Former ACEP president on PA supervision and lawsuits

[sozme]

Video here (only place I can find the relevant video is on Facebook currently). (relevant section beings at 5 minutes 52 seconds)

"Supervision [as a malpractice risk] has gone on a rocket ship ride ... People are walking by signing charts and not actually seeing the patients."


So this is Dr. Henry, former president of the American College of Emergency Physicians and expert on medicolegal risks. In this segment of the video from some conference in 2014 (beginning approx. at 5:52), he talks about supervision of PAs. Makes the comment that the newest thing in medical malpractice and a source of many new lawsuits concerns the failure to supervise mid-level providers such as PAs.

Then he goes into some vagaries about EM doctors not wanting to "have the discussion" about supervision of PAs and what it actually means. He goes on to imply that this is because they would be "uncomfortable" with the ensuing discussion. I didn't know exactly what he meant, but if you listen further he mentions that "half" of the EDs in Iowa are run by PAs and that the death rate between PA-run EDs and MD-run EDs is the same (1 per person, which is a common joke he uses).

Obviously he is being jocular here, but when you couple it with what he says about discomfort with having the discussion on supervision "for a lot of reasons" I am left wondering if he meant that EM physicians are afraid to exercise any supervisory role over PAs because ultimately PAs don't need supervision. Of course, I could be completely wrong here, and interpreting these statements incorrectly.

Aside from that, the entire video is pretty good and wanted to know your thoughts on lawsuits related to supervision of non-physician practitioners.

---

Members don't see this ad.

 

[deuist]

Supervision of mid-levels becomes difficult when you work at a shop where the PA will see a patient and discharge him home without ever alerting the attending. At the end of my shift, I usually get a stack of charts from patients who have long left the emergency department. Some of the notes are so poorly written that I have no idea what happened to the patient during his ED stayed. And yet I am somehow expected to cosign all the charts so that we can bill for them. Even more annoying are the mid-levels in triage who shotgun order a bunch of unnecessary tests that I am now responsible for waiting for the results to post. Supervision is definitely a problem in our field. I think that one of the other commentators on this forum said it best when we should start letting the mid-level's practice unsupervised, sign their own charts, and carry their own malpractice insurance. Once that happens, we'll see how quickly hospitals swing back to physician-only emergency departments.

 

[Lord Humongus]

If ACEP, ASA, and other specialty organizations truly had the best interests of their members at heart it seems that they could very easily stop midlevel encroachment. Simply institute very strict standards regarding the supervision of midlevels under penalty of losing Board Certification.

Right now docs are being pressured into supervision situations that they are not comfortable with and which are bad for the long term health of the profession because if one doc refuses to take a job, another one will. Making it "illegal" to supervise a greater than 1:1 ratio and/or not see a patient before signing off on a midlevel's treatment plan would put a stop to this trend in a hurry.

 

[deleted109597]

This is a CMG issue alone. They expect you to sign the charts, without seeing the patients. And above all, you often can't even tell them how to do it. It becomes a bizarre supervision scenario in where you're responsible for the outcome without having control of the process.

 

[Mad Jack]

This is a CMG issue alone. They expect you to sign the charts, without seeing the patients. And above all, you often can't even tell them how to do it. It becomes a bizarre supervision scenario in where you're responsible for the outcome without having control of the process.

How could a physician ever justify that to a jury?

"Did you examine the patient?"

"No."

"Did you consult, in real time, with your assistant?"

"No."

"Then how could you ensure proper care was provided? I rest my case."

 

[em1234]

the last credentialing paperwork I filled out had the typical malpractice history page and a separate page for malpractice history as a result of midlevel supervision. It's own separate page!

 

[Janders]

This is a CMG issue alone. They expect you to sign the charts, without seeing the patients. And above all, you often can't even tell them how to do it. It becomes a bizarre supervision scenario in where you're responsible for the outcome without having control of the process.

I tend to agree with this point. In the democratic groups I know, PAs are typically kept on a tight leash, typically with all their patients being presented prior to patient discharge, except for the VERY basic stuff like suture removal. Not so in some of the CMG groups...

 

[The White Coat Investor]

I tend to agree with this point. In the democratic groups I know, PAs are typically kept on a tight leash, typically with all their patients being presented prior to patient discharge, except for the VERY basic stuff like suture removal. Not so in some of the CMG groups...

