A Clinical Look at Clinical Doctorates

[Taurus]

Interesting read. As I've said before, I don't think the DNP will increase scope or pay; it will just increase the degree holder's loan debt and raise the ire of physicians.

http://chronicle.com/free/v52/i46/46b01201.htm

A Clinical Look at Clinical Doctorates
By WILLIAM L. SILER and DIANE SMITH RANDOLPH

Universities complain about clinical doctorates, arguing that degrees like doctor of pharmacy represent little more than degree creep and are not equivalent to, say, the Ph.D. or M.D. But few institutions have done much more than complain, instead coming to rely on the revenues clinical programs bring them — especially given that many students in those programs pay tuition over a longer period than do students earning bachelor's or master's degrees in the same fields. And clinical doctorates have become increasingly established over time.

The doctor-of-pharmacy degree, created in 1950, has served as a model for clinical doctorates in other fields. The American Council on Education began its justification for the new degree with the fact that the body of pharmacological knowledge was expanding, and mastering it required enough credit hours to merit a doctorate. The ACE also noted that pharmacists were practicing in new settings such as retail chains like Walgreens, and dealing with new diagnoses and new drugs. Finally, the council argued that pharmacology's status among other health-care professions required that its practitioners be called "Doctor."

Since 1950 other professions have created or considered clinical doctorates, such as doctors of audiology, nursing, occupational therapy, and physical therapy. Most of the professions use arguments like those for the pharmacists, with some recent additions: that the clinical doctorate will help practitioners work without requiring referrals by physicians, and it will allow them to charge more for their services.

Those new arguments are intriguing because they suggest that it is the degree, rather than the profession, that commands respect and recognition. In fact, clinical doctorates have so far had little effect on status, compensation, or reimbursement. There is even mounting evidence that the pharmacy doctorate, for example, has led to growing job dissatisfaction as the expectations of new practitioners clash with the realities of American health care — like the fact that insurance companies pay for the kind of service provided, rather than the educational level of the provider.

Some professional organizations have pushed for clinical doctorates even though their members oppose the degrees, on the basis that the doctorates are good for the professions. Established practitioners with only a bachelor's degree may oppose the introduction of a clinical doctorate because they feel their experience makes them more qualified than a new graduate with a higher degree.

One response to objections from practitioners is a transitional degree, which awards them a doctorate for taking a few courses after having worked in the field with the required bachelor's or master's degree. Because transitional degrees are given to people who are already licensed professionals, accrediting bodies generally feel that reviewing the degrees is outside their scope; thus the degrees are seldom evaluated.

On the other hand, professions typically try to ensure the quality of new professionals by requiring them to pass a licensing exam, and by allowing only graduates of accredited programs to take the exam. Many universities have been willing to offer clinical doctorates, in spite of their reservations about the degrees' academic credibility, because they fear if they do not, students in the field will attend other universities that do.

Employers who hire new practitioners often oppose clinical doctorates. The professions frequently explain that position away as a result of corporate greed, claiming that industry is willing to place corporate profits above the quality of patients' care. But employers point out that they are reimbursed for clinical services, not according to the degrees held by their clinicians. Employers also argue that if new holders of clinical doctorates do make more money than graduates a few years ago with lower degrees, that is not because of their increased education, but because of the growing shortage of clinicians — which is being exacerbated by the increased length of time it takes to earn a clinical degree.

So far, few people have investigated the clinical doctorates' implications for the public health of Americans, but it is easy to argue that the degrees could have unintended adverse effects.

First, the explosion of those doctorates threatens research, which is particularly important today with the growing emphasis on evidence-based medicine. The doctorate programs require minimal research from their students, unlike Ph.D. programs, and as colleges and universities scramble to maintain their share of the student market, they push professors' research activities further down on the list of the programs' priorities.

The programs also find themselves scrambling to get many of their faculty members a doctoral degree — any doctoral degree — as quickly as possible. Professors who themselves lack Ph.D.'s and who choose to get clinical doctorates learn little in the process about conducting research or advising students who seek research opportunities.

Second, because clinical doctorates require more time and thus tuition than a bachelor's or master's degree, doctorate programs may reduce the number of new graduates at a time when health-care workers are in increasingly short supply. The market may respond by using assistants and technicians to provide more clinical services, deploying people with higher credentials as supervisors and administrators. That has already begun to happen in the field of pharmacology, and job satisfaction and morale are declining because practitioners have less chance to use their clinical expertise and interact with patients.

Third, the increased time and cost involved may also exacerbate health-care disparities in our society. Few health-care professionals now come from minority populations, whose members are much better represented at the level of technician or aide, and students from those groups may be less able to afford the longer educational programs than are students from more-advantaged populations. If minority students see assistant positions as good employment opportunities that are easier and cheaper to get, we may reinforce the pattern of having minority assistants provide the actual services to patients, while supervisors come from more-privileged backgrounds. And given that students from underserved areas are more likely to return to practice in those areas, decreasing the number of minority students could make health care even less available there.

Professional organizations want to raise the status of their professions; universities want their enrollments to increase, or at least not to decline. Neither side can objectively evaluate clinical doctorates.

At the turn of the last century, the medical profession had the vision and integrity to ask the Carnegie Foundation for the Advancement of Teaching to study medical education, with the goal of strengthening it. The result was the landmark report of the Flexner Commission, which recommended standardization of medical-school programs. It's time to have a similar external study of clinical doctorates, to establish uniform criteria for them and for the professions that offer them.

William L. Siler is associate dean for research and an associate professor of physical therapy, and Diane Smith Randolph is an assistant professor of occupational therapy, at Saint Louis University's Doisy College of Health Sciences.

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[deleted6669]

I saw a pt today and told them I was a PA. they said" oh, are you like one of those NP nursing physicians".....sigh.....

 

[fab4fan]

Where I'm from, we'd just think you saying you were a Pennsylvanian.

I saw a pt today and told them I was a PA. they said" oh, are you like one of those NP nursing physicians".....sigh.....

 

[MacGyver]

Finally, the council argued that pharmacology's status among other health-care professions required that its practitioners be called "Doctor."

Once you eliminate all the bull**** smoke and mirrors, THIS is what its all about. Its what the NPs want, its want the PAs want, its what everybody wants.

Everybody wants what we got. They're all so ****ing jealous of us they cant stand it and want to get a piece of the action.

All the rest is just bull**** rhetoric.

 

[prairiedog]

Interesting read. As I've said before, I don't think the DNP will increase scope or pay; it will just increase the degree holder's loan debt and raise the ire of physicians.

http://chronicle.com/free/v52/i46/46b01201.htm

A Clinical Look at Clinical Doctorates
By WILLIAM L. SILER and DIANE SMITH RANDOLPH


There is even mounting evidence that the pharmacy doctorate, for example, has led to growing job dissatisfaction as the expectations of new practitioners clash with the realities of American health care — like the fact that insurance companies pay for the kind of service provided, rather than the educational level of the provider.
Employers who hire new practitioners often oppose clinical doctorates. The professions frequently explain that position away as a result of corporate greed, claiming that industry is willing to place corporate profits above the quality of patients' care. But employers point out that they are reimbursed for clinical services, not according to the degrees held by their clinicians. .

