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Notes -
Just so so wrong. Even in other countries with faster tracking the thing that gets cut down is undergrad (which is fair but hard to do in America, has its own significant problems, and is logistically unfeasible without completely uprooting our system in a way that isn't happening, and only shaves off two years anyway). We have some good evidence for this in the highly limited care given by providers - the NP lobbying groups best data says that NPs outcomes in simple cases is about equal with physicians outcomes in complicated cases (of course they jazz it up but that's what their data says, never mind the MD studies). Keep in mind that doctors are also the only ones getting that much training, everyone else is considerably less....and it shows. Ask any psychiatrist off the record about how the NPs and PAs are doing and they'll be able to convince you to never send a loved one to either.
As for your other point, flow chart care just doesn't work, no matter how much the MBA types may want it to. Decision support tools are miles off, for some godforsaken reason you can replace artists with an "AI" but the EKG autoread (which is one of the most computationally simple tasks imaginable) would get people killed if put in charge.
In addition to the always underestimated medical complexity, you have the human element - patient entitlement these days is sky high (as exhibited in this thread), people are always demanding things that are not indicated or are outright bad for them (ex: antibiotics for viruses) and your flowchart clinic would be immediately going off the chart or burned down.
That's not taking into the account the unacceptability of failure and legal environment, as soon as someone dies because of an edge case (which happens all the time) flowchart clinic would get sued into oblivion.
If you accepted upfront that 10% of people are going to have an unnecessarily bad outcome and 1% of people are going to die unnecessarily you'd be able to do as you say, but nobody is signing up for that. We (rightly so) value human life too much for that.
Really? What are the numbers under the status quo?
The unnecessarily is doing work for me but I can't construct any real numbers without a lot more clarification and information, for instance you could do OP's flowchart suggestion if you were cautious and dumped people to a real level of care at a drop of a hat (this is basically how urgent care works, anything that shouldn't actually be managed by a primary care gets sent to the ED and billed by the ED and the urgent care).
The idea that medicine is somehow not complicated is a common one but is indicative of near absent epistemic humility. I'm a doctor and probably in greater than 90th percentile knowledge of other specialties and I can't use the other disciplines algorithms at a standard of care level. The field is big, technical, but also fuzzy (thus the "Art and Science of Healthcare").
We can see this in revealed preferences in innumerable ways (ex: calling consults even when we are 95% sure what is going on because we don't want to make a mistake or get sued).
I sympathize but this struck me as the argument against self-driving cars: it's a difficult problem, there are fuzzy situations, as such it's basically impossible for the cars to drive perfectly, and therefore it's not a viable technology. But this is of course ridiculous: self-driving cars don't need to drive perfectly to be viable, they only need to drive better than the current humans on the road, who are as a group atrocious.
So the real question is, what number of people are dying "unnecessarily" or having "unnecessarily bad outcomes" under the status quo where care may be high quality but expensive and illegible to the end user, as compared to a scenario where care might be less cautious but more accessible. First, you seem to be implying that the base rate of unnecessary bad outcomes or death under current practices is much less than 10%/1%, but we know that medical errors are not uncommon. Is it less than those figures? How much less? Recent figures put the annual number of deaths in the U.S. due to medical error at about 250,000 annually. Is your position that this is substantially less than 1%, or that these are necessary errors?
Second, how many people don't go to the doctor because they are afraid of predatory billing or just because it's too much hassle? How many people experience complications from tests and procedures that had a low probability of being useful? How many people consume ER resources just because it's easier to ignore the bill than with a normal office visit? It's not fair to compare a potentially reformed system as a whole against a subset of outcomes under the status quo.
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I'm married to one, she disagrees. Most of her beefs have been with the embarrassingly dysfunctional nature of the hospitals she's been in that would never stand if there was real competition. EDs that either have no way of checking how many bed the psych department has open or for some reason refuses to believe either those tools or the doctors who tell them they have no beds. Spending countless hours on hold with pharma companies because for some reason totally inconceivable to me you need multiple doctorates to navigate call trees. The pure waste of it all has had me furious more than a few times.
If by "unnecessarily bad outcomes" you mean their nose bleed takes longer to figure out then sure I think people would be more than happy to deal with that and save hundreds of dollars.
No way this is accurate.
Why yes, we're discussing the legal framework your lobbying group has been enmeshed in creating. "We'll crush your upstarts like the pathetic little bugs they are if they dare" is precisely the thing I'm arguing should be abolished.
