Now we're going to look at doctors and nurses, the people who provide frontline patient care in a little bit more detail. When a patient comes into the hospital for a suspected heart attack, they're seen in the emergency room by an emergency room doctor. Sometimes they might get an x-ray and a radiologist would look at the slide. Then they get admitted to the intensive care unit and a intensivist or a hospital based doctor will see them. If they get discharged, they'll see their primary care doctor. There are many, many different doctors in the system. In addition to those, there are surgeons, there are obstetricians and gynecologists, there are pathologists who look at slides and determine diagnoses. There are about 900,000 doctors in the United States. Most of them are based in the office, some around 20% are actually based at the hospital. Then there are a few researchers in the country and about 110,000 doctors in training. Most doctors actually are in small practices of four or more physicians. An increasing number however, are affiliated with hospitals and based at hospitals. Payment to doctors is just as complicated as payment to hospitals. The first thing it involves is something called the CPT code or a current Procedural Terminology code. They classify things doctors do into six different categories such as, radiological procedures, and surgical procedures, and anesthesia, and ENM or evaluation and management procedures for office bates visits. Those different codes are then grouped together under one coherent diagnosis. For example, rule out a heart attack myocardial infarction. Those are grouped under ICD codes, International Classification of Disease codes. We're in the midst of a transition between the ICD-9 and a much more specific and detailed ICD-10 codes. When a group of CPT codes are mixed with ICD diagnosis, they then go to the insurance company who determine how to pay for it. They use something called, the RVU scale or the Relative Value Unit scale. That's composed of three components. First, physician work. The amount of time, skill, and training required to deliver the particular group of services. Second, there are practice expenses, non-physician labor, the facilities they need, any specialized equipment, and other practice expenses. And finally, there's costs of malpractice, the premiums the doctors need to pay for their malpractice insurance. Those three components are then added up and again, adjusted by geography for labor cost, the difference in rental cost. The RVU is a number 3, 6, 34.5 that is then multiply that number by a conversion factor which takes that number into actual dollars and cents. That conversion factor varies by whether it's being paid by Medicare or private insurance. For example, Medicare pays about 34 and a half dollars per RVU. Commercial insurance usually has two different conversion factors, one for medical procedures and a higher one for surgical procedures. Typically, on the RVU scale, surgical procedures and other procedures are paid more, whereas evaluation and management activities, things that happen in physician offices typically get paid less. This has led to a very big financial difference between specialists, and surgeons, and primary care doctors. The difference can be huge. The average income for a primary care doctor is about $200,000. On the other hand, people like spinal surgeons can make over $600,000. Over a 35 year career, that annual salary difference can be as much as $14 million. It doesn't take someone only interested in money to realize, that that will lead to a very big divide between a few number of primary care doctors and a large number of specialists. And in the United States we typically have an imbalance, too few primary care doctors, too many specialists. Most European countries have more primary care doctors and restrict the number of specialists they have. It is one of the big challenges of the American healthcare system that we typically have too few primary care doctors. The number of doctors we have, how we pay doctors, also incredibly complex. But doctors are not the only kind of people that a person with a heart attack will experience in the hospital or in the office. There are also many nurses. The United States we have about 3.6 Million nurses, most of them are registered nurses or RNs. There are a number of licensed practical nurses or LPNs in this country. They frequently work in skilled nursing facilities or nursing homes. In addition, there are more specialized nurse practitioners who have advanced training. Nursing remains a predominantly women's work. Only around 10% of nurses are men. One of the big challenges in the nursing profession going forward is, how much can we entrust of care to nurses? This is called the scope of practice laws. Scope of practice laws is, how much freedom nurses have, are state-based laws they're not set at the federal or national level, and they vary widely across the country. In some states, actually nurse practitioners are given wide latitude and can really work as independent primary care providers. In other states, they're very restricted and must work under a doctor. As we go forward, is going to be one of the big challenges in the country as we try to get more primary care providers and entrust more care of patients to nurses. Next, we're going to look at a variety of other players in the healthcare space. There's home healthcare agencies, hospices, as well as drug and device manufacturers, and regulators. There's just a whole slew of other people involved in healthcare.