William L. Siler is associate dean for research and an associate professor of physical therapy, and Diane Smith Randolph is an assistant professor of occupational therapy, at Saint Louis University's Doisy College of Health Sciences.

Is this true? Insurance companies pay for the service not the educational level? I was under the impression a PA often (not always) received less for the same service performed by a MD? If not, why is there “incident to” reimbursement?

 

[deleted6669]

Is this true? Insurance companies pay for the service not the educational level? I was under the impression a PA often (not always) received less for the same service performed by a MD? If not, why is there “incident to” reimbursement?

medicare( and someother insurance providers but not all) reimburse pa and np charges at 85% of the md rate if no physician is involved in the case. if a doc is involved you can bill at 100%. for example on a multisysten trauma pt the doc stabilizes the pt and the pa sutures a bunch of complex lacs- this would bill at the physician rate as an md was involved with the case even though they are not directly supervising.

 

[core0]

Is this true? Insurance companies pay for the service not the educational level? I was under the impression a PA often (not always) received less for the same service performed by a MD? If not, why is there “incident to” reimbursement?

I agree with what EMEDPA stated. However the statement is generally correct that insurance pays for the service not the educational level. The difference between PA/NP payment and physician payments comes from practice cost analysis done in the 1990s. At that time physicians had significantly more debt and malpractice costs than PA/NPs so this is the basis of the difference. Incident to reimbursement is 100% since the physician is involved in the initial encounter therefore the practice incurs all the "costs" associated with that encounter.

David Carpenter, PA-C

 

[Taurus]

Also keep mind that if rules are changed so that a service is reimbursed at the same rate no matter the degree level, then that would create an incentive for a "race to bottom". People would find the degree that is the easiet and quickest to complete but not necessarily best for the patient. It's human nature to want to do the least amount of work to get the same reward. At this point, I see that as the NP degree which is all over the map in regards to quality. There's something wrong with an advanced clinical degree if you can get it online. I really doubt the govt wants a race to the bottom situation. The govt wants clinicians who are competent and will maintain healthcare quality.

 

[prairiedog]

I agree with what EMEDPA stated. However the statement is generally correct that insurance pays for the service not the educational level. The difference between PA/NP payment and physician payments comes from practice cost analysis done in the 1990s. At that time physicians had significantly more debt and malpractice costs than PA/NPs so this is the basis of the difference. Incident to reimbursement is 100% since the physician is involved in the initial encounter therefore the practice incurs all the "costs" associated with that encounter.

David Carpenter, PA-C

Thus, if insurance pays for the service provided why would an agency not hire more PAs? Isn't a PA salary significantly less than a MD (usually about 1/2 of a MD?)

 

[core0]

Thus, if insurance pays for the service provided why would an agency not hire more PAs? Isn't a PA salary significantly less than a MD (usually about 1/2 of a MD?)

The first is that the providers are not equivalent. While there may be individual variation, in general a PA of given experience will not handle the same type of patients as a physician of given experience.

The second is the practice model. Most practices are owned by physicians. There need to be sufficient physicians to take call and provide backup for PAs (I have used PAs here but in most practice this applies to NPs also. While NPs may not need "supervision" the practice is still liable for any decision that they make so a smart practice has backup). It is rare for PAs/NPs to be partners. There generally comes a point in a practice where taking another partner will "divide the pie" further without bringing in more income for a practice. At this point it frequently becomes beneficial to look at hiring a NPP instead of another physician. Any practice has to look at the overall practice mix. There are some practices that have a high proportion of NPPs to physicians while other practices have few NPPs per physician.

It also has to do with the distribution of NPPs within medicine. While PAs originally were intended to do primary care medicine, currently more than 1/2 of PAs work in either specialty care or surgery. Here the difference between PA and physician salary is greater, but the benefit to the practice is also greater.

When you talk about agencies as opposed to practices then you do see more NPPs used compared to private practice. Kaiser and VA are some of the biggest employers of PAs. In a capitated model NPPs provide the most bang for the buck as long as they are capable of handling the payor mix.

If you look at a non-insurance model the "minute clinic" use NPPs exclusively. On the other hand that model would be a waste to use a Physician (or a PA in my opinion).

David Carpenter, PA-C

 

[Taurus]

While NPs may not need "supervision" the practice is still liable for any decision that they make so a smart practice has backup).

This is a good point. Lawyers wouldn't waste time going after a single NP because there's not enough assets to make it worthwhile. However, a smart lawyer will go after the entire independent NP practice, especially one that is generating significant revenue. Now that's a worthwhile target.

 

[deleted87716]

Lawyers wouldn't waste time going after a single NP because there's not enough assets to make it worthwhile.

All that's needed is a malpractice insurance policy. Personal assets are practically never a factor.

However, a smart lawyer will go after the entire independent NP practice, especially one that is generating significant revenue. Now that's a worthwhile target.

Malpractice cases are typically filed against individuals, not entire practices. Assets and/or revenue are not usually relevant to a malpractice case.

 

[core0]

All that's needed is a malpractice insurance policy. Personal assets are practically never a factor.



Malpractice cases are typically filed against individuals, not entire practices. Assets and/or revenue are not usually relevant to a malpractice case.

Actually when the provider is a employee not a partner the practice is frequently named. While NPs may be "indpendent" providers that assumes they are working within their scope and education. The newest trend is to sue for NPs working outside their scope. For example an FNP doing inpatient work. If you can "prove" that they are outside the scope of practice then you can turn it from a med mal case into a straight liability case which escapes the med mal pain and suffering limits. This has been done in Louisiana and Texas that I am aware of.

I have also seen practices roped into malpractice cases when physicians or other providers are employees. My understanding is that the practice retains some liability for the actions of employees. Most practices keep fairly high liability policies (that cover all employees ie nurses etc.)

David Carpenter, PA-C

 

[Taurus]

All that's needed is a malpractice insurance policy. Personal assets are practically never a factor.

Malpractice cases are typically filed against individuals, not entire practices. Assets and/or revenue are not usually relevant to a malpractice case.

Lawyers are after anything with the deepest pockets, no matter how slightly involved they are. A savvy lawyer will sue the NP and the NP practice that the NP works for and then see what they can get. It's the throw everything on the wall and see what sticks approach.

If NP's want to claim they're equivalent to physicians, let them face the same challenges and consequences. These NP's better know what is the standard of care when it comes to diagnosis and treatment because the lawyers will probably get some dept chairman in that medical specialty as a witness against them. The excuse, "well, I didn't know because I'm just a nurse" won't fly. If you didn't know, then why are you diagnosing and treatmenting without supervision?

 

[prairiedog]

The first is that the providers are not equivalent. While there may be individual variation, in general a PA of given experience will not handle the same type of patients as a physician of given experience.

The second is the practice model. Most practices are owned by physicians. There need to be sufficient physicians to take call and provide backup for PAs (I have used PAs here but in most practice this applies to NPs also. While NPs may not need "supervision" the practice is still liable for any decision that they make so a smart practice has backup). It is rare for PAs/NPs to be partners. There generally comes a point in a practice where taking another partner will "divide the pie" further without bringing in more income for a practice. At this point it frequently becomes beneficial to look at hiring a NPP instead of another physician. Any practice has to look at the overall practice mix. There are some practices that have a high proportion of NPPs to physicians while other practices have few NPPs per physician.

