The Indisputable Math: Mandated Physician Supervision as a Profit Center

by faithgibson on December 4, 2012

in Contemporary Childbirth Politics

Part II ~ continued from Legally Mandated MD-Supervision of Non-physician Practitioners: a costly, unethical & unfair medical monopoly

Historical background: By 1910, the AMA’s plan to eliminate “the healing arts” was well on its way. At stake were multi-disciplinary forms of health care that included allopathic MDs, several types of drugless practitioners (naturopathic, osteopathic, homeopathic, and Chinese medicine doctors), as well as midwives and herbalists. By the early 1920s, the traditional system that provided health-related care and various kinds of medical services for the ill and injured was replaced by an MD-centric, allopathic-only form of medical practice. This sickness-oriented system focused almost exclusively on the use of prescription drugs and surgery, a model of care that generally does not focus on preserving health or preventing disease, but instead only became relevant after people were sick or injured.

Over time the political influence of the AMA has successfully prohibited the independent practice of non-physician primary care practitioners in a majority of states. At present, only 12 states have licensing laws that allow advanced nurse providers and midwives to fully provide care as independent agents.

However, even these state laws are now trumped by the AMA’s successful effort to get federal Medicare and Medicaid laws passed prohibiting reimbursement of non-physician practitioners unless the nurse-practitioner or professional midwife is under the supervision of a physician.

Within the healthcare industry, public and private hospitals and private health insurance companies all follow these same federal guidelines.

Between A Rock and a hard place

I talked to nurse-practitioners and professional midwives in different states (those that do and those that don’t restrict independent practice) and the affect involuntary physician supervision imposes on patients and practitioners is not a pretty picture. Were this situation reversed and physicians were being legally mandated by another profession to work under the ‘higher authority’ of a different healthcare discipline, the medical profession would never, ever stand for this nonsense for a single minute.

An example of how this rigged game works was provided by a ‘mid-level’ who is employed by a group practice of MDs. These doctors provide obstetrical care to more than 4,000 medically-indigent women every year in a large metropolitan area. Based on the Medicaid’s standard “global fee” for obstetrical services, this volume of normal vaginal births would directly generate over $9.2 million in revenue. With a Cesarean rate in the US of approximately 33%, surgical deliveries and care of women with other complications would add another $1.8 million or a total of $11 million in compensation.

For such a high volume practice, there are two possibilities: — the ideal and the rude reality. 

Here’s a short description of group medical practices under the two contrasting laws:

The Ideal — providing safe, effective and individualized care to low-income women, while the taxpayers who subsidize the federal program get their money’s worth:

In the 22 states states where non-physician practitioners are able to practice independently, it would be logical for this obstetrical practice to hire a dozen nurse practitioners and professional midwives in addition to the groups’ obstetricians. As a multi-disciplinary groups, both physicians and midwives would  be able to provide continuity of care by doing prenatal care and attending births of these same patients at local hospitals or a free-standing birth center.

According to recent literature on nurse practitioners, this type of primary-care provider typically sees 10 to 16 patients per 8-hr work day, which means at least 30 minutes for each appointment. Over the full course of prenatal and postpartum care the typical maternity patient receives about 9 hours of one-on-one attention from her nurse-practitioners and/or a physician. In this idea practice situation, professional midwives would also be present in the hospital to manage the mother-to-be’s active labor, birth and immediate postpartum.

Average practitioner time for intrapartum services by this group practice would be 3 to 5 hours of direct, one-on-one care during the labor and birth and first hour of the immediate postpartum-neonatal period. The spontaneous birth rate associated with this highly effective form of personalized care by midwives is generally over 85-90%, with operative deliveries – forceps, vacuum and Cesarean surgery — under 15% . This is 1/3 to 2/3 less than the current average obstetrical practice (down from 32.8% to 10% or less).

