21 am
runner3081 wrote:
Mon May 11, 2020 9:08 pm
It has changed, in three ways.

2) .... (Coupled with many people who will no longer have insurance after losing their jobs)
I think that job-based health insurance will not be the major game in town in the not-too-distant future. It will still be a player, but many in the public will push for other options.
Employer-based health insurance, along with employer-based retirement accounts, are in my opinion two of the most backwards parts of the US system. I would welcome that sort of shift.
And employer-based insurance premiums paid for with pre-tax dollars is one of the biggest entitlements in the United States. And you only appreciate that entitlement when you no longer have access to it.

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Re: Healthcare post COVID-19

Post by goodenyou » Fri May 15, 2020 6:55 pm

There will be a thick layer of inefficiency in the system because of COVID. Volume is down and there is a significant time sink in doing surgery due to all the precautions. It was barely cost-effective to do surgery on government payers (and some commercial carriers as well) before the COVID crisis. Now, with the added time in the operating room, it is not cost-effective for many surgeons. The wait times for elective surgeries will likely go up especially for government payers. Surgeons who can do better seeing patients in the office may elect to spend more time in the office.
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Re: Healthcare post COVID-19

Post by climber2020 » Fri May 15, 2020 7:00 pm

goodenyou wrote:
Fri May 15, 2020 6:55 pm
There will be a thick layer of inefficiency in the system because of COVID. Volume is down and there is a significant time sink in doing surgery due to all the precautions. It was barely cost-effective to do surgery on government payers (and some commercial carriers as well) before the COVID crisis. Now, with the added time in the operating room, it is not cost-effective for many surgeons. The wait times for elective surgeries will likely go up especially for government payers. Surgeons who can do better seeing patients in the office may elect to spend more time in the office.
Even before the pandemic, I stopped doing many surgical procedures because the reimbursement dropped to the point it wasn't worth my time anymore, and all it was doing was adding malpractice risk. I agree that this trend will likely continue.

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Re: Healthcare post COVID-19

Post by Dennisl » Fri May 15, 2020 8:19 pm

ram wrote:
Thu May 14, 2020 1:45 pm
The ability of the televideo/ telephone visit volumes to persist post COVID will depend on the willingness of the patient (his/her insurance) to pay for it.

If people like it then they will need to push their insurer to pay for it.
This. Telephone visits don’t pay enough to cover overhead, so many offices only offer video visits, aka telehealth, which pay close to an in person office visit. Telehealth is definitely here to stay. One of the big problems is that the people need it the most often don’t have access. My rural folks often have slow internet and my older folks just can’t seem to figure it out no matter how easy we try to make it for them.

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Re: Healthcare post COVID-19

Post by BH+ » Fri May 15, 2020 9:01 pm

I am a bit worried that healthcare has become a hazardous occupation. Given high fatalities among healthcare professionals, every young and bright student who desires to become a doctor, nurse, technician, etc. needs to grapple with, and come to terms with the possibility that they could be putting their lives and those of their families at risk. That needs to factor into their decision and it is not easy. I guess a similar decision is made by those joining the military or those working in dangerous parts of the world (although families are still safe), but I doubt healthcare workers were consciously taking that possibility into account in the past. The result could drain healthcare of talent, given that most of these individuals have other safer options.

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Re: Healthcare post COVID-19

Post by tyrnup13 » Sat May 16, 2020 6:14 pm

Radiologist here, working today.

The past two months have been really nice, with decreased ED utilization and thus less imaging. I thought it might offer a time for reflection on how services are utilized, both amongst physicians and patients.

Unfortunately, the past week, our volumes have almost increased back to normal. Today is just like or worse than a pre-COVID day.