It also has to do with the distribution of NPPs within medicine. While PAs originally were intended to do primary care medicine, currently more than 1/2 of PAs work in either specialty care or surgery. Here the difference between PA and physician salary is greater, but the benefit to the practice is also greater.

When you talk about agencies as opposed to practices then you do see more NPPs used compared to private practice. Kaiser and VA are some of the biggest employers of PAs. In a capitated model NPPs provide the most bang for the buck as long as they are capable of handling the payor mix.

If you look at a non-insurance model the "minute clinic" use NPPs exclusively. On the other hand that model would be a waste to use a Physician (or a PA in my opinion).

David Carpenter, PA-C

I am missing your point. I understand the providers are not equilivant. I am asking about the service provided. If I am seen for a sore throat and the charge is $75 for the service would there be an extra charge for the education? I also understand that PA and MD may not see the same type of patients with the more complex going to the MD. Yet, when reimbursement is for a “service” I think you indicated earlier, education has no impact on the reimbursement.

 

[lawguil]

Such a valid article in my opinion with such economic consequences.

At my place of employment, we don't recognize the clinical doctorate degrees - although we award them.

Terminal degree = PhD or EdD

Vocational fields = nothing except teaching other vocational students.

 

[Taurus]

I am missing your point. I understand the providers are not equilivant. I am asking about the service provided. If I am seen for a sore throat and the charge is $75 for the service would there be an extra charge for the education? I also understand that PA and MD may not see the same type of patients with the more complex going to the MD. Yet, when reimbursement is for a “service” I think you indicated earlier, education has no impact on the reimbursement.

If the copay is the same for seeing a physician or an independent NP, which one do you think most people would pick? Most people understand there is a big difference in the quality of care delivered between someone who has been trained rigorously in medicine for nearly a decade versus someone who has been trained less rigorously for just 2 years. The depth and breadth of knowledge just doesn't compare. An NP may think that most people coming in with heartburn type pain is just GERD while a physician may recognize as a symptom of MI when the entire H&P is taken into account.

I've read serveral stories on SDN and I have seen patients who were misdiagnosed by NP's for something quite obvious. When the treatment that the NP prescibed didn't work, then patients go to the physicians and the NP never knows that they screwed up. They think they're doing a great job and should be considered just as good as physicians. Patients don't always have a second chance to seek a physician later on if the condition is a life-threatening one like an MI or DKA.

 

[rocktor30]

So, do people here actually have an operational understanding of how medicine is reimbursed or are you guys speaking from suppositions? It's amazing that no one here who's spoken on reimbursement has mentioned RVUs, DRGs, RBRVS, AMA, CMS, etc.

And, core0, KentW is correct when it comes to lawsuits. Policies and individuals are the most frequently named defendants in med mal cases. It is very tough to win a judgement against an entire institution and the cost/benefit for the prosecution is just not attractive unless the insitution as a whole is shoddy with a bad rap sheet / or the case is irreputably one of absurdly profound negligence. And do not be naive to think that you cannot be named in a case. Every person holding a license to practice some form of healthcare must have an individual insurance policy, even if the premiums are paid for by the employing institution. It is the law. Also, NPs are never "independent" practitioners, they must alwasy have "supervision" (read, the clinical director of their workplace MUST be an MD, even if not on site).

 

[core0]

I am missing your point. I understand the providers are not equilivant. I am asking about the service provided. If I am seen for a sore throat and the charge is $75 for the service would there be an extra charge for the education? I also understand that PA and MD may not see the same type of patients with the more complex going to the MD. Yet, when reimbursement is for a “service” I think you indicated earlier, education has no impact on the reimbursement.

In the case that we were speaking about we were talking about it was insurance payment. The reimbursement in this case is from the insurance company (or medicare) which sets the payment. Medicare which is a take it or leave it proposition says that they pay 85% of the physician fee for NPP. The basis for this is the lesser costs. Medicare assumes that you will not be seeing someone that is outside your scope. In addition the payments assume that physicians are seeing higher acuity patients (which is born out in billing data).

If you are talking cash only basis, you will find that physicians charge more than NPPs. If you look at the models for minute clinic type operations, the ones that use Physicians only (one company that I am aware of) charge about 50% more than the companies that use NPPs. This is probably due to the differences in salaries.

For most medical consumers the co pay is a small part of the bill. The real costs of medicine are largely invisible.

David Carpenter, PA-C

 

[core0]

So, do people here actually have an operational understanding of how medicine is reimbursed or are you guys speaking from suppositions? It's amazing that no one here who's spoken on reimbursement has mentioned RVUs, DRGs, RBRVS, AMA, CMS, etc.

RVUs are essentially irrelevant in most medical practices. CPT codes and ICD-9 codes are what insurance companies pay on. There is a relationship between RVUs and CPT codes but the average provider really has no control over RVUs.

And, core0, KentW is correct when it comes to lawsuits. Policies and individuals are the most frequently named defendants in med mal cases. It is very tough to win a judgement against an entire institution and the cost/benefit for the prosecution is just not attractive unless the insitution as a whole is shoddy with a bad rap sheet / or the case is irreputably one of absurdly profound negligence. And do not be naive to think that you cannot be named in a case. Every person holding a license to practice some form of healthcare must have an individual insurance policy, even if the premiums are paid for by the employing institution. It is the law. Also, NPs are never "independent" practitioners, they must alwasy have "supervision" (read, the clinical director of their workplace MUST be an MD, even if not on site).

You should look up Darling vs. Charleston Memorial Hospital. This was the case that set up hospital liability for their staffs. This has been extended to medical practices. This generally does not apply to partners but does apply to employees. When you get ready to apply for staff privileges you will have to prove yourself all over again. As a physician you will have an unlimited license to practice medicine or surgery. You will be restricted on inpatient work by your training but there is no restriction on what you can do on outpatient work.

NPs on the other hand have a scope of practice as nurses that relates to their training as NPs. Operating outside the scope of practice has a much lower standard than if they are operating inside the scope. The published scope for most NP practices is incredibly ill defined. If the lawyer can show that the NP is outside their scope then the liability is to the NP and to the corporation or hospital for allowing them to practice outside the scope. This is the basis of liability that most corporations are worried (or should be) about.

As far as NPs practicing independently, you should also read many of the posts here. NPs can practice without any physician involvement in 8 states. They need a collaborating physician to bill for medicare. About 2% of NPs practice in this model.

David Carpenter, PA-C

 

[rocktor30]

Medicare which is a take it or leave it proposition says that they pay 85% of the physician fee for NPP. The basis for this is the lesser costs. Medicare assumes that you will not be seeing someone that is outside your scope. In addition the payments assume that physicians are seeing higher acuity patients (which is born out in billing data).

If you are talking cash only basis, you will find that physicians charge more than NPPs. If you look at the models for minute clinic type operations, the ones that use Physicians only (one company that I am aware of) charge about 50% more than the companies that use NPPs. This is probably due to the differences in salaries.

For most medical consumers the co pay is a small part of the bill. The real costs of medicine are largely invisible.

David Carpenter, PA-C[/quote]

Yes, I fully understand medicare reimbursment, but clearly you missed my point. Do you know how medicare sets fee schedules? If not, then you cannot participate in a discussion as to they why MDs are reimbursed higher than NP, PAs, etc. Merely reinstating that the fees for ancillary services are set at 85% is not satisfactory. ANd all would be wise to know that private insurance companies, which include HMOs, take their cue on reimbursment DIRECTLY from medicare fee schedules.

