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Healthcare insurance but no healthcare access

Lucy VanPelt The Doctor is INCalifornia doesn’t have enough doctors to provide healthcare to newly “insured” patients under the UnAffordable Care Act.

California state senator Ed Hernandez asks “”What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?”

Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years?

The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients.

California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together.

Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not?

If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money.
If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur.

These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea.

Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea.
We all should be part of a team, but not everyone is able to play quarterback.
I predict that these types of policies, if implemented, will ultimately increase the demand for physicians.

Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care.

But remember that everyone will be insured, so things will be OK.

In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists, and possibly even Lucy VanPelt expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted on KevinMD’s site a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.”

You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.

I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be [independently] treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.


  1. In a world of high level specialization of medical care, I don’t see how lower level providers can provide competent care. Even in ophthalmology, we outsource inflammation management to rheumatologist. ( RnB of Humira vs Imuran anyone), temporal artery biopsies to real surgeons and blood sugar control to real docs. A “medical success” rate of 90% is expected doing nothing, 99% by common sense and a script and 99.99% only by competency. A med-mal suit every year or 2 pretty pathetic care.

  2. I agree with alot of what you said.

    I am an emergency nurse practitioner and in Rural America where they can’t afford a ACEP ED I function.
    I am not allowed to take and pass ATLS
    To answer you comment, when a patient on the floor crash the MD does call me, when they need a chest tube or CVL they do call the ARNP, when I had 6 trauma patients from a MVA the surgeon (MD) asked me to perform a FAST exam and inform him what needs to be done. When a delivery crashes and they are unable to intubate they call me and when they need a U line they do call me. I agree my medical director should be an ACEP physician and I am more than happy to review my records and continue to learn, but I am amazed when I do call an ED with ACEP MD they feel it is beneath them to talk to an ARNP about pt care.
    If I am a freak’n idiot you should take the patient
    If I am amazing and asking for your help you should give it
    If I am wrong you should offer your expertise and point me in the right direction
    So I am not sure who has the attitude?

    • Actually, you can take the ATLS course, you just don’t get the certificate.

      Rural hospitals usually can afford emergency physicians, but many times choose to cut costs by not hiring them.
      If you’re credentialed in performing chest tubes, FAST exams, and emergent deliveries, then have at it. But just because you possess those skills doesn’t mean that everyone else who has taken a BLS class is capable of doing them as well. That’s the issue: How much training is needed to provide proper medical care? Maybe it doesn’t require 10 years of training, but if not, then how much training should it require? And if you give an answer of “x” years, then why can’t it be “x-1” years instead? I don’t have the answer which is why I’d propose doing away with all licensing and requiring people to pass written and practical tests before they are allowed to practice. If you can pass the tests in third grade, go give phone advice and make your fortune. Then it is up to patients to determine who they believe and who they trust – just like juries gauge expert witnesses.

      Some people argue they should be qualified through “experience” when we don’t have any way of gauging how they gain their “experience.” Every time I hear that term I think back to a quote I once heard: “Experience is that which allows to make the same mistakes over and over again with greater and greater confidence.”

      I get talked down to when I transfer patients from the rural hospital where I moonlight into the regional trauma center. They don’t know that I also work in an ED at a hospital that is bigger than theirs. That’s something you’ll have to learn to live with regardless of your degree.

  3. Agree with your take on the LATimes article. Here’s what I published on my blog:
    “Optometrists primarily write prescriptions for eyeglasses and contact lenses. Would you trust an optometrist to remove your appendix?

    I’d argue that removing an appendix requires only a fraction of the clinical acumen and medical knowledge that is involved in properly diagnosing diabetes mellitus and appropriately managing it. Having “constant thirst and frequent urination” by no means equates to having diabetes mellitus. Some patients will get these symptoms because of brain tumors, or pregnancy, or kidney problems. Optometrists aren’t trained in diagnosing these conditions. To put it bluntly, if optometrists were responsible for diagnosing patients complaining of thirst and frequent urination, diagnoses would be bungled and people would die.