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Re: Healthcare post COVID-19

Post by ram » Sat May 16, 2020 6:36 pm

rich126 wrote:
Thu May 14, 2020 11:08 pm
A question would be how this will affect future employment opportunities. Will many people leave healthcare due to their experiences? Does it identify shortages or excesses in certain areas? Are insurance companies losing money and if so will it triggers higher payments, lower payments to doctors? Lots of unknowns.
Insurance companies are benefiting from lower resource use by patients.
Physicians and health care institutions are losing.
https://www.modernhealthcare.com/insura ... st-quarter
Ram

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Re: Healthcare post COVID-19

Post by goodenyou » Sat May 16, 2020 11:23 pm

ram wrote:
Sat May 16, 2020 6:36 pm
rich126 wrote:
Thu May 14, 2020 11:08 pm
A question would be how this will affect future employment opportunities. Will many people leave healthcare due to their experiences? Does it identify shortages or excesses in certain areas? Are insurance companies losing money and if so will it triggers higher payments, lower payments to doctors? Lots of unknowns.
Insurance companies are benefiting from lower resource use by patients.
Physicians and health care institutions are losing.
https://www.modernhealthcare.com/insura ... st-quarter
And so will many many employees in my office as well as vendors. 17% of GDP is a lot of people eating off the healthcare dollar.

Recent GME graduates are going to have a hell of a time.
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Re: Healthcare post COVID-19

Post by jayk238 » Sat May 16, 2020 11:38 pm

Wonderful thoughtful posts by physicians here.
I wonder the following: telemedicine is here but will patients pay the full price? If pt are on high deductibles (even if insurance covers it) will they pay full price equal to in office visit? Or be delinquent as they often are anyway?

Will midlevel creep extend into care excessively?

Will pcps ever see a return to normal volume? If elderly patients stay put and dont use telemed etc what will happen to internists.

One thing i wonder is will internists return to the traditional role of outpt and inpt? I am wondering if i should do this.

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Re: Healthcare post COVID-19

Post by goodenyou » Sun May 17, 2020 12:13 am

jayk238 wrote:
Sat May 16, 2020 11:38 pm
Wonderful thoughtful posts by physicians here.
I wonder the following: telemedicine is here but will patients pay the full price? If pt are on high deductibles (even if insurance covers it) will they pay full price equal to in office visit? Or be delinquent as they often are anyway?

Will midlevel creep extend into care excessively?

Will pcps ever see a return to normal volume? If elderly patients stay put and dont use telemed etc what will happen to internists.

One thing i wonder is will internists return to the traditional role of outpt and inpt? I am wondering if i should do this.
There will be a continuing erosion of the duties once performed by physicians. A lot of routine care will be given by providers that have spent less time and money on their education. You would be crazy to go into primary care after spending hundreds of thousands on your education and 7 years after you graduate from college. Admission to the MD club has lost its luster. It takes about 5 years after you finish your Residency to figure this out. The excitement of admission to medical school and matching in a Residency eventually wears off after you start paying off the loans and start practicing.

The revenue generated from telemedicine is paltry in our experience. It doesn’t make a dent in the high fixed costs of running a practice. There will likely be more consolidation of practices into large healthcare systems that can strong arm payers into reimbursing more based on the facility site premium. Of course, this will be borne by the patient since most patients have higher deductibles. This will happen for a few more years until there is more regulation and legislation to lower the fees. Then, there will be a reduction in physician’s salary and there will no longer be choices for physicians to go back into private practice. It’s already well on its way.

This is the experience of a specialty surgeon of 25 years married to a Dermatology Certified NP.
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Re: Healthcare post COVID-19

Post by potatopancake » Sun May 17, 2020 5:26 am

Total agreement with the above post. The existence of dermatology certified NPs is proof that the system is changing unfavorably for physicians. Dermatology is the most competitive non-surgical field for medical students. It is a four year residency program and the majority (~66%) took an additional year in medical school to complete research to become better candidates. Together, this is a nine year training program which is far from guaranteed, with match rates in the 60 - 70 % range. Now, I see a PA dermatologist who completed school in two years and was trained, on the job, for three months by a supervising physician. The healthcare system has changed and medical education has not.