 

[core0]

Yes, I fully understand medicare reimbursment, but clearly you missed my point. Do you know how medicare sets fee schedules? If not, then you cannot participate in a discussion as to they why MDs are reimbursed higher than NP, PAs, etc. Merely reinstating that the fees for ancillary services are set at 85% is not satisfactory. ANd all would be wise to know that private insurance companies, which include HMOs, take their cue on reimbursment DIRECTLY from medicare fee schedules.

I do fully understand how Medicare sets fees. I work on one of the work committees that advises a specialty organization on RVUs. It is set out quite clearly in the Medicare fee schedule. As I stated earlier the way that Medicare determined the fee schedule for NPPs was by taking the costs of the practice including the debt of the physician. The analysis was done in the 1990s if I remember correctly and predated allowing NPs to charge for inpatient work as part of the revised 1999 HCFA changes in billing. This also changed incident to rules and qualifications for PAs and NPs.

David Carpenter, PA-C

 

[rocktor30]

Medicare did not determine the fee schedule for NPs. The Medicare Physician Payment Schedule and RVUs associated with evaluation and management services most commonly reported by NPs was developed under the assumption that the "physician work component" be provided by a physician. Reimbursing NPs and PAs at 85% was an arbitrary decision on behalf of CMS.

I believe the analysis you are referring to from the 1990's is the development of the indirect practice cost allocations, which CMS factors into the total practice expense calculation. You are correct that this portion of practice expense (roughly half of practice expense) was developed in the 1990s - based on the 1999 AMA Socioeconomic Monitoring Survey (which itself was based on 1997 data) and is medical specialty-specific. However, the remaining half of practice expense, direct practice expense, is based on data that is no more than 2 years old at the time a code is reviewed by the RUC.

RVUs are essentially irrelevant in most medical practices. CPT codes and ICD-9 codes are what insurance companies pay on. There is a relationship between RVUs and CPT codes but the average provider really has no control over RVUs.

This makes no sense - I think you are confusing CPT/ICD/RVU. RVUs form the basis of physician reimbursement. RVUs are associated with CPT codes (ICD-9 codes are merely codification of diagnoses, for which no reimbursement is associated). It is true that the average provider has no control over RVUs, but, rest assured, RVUs are used to calculate payment for physician services in nearly every payor system.

I think any discussion of practice expense or physician debt, is moot because NPs and PAs would only get paid on the physician work RVUs.

That being said, PAs and NPs who bill are, in fact, placed into a separate category of "non-physician" providers.

Moreover, some non-physician providers can bill Medicare independently (not NPs or PAs) and value their own "work" through the Health Care Professionals Advisory Committee (HCPAC) which has representation on the RUC.

Medicare reimbursement, therefore, is dependent on level of education.

Thanks for the reference on Darling v. Charleston Memorial. For a more complete picture, refer to the tenets of vicarious liability, respondeat superior, and apparent agency - section 409 of the Restatement (Second) of Torts. A nice case that puts this all together is Roessler v. Novak 858 So.2d 1158 (Fla. 2003)

 

[MacGyver]

lawyers will probably get some dept chairman in that medical specialty as a witness against them.

Wont work, nurses already have that covered.

1) According to state nursing boards and state nursing laws, no matter what a nurse does, its considered the practice of "nursing" not "medicine"

2) Therefore to take an NP to court means that MD expert testimony is not allowed and you have to have an NP testify against them.

 

[core0]

Wont work, nurses already have that covered.

1) According to state nursing boards and state nursing laws, no matter what a nurse does, its considered the practice of "nursing" not "medicine"

However nurses are held to the community standard of care. For RNs that is a nursing standard. For NPs it is a medical standard. In general the courts don't care what the nursing board thinks except in regard to scope of practice and licensure.

2) Therefore to take an NP to court means that MD expert testimony is not allowed and you have to have an NP testify against them.

Again incorrect. You can get anyone to testify. Whether that expert testimony is allowed is the real question. Since you are dealing with community standard of care, it is frequent to have MDs testify in cases regarding NPs. Just as it would be appropriate for Anesthesiologists to testify in cases with CNRAs. Generally since NPs do not have the same level of training as a physician they are not allowed to testify about medical practice of physician (although some have tried).

David Carpenter, PA-C

 

[MacGyver]

Again incorrect. You can get anyone to testify. Whether that expert testimony is allowed is the real question. Since you are dealing with community standard of care, it is frequent to have MDs testify in cases regarding NPs. Just as it would be appropriate for Anesthesiologists to testify in cases with CNRAs. Generally since NPs do not have the same level of training as a physician they are not allowed to testify about medical practice of physician (although some have tried).

David Carpenter, PA-C

A doctor cant testify about the practice of "nursing" and like it or not, the state nursing boards have SOLE AUTHORITY to define what "nursing" is

 

[core0]

Medicare did not determine the fee schedule for NPs. The Medicare Physician Payment Schedule and RVUs associated with evaluation and management services most commonly reported by NPs was developed under the assumption that the "physician work component" be provided by a physician. Reimbursing NPs and PAs at 85% was an arbitrary decision on behalf of CMS.



For what its worth the Medicare Payment Advisory Committee agrees that it is somewhat arbitrary but feels that more research is needed before changing:
"Given the design of Medicare's payment system for physician services, we cannot assess the appropriateness of the current 85 percent payment differential for NPs, PAs, and CNSs. A payment differential is appropriate if NPPs and physicians are producing a different product. We cannot judge whether NPPs are producing the same product as physicians, however. On the one hand, studies have shown comparable patient outcomes for the services provided by NPPs and physicians, which argues against a differential. On the other hand, the payment system's billing codes are too imprecise to capture what may be subtle differences between the services provided by the two types of practitioners. We conclude, therefore, that further study is necessary before the 85 percent payment differential is changed."
The full report can be found here:
http://www.medpac.gov/publications/congressional_reports/jun02_NonPhysPay.pdf


I believe the analysis you are referring to from the 1990's is the development of the indirect practice cost allocations, which CMS factors into the total practice expense calculation. You are correct that this portion of practice expense (roughly half of practice expense) was developed in the 1990s - based on the 1999 AMA Socioeconomic Monitoring Survey (which itself was based on 1997 data) and is medical specialty-specific. However, the remaining half of practice expense, direct practice expense, is based on data that is no more than 2 years old at the time a code is reviewed by the RUC.

RVUs are essentially irrelevant in most medical practices. CPT codes and ICD-9 codes are what insurance companies pay on. There is a relationship between RVUs and CPT codes but the average provider really has no control over RVUs.


This makes no sense - I think you are confusing CPT/ICD/RVU. RVUs form the basis of physician reimbursement. RVUs are associated with CPT codes (ICD-9 codes are merely codification of diagnoses, for which no reimbursement is associated). It is true that the average provider has no control over RVUs, but, rest assured, RVUs are used to calculate payment for physician services in nearly every payor system.


What I meant by this is the average practice or physician has no real control over what the RVUs are for a different CPT.

I think any discussion of practice expense or physician debt, is moot because NPs and PAs would only get paid on the physician work RVUs.