I refuse to believe she doesn't see a reduction in quality of care provided by mid-levels.
Ask her: "insert pet name here do you see any differences in quality of formulation and medication management (including things like benzo use) between NPs and MD/DOs?"
The rest of her relayed complaints are def real and accurate enough to make me believe you (and won't get any complaints from me, although as always theirs hidden complexity responsible for why those things are the way they are, especially the ED stuff).
Your nosebleed is not meant to be managed by an ED, your PCP should have same day sick slots. It's meant to be managed by a cost effective and cheap entity instead of the TRIGGER THE FULL IS THIS PERSON DYING APPARATUS (which they can't not trigger because liability). If they don't it's because PCPs are underpaid and overworked and most don't want to be one....
The AMA is the villain meme pisses me off so much because it's a "the sky is green" level take. At one point it might have been accurate but at this point the AMA has been lobbying against physician interests for decades and one of those things is deliberately increasing the amount of competition for physicians. Those idiots are on your "side."
And that's not getting into some of the shop talk level stuff here, you can't snap your fingers and make more surgeons for instance. If you gave every hospital a million dollars for every extra surgeon they trained (at the same quality as current) they just couldn't do it. For example currently we are talking about increasing the length of surgery residency (already 4+4+5+(0-3+)) because we can't train them adequately as is (because of the increase in robotic surgery and increasing specialization and IR and blah blah blah).
I don't necessarily have a problem with physicians themselves so much as this attitude that seems to be shared by so many of my partner's colleagues that nothing can possibly be done to fix these systems and instead all the complaints are about individual doctors or features of the system. I've spoken to developers of Epic or one of the Epic competitors briefly and they also noted Doctors are generally hesitant to streamline processes(and working in a heavily regulated industry myself I understand the people aren't the only source of change resistance). But when you have someone who received a decade or more of education personally spending most of their time doing tasks a bright high school student could accomplish it's time to seriously consider burning the whole thing down and restarting.
Maybe you've been burned by incremental changes not panning out in the past but you need to understand that from the outside looking in the whole system is insane and every anecdote I hear only further cements this view. Maybe people in the medical field are just so used to dollar amounts not meaning anything that they truly believe it is reasonable for packing a nose bleed to cost $500 but that's a rate for like, world's greatest expert to fly in and consult in any other field. I'm willing to believe you that there is some important art involved here but if that's how much it's worth to do that service there should be vocational classes for it and someone without an advanced degree should be doing it. The average hourly wage in the united states is something like $30/hour if we call the bandages a hundred bucks that is 13 hours of average wage to pack a nose, someone could make the average American hourly wage and do this procedure 3 times a week to be working full time. Obviously none of this is that simple but do you not see how this doesn't pass the smell test(no pun intended)?
These days physicians aren't in charge of anything, we've been pushed out of administrative and leadership roles (for a combination of reasons including legislation and the fact that nurses are scrambling for admin roles etc. etc.).
I'm not sure that's the correct read from the Epic devs you've spoken to, it's pretty common to use Epic installs as a way to hone broken processes but that's in the limited domains where physicians have control over workflow, which isn't too much. The admin side of things do want to make things more efficient and sometimes that works but other times things are weird for a reason (such as excessive regulatory burden) and people coming in from non healthcare business just can't get the complexity through their heads (Epic is generally good about this, but Apple and Google both dipped into healthcare IT and fled for a reason).
It is true that lots of doctors have limited technical ability and don't elect to use tools like hotkeys and that's probably what the devs are talking about. It's also true that doctors spend a lot of time complaining about documentation and administrative burden but then don't optimize their personal workflow. That's not a new problem though.
Re: the 500 dollar rate. The PA isn't getting paid that, 450+ dollars of that fee is going into whoever owns the PA (likely a private equity backed practice management group these days). Also possible that the charge is that high as part of the insurance negotiation dance and whoever owns the PA is just an asshole (again more likely with the outside investment). Also possible that OP is confused and it's supposed to be overall professional fee charge for the facility the ED is an extremely high level of care and the average patient might be using the services of 30+ employees or something else crazy like that (a lot of which is invisible like the cleaning staff and unit clerks).
People aren't supposed to go to the ED unless they need it.
Also for a lot of visits you don't pay for the service you got, you pay for the rule out (which may or may not involve additional testing).
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