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Re: Healthcare post COVID-19

Post by goodenyou » Sun May 17, 2020 8:01 am

potatopancake wrote:
Sun May 17, 2020 5:26 am
Total agreement with the above post. The existence of dermatology certified NPs is proof that the system is changing unfavorably for physicians. Dermatology is the most competitive non-surgical field for medical students. It is a four year residency program and the majority (~66%) took an additional year in medical school to complete research to become better candidates. Together, this is a nine year training program which is far from guaranteed, with match rates in the 60 - 70 % range. Now, I see a PA dermatologist who completed school in two years and was trained, on the job, for three months by a supervising physician. The healthcare system has changed and medical education has not.
The American Board of Dermatology wanted to remove board certification from a Dermatologist because he started a group to board certify physician assistants in Dermatology. It was a business that he would profit from. You can get an NP in 3 years after a BSN, sit for a certifying exam after 2,000 hours of clinical Dermatology and have a Dermatology NP certification. Because of scarcity (extremely hard to get a Dermatology Residency) and expanding roles of mid levels In Dermatology (especially consumer-driven cosmetics), you can do very vey well. Heck, the CRNAs that work with me make close to $300k. We are asking medical students to continue to spend the same amount of time (7-10 years beyond college) and an average of $230,000 while the whole healthcare delivery system is dismantled around them. Doctors should have woken up, but it’s not their nature. They are paying a dear price for it now and will continue to in the future.
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Re: Healthcare post COVID-19

Post by Galaxy8 » Sun May 17, 2020 8:35 am

goodenyou wrote:
Sun May 17, 2020 8:01 am
Heck, the CRNAs that work with me make close to $300k. We are asking medical students to continue to spend the same amount of time (7-10 years beyond college) and an average of $230,000 while the whole healthcare delivery system is dismantled around them. Doctors should have woken up, but it’s not their nature. They are paying a dear price for it now and will continue to in the future.

This. I am not sure medical school is worth it anymore.

$230k is average, but I know many with over $300k, some with over $400k, and a few over $500k. :o :shock: :oops: I know quite a few people who have had to chase the money when looking for a job rather than finding something they're happy with.

Many of my friends in private practice have taken nice paycuts these past two months, but my massive academic center has only cut some overtime. Even our surgeons who aren't operating are guaranteed to continue getting base pay. On the volume side, we've rebounded to 70% pre-COVID ED volumes, but the acuity and admission rate is markedly higher so it is feeling a whole lot busier.

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Re: Healthcare post COVID-19

Post by jayk238 » Tue May 19, 2020 9:04 pm

goodenyou wrote:
Sun May 17, 2020 12:13 am
jayk238 wrote:
Sat May 16, 2020 11:38 pm
Wonderful thoughtful posts by physicians here.
I wonder the following: telemedicine is here but will patients pay the full price? If pt are on high deductibles (even if insurance covers it) will they pay full price equal to in office visit? Or be delinquent as they often are anyway?

Will midlevel creep extend into care excessively?

Will pcps ever see a return to normal volume? If elderly patients stay put and dont use telemed etc what will happen to internists.

One thing i wonder is will internists return to the traditional role of outpt and inpt? I am wondering if i should do this.
There will be a continuing erosion of the duties once performed by physicians. A lot of routine care will be given by providers that have spent less time and money on their education. You would be crazy to go into primary care after spending hundreds of thousands on your education and 7 years after you graduate from college. Admission to the MD club has lost its luster. It takes about 5 years after you finish your Residency to figure this out. The excitement of admission to medical school and matching in a Residency eventually wears off after you start paying off the loans and start practicing.

The revenue generated from telemedicine is paltry in our experience. It doesn’t make a dent in the high fixed costs of running a practice. There will likely be more consolidation of practices into large healthcare systems that can strong arm payers into reimbursing more based on the facility site premium. Of course, this will be borne by the patient since most patients have higher deductibles. This will happen for a few more years until there is more regulation and legislation to lower the fees. Then, there will be a reduction in physician’s salary and there will no longer be choices for physicians to go back into private practice. It’s already well on its way.

This is the experience of a specialty surgeon of 25 years married to a Dermatology Certified NP.
I think this pandemic will require me to make changes to my career.
I am not as concerned about my income/career as a PCP in that I will have a steady career seeing complicated elderly patients. Many of them only want doctors and can't really be treated by FP/NPs anyway. Furthermore, I will probably go back to the old model of being an internist and work in the hospital as well. While large academic centers have largely turfed a lot of work to specialists there is room in the rural place. There are very few skilled practitioners let alone doctors who can intubate, central line, manage vents, etc on their own. I think this is where i will go and have a split PCP/hospitalist job. These are skills and jobs (complicated outpt ) and hospitalist working in open ICUs that truly require full use of medical knowledge/training that cannot be obtained easily otherwise. While it will require more hours/work from me I am not concerned about pay/job security in that regard.