    I don’t pretend to be able to do an optometrist’s job. I wish that this optometrist (who is the head of the California Senate Health Committee) would not pretend that he can do mine.”

  4. What?! You’re kidding…..there won’t be enough doctors for everybody?!! Shocking. The future is definitely PAs, NPs whether you like it or not. Its already happening.

    I hear all these docs opposing Obamacare, but what is your alternative? The current system cannot be sustained. Rationing is coming. Obamacare will just speed up the process.

    • I find it fundamentally unfair that Obamacare discriminates against struggling families with parents who work while providing free “insurance” to families with parents that sit home and do nothing. Patients with Medicaid are free to bounce from ED to ED if they don’t get what they want or if they want a second opinion. Patients who make too much money to be considered for Medicaid but who are struggling financially are left out of the loop completely because they could never afford their care.
      Solution #1 is to scrap the whole “insurance” farce. Obamacare is a tax. The election is over. You don’t have to worry about re-elections for a couple more years at least. Call it a tax. Tax every citizen in this country and provide every citizen with free medical care. You go to a county or VA clinic/hospital, your care is free. End of story. Doesn’t matter if you make $10/year or $10 million/year. That’s our “safety net.” Now non-government hospitals have to compete for non-federal patients. How do they do so? Emphasize the other two aspects of the “engineer’s triangle” – speed and quality. We provide the best doctors and the newest equipment. Same day surgeries. Luxurious rooms. Yada yada yada. Patients then make the free market decision whether they save money and purchase insurance so that they can get quicker and better care at a private hospital or whether they wait 12 months for a free hip replacement at the federal hospital.
      Solution #2 involves a consumption tax. Everyone is so worried that 50% of the country doesn’t pay income tax, fine. If all of those people paid a national sales tax on everything they purchased, they’d be contributing a lot more to the system. In addition, all the foreign tourists would contribute to the system when they purchase items. So would the “illegal aliens” who still go into stores and purchase food and who still purchase gas at the pump.
      Solution #3 is to deregulate. A tremendous amount of money is spent on administrative activities imposed by the government which in all likelihood detract from quality medical care. I spend 2/3 of my shift charting so the hospital gets paid and so I make sure I meet “quality indicators” imposed by the feds. How sad is it that we have all become data entry personnel and part time health care providers? If patients want labs, they should be able to walk into a lab and pay for them. No prescription required. Ditto x-rays. Ditto many medications.
      I’ve talked about other ways to improve the system. It won’t get better unless patients have skin in the game.
      Unfortunately, policies are being created by people who have little knowledge about the provision of health care and with no regard to the effects of those policies. Those policies are decimating health care.
      I’m glad that I’m a doctor.

      • “Unfortunately, policies are being created by people who have little knowledge about the provision of health care and with no regard to the effects of those policies. ”

        Actually, policies are created by lobbyists, who generally write much of the legislation and the spread the dollars around to get it enacted. Physicians have a very powerful lobby in the AMA. For some reason, though, the AMA signed on to Obamacare.

    • BTW – congrats on your blog :-)
      You earned every one of those hits.

  5. To bad we don’t have barber’s anymore–we could have them take the blue stripe out of the pole…..

  6. As a pharmacist in the community setting I have no idea where I would find time for such endeavors. In between scripts, fighting with insurance companies and wholesalers that takes up most of the time. The rest of the time I use to read blogs and post comments for an outlet. Don’t take that away from me.
    My friends that work clinical services at various hospitals are already worked to their max. Is there going to be a massive hiring spree? Or is it going to continue to do more with less? Also no one would do anything until insurance companies reimburse for services. Even if we were given provider status, why take on risk with no benefit.
    At the end of all of this, yes some disease states I think can be well controlled using alternative sources of professionals but the patient still has to have a global assessment done periodically by a physician. I think collaborative practices make more sense. Take some work off of physicians to free them up for other activities that only they are able to do.