There was some methodology to the initial study. It mainly looked at the difference in practice expenses. MPFS is calculated by the RVU, Geographic Cost Index and the conversion factor. There are three separate categories for RVUs; physician work, malpractice and practice expense. I cannot find the article that described the process but at that time the physician debt was regarded as a practice expense (although not directly reimbursed) and the malpractice RVU for NPPs is significantly less than physicians.

That being said, PAs and NPs who bill are, in fact, placed into a separate category of "non-physician" providers.

That actually predates the balanced budget act of 1997 which codified payments for NPs and CNS in hospitals and balanced the NP and CNS payments which ranged from 60% to 80% of the physician fees. Interestingly CNM payments were left unchanged at 65%.

Moreover, some non-physician providers can bill Medicare independently (not NPs or PAs) and value their own "work" through the Health Care Professionals Advisory Committee (HCPAC) which has representation on the RUC.

Medicare reimbursement, therefore, is dependent on level of education.

Thanks for the reference on Darling v. Charleston Memorial. For a more complete picture, refer to the tenets of vicarious liability, respondeat superior, and apparent agency - section 409 of the Restatement (Second) of Torts. A nice case that puts this all together is Roessler v. Novak 858 So.2d 1158 (Fla. 2003)

There has been no implicit determination that payment is determined by education. To look at this from a physician standpoint a fellowship trained physician seeing a patient gets no more reimbursement for seeing a patient than a non-fellowship trained physician. So clearly among physicians there is no differentiation by education.

Instead reimbursement it is differentiated (in my opinion) by the difference in perceived work value and practice expense. It is unlikely to change since any changes have to be revenue neutral and the expense would have to come from somewhere. Medicare could change the RVU by calculating malpractice and practice expense RVUs separately for NPPs but that would be a nightmare since they seem to have problems with physician practice expenses and malpractice.

I am not sure what Roessler v. Novak has to do with this. It seems to deal with independent contractors and hospitals. I am not a lawyer, but Darling established the liability for hospitals for acts preformed by medical staff. It codifies that preforming credentialing makes the hospital liable for allowing someone to operate outside of their scope (at least thats my non lawyer understanding).

David Carpenter, PA-C

 

[rocktor30]

There has been no implicit determination that payment is determined by education. To look at this from a physician standpoint a fellowship trained physician seeing a patient gets no more reimbursement for seeing a patient than a non-fellowship trained physician. So clearly among physicians there is no differentiation by education.

Apples and organges, here. You and I are not having a discussion about reimbursement between different physician groups, so this is irrelevant and does nothing to prove your point. We are having a discussion about physician and non-physician reimbursement. There is a difference in valuation of services provided by MDs and people who are not MDs. Your own research and statements prove this: and it is "implicit" (implied). I think you meant to say it is not explicitly described.

Instead reimbursement it is differentiated (in my opinion) by the difference in perceived work value and practice expense.

Sigh. I am now tired because after that lengthy discussion, you still seem more intent on arguing based on opinion and not the facts - mainly because the facts have been shown to defeat this assumption.

So if we are going to argue based on our opinions, here it is:

You are not a doctor. You may try as best you can to convince the world of this, and I will be right there making sure the facts are always presented correctly and in plain sight. I have a stronger scientific background, longer clinical training, and have sacrificed more and worked harder than you. Your 18 months of training will never give you the expertise of the 7+ years ALL MDs must endure.

I can say this with positivity because I was an RN for 6 years, and went to NP shcool, and used to complain about how unfairly NPs get treated, too. But the fact of the matter is, there is no comparison in the level of educational sophistication between the ancillary services and MDs. Your schooling is just not even in the same league. You simply haven't earned the right to earn as much money or be provided with the same responsibility, just because you have physically worked in a hospital for any number of years. If you think your training and knowledge rivals that of physicians, I feel sorry for you and find you an even greater danger to the public.
(In my life, I have found that people who want professional equality without working for it, usually have some proverbial chip on their shoulder that makes it impossible for them to attain higher goals.)

Instead of whining about how unfair the system is, try putting in some grueling training. Quit your b****ing and go get a medical degree. Your lazyness or fear of facing that education should not be rewarded with disproportionate benefits.

I am signing off this thread now.....

 

[core0]

There has been no implicit determination that payment is determined by education. To look at this from a physician standpoint a fellowship trained physician seeing a patient gets no more reimbursement for seeing a patient than a non-fellowship trained physician. So clearly among physicians there is no differentiation by education.

Apples and organges, here. You and I are not having a discussion about reimbursement between different physician groups, so this is irrelevant and does nothing to prove your point. We are having a discussion about physician and non-physician reimbursement. There is a difference in valuation of services provided by MDs and people who are not MDs. Your own research and statements prove this: and it is "implicit" (implied). I think you meant to say it is not explicitly described.

Instead reimbursement it is differentiated (in my opinion) by the difference in perceived work value and practice expense.

Sigh. I am now tired because after that lengthy discussion, you still seem more intent on arguing based on opinion and not the facts - mainly because the facts have been shown to defeat this assumption.

So if we are going to argue based on our opinions, here it is:

You are not a doctor. You may try as best you can to convince the world of this, and I will be right there making sure the facts are always presented correctly and in plain sight. I have a stronger scientific background, longer clinical training, and have sacrificed more and worked harder than you. Your 18 months of training will never give you the expertise of the 7+ years ALL MDs must endure.

I can say this with positivity because I was an RN for 6 years, and went to NP school, and used to complain about how unfairly NPs get treated, too. But the fact of the matter is, there is no comparison in the level of educational sophistication between the ancillary services and MDs. Your schooling is just not even in the same league. You simply haven't earned the right to earn as much money or be provided with the same responsibility, just because you have physically worked in a hospital for any number of years. If you think your training and knowledge rivals that of physicians, I feel sorry for you and find you an even greater danger to the public.
(In my life, I have found that people who want professional equality without working for it, usually have some proverbial chip on their shoulder that makes it impossible for them to attain higher goals.)

Instead of whining about how unfair the system is, try putting in some grueling training. Quit your b****ing and go get a medical degree. Your lazyness or fear of facing that education should not be rewarded with disproportionate benefits.

I am signing off this thread now.....

Well lets see. According to your forum you are not a doctor either while I have been in practice for seven years collecting payment (actually the practice does since that where payment is assigned). I would be tempted to call BS on your "I am an RN and NP" since you are apparently the only NP in the history of nursing that does not know that "NPs practice independently" in the mantra of the ANA. To refresh your memory:

It is the law. Also, NPs are never "independent" practitioners, they must alwasy have "supervision" (read, the clinical director of their workplace MUST be an MD, even if not on site).

Assuming you actually went to NP school you would know that this is completely incorrect.

As far as you other statements, I am not bitching about the payment. I think that given the costs associated with my practice the 85% payment is completely fair. I completely agree with the premise of the article that Taurus posted: that there is no increased reimbursement for increased education (at least among PharmD and PT/OT). This goes against your argument that there is increased payment for increased education. Yes that is my opinion, but it is backed up by statements from the HCFA OIG and the Medicare payment advisory committee. I would challenge you to provide any published information that medicare pays more for advanced education.

As to the rest of your ad hominen attacks, I have been around long enough for people that have read my posts to know that I respect the knowledge that my supervising physicians have and work within my boundaries.