Towhit- dermatology was never the profession it was supposed to be. 30 years ago the best doctors became internists, radiation oncologists, and research scientists. Its only in the age of HMO/managed care/CMS era that derm with its insurance-free procedures/care and FFS payment structure for high throughput biopsies, skin exams was ripe for the taking from PA/NPs. It requires almost no real skillsets beyond looking at pictures of the skin/enough clinical hours and littel to know human pathophysiology justifying years of actual medical school. Theres no high complexity involving hospital care

The quality of the NP/PA derm on the other hand is not the equivalent of doctors as I've heard repeatedly from pathologists.

I think most of the ROADs employment will drastically change as a result. It is inevitable because they have always commanded an extraordinarily high amount of income for a relatively low amount of effort. Literally they are jobs for people who want cush lifestyles.

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Re: Healthcare post COVID-19

Post by jayk238 » Wed May 20, 2020 10:32 am

goodenyou wrote:
Sun May 17, 2020 8:01 am
potatopancake wrote:
Sun May 17, 2020 5:26 am
Total agreement with the above post. The existence of dermatology certified NPs is proof that the system is changing unfavorably for physicians. Dermatology is the most competitive non-surgical field for medical students. It is a four year residency program and the majority (~66%) took an additional year in medical school to complete research to become better candidates. Together, this is a nine year training program which is far from guaranteed, with match rates in the 60 - 70 % range. Now, I see a PA dermatologist who completed school in two years and was trained, on the job, for three months by a supervising physician. The healthcare system has changed and medical education has not.
The American Board of Dermatology wanted to remove board certification from a Dermatologist because he started a group to board certify physician assistants in Dermatology. It was a business that he would profit from. You can get an NP in 3 years after a BSN, sit for a certifying exam after 2,000 hours of clinical Dermatology and have a Dermatology NP certification. Because of scarcity (extremely hard to get a Dermatology Residency) and expanding roles of mid levels In Dermatology (especially consumer-driven cosmetics), you can do very vey well. Heck, the CRNAs that work with me make close to $300k. We are asking medical students to continue to spend the same amount of time (7-10 years beyond college) and an average of $230,000 while the whole healthcare delivery system is dismantled around them. Doctors should have woken up, but it’s not their nature. They are paying a dear price for it now and will continue to in the future.
https://www.bloomberg.com/news/features ... nd=premium

This explains everything including the push to NPs and PAs its less about medicine being complicated and more about cutting corners. Its harder to do that with complex patients like an internists office or a rural hospitalist

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Re: Healthcare post COVID-19

Post by eagleeyes » Wed May 20, 2020 11:02 am

The erosion of medicine is a complex and nuanced topic. Many factors and moving parts come into play.

Somethings to think about. The corporatization of medical fields including dermatology, anesthesia, radiology, and others specialists results in tremendous pressure on these groups to produce.

Erosion of medical care can also be partially blamed upon introduction and delegation of responsibility to NP and PAs who have a substantially smaller base of knowledge than their corresponding physicians. It takes them longer to arrive at the same diagnosis and is substantially more expensive. They often order complete blood work, extensive imaging (mri and ct scans), multi specialty consults without thinking. This results in massive bills for patients. Interestingly patients believe they are getting great care because “everything” is being done.

Case in point. ER triages are often staffed by non physicians, who for a patient thatcomes in with history of fall will routinely order head and cervical spine ct. facial bruising? Additional facial ct is also acquired.

