Turf Wars and Disruptive Innovation
Two recent developments regarding the role of physician extenders are making waves.
One involves the American Medical Association, which released a statement rejecting an Institute of Medicine report that advocates expanding the role of advanced-training nurses to address shortages of primary care physicians. (To simplify I will refer to them as NPs – nurse practitioners, although other designations exist).
The other involves a lawsuit pitting the Colorado Society of Anesthesiologists (CSA) and the Colorado Medical Society against the state. Colorado will became the 16th state to opt out of certain Medicare rules and will allow Certified Registered Nurse Anesthetists (CRNAs) to practice in rural areas without direct physician supervision.
Both of these objections use the argument that allowing lesser-trained professionals to assume the responsibilities of physicians, without supervision, will lead to impaired patient outcomes. The questions regarding outcomes can be very difficult to answer, and often statistics are cited to promote the agenda of the side presenting them. For example, CSA president Dr. Daniel J. Janik cites data that claims 25 to 60 more deaths per 10,000 anesthetics where a physician is not involved.
Although I cannot resolve the statistical argument here, I can observe that because anesthesia is so safe, it will take a large number of data points to show any difference between anesthesiologists and CRNAs. The safety improvements are credited to the hard work of the specialty, which has implemented many monitoring and procedural standards that have made surgery far safer than it was in prior decades.
In most articles about Turf Wars, there is far too little attention to the role of Disruptive Innovation which helps to bring about the conflict. In these situations, the disruptor is not a new technology, but a new type of training; the NPs and CRNAs.
In most industries, Disruptors seldom succeed by symmetrically engaging those being disrupted. Success comes first by gaining legitimacy in fringe areas where the disruptor is welcome, and then moving “upmarket” into other areas.
Sometimes, those being disrupted fail to catch on or do not care, because they may feel that the problems will be borne by the next generation. It starts with the anesthesiologists who don’t cover less desirable hospitals, with plastic surgeons who are too busy to do breast reconstruction or cover emergency call, and with radiologists who don’t want to read films on weekends or at night. In all these cases, it is physician behavior that creates these market gaps, which provide an invitation for the disruptive innovator.
Those market voids eventually get filled. CRNAs step in, allowing the rural hospital’s operating room to function. Other types of surgeons handle facial injuries and in some cases, breast reconstructions. Nighthawk and similar teleradiology services handle the night and weekend work. Once the disruptor gets a chance to prove that they can do the work, its very hard to make an argument that they cannot do so safely. Sometimes that simply cannot be proven.
Another often ignored point is this: by accepting disruptors as legitimate replacements, it is implied that much of the greater training of the disruptee is either superfluous or irrelevant. If that is the case, why not slash the length and intensity of all residency programs? We don’t hear many calls for that. Residency programs serve as a crucible in which the trainee is marinated until they hopefully emerge as a competent professional. It is not easy to define which elements of the program are important and which are not, so removing components is fraught with hazard.
In the march toward disruption of anesthesiologists and primary care physicians, it is often stated that disruptors will provide less expensive care. This is may be true for the provision of anesthesia services, if CRNA salaries remain below that of anesthesiologists. But in primary care, it is another story entirely. There are four areas where the primary care physician controls the further flow of health care dollars: requests for consultations, medication decisions, diagnostic testing, and decisions for hospitalization. To be sure, incentive structures often influence these, no matter who is acting in the primary care role. But all things being equal, the system needs to see the lowest utilization as necessary to achieve good outcomes. I am not aware of evidence that a full-service primary care operation (as opposed to retail clinics which usually handle a limited set of problems) will have the same costs when staffed by NPs as by primary care physicians. A small percentage change, in either direction, of any of the above four areas can vastly alter the national healthcare bill. So the disruption of the nation’s primary care structure may produce savings, or much greater costs.
The AMA’s response to the Institute of Medicine can be seen here.
The Colorado Society of Anesthesiologists letter to Governor Bill Ritter.