Nurses and Doctors Fighting Over Team-Based Health Care

Nurse practitioner doing her thing at Walgreens.

Photo by Scott Olson/Getty Images

There’s a lot of interest right now in what are called “team-based models” of health care delivery, which more or less means what it sounds like—patients typically receive health care services from more than one person, so there’s both an economic and a medical logic to the idea that this should present itself as treatment by a single team cooperating and coordinating rather than by a diverse array of independent agents who are in a sense competing with one another for money. 

The American Medical Association wants the world to know that it’s totally on board with this idea and just has a few suggestions for how to implement it.

For example, according to the AMA all teams should be led by M.D.-wielding doctors. And what’s more, all payments to teams should flow directly to M.D.-wielding doctors. Then M.D.-wielding doctors should divvy up the money among other teams. The neat thing about this, of course, is that if all payments have to flow through an M.D. and if M.D.s get to make the decisions about how to divide the money, then M.D.’s have the power to decide that the M.D.’s deserve a cut of all services rendered regardless of the work the M.D.s actually do.

This is a financial and economic model that you may be familiar with from such enterprises as your local dentist or The Sopranos. In many cases, neither Tony Soprano nor your dentist is actually providing any services to the customer. You just want to get your teeth cleaned or buy some drugs. But the drug dealer needs to kick some money upstairs to avoid getting beat up by the mob—since dealing drugs is illegal, you have to legal recourse to stop the mob from beating you up so you’d better pay. For the dental hygenist it’s an essentially parallel situation, in most states you’re not allowed to clean teeth unless you’re “supervised” by a D.D.S. who takes a cut off the top of your work. It’s a very convenient arrangement, and obviously the American Medical Association would like to see it become the foundation of team-based care methods.

Not surprisingly the American Association of Nurse Practitioners has other ideas and rightly notes that “tying reimbursement exclusively to physicians-led models and limiting innovation around care delivery models” is going to reduce supply and curtail potentially useful business model innovation.

This kind of conflict is worth keeping in mind when assessing the activities of the doctors’ cartel in the United States. Most people quite rightly like, admire, and respect the work that medical doctors do. They’re not like coal companies or financial speculators whose core business activities are suspect. But it’s worth remembering that for basically the same reasons that you like, admire, and respect the work of doctors you should also like, admire, and respect the work of nurse practitioners and other health care professionals who aren’r quite as high up on the food chain. These are all hard-working people who cure disease and help the ailing for a living. And many of the key policy conflicts around the supply-side of health care are about pitting one occupational category of health care provider against another occupational category. Doctors as the best-educated and most-skilled members of the health care tribe are naturally going to be the most highly-paid members. But for exactly that reason, you don’t necessarily want them doing all the health care provision or making all the decisions about how money should flow around the system.