"Collaboration" with NP

[heyjack70]

Wondering if anyone has similar experiences. I work on an inpatient unit and cover consults on medical floors on call days. We have inpatient NPs and two psychiatrists. The NPs get supervision with the medical director but essentially function independently. In this state NPs have independent practice, but the hospital bylaws prevent independent NP practice in the hospital, and they cannot see consult patients at all. Anyways, the consult service is quite busy and the medical director is interested in advocating for the NP to see consult patients and "collaborating" with a physician, which essentially means supervising and signing off on their note. I don't want to collaborate with the NP; I have doubts about the NPs training in regards to consulting on medically ill patient's in the hospital. The NP is good with psych and basic family medicine like HTN and sore throats, but is lacking in delirium and other acute illness exposure which is of course frequently seen on consults. Do any of you work in "collaboration" with NPs, and if so do you get paid for this? I'm currently paid on RVU production and was wondering how this might be factored in. The medical director is older and does not seem concerned about reimbursement issues and is just happy to have someone else picking up extra consults when he is on call, so I doubt I have much support from him in opposing this. I don't think it will be forced on me as I can just choose to see all of the consults myself and bypass the NP seeing consults on my call days, however this will make it obvious that I am avoiding letting the NP ease the burden.

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[deleted480308]

My bet is you won't end up getting reimbursed properly and the NP's won't really end up checking with you. They will want to act like they are independent while calling it collaborating..... but will want your signature and liability on the line as if you were supervising.

 

[Shikima]

Where I'm at, we recently hired a new NP grad just to do the work you're describing. I and others shared the same concerns you're expressing with the level of training and she underwent a 6 month orientation prior to seeing patients on her own and will still staff each case. In effect, she is getting a paid internship right now. You could advocate for this and come to an agreement where the consults completed are under your RVU structure when teaching, training and/or staffing the cases - It could work out to your favor in the end, but then I don't have a crystal ball either....

 

[Bartelby]

Personally I would treat it a lot like supervising a resident. They can do the full history and exam, come up with their ideas for management, and present to you but you should probably lay eyes on the patient for a confirmation that they are on the right path. If you get paid to do this that could be okay. If it is supposed to be more of a *wink wink, nudge nudge* supervision where you just sign off most of the time I would not be in for that.

Of course in time as you get to know the NP and they get more comfortable with consult skills the amount of time to staff each case will likely drop.

 

[vistaril]

guys we can imagine NP 'collaboration' to be whatever we desire in our minds(an internship, an attending/resident relationship, etc) but what it is trending towards in the real world is a VERY different thing. And that's only going to get worse over time.

Groups now are hiring NPs in outpt settings as simply another provider. Fairly interchangeable between bringing on a staff psychiatrist or staff NP. The same patients are going to be booked. Groups consider it a medication provider regardless. Now what I have noticed is the psychs are getting paid a bit more than the psych nps, but they are also seeing their follow ups more frequently. Say 3/hr instead of 2/hr for the np at some places. Which is sort of odd in one respect because we have more therapy training than them. And guess what the salary difference is? A little more than.....3/2. My guess is that groups are setting up this higher frequency for the psychs not because they believe the psychs can safely work more efficiently but rather because they want to maintain salary differences and the only way to do this is to just have the psychs generate more revenue by keeping them busier. but I may be wrong there and there are other reasons.

As fonzie can attest to, when you're out there looking for salaried(or hourly 1099) outpt positions in the real world and community mental health centers, they view psychs and nps as interchangeable. The exception is administrative positions of course.

Also this applies to outpt more than inpatient. NPs are still going to explode in the inpatient scene, but in this area I think the value is more to decrease the total number of psychs needed to cover inpatient settings. whereas in outpt world there is more of a true equivalence.

 

[Shikima]

guys we can imagine NP 'collaboration' to be whatever we desire in our minds(an internship, an attending/resident relationship, etc) but what it is trending towards in the real world is a VERY different thing. And that's only going to get worse over time.

Groups now are hiring NPs in outpt settings as simply another provider. Fairly interchangeable between bringing on a staff psychiatrist or staff NP. The same patients are going to be booked. Groups consider it a medication provider regardless. Now what I have noticed is the psychs are getting paid a bit more than the psych nps, but they are also seeing their follow ups more frequently. Say 3/hr instead of 2/hr for the np at some places. Which is sort of odd in one respect because we have more therapy training than them. And guess what the salary difference is? A little more than.....3/2. My guess is that groups are setting up this higher frequency for the psychs not because they believe the psychs can safely work more efficiently but rather because they want to maintain salary differences and the only way to do this is to just have the psychs generate more revenue by keeping them busier. but I may be wrong there and there are other reasons.

As fonzie can attest to, when you're out there looking for salaried(or hourly 1099) outpt positions in the real world and community mental health centers, they view psychs and nps as interchangeable. The exception is administrative positions of course.

Also this applies to outpt more than inpatient. NPs are still going to explode in the inpatient scene, but in this area I think the value is more to decrease the total number of psychs needed to cover inpatient settings. whereas in outpt world there is more of a true equivalence.

Sounds like the environment Gassers are working in with CRNAs...

 

[notdeadyet]

Now what I have noticed is the psychs are getting paid a bit more than the psych nps....

Again, this is why generalizations are less than helpful. If you are being offered salaries only "a bit" more than what NPs are being offered, this might be a reflection of your application, your location, or the employers you are looking at.