  7. I don’t see what is wrong with letting NP’s in particular manage the 80% they can and refer to another provider those cases they cannot. This would free up physicians to treat the truly complex cases (and probably charge more). This should be a win-win. Physicians should be more concerned with DC’s, homeopaths, naturopaths. etc trying to be licensed as PCP’s.

    • The problem is that without adequate training, people don’t know how much they don’t know.

      One recent example: Patient went to four different care settings for sore throat over a 5-day period. Strep positive on each of four visits. My ED was the third visit that day? Why did they keep repeating the test? She had been given three different antibiotics. None were working.
      She had a classic “hot potato” voice and also had trismus. I knew the diagnosis before I even looked in her mouth. Yet people at the walk in clinic and at the previous ED fast track from earlier in the day apparently didn’t pick up on those signs, and neither did our triage nurse. Should we expect them to?
      I don’t use this example to try to show that I’m some astounding clinician, only to show that it is sometimes difficult to appreciate the nuances between what is a “complex” case and what is not. Training and education may make the difference.

      That being said, with the inadequacy of access to medical care in this country, I think everyone who can pass a basic medical exam should be able to practice medicine … and should also be held to the standards of a reasonably prudent medical practitioner – whatever that standard ends up being. Practice bad medicine and you’re on the hook for the multimillion dollar judgment.

      In addition, patients should be able to decide who they trust and, just like any other profession, it should be the patients’ responsibility to determine who treats them.

      Maybe we would need some modifications for emergency care, but this would be a good first step.

      • For every example of a misdiagnosis by a NP that you give me I can give you one right back of a misdiagnosis by a MD. We ALL, whether we are NP’s or MD’s make mistakes occasionally–hopefully, rarely. We also all know that there are good NP’s and bad NP’s and good MD’s and bad MD’s.

    • One of the issues is what level of care are the NPs able to provide. Often, they do not want their practice restricted nor do they want to be held to same medical malpractice liability as MDs or DOs. We constantly get transfers from other hospital ERs where the patient is wrongly diagnosed by an ARNP. Most recently, cardiogenic shock being mistaken for pneumonia and a thorasic aortic disection for pleuric chest pain.

  8. They should just take providers out of the picture altogether. All they need to do is pay for Internet access for every American.

    It is so easy now to find a diagnosis and treatment from Dr. Google. Why not just cut out the middleman?


    • You say you’re joking, but a lot of people do this already and I don’t think it is a bad thing.
      Just like looking up on YouTube how to fix your plumbing. If you’re willing to take the chances, you can save a lot of money as opposed to hiring that overpaid pipefitter.
      Many times a shift I have people tell me what they think they have based on their symptoms. Usually those guesses are based on internet searches or on the opinions of a survey of office co-workers. Infrequently are the diagnoses correct. Many times, the diagnoses are out in left field.
      But then people are hopefully more likely to feel like they have gotten their money’s worth when I make the correct diagnosis and fix the problem. And just maybe they walk away thinking that next time they’ll just go to the regular doctor instead of Dr. Google.

      • I am only half joking. Dr. Google has helped me greatly if only advising me how to frame my questions. I have too much respect for my doc’s education and training; I don’t presume to tell her anything, I DO ask her to tell me if my thinking is reasonable and if not, to point me in the right direction.

        I actually agree with the point that we are certain to see many problems erupting “unexpectedly” as patients are pawned off on not-quite-doctors. The government’s approach is just absurd and getting more so all the time.

      • Since the medical center system installed their new geewhiz EMR system, all I see in most visits is somebody’s back side and the screen they are attending.

        With distressing frequency I see on that screen what looks to me to be a pop-up Google search window.

