I was hoping that you guys could be a bit more specific with the amount of work you do that the mid-levels you work with don't do. Smq123 did describe that about 20-30% of the work she does is not routine and probably could not be done by most mid-levels. It would be nice if you all could have given us a better understanding of what that 20-30% is even if it just involved anecdotes from your most recent work day. Once again maybe it's just my fault for not better understanding the differences you have provided.
I just quickly googled what a "capitated model" is (sounds like DPC). How would that squeeze out NPs/PAs unless they change their curriculum? Once again I am genuinely asking...not criticizing. It's difficult to convey tone on the internet which is maybe why it sounds like every question is actually criticism.
It's ok....it's hard to remember that stuff that is now habitual to us as a practicing physician was once new and foreign.
So, to answer your questions in reverse order...DPC is not at all like a capitated model.
DPC is literally like joining a country club. You pay a set amount of money per year (let's say $10,000 for the sake of argument). As a result, you now have open access to the amenities that the country club offers - you can play golf whenever you like, or use the swimming pool whenever you like, or bring your family for brunch or dinner whenever you want.
A capitated model is where the insurance company guarantees a certain set amount of money per patient per year - again, let's say $10,000 for the sake of argument. If the patient never uses any resources (never goes to the ER, never gets a CT scan or an MRI, never goes to urgent care), then the primary care doctor will be paid the full $10,000 at the end of the year. Great!
However, if that same patient, the following year, has a bad year and has to go to the ER for an emergent hernia repair, and then 6 months later needs an MRI for a torn meniscus, and then needs to see ortho after that - all those visits to the ER, the MRI center, and the ortho get taken out of that $10,000. And those are all expensive things; it is possible that the primary care doctor will not see any money from that pt.'s account at all.
So, obviously, if you have a physician who can take care of most things in the office without having to rely on a referral or expensive imaging test is more beneficial for the practice than a physician (or an NP/PA) who refers absolutely everything out. However, it is hard to find an NP/PA who can do that.
Keeping the above in mind...
- A patient comes in complaining of daily migraines.
I have seen inexperienced NPs/PAs either a) send the patient to neurology, or b) order an expensive MRI (because all migraines need an MRI, right?) or c) send the patient out on daily Imitrex or Fioricet and then wonder why the patient's insurance company refuses to pay for any of this.
If you have a pretty compliant patient population with great insurance, this might be ok. That is becoming increasingly rare. A patient might never go to the neurologist because "I can't take time off of work," or "I can't afford the copay right now," and then be dismissed as "noncompliant" while still suffering from daily migraines. Or the insurance company will refuse to pay for the MRI because you can't document that it is clinically necessary, so the patient never gets it done, and leaves that clinic to find another doctor who can help her. Option C is definitely a no-go because there are precious few insurance companies willing to pay for daily Imitrex. Daily Fioricet just makes the problem worse. Options a and b are also frowned upon in this capitated world because, again - cost.
Most good physicians that I know, even those relatively fresh out of residency, would approach the patient differently. They evaluate the patient for red flags, and finding no evidence of these, decide that CT or MRI is not necessary at this time. They would usually counsel the patient on the importance of avoiding caffeine, staying hydrated, getting adequate sleep, and not relying heavily on Excedrin, because of the risk of rebound. They would then start the patient on migraine prophylaxis (beta-blocker, Topamax, Gabapentin), and only send to neurology if pt. has failed everything.
Are there NPs/PAs who would know enough to do the second track? Sure, although they are not in the majority and worth their weight in gold. Are there MDs who would do the first track? Sure....lazy people are found in all disciplines. But, for the most part, that is the difference in approach.