David Carpenter, PA-C

 

[chimichanga]

...You can get anyone to testify. Whether that expert testimony is allowed is the real question. Since you are dealing with community standard of care, it is frequent to have MDs testify in cases regarding NPs. Just as it would be appropriate for Anesthesiologists to testify in cases with CNRAs. Generally since NPs do not have the same level of training as a physician they are not allowed to testify about medical practice of physician (although some have tried).

David Carpenter, PA-C

I can speak for AZ, as I was an expert witness (last year) for a case about nursing care delivered in the ED and tele, that originated in 2000.

An MD had initially testified (for the defendant) to the nursing care, but as of 1/1/2006, the law changed. Now nurses have to testify for/against nurses (as experts), and docs for docs, RT for RT, etc...I asked my lawyer about NPs, and he said NPs for NPs only...

So I was deposed as the expert, and testified as the expert in trial...

And the MD's deposition (pertaining to the nursing standards of care) was deemed inadmissable, d/t the new law...

 

[rocktor30]

Well lets see. According to your forum you are not a doctor either while I have been in practice for seven years collecting payment (actually the practice does since that where payment is assigned). I would be tempted to call BS on your "I am an RN and NP" since you are apparently the only NP in the history of nursing that does not know that "NPs practice independently" in the mantra of the ANA.

I am a fourth year medical student. 7 months away from my "MD". I actually still have my RN license, and I never made the statement that I was a practicing or non-practicing NP. I attended NP school before realizing it was a defunct and purposeless path for me - and I gave that fact as a direct testimony that NP school is nowhere near as rigorous as med school. You made the assumption above.

And NPs in my state, should I have decided to pursue that course, cannot practice outside the supervision of an MD. As for ANA mantras, an organization's political goals do not make them public policy. So the wishes of that national organization are still subject to the laws of individual states in deciding what NPs can and cannot do. In 42 of our 50 states, NPs are not allowed to practice independent of physicians. And even in those 8 states where they can perform Histories and physicals and bill private insurance, by your own admission, they cannot bill medicare. Now, does that sound "independent"?

I completely agree with the premise of the article that Taurus posted: that there is no increased reimbursement for increased education (at least among PharmD and PT/OT). This goes against your argument that there is increased payment for increased education. Yes that is my opinion, but it is backed up by statements from the HCFA OIG and the Medicare payment advisory committee. I would challenge you to provide any published information that medicare pays more for advanced education.

Given that you keep quoting MedPAC, I am wondering how you can state they do not differentiate between levels of education when there are two distinct categories of "physician" and "non-physician" reimbursement?!?!?!? They constitute 100% payment for physicians (MD, DO, DDS, DMD) and 85% for the people who are not (CNSs, NPs, PAs, CNMs)! It is right there in the numbers! Moreover, you can find definitions of what consitutes "Physicians" from "non-physicians" (aka "practitioners") in the CMS Medicare Manual. You keep perseverating on differences in training within these two groups, while I have been focusing on the differences between them.

So if you don't want to accept that higher education is paid more, then realize that people are certainly paid less for not achieving an MD degree. I don't have to provide extra publications. It's all contained within the documents you use for your own defense.

One last comment before I sign out for good, you have not provided said HCFA or OIG documents, so I will not refer to the validity of your interpretation of them. And you do realize that HCFA is now CMS. And OIG is an entirely separate entity.

Farewell.

 

[lawguil]

As far as you other statements, I am not bitching about the payment. I think that given the costs associated with my practice the 85% payment is completely fair. I completely agree with the premise of the article that Taurus posted: that there is no increased reimbursement for increased education (at least among PharmD and PT/OT). This goes against your argument that there is increased payment for increased education. Yes that is my opinion, but it is backed up by statements from the HCFA OIG and the Medicare payment advisory committee. I would challenge you to provide any published information that medicare pays more for advanced education.

As to the rest of your ad hominen attacks, I have been around long enough for people that have read my posts to know that I respect the knowledge that my supervising physicians have and work within my boundaries.

David Carpenter, PA-C

Agree with David - pay is based on professionalcredentials, not degree:

"D"PT is reimbursed the same as a BSPT
MS, PA-C reimpursed the same as a BS, PA-C
PhD, MD reimbursed the same as an MD
"D"NP reimbursed the same as an NP

Why should it be any different? The "degree" doesn't make you qualified. Everybody seems to have it all wrong - in vocational fields, it's the professional credentials that should be celebrated, not the degree.

L.

 

[core0]

snip

First of all is there a reason that you are double posting? It is considered courteous to go back and edit out the double post if you make a mistake.

As far as quoting medpac and then there being two different levels of providers, this is a direct quote:
"In contrast to physicians—who are paid 100 percent of the physician fee schedule rate with no differentiation by specialty—the payment rate for nonphysician practitioners who bill independently for their services differs by the type of practitioner. NPs, CNSs, and PAs are paid at 85 percent of the physician fee schedule and CNMs are paid at 65 percent of the physician fee schedule.2 These payment differentials have no specific
analytic foundation."

"In addressing these questions, the Commission first asked whether physicians and NPPs produce the same product. In principle, Medicare should set its payment for a service equal to the cost that an efficient provider would incur in furnishing that service."

As you can see here Medpac at least feels that the product is what is being compensated and states there is no analytic reason for the difference in payment.

As far as payment differentials, there are actually three that apply to NPPs. CRNAs are paid at 100% or 50% if a physician is involved, PA/NP/CNS who are paid at 85% and CNM who are paid at 65%. According to your theory then CRNAs have the same educational level as an anesthesiologist (try that on gasnet to see how it flys). In addition CNMs do not have the same educational background as other NPPs according to your theory. Finally your theory does not address incident to which is paid at 100%.

You have a lot of name calling and rhetoric, but you have yet to provide one single citation that medicare reimbursement is linked to education. For your information here is the OIG report (and yes I realize it is CMS but I have been working with HCFA for much longer). http://oig.hhs.gov/oei/reports/oei-02-00-00290.pdf

If you want my theory for what it is this is what happened. We know that CNM fees were left the same because they were left out of the balanced budget act of 1997 (reasons unknown). Medicare has stated in both the Medpac report and the OIG report that the system should reward the work done by the most efficient provider (this is the baseline). Studies done after 1997 show that physicians are more efficient providers overall than NPPs. Studies done after 1997 show that NPPs on the average see complex patients as based on CPT codes. Surveys before 1997 showed practice expenses for NPPs were lower than physicians (primarily in malpractice).

Medicare had a choice. They could raise the NPP rate to 100% (with all the political consequences that this entails), they could fiddle with the RVU for malpractice expense and practice expense, or they could set a global discount for non physician provider services.

Maybe without stating it Medicare is paying more for education but the evidence against it is strong
1. CRNA payment
2. CNM payment
3. They pay the same for any NPP regardless of degree
4. They do not pay more for physicians with advanced degrees
5. They do not pay more for physcians that have completed additional training or any training.

This shows pretty clearly that medicare does not differentiate by education. You have committed a pretty classic type I error.