For this Medicaid group practicing as independent professionals, the total time spent with each new mother would be a minimum of 12 hours of one-on-one care by a non-physsician primary care practitioner. This time frame provides caregivers with personal knowledge of the childbearing woman, her family, economic situation and general health issues, such as the need for reliable contraception or her risk for depression, substance abuse, hypertension, type II diabetes or obesity or the issue of spousal abuse. Such a therapeutic relationship offers an opportunity for patients to talk about issues of importance to them, while the practitioner has time to listen patiently,  ask questions to help determine the course of action that is most helpful and to provide health education as appropriate.

This defines the necessary characteristics of healthcare that is able to preserve and protect the mother’s current health status, help to stabilize any chronic condition and reduce the risk of future illness. The simple expenditure of a healthcare professional’s time is cost-saving as well as life-saving.

The global fee paid by Medicare for comprehensive care is $2300 for normal vaginal birth, with an average 20% higher reimbursement for operative deliveries and care of maternity patients with medical complications.  Total revenue for a group practice with this level of a patient load would be approximately $11 million annually.

Assuming that 50% of that revenue goes to pay overhead expenses — office rent, utilities, support staff salaries, and professional liability insurance premiums, this multi-disciplinary practice would still generate an annual income of 5.5 million or an average salary for each of its 18 professional providers of $305,000.

Rude Reality

Unfortunately, the story told by nurse practitioners employed in one of the 28 states where doctors are able to enforce a monopoly through involuntary supervision is starkly different.

One example come from a ‘mid-level’ employed by a group medical practice where the majority of the prenatal and postpartum care is done by salaried nurse practitioners and midwives. In this office, all appointments are scheduled at 5-minutes intervals, a schedule that includes newly pregnant women seen for the first time, return prenatal visits and 6-wk postpartum patients.  Each of these professionals (MDs as well as mid-levels) are seeing 40 to 60 patients every day, five days a week. This 2 1/2 to 6 times more than is considered an appropriate work-load for nurse-practitioners.

While midwives are professionally-trained and licensed to attend normal labors and births, the doctors in this practice have chosen to do all of the deliveries themselves. That means laboring women are sent to the hospital and all the care during the many hours of labor is provided by L&D nurses. This aspect of the patient’s maternity care is not part of the medical practice’s ‘global fee’ but instead is billed separately to the Medicaid program by the hospital.

During this time, one of the doctors in this group practice is available by phone to answer questions by the nurses or in case a complication arises. But the MD is not normally present until the nurse notifies him or her that the mother-to-be is ready to deliver, or a Cesarean needs to be done. Average ‘face-time’ for a normal spontaneous delivery is as short as 12 minutes. If a complication occurs or if a surgical delivery is performed, the physician may need to be present for as long as 2 hours.

With an average of eight 5-minute prenatal visits during pregnancy and figuring in a maximum of 2 hours during the birth and one 6-wk postpartum visit (also scheduled at 5-minute intervals), the total combined ‘face-time’ for this practice is still under three hours. Based on Medicaid’s lowest level of compensation for a spontaneous vaginal birth (no instruments, no surgery, no complications), physicians in this group Medicaid practice are being paid approximately $766.00 an hour for their services. It should be noted that in many instances these services are actually being provided by their nurse-practitioners and midwives, who are being compensated at a rate of $50 an hour or less.

However, the annual income of each physician in this group practice would be just under a million dollars — $916,666,667 to be exact. This is quite a contrast with the salaries for the nurse midwives which are significantly under $90,000.

As for meeting the health and maternity care needs of childbearing women and their offspring, can a handful of 5-minute appointments possibly preserve and protect the health and wellbeing mother and baby and meet the basic goal of maternity care, which is healthy productive citizens?

Is it appropriate for the medical profession to use its political influence to take other professions hostage and make it illegal for professional educated non-physician primary care practitioners to provide care that directly to patients in non-acute healthcare setting?

The next post on this topic are excerpts from historical and contemporary documents that trance the history of this institutionalized medical monopoly and the exploitation that results.


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