        The only shops where this is not true is Physical Therapy (No computer’s in sight except the Reception-Appointment desks where you might hear imprecations about being able to view a patient’s appointment records, but not modify them. ??!), Dermatology (which might not be on the system), the Wound Center I have not been there in a while–may be changed),the Nurse Practitioner from Cardiology who walks over from Cardiology to Physical Therapy or to the Wound Center to attend my Swollen feet and legs, and the ENT Doctor. Audiology would not make an advance appointment six….make that eight or nine months ago because they didn’t trust the changeover–and I have just now made an appointment so we will see.

        So, as we used to say, “with time to spare, go by air”, it is now “If it is not urgent, see the doctor. If it is, try Google unless you are losing fluids, then see the Urgent Care office at the supermarket”. Doesn’t rhyme but that is the best I can do.

  9. WC…
    I once took a practice Nursing Exam for licensing because I knew someone who could give it to me. The “proctor” said that it was too bad I couldn’t challenge taking the test because of the results. I am still not schooled as an RN, but there are people out who could pass with flying colors…and they’re not allowed to challenge the system. I was not degreed then but my Army training and experience is the only thing I can attribute it to. I could have been one helluva nurse….haa.
    Believe me when I tell you that I am stocking up on expendable medical supplies and brushing up on things I have learned because I am afraid it’s going to get bad…I am even looking at finding a doc who will be my own personal go to guy for a chunk of change…I’m not kidding. I will want to be under the radar if this gets worse.

  10. Doctors can be such arrogant @sses. While I get your point, I’d rather have a competent NP who has the sense to refer me to a specialist when the issue is beyond him than an MD who believes he knows everything (so I should just shut up and take the prescribed meds – never mind that they don’t address the actual problem, just the symptoms (typical).

  11. I agree with WC, you don’t know what you don’t know (this goes for some MDs as well). In ophthalmology we have been fighting optometry about scope of practice for years. In reality it is a very vocal minority that is pushing this agenda. The problem with optometry is they are turning out many more optometrist than they need. 3 or 4 more schools opened in the last few years. Private practice is a struggle and there are a finite number of Walmarts. Consequently, they need to find new ways to pay off their 6 figure debt. Hence the drive for expansion away from the eye and into more areas related to systemic disease. I mean it already says doctor on their white coat, how hard can it be.

  12. Back up-stream here there was an apparent knock on “unqualified” practitioners like Nurse Practitioners and Chiropractors.

    The error regarding Nurse Practitioners is so obviously xenophobic that I can’t be much help, on the issue of Chiropractors, I this to say:

    I am nearly 74 and since I was quite young I have had no respect for Chiropractors.

    Most of thirty years ago I developed pains in my arms and sometimes tingling numbness in my fingers.

    The doctor diagnosed “Carpal Tunnel Syndrome” since that was the Malady de die. I was given a script for Naproxen Sodium [side question–I am not supposed to eat salt, but all of ny many drugs seem to be xxxxx Sodium. Why is that?] which I later decided had unpleasant psychological effects and sent to see a Physical Therapist who did some electrical mumbo jumbo along the nerves of my forearms and who taught me some posture hygiene and I was able to manage the pain for a long time.

    A few years ago, the GP got tired of my whining about the increasing pain in a shoulder and sent to a PT (the earlier one had long sice retired) who did some ultrasonic and LASER mumbo jumbo along with some massage and traction stuff and genuinely did some good. And apparently burned out my insurance support.

    Last year the other shoulder developed pains that wore the worst ever–incapacitating. (I was later able to tell a check-in-whatever-she-is at the GP shop that on her one-to-ten-pain-scale foolishness I knew where twelve is.)

    Members of my family (athletes, most of them) insisted that I really ought to see a Chiropractor (my wife was seeing one that Kansas City daughter’s DC had recommended here and had good results from longstanding back pains) and so I did.

    In the course of several weeks (during which I was told to expect things to get worse before getting better) the pain and tingly fingers went away and now 6 or so months later I am (with respect to arms, etc., pain free.

    The Chiropractors in that office still have posters, comments, and TV pronouncements that I believe to be borderline fraudulent, I have to say that they were able to do more for me than translate “arm nerve hurts” to Latin.

    Last year the pains

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