Exactly. My PAs are my employees. If their charts suck, I tell them to fix them or they're fired. If they're not bringing me patients appropriately, I educate them once, then fire them if they do it again. I sit next to my PA all shift. It is very easy for them to tell me about a patient that is anything significant at all, and if they talk to me about the patient, I generally go and examine them.

I don't think I'd work at a place where I had no control over the PA but had to sign their charts. Yet another reason being an owner is a good thing.

 

[cbrons]

I tend to agree with this point. In the democratic groups I know, PAs are typically kept on a tight leash, typically with all their patients being presented prior to patient discharge, except for the VERY basic stuff like suture removal. Not so in some of the CMG groups...

What do you mean by "democratic" vs CMG groups?

 

[deleted547339]

What do you mean by "democratic" vs CMG groups?

Basics of EM practice. There are a few models of practice/employment models:

Hospital employee - you get a w2 and a salary
SDG - small democratic group - group where a few physicians are all part owners - they subsequently contract with a hospital
CMG - corporate mega group - big, evil company that contracts across many hospital (usually in many states). most common being Team Health, EM-Care, Pegasus, Hospital-Physicain partners, schumacher, CEP, etc.

As an aside, it seems like most of those in the third category start off in the second category.

 

[goodoldalky]

CMG - corporate mega group

Contract management group

 

[deleted547339]

Contract management group

My bad. You are correct.

 

[WilcoWorld]

My bad. You are correct.

Freudian slip

 

[TooMuchResearch]

Freudian slip

I assumed it was intentional.

 

[deuist]

How could a physician ever justify that to a jury?

"Did you examine the patient?"

"No."

"Did you consult, in real time, with your assistant?"

"No."

"Then how could you ensure proper care was provided? I rest my case."

That's why I write on every chart that I merely read the chart and am signing it. I don't put anything down about seeing the patients.

 

[goodoldalky]

Greg makes a point about the independent practice that midlevels have to varying degrees in EDs around the country. However, Greg is also very old school and to me at least, it seems like a lot of his ideology is really outdated. Just my opinion and your mileage may vary. He's one of my favorite speakers, but mainly because of his irreverence and entertainment value.
And let's be honest, there is no way that I (and I know many providers are in this bucket) can see every patient that is being attributed to me by MLPs. I am seeing a full complement of my own patients, theirs when requested, and I don't have time for anything else. I also don't have much of a problem signing off on low acuity charts, although the level of supervision required depends on the case and the level of competency of the MLP involved, which is of course quite variable. How bad can you screw up a cold or scabies? Moderately bad, but these are low liability cases. As was alluded to by a previous poster, in these cases, my attestation is something along the lines of, "I was available for consultation, and have read and agree with the chart."

 

[namethatsmell]

As was alluded to by a previous poster, in these cases, my attestation is something along the lines of, "I was available for consultation, and have read and agree with the chart."

My understanding is that even with this attestation you're still at risk the second you put your name on the chart. Does this afford any meaningful protection from liability?

 

[deleted109597]

My understanding is that even with this attestation you're still at risk the second you put your name on the chart. Does this afford any meaningful protection from liability?

You're liable for being in the department when it happens. Even if you're never aware of it.

 

[namethatsmell]

You're liable for being in the department when it happens. Even if you're never aware of it.

Yeah, as I suspected. Hooray, legal system.

 

[The White Coat Investor]

You're not getting away from the liability so you might as well get paid for it. I figure supervising a mid-level is worth about $50 an hour, so if I weren't getting that, I'd move on.

 

[Arcan57]

For those that advocate independent MLP practice in the ED, I would be very wary of ceding low acuity patients (and their bills) to a non-physician. Well it sounds great, the malpractice exposure is actually pretty low and our pay would take a huge nose dive if we no longer had the worried well figuring into our pay. Think of it as similar to what happens when UCs and FSEDs siphon off the wel insured not sick patients from a hospital ED.

 

[GeneralVeers]

It's not practical to want to see every patient the PA sees before discharge. If I had to do that, then I would just take take care of the patient myself, as I could do it faster, and with fewer tests. The reality is that we need midlevels to see all the low acuity BS. They miss stuff. All the time in fact. I'm not sure what the solution is, short of hiring another doctor to see those patients, with the resulting drop in my salary too.

 

[deuist]

Not to mention that there simply aren't enough docs to go around. I once heard that the U.S. is short about 16,000 residency-trained, board-certified emergency physicians.

