A challenge of not having quality metrics

by jerry on February 18, 2023

Kaiser Health News reported on a growing trend in which emergency rooms are increasingly staffed with midlevel practitioners (nurse practitioners and physician assistants) instead of physicians. Apparently, emergency medicine physicians are paid about two-and-a-half times what midlevel practitioners are paid. Private equity investors (generally not from the healthcare industry) have been buying up staffing agencies and changing the mix of providers to save money.

The article points out that "definitive evidence remains elusive that replacing ER doctors with nonphysicians has a negative impact on patients", although specific studies might find otherwise. One study found that "treatment by a nurse practitioner resulted on average in a 7% increase in cost of care and an 11% increase in length of stay, extending patients' time in the ER by minutes for minor visits and hours for longer ones." However, given that the hospital that owns the emergency room is not bearing the increased cost (and perhaps even benefits financially from the added revenue), it is not surprising that staffing agencies are keen to save on labor costs by replacing physicians. It is also not surprising that a leader of an organization representing physician assistants believes that this trend is positive.

A major question remains as to whether patient care is deteriorating because of this trend. If the industry had widely established and public metrics to evaluate quality of patient care, administrators could make much more informed decisions. For example, an administrator might feel a two percent drop in quality is worth a 70% drop in cost. Without knowing how quality of care is being affected, it is difficult to understand the tradeoffs. For now, it seems that policy should be adjusted so that patients who return to the emergency room within the same day for the same issue should not be charged for separate visits when the earlier visits failed to detect an issue that ultimately became recognized (as was the case in the anecdote that opened the article).