David Carpenter, PA-C

 

[villdkatta]

quote=
I've read serveral stories on SDN and I have seen patients who were misdiagnosed by NP's for something quite obvious. When the treatment that the NP prescibed didn't work, then patients go to the physicians and the NP never knows that they screwed up. They think they're doing a great job and should be considered just as good as physicians. Patients don't always have a second chance to seek a physician later on if the condition is a life-threatening one like an MI or DKA.[/quote][/U][/I]


I'm not trying to pick a fight with you, but sadly, I've seen negligence by all types of health care staff. Most NPs (at least the ones I know and work with) don't feel that our knowledge or training is "just as good" as that of physicians (but of course, there are arrogant fools in every field). Those that are foolish enough to believe their training and knowledge is equivalent to that of an MD certainly don't speak for all of us.

I'm a good clinician in my own right, but much of my strength is being constantly well aware of what I don't know, and finding out the answer. I do an excellent job of providing health promotion and disease prevention, and I'm astute enough to realize when someone has a medical issue that's out of my league.

I know you're speaking from your experience, and I'm sorry that it doesn't sound like you've had a positive experience with NPs. However, I don't think NPs exclusively own the market on stupidity, either. I could tell you a recent experience of my own about that, but I won't, because it's irrelevant. Suffice it to say that when I see errors or negligence by any member of the health care team, I try my best to fix it, and to remember that we all have something in common - we're all human, and we all have to be vigilant and try not to miss the obvious, or even the not-so-obvious, for the patients who have entrusted their care to us.

Lastly, I'm curious as to why you stated that the NP(s) that missed such an obvious sign would never know that the GERD he or she diagnosed was really an MI. In the interest in open and honest communication (and certainly in the best interest of the patient), I would have no problem picking up the phone and contacting the professional in question. I've done so in the past, and although it's certainly a difficult conversation (with many awkward pauses on the other end of the line) it certainly seems to help the patient, and is probably much more productive than griping about it on an internet forum. Again, I don't mean to offend, but please don't lump all NPs together.

Thanks for letting me speak my .02.


Kim

 

[lawguil]

quote=

I'm a good clinician in my own right, but much of my strength is being constantly well aware of what I don't know, and finding out the answer.

Kim

That's an awfully big assumption - I'm just not sure how "aware" one can be about what they don't know. I understand that you may know area's that you are weak, but when you lack the breadth of generalist education and training in the medical model..........

Basically, a nurse practitioner, according to your theory, must all be aware that they don't know very much - because their education is so deficient. Adding the word dr before your name won't change what you know! Education and experience will!

 

[villdkatta]

That's an awfully big assumption - I'm just not sure how "aware" one can be about what they don't know. I understand that you may know area's that you are weak, but when you lack the breadth of generalist education and training in the medical model..........

Basically, a nurse practitioner, according to your theory, must all be aware that they don't know very much - because their education is so deficient. Adding the word dr before your name won't change what you know! Education and experience will!

Agreed. I think that, at least for me, a doctorate would be a waste of time. I find that obtaining experience is the best way to go.

 

[horsenurse25]

quote=
I've read serveral stories on SDN and I have seen patients who were misdiagnosed by NP's for something quite obvious. When the treatment that the NP prescibed didn't work, then patients go to the physicians and the NP never knows that they screwed up. They think they're doing a great job and should be considered just as good as physicians. Patients don't always have a second chance to seek a physician later on if the condition is a life-threatening one like an MI or DKA.[/u][/i]


I'm not trying to pick a fight with you, but sadly, I've seen negligence by all types of health care staff. Most NPs (at least the ones I know and work with) don't feel that our knowledge or training is "just as good" as that of physicians (but of course, there are arrogant fools in every field). Those that are foolish enough to believe their training and knowledge is equivalent to that of an MD certainly don't speak for all of us.

I'm a good clinician in my own right, but much of my strength is being constantly well aware of what I don't know, and finding out the answer. I do an excellent job of providing health promotion and disease prevention, and I'm astute enough to realize when someone has a medical issue that's out of my league.

I know you're speaking from your experience, and I'm sorry that it doesn't sound like you've had a positive experience with NPs. However, I don't think NPs exclusively own the market on stupidity, either. I could tell you a recent experience of my own about that, but I won't, because it's irrelevant. Suffice it to say that when I see errors or negligence by any member of the health care team, I try my best to fix it, and to remember that we all have something in common - we're all human, and we all have to be vigilant and try not to miss the obvious, or even the not-so-obvious, for the patients who have entrusted their care to us.

Lastly, I'm curious as to why you stated that the NP(s) that missed such an obvious sign would never know that the GERD he or she diagnosed was really an MI. In the interest in open and honest communication (and certainly in the best interest of the patient), I would have no problem picking up the phone and contacting the professional in question. I've done so in the past, and although it's certainly a difficult conversation (with many awkward pauses on the other end of the line) it certainly seems to help the patient, and is probably much more productive than griping about it on an internet forum. Again, I don't mean to offend, but please don't lump all NPs together.

Thanks for letting me speak my .02.


Kim

Nice post.

You know, that GERD/MI story has been trotted out every chance possible to disparage the profession. Do you want me to trot out some of my MD stories??? They also would fill a bucketload....

It does not really matter what some people on this board think and say. In the real world, midlevels are invaluable and are only going to grow as a profession. The venomous words are a defensive twitch against tradition rather than real world application.

The medical system and the medical education system could use a serious shake-up...and it is coming.

I have yet to meet a REAL doctor that is not happy and grateful and thrilled to have a NP/PA working with them. Perhaps they are the ones that are really interested in patients, not just medicine.

 

[lawguil]

This isn't about what MD/DO/NP/PA made a mistake. It's about education...Are entry level (insert profession) properly prepared for the level of autonomy they have when they begin practice.

Basically, if a clinician is improperly educated and thus inclined to make a mistake/miss dx and provide inappropriate care or isn't properly supervised, then that is the real issue for concern.

Citing this xyz practitioner missed this condition x 10 really doesn't matter. They likely made a mistake and mistakes will be made by properly prepared clinicians.....It's when the education is lacking and errors are made....that is the issue.

I think when NP's want to use the facade of doctorate level education or being the equivalent of a physician without the training and experience of a physician...or aren't properly supervised.....or have a level of autonomy and scope of practice that isn't reflected in their education.....that is a problem.
When you win your scope because of your political might rather than it being based on your educational competencies.......that is a situation in healthcare that is ripe for change.

 

[prairiedog]

This isn't about what MD/DO/NP/PA made a mistake. It's about education...Are entry level (insert profession) properly prepared for the level of autonomy they have when they begin practice.

Basically, if a clinician is improperly educated and thus inclined to make a mistake/miss dx and provide inappropriate care or isn't properly supervised, then that is the real issue for concern.

Citing this xyz practitioner missed this condition x 10 really doesn't matter. They likely made a mistake and mistakes will be made by properly prepared clinicians.....It's when the education is lacking and errors are made....that is the issue.

I think when NP's want to use the facade of doctorate level education or being the equivalent of a physician without the training and experience of a physician...or aren't properly supervised.....or have a level of autonomy and scope of practice that isn't reflected in their education.....that is a problem.
When you win your scope because of your political might rather than it being based on your educational competencies.......that is a situation in healthcare that is ripe for change.

When do you think NPs want to use the facade of doctortate level education? When do you think they believe NPs are equivalent to a MD? What do you mean "not properly supervised" ? Are you suggesting it is ok to make mistakes if you have "properly prepared clinicians"?

