That seems unfair to the patients. When I go to a doctor I want to see a doctor, not a PA or an NP.

And wouldn’t that make TVH more profitable? Hire some doctors and lots of PAs and NPs and direct a lot of your patients to the PA or NP.

Do you have a ballpark idea what the difference is in pay between a doctor and a PA or an NP? I doubt if they get 85% of a doctor’s pay.

Legnth of doctors vist.
 

While routine physical can be long, most doctor's visits are quite short. Not sure if figure quoted is hourly rate or per visit rate. Even on physical, part of the time is non-doctor time.
Pressure to keep costs down throughout medical system, but costs still growing faster than inflation.

I suspected that and Chat GPT agrees with you! .

So with PA/NP's, the provider is making about 30% or so? (I'm assuming PA/NP salaries are about 60% of an MD's salary?).

How does a medical practice pay for admin, overhead & profit, if "office visits" barely break even?

(Also curious ... most studies I've seen, conclude that "outcomes" are comparable between Dr care & PA/NP care. True?)

I don’t believe they can do that legally, but I’m sure there are ways.

Wow! How do they get away with charging a copay twice for same thing? just nuts!

In my case, I cannot be "directed" to a PA or an NP. Unless I have an emergency, I tell the scheduler that I will only make an appointment with a medical doctor. Period.

There's a lot there to respond to, so here's the highlights:

10 years ago our nurse practitioners, between salary bonus and benefits, had a compensation package of about $130,000. And no, that is not 85% of a physician's income. We made minimal "profit" on our NPs.

I don't know where that "break even" idea came from. Primary care practices generally run at about 55% overhead, we were a bit better at 47% overhead. So individually we kept about $53K out of every $100K billed and collected (another issue). But out of that we then individually paid malpractice insurance, disability insurance, overhead insurance and taxes. So on average, a primary care physician was left with 19 cents on every dollar collected.

So on average, when you see Dr. "X" billed out $1 million and are "shocked", that translates to $900K collected, $405K after overhead and about $275K after expenses---with no benefits and no pension for retirement. This comes out to less total compensation than a police sergeant married to a high school guidance counselor in a medium sized town.

Retired CFO of a hospital system here. I was working when hospitals started employing MD’s, and probably hired thousands of PCP’s in my career. They were mostly paid under a fairly complex production system, which provided a $ amount per RVU (relative value unit), with incentives for things such as quality and patient satisfaction. We always lost money on the PCP line of business, and when reporting these results to the Board, I began to refer to the PCP’s as our “sales force”. They got this, and understood that it was a supply/demand issue, and PCP’s were needed to feed our Cardiac, Oncology, Orthopedic etc. programs.

Of course, out of that $250,000, those young doctors have to pay large amounts of tax and they have to repay their med school loans. In private practice, they also have to pay for rent, employees, and all that. Around here, young GPs often went to low-rated med schools. They passed their exams, but you don’t know whether they were nic in their class standing or at the bottom. Doctors who were at the top of their class are likely to be much better at diagnosis. The life saver—literally—is that these days, lots of these mediocre doctors and physicians assistants and nurse practitioners (who may be good, but their training was only med school LITE) have excellent programs on their laptops that coach them in what to notice and ask about. They soon improve a lot. Still yes, their job is mostly to diagnose and dispense for minor problems and know when to refer patients to specialists. Sometimes they can get the patient in to see a specialist quite quickly.

I’ll mention something I mentioned last week. The best thing about Medicare and my supplemental insurance (Blue Cross/Blue Shield from Pennsylvania) is that hospitals and doctors can bill whatever they want, but the insurance decides what they will pay and what can be passed on to the patient. Thus, I had major surgery this year using the Da Vinci Robot, a top specialist, radiologists, MRIs and CTs, etc. The hospital and doctors billed me about $130,000. My two insurances paid about $15,000 total between them. I paid only my $257 annual deductible. This is why hospitals and doctors are using creative billing. If they claim you make minor heart arrhythmias, that might get them an extra $100 after they bill $1,000 for it. The Villages Imaging may bill $5,000 for an MRI or CT scan using machines that cost a million or more but get paid $150 to $300. Really. Being a doctor is not necessarily lucrative these days, especially if all your patients are on Medicare or Medicaid.

