ADVISORY e-ALERT     July 1, 2010
Advisory Law Group, a Professional Corporation
Healthcare definition:  The Long Con - a meticulously planned, long term confidence scam designed to obtain a large return from the "mark."  The opposite of the Short Con designed to instantly fleece the mark of the money or property on his person.
Nobel Prize winner Nels Bohr commented that prediction is very difficult, especially about the future. 
But what did he know?  After all, they're handing out Nobel Prizes to almost anyone these days, apparently for what they might do in the future!
Certainly, some things are easier to predict.  For example, the very different role of physicians in the healthcare system of the future. 
If you're a frequent reader of my articles, you know that I believe that we don't have a healthcare system, but, rather, a healthcare market.  But, as words matter in persuasion, propaganda and politics, the public at large, and many within the market itself, were sold on the "system" approach - voila, there was a "system" to fix.  Of course, the fix was in; thus, Obamacare. 
So just how will physicians fit within the "system?"  A prominent role in return for the AMA's support of Obamacare?  Maybe not.
Consider these three trends that appear to be converging on your medical degree:
1.  The Struggle over Money and Control - As Obamacare has promised more care for less money, the battle over control of limited healthcare dollars and of the design of the delivery system has intensified.  Having the power to allocate money within a structure means that those in control will have the ability to shift funding to themselves and to their favored participants.  (See the May issue of the Advisory E-Alert for the article on Accountable Care Organizations.)
2.  The Shift to the Lowest Cost Alternative - With fewer healthcare dollars per patient to spend, those doing the allocating will be tempted to select the provider who offers the service at the lowest price.  There will be a predisposition toward acceptance of substitute classes of providers, and the adoption of lower standards as to what constitutes an acceptable substitute service.
3.  Doctorates for All - Just as it has become in pharmacy and physical therapy, the new gold standard in registered nurse education is a doctoral program awarding a PhD, DrNP, or other variant.  Nurses with doctorates want recognition of their status:  "Hello Mr. Smith, I'm Dr. Jones."  No, not exactly.
If there are less dollars to go around and if nurses and other paraprofessionals can, at least in terms of public perception, deliver the "same" service (or, at least, a level of service benchmarked to the mediocrity of "national healthcare"), and if those paraprofessionals are "doctors," can we then expect a major reboot of the "system" in which M.D.s are removed from the flow chart, or relegated to a less prominent role, and replaced with cheaper "doctors?"
Let's look at the CRNA vs. anesthesiologist war for a clue.
CRNAs trot out studies, including their latest American Association of Nurse Anesthetists funded Lewin Group study, concluding that CRNAs acting independently provide anesthesia services at the lowest economic cost, with no difference in the level of care. 
Political and economic pressure have forced regulatory change:  Fifteen states have opted out of Medicare's CRNA supervision rule, and CMS guidelines permit CRNAs to administer labor epidurals for the purpose of analgesia without physician supervision.
The battle is on for public perception, but nurses consistently come in first in the annual Gallup Poll on the public's opinion on honesty and ethical standards.  Even the English language has the odds stacked in favor of nurses.  (I wrote this short story to demonstrate:  "Sally nursed the escaped convict back to health.  Afraid he'd be identified, the convict doctored Sally's drink.")
Hospital administrators are already more willing than ever to accept CRNA delivered anesthesia from their contracted providers.  la the movie Invasion of the Body Snatchers, once those nurses are "doctors," the transition will be complete. 
No Magic Pill
There's no magic pill to resolve this dilemma.
On the political front, there's the ballot box.
On the medical society front, there's tremendous P.R. work to be done to convince the public of the deceptive substitution of providers.
And, on the levels that can more easily be impacted by your personal involvement:
There's the fight, at the medical staff level, to protect patients by making certain that physicians control medical care and that paraprofessionals are supervised by the appropriate physician specialist in implementing that physician's orders. 
On the medical group level, it's avoiding establishing business practices that foster acceptance by your patients and referring physicians of your group's paraprofessionals as substitutes for your physicians themselves:  Physician extenders are one thing; physician executioners are quite another.
Whether by plan or coincidence, the substitution of paraprofessionals for physicians is a major element of the long con of national healthcare.  As they say, if you don't know who the mark is, it's you.
For help in waging your battle for your group's continuing role in healthcare, contact Mark F. Weiss now. 


Accountable Care Organizations:  Accountable to Whom?, published on on June 10, 2010.


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The chances are great that a hospital administrator is scheming to control your financial future through an Accountable Care Organization.
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