 

[Therapist4Chnge]

I thought the DNP is looking to doing what the DSW is doing, being more of an academic distinction? I haven't seen or read anywhere that they are trying to be 'the same' as a physician, and I think more education is generally better than less education. This may bring the ire of those who are afraid of raising the baseline educational requirements, but I'd have a hard time arguing against someone wanting more education.

-t

 

[lawguil]

When do you think NPs want to use the facade of doctortate level education? When do you think they believe NPs are equivalent to a MD? What do you mean "not properly supervised" ? Are you suggesting it is ok to make mistakes if you have "properly prepared clinicians"?

Why pretend that the DNP is a doctorate level education?
Neither is the DNP or the PharmD or the (insert allied health profession).

There is nothing wrong with improving education.......I work in education and we are constantly changing curriculum.... but we never change the name of the degree.

Also....direct access for nurses.....is that proper supervision?

Read the article above from the original post....maybe you'll understand....maybe not.

http://chronicle.com/free/v52/i46/46b01201.htm

Updating the educational standards to meet professional demands yes....changing the name of the degree for political leverage, make a mockery of education, and .....................................No!

Who are you trying to fool?

 

[lawguil]

I thought the DNP is looking to doing what the DSW is doing, being more of an academic distinction? I haven't seen or read anywhere that they are trying to be 'the same' as a physician, and I think more education is generally better than less education. This may bring the ire of those who are afraid of raising the baseline educational requirements, but I'd have a hard time arguing against someone wanting more education.

-t

It makes a mockery of education and the profession. DNP academic? you have got to be kidding me.......it's purely vocational.
Updating the education or improving a program doesn't warrent a higher degree................

DNP named principal investigator ............1million dollar grant......never going to happen.......

 

[prairiedog]

Why pretend that the DNP is a doctorate level education?
Neither is the DNP or the PharmD or the (insert allied health profession).

There is nothing wrong with improving education.......I work in education and we are constantly changing curriculum.... but we never change the name of the degree.

Also....direct access for nurses.....is that proper supervision?

Read the article above from the original post....maybe you'll understand....maybe not.

http://chronicle.com/free/v52/i46/46b01201.htm

Updating the educational standards to meet professional demands yes....changing the name of the degree for political leverage, make a mockery of education, and .....................................No!

Who are you trying to fool?

I recall you are in Athletic Training, I understand degree creep is happening here also? Be careful when using the word never, things have a way of coming back.
I read the article posted , why do feel the need to insult ? "maybe you'll understand maybe not" The subjective article is just that, subjective.
The DNP proposes to add course/clinical time, have you seen otherwise?

 

[lawguil]

I recall you are in Athletic Training, I understand degree creep is happening here also? Be careful when using the word never, things have a way of coming back.
I read the article posted , why do feel the need to insult ? "maybe you'll understand maybe not" The subjective article is just that, subjective.
The DNP proposes to add course/clinical time, have you seen otherwise?

More clinical time and coursework doesn't = doctorate

I think you can look at PT for instance.....The change from BSPT to MSPT to DPT is nearly unremarkable. The differences that you see in the DPT could easily been accomadated in a BSPT program. Basically, they just updated the education to reflect the needs of current practice......not very impressive.

I

I havn't personally compared the MSNP to the DNP, but I have seen comparisons of DNP to PA schooling........my understanding is that the DNP still doesn't = PA education..........

My professional background is in AT and PT.....More so AT. It was a consideration by the NATA to move entry level to a MS, but there seem to be consensus on the commitee that they would be doing it only for political reasons rather than educational, concerned that the quality students might depreciate, and the cost of education vs. income would only hurt the AT providers.

Your thoughts?

 

[prairiedog]

More clinical time and coursework doesn't = doctorate

I think you can look at PT for instance.....The change from BSPT to MSPT to DPT is nearly unremarkable. The differences that you see in the DPT could easily been accomadated in a BSPT program. Basically, they just updated the education to reflect the needs of current practice......not very impressive.

I

I havn't personally compared the MSNP to the DNP, but I have seen comparisons of DNP to PA schooling........my understanding is that the DNP still doesn't = PA education..........

My professional background is in AT and PT.....More so AT. It was a consideration by the NATA to move entry level to a MS, but there seem to be consensus on the commitee that they would be doing it only for political reasons rather than educational, concerned that the quality students might depreciate, and the cost of education vs. income would only hurt the AT providers.

Your thoughts?

AT will be masters within 3 years and doctorate in next 10 years(IMHO). The quality students will increase, many new students will find the increased education appealing. I think the cost of education vs income already hurts before degree creep.

 

[lawguil]

AT will be masters within 3 years and doctorate in next 10 years(IMHO). The quality students will increase, many new students will find the increased education appealing. I think the cost of education vs income already hurts before degree creep.

AT's interested in doctorate education currently and should continue to pursue the PhD.....The NATA already know this and have seen how the "clinical doctorate" degrees will adversely affect research.

You pick the more dynamic individual:

ATC, PhD
or
DATC...basically requiring a bachelors of any background before being admitted into an entrly level AT program.........I hope it never happens!

I've personally seen how it's affected the quality of students in PT......BSPT students were superior.......but i'm only at one school......

No sense in argueing.....You seem to believe in the degree creep......I take issue with it.....The fact is a PT is a PT.............and a Pharmacist is a pharmacist..............proper education is important, the question is are we doing a good job and the degree awarded is no indication of anything.

 

[Taurus]

In my opinion, a profession does itself no favor by degree creep. If you have stratification of the profession, then the top degree means something and it will be valued more. A PhD is more valued and respected than a master's because people assume, usually correctly, that a person has to be smarter, more dedicated, and more capable to complete a PhD versus a master's. Most people can do a master's, but only a small percentage of people can do a PhD. If everyone in the profession has the same degree, then it's really hard to differentiate the top people from the bottom ones. A single DPT among many bachelor PT's is impressive. A DPT among many DPT is not. Hence, the value of that degree will never reach the level that it could be. That's why the DPT and PharmD salaries are not that much different than their bachelor counterparts. A DNP is not worth more than an NP. No wonder some NP's were pissed about the creation of the DNP.

 

[prairiedog]

No wonder some NP's were pissed about the creation of the DNP.

Do you mean they became intoxicated?

 

[fab4fan]

Do you mean they became intoxicated?

LOL...good one.

I think it's unnecessary. There are lots of NPs in my area; off the top of my head, I can't think of any that are in solo practice. I haven't heard any of them wanting the DNP.

For me, it would be a waste of time and $$$ to get a DNP and still work in collaboration with someone. I'd rather just blow my money on a degree that I wanted to get for my own interest, if that's how it has to be. I have no intention of getting a doctoral degree in nursing.

 

[horsenurse25]

A friend of mine is getting her DNP.

She is getting it because there is a serious shortage of nursing faculty worldwide, much less nation wide. She wishes to continue to teach at the University level and since every other faculty (History, English, Economics, you name it) for the most part requires professors to have their doctorate she must as well.

Believe it or not, every time a nurse tries to achieve higher education it is not because they are trying to take jobs away from doctors...

Perhaps you guys would like nurses keep sitting at the back of the education bus.

Back Nurse, Back! D@mn you.