What you describe is most definitely not the case in my neck of the woods.

 

[vistaril]

Again, this is why generalizations are less than helpful. If you are being offered salaries only "a bit" more than what NPs are being offered, this might be a reflection of your application, your location, or the employers you are looking at.

What you describe is most definitely not the case in my neck of the woods.

it depends on what role the person is going to be performing. If a business is going to hire someone to do med mgt outpt, then the business is obviously going to base their salary on a percentage of their revenue minus expenses. Thus the difference between the salaries is going to reflect the difference between the revenue they are generating for the group. Then it's just a matter of looking at what providers are reimbursing psychs and psych nps for these services.....you are right that this is location dependent to some extent.

For these type of exclusively clinical roles in insurance based practices, things like experience often aren't worth a whole lot. It's a big advantage in getting a job because the group knows that veterans with a lot of experience and a good track record are more likely to stick and elevate the overall rep of the group. But to be blunt....the reimbursements are what they are. Blue cross doesn't pay more for that 99214 to someone with 17 years experience vs 5, and that's what the group obviously cares most about(and what is most linked to salary). Now it's possible that an experienced and/or 'better' psych can stack patients more efficiently(while maintaining safety).....if so, that's where the extra revenue can be generated. Same principle vs psychs and psych nps- if a psych can see patients a lot faster/safer than the psych np, that's extra revenue vs them. I've seen a lot of psych nps who can stack and whack though.

I just think the biggest concern for us as psychiatrists going forward is the presence of psych nps and how their numbers are going to increase a lot over time, and what that will do to the market for board certified psychs overall. I hope Im proven wrong.

 

[vistaril]

Sounds like the environment Gassers are working in with CRNAs...

Why I think anesthesia is in a much better position than us with np encroachment going forward is........it is hard and takes a lot of commitment to be a crna. These people have much higher barriers to enter the field(need ICU or crit care experience) than psych nps. Also, it's what...almost a 3 year program(30 months?) which is intensive enough where people do the program full time and have to quit their previous job. it's a big commitment. The requirements to get in and the commitment during the school/training takes most rns out of the running for this. the average 30 year old nurse isn't at a point in life where they can just drop everything and enroll in full time school for several years.

Psych np programs, otoh, are much different. You don't need certain types of experience. Depending on the area of the country and the program, they may or may not be competitive to get into but are less competitive overall than crna programs. By far the most important difference, however, is that going through a psych np program DOES NOT require the student stop working their previous job. These students go on with life just as they had before, still working their previous job at previous salary. The requirements of most programs are such that they can fit it in their schedule during the program to get the psych np.

This difference is huge......the ability to conveniently fit a psych np into a very busy schedule is what makes it so attractive for some. And another reason the numbers are going to explode in the future. I knew of psych nps who would still pound out 50-60 hrs per week at their regular rn jobs. You don't ever see that with crna students.

 

[sunlioness]

I'm not sure how other organizations handle, especially in states with independent practice. But here where we are on a production based salary, a significant percentage of NP generated RVUs is credited to their primary physician collaborator. The psychiatrist makes more that they would without the NP and the NP effectively earns less per RVU than a psychiatrist.

 

[W19]

Why I think anesthesia is in a much better position than us with np encroachment going forward is........it is hard and takes a lot of commitment to be a crna. These people have much higher barriers to enter the field(need ICU or crit care experience) than psych nps. Also, it's what...almost a 3 year program(30 months?) which is intensive enough where people do the program full time and have to quit their previous job. it's a big commitment. The requirements to get in and the commitment during the school/training takes most rns out of the running for this. the average 30 year old nurse isn't at a point in life where they can just drop everything and enroll in full time school for several years.

Psych np programs, otoh, are much different. You don't need certain types of experience. Depending on the area of the country and the program, they may or may not be competitive to get into but are less competitive overall than crna programs. By far the most important difference, however, is that going through a psych np program DOES NOT require the student stop working their previous job. These students go on with life just as they had before, still working their previous job at previous salary. The requirements of most programs are such that they can fit it in their schedule during the program to get the psych np.

This difference is huge......the ability to conveniently fit a psych np into a very busy schedule is what makes it so attractive for some. And another reason the numbers are going to explode in the future. I knew of psych nps who would still pound out 50-60 hrs per week at their regular rn jobs. You don't ever see that with crna students.

You forgot one thing, vistaril... There is a reason psych is not appealing to med students even if it has somewhat comparable lifestyle to derm, PM&R etc... and compensation is not that bad... It is the same reason psychNP is not appealing to most RN... Most of these people care more about prestige or 'doctor(ish)' than med students.

 

[smalltownpsych]

The one psych NP I know is more like a typical psych nurse that has some extra knowledge of medications and likes to throw out phrases like, "That patient has a touch of Bipolar" or even better, "I think this patient has some Borderline stuff going on more than anything." That second line made me want to make some type of sarcastic response when she was describing my chronically suicidal, chronically cutting, emotionally labile victim of childhood sexual abuse. "No sh@#." and "Is this why your cocktail of meds is not helping and do you even understand the physiology or psychology of trauma at all, not to mention how to treat it pharmacologically?"

I do not think mid levels should have independent practice, but I also think that is the direction that we are heading more and more. People with money will pay for real doctors and the rest will get Walmart healthcare and unfortunately, that is what most people want.