New York Times prescription for “When the Doctor Is Not Needed”

In the latest installment of what its editors describe as a “continuing examination of ways to cut the costs of medical care while improving quality,” the New York Times on December 15 published an editorial titled “When the Doctor Is Not Needed.”

Ostensibly a discussion of ways to deal with a shortage of doctors in many parts of the United States, the piece is, in fact, an argument for curtailing access to physicians for millions of ordinary Americans.

The Times has carried out a years-long campaign against “unnecessary” tests, procedures and medications—touching on everything from the supposed danger of cancer screenings and “overtreatment” for cardiovascular disease to the “squandering” of resources on end-of-life care.

Turning to the “problem” of over-utilization of physician services, the leading voice of American liberalism suggests that the “sensible solution” is “to rely much more on nurse practitioners, physician assistants, pharmacists, community members and even the patients themselves to do many of the routine tasks traditionally reserved for doctors.”

Such an approach, the newspaper asserts, can result in “routine service that is every bit as good or even better than what patients would receive from a doctor.”

To be sure, medical professionals such as nurses, physician assistants and pharmacists play a critically important role in patient care. There is room for expansion of the training and services these practitioners provide in addition to those of physicians.

An examination of the Times editorial, however, makes clear that improving patient care through utilization of the services of these medical professionals is not the driving force behind the authors’ argument that in many cases “the doctor is not needed.” Rather, the concern is to cut costs.

“[B]ecause they are paid less than the doctors,” the editorial notes, “they can save the patient and the health care system money.”

As promoter-in-chief of the Obama administration’s health care overhaul, the Times has worked tirelessly to advance the argument that “less care” equals “better care.” The editors acknowledge at the beginning of last Saturday’s editorial that the expansion of health care coverage through the individual mandate at the center of the Obama health care “reform” will exacerbate the shortage of primary care physicians.

“Expanding medical schools and residency programs could help in the long run,” the editorial notes. But for the time being, the Times argues, the solution is to farm out care normally provided by doctors not only to nurses, pharmacists and other medical professionals, but also to the patients themselves and others with no medical training.

Before moving on to patient “self-treatment,” the editorial argues for loosening state and federal restrictions on pharmacists and nurse practitioners, allowing them to diagnose and treat illnesses and prescribe medications without a doctor’s involvement.

The Times cites approvingly the relatively new phenomenon of retail health clinics such as the “Minute Clinic” of the CVS drug store chain and Walgreens’ “Take Care Clinic,” staffed by nurse practitioners and physician assistants. These for-profit operations now number more than 1,300 across the US and their use has increased ten-fold from 2007 to 2009 among those with commercial health insurance.

The editorial points to a study of CVS retail clinics in Minnesota by the RAND Corporation, the Pentagon-backed think tank, which found “that in many cases they delivered better and much cheaper care than doctor’s offices, urgent care centers and emergency rooms.”

The editorial conveniently ignores some of the key findings of the study. In a press release, RAND Corporation notes, “We found use of retail clinics did have a negative impact on some aspects of primary care.” According to the study, “Patients who visited retail clinics also had less continuity of care, such as seeing the same physician for their medical needs.” Apparently, the Times editors are more interested in the study results showing care at such clinics “is much cheaper” than at a doctor’s office.

The editorial moves on to consider the “novel approach” of training “local community members who have experience caring for others to deliver routine services for patients at home.” In a test program at Medicaid centers in Houston, Texas, and Harrisonburg, Virginia, aides are trained to “consult with patients over the phone by asking questions devised by experts.” They may also visit the patient and send photos or videos by cell phone to a supervising nurse, who makes the final decisions on patient care.

Leaders of the pilot study contend that the program has the potential to avert “62 percent of the visits to a Houston clinic and 74 percent of the emergency room visits in Harrisonburg.” More important for the Times, however, are the near-poverty wages of the aides, who are typically paid about $25,000 a year. A call or visit by an aide costs about $17, compared with Medicaid payment rates of $200 for a Houston clinic visit, or $175 for an emergency room visit in Harrisonburg.

The final area of potential cost savings touted by the Times is “self-care at home.” The newspaper cites a program at Vanderbilt Medical Center that “lets patients with hypertension, diabetes and congestive heart failure decide whether they want a care coordinator to visit them at home or prefer to measure their own blood pressure, pulse or glucose levels and enter the results online, where the data can be immediately reviewed by their primary care doctor.”

The editorial does not indicate whether the Vanderbilt program has actually improved patient care. Apparently it does cut costs.

The Times notes that a hospital in Sweden has taken this “self-care” idea “a step further” by having more than half of its kidney dialysis patients administer the treatment themselves. “Costs have been cut in half, and complications and infections have been greatly reduced,” the Times writes. This is apparently due to a less burdensome process for patients, leading to more frequent dialysis. Actual figures on improvements in complications and infection rates are not cited.

What other types of “self-care” are the Times editors prepared to recommend? What other services or procedures do they consider candidates to be administered without the participation of a physician, or any trained medical professional? The possibilities are both endless and terrifying.