To be sure, this is not solely their fault. The litigious nature of our society compels all health care personnel to leave no stone unturned as it may lead to a lawsuit for “failure to diagnose”

This is a complex topic that can not be cleanly distilled in a short post like this, but is a starting point

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Re: Healthcare post COVID-19

Post by goodenyou » Wed May 20, 2020 1:25 pm

jayk238 wrote:
Wed May 20, 2020 10:32 am
goodenyou wrote:
Sun May 17, 2020 8:01 am
potatopancake wrote:
Sun May 17, 2020 5:26 am
Total agreement with the above post. The existence of dermatology certified NPs is proof that the system is changing unfavorably for physicians. Dermatology is the most competitive non-surgical field for medical students. It is a four year residency program and the majority (~66%) took an additional year in medical school to complete research to become better candidates. Together, this is a nine year training program which is far from guaranteed, with match rates in the 60 - 70 % range. Now, I see a PA dermatologist who completed school in two years and was trained, on the job, for three months by a supervising physician. The healthcare system has changed and medical education has not.
The American Board of Dermatology wanted to remove board certification from a Dermatologist because he started a group to board certify physician assistants in Dermatology. It was a business that he would profit from. You can get an NP in 3 years after a BSN, sit for a certifying exam after 2,000 hours of clinical Dermatology and have a Dermatology NP certification. Because of scarcity (extremely hard to get a Dermatology Residency) and expanding roles of mid levels In Dermatology (especially consumer-driven cosmetics), you can do very vey well. Heck, the CRNAs that work with me make close to $300k. We are asking medical students to continue to spend the same amount of time (7-10 years beyond college) and an average of $230,000 while the whole healthcare delivery system is dismantled around them. Doctors should have woken up, but it’s not their nature. They are paying a dear price for it now and will continue to in the future.
https://www.bloomberg.com/news/features ... nd=premium

This explains everything including the push to NPs and PAs its less about medicine being complicated and more about cutting corners. Its harder to do that with complex patients like an internists office or a rural hospitalist
You are preaching to the choir. It is not cost-effective personally for me to do complex and risky surgeries with risk of complications and poor reimbursement AND a 90-day global. The extensive turnaround time in the operating room alone in the COVID era with all the respiratory precautions makes being in the operating room for hours a loss. I could see many patients very easily in the office in the time it takes me to do surgery and turn over the room. The revenue generated in the office per unit time is therefore higher. I would gladly hand over the scalpel to a mid-level. This is not what society wants. It is cost-effective for society to have highly-skilled and trained surgeons do the complex surgery for poor reimbursement and allow the less-trained mid-levels to do the "easy stuff". I wish I could come into the operating room during the "difficult part" of the operation, and have my mid-level close-up and complete the operation. There is no such leverage model for this. It used to exist in training programs, but that ship has sailed a long time ago. Also, in times of scarcity and declining surgical reimbursement, this model does not work.

My wife, OTOH, is Dermatology NP certified. She can and has diagnosed many more difficult dermatological conditions than most PCPs. She gets numerous teledermatology requests from many of my MD colleagues as well as family and friends. She gets the proverbial "can I text you a picture of the rash/lesion?" She has an extensive knowledge base from many years of practice. Not as much as a seasoned Dermatologist, of course, but pretty extensive. She has enough judgement to know her limitations and when to have the MD evaluate a difficult or suspicious case. She can "extend" a Dermatology practice and decrease the enormous wait times. This is where it can make sense.

There is a reason Dermatology Pharma reps still show up in Dermatology offices. A lot of dermatology is consumer-based and patients will pay for treatments and co-pays without argument.
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Re: Healthcare post COVID-19

Post by eagleeyes » Wed May 20, 2020 1:47 pm

I think NP/PA can thrive in a limited scope of practice. They certainly have a role in medicine. But they come with limitations.

I personally would not allow a mid level to examine me or my family members. Just wouldn’t happen.

In dermatology, Most NPs/PAs would likely have higher biopsy rates, higher follow up rates, and inescapably higher cancer miss rates, stacked up against the MD. If people are willing to accept this, and go with a mid level, that is completely fine.

Experience matters. While many are probably quite good, the underlying fund of knowledge that one acquires as a physician as well as the ability to think through a differential diagnosis is not applicable to most mid levels.

(Above statement will come across as disrespectful, so my apologies in advance)

There are lots of boards that do lots of certifications. The rigorousness of those boards has been called into question with NP school mills.

Physician extenders can be helpful in decreasing wait times, but what’s the point if you have to go back and see a doctor the second time, because you weren’t diagnosed correctly the first time? Or worse, your melanoma was misdiagnosed as a benign mole?

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