To be honest, I've never really understood the objection to NPs. They're supervised by MDs, so one can assume that anything beyond their expertise will be discussed with their supervising MD. That is the way it works at the clinic that my wife and I go to, anyway. One MD, three NPs. We always have the option of being seen by the MD, but the fly in that particular ointment is that we might have to wait longer to be seen by the MD than by an NP, which is understandable.

Seems to work that way at other practices too. After successfully evading cardiologists for the past four years, my wife and our NP finally got me to agree to go to one, a guy who really seems on the ball. I'll be completing the tests this coming Monday. I've already scheduled the visit to discuss the test results: I was offered the option of seeing an NP for this (two weeks from now) or seeing the Cardiologist (mid-November). I picked November, as if anything untoward showed up on the tests that demanded attention before November I'd be called anyway.

TVH took me when I was on my employor’s medical plan. You must have had one they didn’t accept.

I don't have any objection to NPs. But, many MDs have dedicated their life to the practice of medicine, and they do not merely consider it a job. And, they have malpractice insurance. There are NPs who are very dedicated, but there are many who consider their work to be just a job with a paycheck. I remember a few years ago, I went to an urgent care facility, and I was treated by a woman who had no identification on her clothes, and she didn't even offer to tell me her name. I had to ask for her name, but I still don't know what her qualifications were.

What people haven't talked about is the overall shortage in pretty much all medical fields. Sometimes we see NP and PAs because staffing levels don't support everyone seeing an MD. Most of us remember when it wasn't hard to get into see our MD on the same day as a walk-in. Those days are gone and unlikely to return. Government run healthcare is largely to blame because the payment system (amount, complexity, and requirements) is driving people away.

For example, our 4-hospital system was just driven to convert our individual EMRs to a single EMR called EPIC for around $150M. The process was a nightmare; the company acted like we were their first client, which we were far from being, and the EPIC processes were little more than generic, e.g. Epic had their way to do things (patient flow, schedules, limited interfaces, support) and pushed us to do things their way (not what staff wanted to hear). What does the government reimburse for the required EMR? ZERO dollars! Overall, it will improve the exchange of information between hospitals when we share a patient, but for $150M and I don't know what EPIC charges for the annual licenses and support contracts. But remember, having an EMR is a government requirement that we don't get paid anything for having.

Manpower had been a problem since before COVID, but COVID drove a lot of people out of the field or into retirement. As of 1.5 years ago when I retired, my hospital was grossing more than it ever had (and we were always lean and in the black), but post-COVID, losing $2M/month largely due to the cost of travelers/LOCUMs. It took years to find my replacement, even offering top pay and living in a really nice area. Don't look for things to get any better with the government driving the payment system.

The government requires hospitals to do more and more while bundling more and more charges with the aggregate payment continually being substantially reduced. In my primary field of radiation oncology bundling charges has been very painful, but at least we're still profitable. However, our ability to cover the cost of hospital services that are routinely losses is much more limited. There are only a handful of hospital services that make the money to pay for the others. Then there are the no-pay patients we care for, which can be 35-50% or more of the patients in some areas. We do all the same work, use all the same assets, have all the same malpractice liabilities and zero income. No, the ACA doesn't cover those people as promised.... big surprise.... not! The government is driving this bus, not the hospitals or even the insurance companies.

Interesting, that explains why it was like pulling teeth (before I went on Traditional Medicare) to get my PCP to give me a referral to a specialist outside of their affiliated practice.

I know a couple of doctors who told their kids the opposite. “I advised them not to go into medicine”