David R. Henderson  

Uwe Reinhardt Nails It

Quiggin the Pacifist?... Internships vs. Apprenticeship...

I posted recently on John Goodman's and Virginia Traweek's post on nurse practitioners. There ensued on his site a lively debate among those who want to allow more room for NPs to practice and those who don't. Uwe Reinhardt, a fairly interventionist health economist from Princeton, weighed in on Goodman's side with two comments. Both were excellent. Parenthetically, one thing I appreciate about Uwe is his sense of humor.

Excerpt from Comment 1 (the whole comment is worth reading):

I would be inclined to say that I fully agree with John on this one, were it not for the fact that, if it was ever leaked that John and I agreed on something, we would instantly lose all our respective friends, including Don McCanne.

The fact, though, is that I have harped on the same theme, in the same manner, for over three decades now, influenced in good part by Milton Friedman's classic little book CAPITALISM AND FREEDOM. Additionally, my attitude on this one probably can be traced to the fact that my mother used a midwife rather than a doctor when I was born and, as everyone I hope would agree, I am living proof that midwives can produces truly superb babies.

I recall serving on an Institute of Medicine study panel on dental care just as President Reagan had ascended to the White House. A certain HANES study had found a huge unmet need for basic dental care among poor American children. Quite innocently, as a young punk economist, I proposed that, in the face of a shortage of dentists, we should let dental nurse practitioners on the New Zealand model do straightforward drilling and filling, in their own practice. A blind study in Canada which I cited had shown that on average well trained dental nurses actually did a better job (on school-age children) in simple drilling and filling than did dentists. My plea fell on deaf ears, whereupon I wrote a 30 page minority report that, alas, did not make its way into our study panel's final report. I must have stepped on someone's toes, I reckon.
. . .

One does not have to be a cynical economist to smell a rat upon realizing that most professional licensing laws are composed and legislated at the behest of the professionals themselves, rather than their customers. Paul Feldstein used to have a whole chapter on that in his text on health economics.

I also remember the huge and amusing fight over the question whether opticians should ever be allowed to dilate pupils.

Anecdotes on poor quality of NP care on this blog do not persuade me. There are plenty of anecdotes of poor care among physicians as well.

So, I cheer you on, comrade John, in this march for professional freedom. In the end we will win this fight.

Comment 2:

Response to politicaldoc, Oct. 18:

John and I are not arguing that NPs have the same training and range of professional competence as do physicians. That would be patently absurd. GPs do not have the same training as neurosurgeons or OB/Gyns either.

But we are economists, and as such we always compare some baseline policy -- the status quo -- against a new policy.

The baseline is that many people just cannot afford to see MDs for less severe illnesses or simply can't access one for other reasons (e.g., rural areas).

The alternative we are espousing is to allow NPs to hang up a shingle that says NP, not MD. Friedman would make it illegal for an NP to hang up a shingle with MD on it.

So the choice we see -- especially for poor or rural patients -- is either no care (but theoretically only from an MD) or some relief, albeit from an NP.

After all, we send NPs out into the field with our combat platoons, not MDs. Ditto for ambulances.

There is no reason why NPs should not be electronically connected to MDs at a medical center or in a clinic, but they is also no reason why they should be made economically subservient to MDs.

They should be allowed to compete with doctors, within the more limited scope of practice for which they are trained.

His second comment is especially well stated.

Comments and Sharing

COMMENTS (10 to date)
Silas Barta writes:

I find it amusing to read this praise of Reinhardt, having just found out that he never heard of the Broken Window fallacy in his entire career up to that point, and had to rediscover it himself.

Glad to see he was able to get this issue right without having been exposed to such a concept before.

David R. Henderson writes:

@Silas Barta,
If we think highly of Bastiat for figuring this out (as I do and, I think, you do), then shouldn’t we think highly of Reinhardt for figuring it out? I sense, although I may be wrong, a certain unwillingness on your part to take yes for an answer.

Becky Hargrove writes:

I find this exposure of healthcare realities bracing and hopeful. Now if only there were presidential candidates that could talk about such issues without getting muzzled by the press, other candidates and institutions such as the AMA.

Chris Koresko writes:

David Henderson: Uwe Reinhardt, a fairly interventionist health economist from Princeton, weighed in on Goodman's side with two comments. Both were excellent. Parenthetically, one thing I appreciate about Uwe is his sense of humor.

Is there more of his writing that you would recommend?

PS: I agree with you that discovering a seemingly basic but profoundly important principle on one's own is more impressive than having learned it early on from someone else. On the other hand, his being unaware of it previously might call his earlier work into question.

nzgsw writes:

Actually, we send our Marines into the field with the civilian equivalent of LVNs or LPNs, not NPs. Corpsmen still have to get a university degree to become an RN, and a further graduate-level degree to become an NP.

David R. Henderson writes:

So that makes Reinhardt’s point even stronger, right?

Bryan Willman writes:

I wonder if should make a rule that in exchange for restrictive licenses, universal service is required.

That is, MDs are required, by law, to work practices in ill served places for some time. (Not forever.)

So are plumbers.

It would be different from "pro bono" - the plumber or physician or lawyer working on the pine ridge reservation, or in the dumps of some rude city, would still get paid, perhaps even subsidized.

We have "universal service" rules for telephone service, why not for medicine.

(Because, as a realistic matter, licensing for parties like MDs isn't going away.)

nzgsw writes:

Dr. Henderson,

Indeed it does strengthen the point. And in many cases, I would feel better about the treatment I'd receive from my brother-in-law (a Navy corpsman deployed with the Marines in Afghanistan) than many of my wife's colleagues (RNs), especially the "fresh out" RNs.

Richard F. Belloff, DBA writes:

Reinhardt co-wrote a journal article a few years back entitled: "It's the prices stupid." The jist of the article is that the USA's health care cost issues are largely related to unit prices for services and NOT over utilization, on a compartive basis to other developed countries.

My own research suggests the same and I think it is a pretty easy leap to suggest that cartels are partly causative.

Walter Sobchak writes:

What we want to have happen and what will happen are two entirely different things. I have no opinion about what should happen, because I do not know enough about the subject.

I do observe what is going on around me.

First, the medical world is subject to the same division of labor economies as the rest of the world. Fans of the tv show "House", know that there is a scene in almost every episode where the young doctors take the patient to a laboratory and run a test.

Here in the real world, it has been years since an MD has done something like that. I have been to many doctors both for myself and as the parent or guardian of loved ones. All of the tests and many of the treatments are administered by technicians. X-rays -- tech, blood draws -- tech, stitches -- tech (something I found out when I took a child to the pediatricians office for a gash. We were sent to the hospital).

Secondly, My nephew just graduated from a well known Medical School as an MD. 95% of his graduating class is pursing specialty training. Most family practice and pediatric residencies are filled by DOs, foreigners, and low ranked grads of lower tier Medical Schools.

Third, there will be continuing pressure to lower the cost of and expand access to medical care.

If I had to guess what will happen, I would guess that NPs will be set free and MDs will be even harder to find. There will be some legislative battles, but I think supply and demand and division of labor will win out.

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