 

[Hercules]

It's not practical to want to see every patient the PA sees before discharge. If I had to do that, then I would just take take care of the patient myself, as I could do it faster, and with fewer tests. The reality is that we need midlevels to see all the low acuity BS. They miss stuff. All the time in fact. I'm not sure what the solution is, short of hiring another doctor to see those patients, with the resulting drop in my salary too.

In my group we actually do see all of the PA patients prior to discharge and it works for us. It really doesn't take that much time (usually) and has several benefits for us: every patient gets to see a doctor, there's some quick thin-slicing and quality control, and we get to bill out at 100% instead of 85%.

 

[Boatswain2PA]

There is a big difference between legal/regulatory/ hospital policy "supervision" requirements and actual supervision or leadership. The former is just a set of rules to ensure the lawyers know who they can go after, the latter (actual supervision and leadership) involves patient care and personal development.

As Dr. McNinja said, if you are the attending BE/BC Emergency Physician, you are responsible for everything that happens in your department, whether you know about it or not.

Better to be a leader and develop your people so they can perform to the top of their ability and help you carry the work load.

General V - We all miss stuff.

 

[The White Coat Investor]

In my group we actually do see all of the PA patients prior to discharge and it works for us. It really doesn't take that much time (usually) and has several benefits for us: every patient gets to see a doctor, there's some quick thin-slicing and quality control, and we get to bill out at 100% instead of 85%.

As I recall, I think it's only Medicare patients where you only get 85% if the doc doesn't lay eyes on them. Someone correct me if I'm wrong.

 

[EctopicFetus]

WCI, that is correct only medicare, it does not apply to medicaid, or commercial insurance.

I think this whole discussion can be boiled down to 2 things. 1) your work environment (aka do you benefit from there being PAs), 2) what your group is comfortable with.

Also, I think anyone who thinks you cant screw up fast track / urgent care cases has not worked enough in that environment. I have seen STEMI, ICH, stroke, sepssi all come through there beyond the easy but still sick cases of RSV, open fractures, PE, etc.

 

[Hercules]

WCI, that is correct only medicare, it does not apply to medicaid, or commercial insurance.

Actually there are commercial insurance companies that follow the Medicare reimbursement model. BCBS follows the model in several states including mine. BCBS makes up >70% of the commercial insurance in my state. So between Medicare and BCBS it's a significant chunk of change. On the other hand with a self pay, 85% and 100% of zero work out to the same number.

 

[gutonc]

WCI, that is correct only medicare, it does not apply to medicaid, or commercial insurance.

Actually there are commercial insurance companies that follow the Medicare reimbursement model. BCBS follows the model in several states including mine. BCBS makes up >70% of the commercial insurance in my state. So between Medicare and BCBS it's a significant chunk of change. On the other hand with a self pay, 85% and 100% of zero work out to the same number.

And there are institutions (assuming you are employed) that just won't bother to bill anything other than the 85% if a mid-level is involved. Unless the attending writes a full, separate, equally billable note (in which case, why bother having the mid-level at all), the place I work will just bill the 85% no matter what.

I suspect they leave hundreds of thousands of dollars on the table every month...but they're risk averse.

 

[deleted109597]

And there are institutions (assuming you are employed) that just won't bother to bill anything other than the 85% if a mid-level is involved. Unless the attending writes a full, separate, equally billable note (in which case, why bother having the mid-level at all), the place I work will just bill the 85% no matter what.

I suspect they leave hundreds of thousands of dollars on the table every month...but they're risk averse.

There's a reason that the attestation phrase is valid. Yeah, your employer doesn't like money. Either don't have a midlevel and write your own notes, or don't sign them at all and let them bill at 85%.

 

[EctopicFetus]

Actually there are commercial insurance companies that follow the Medicare reimbursement model. BCBS follows the model in several states including mine. BCBS makes up >70% of the commercial insurance in my state. So between Medicare and BCBS it's a significant chunk of change. On the other hand with a self pay, 85% and 100% of zero work out to the same number.

That may be their practice but as you know anything is negotiable. why wouldnt they (the insurers) try to find ways to pay less. Its what they do. Also, medicare has been working and planning on paying 85% on all pa cases unless physician involvement was required. That fight is ahead.

 

[Hercules]

That may be their practice but as you know anything is negotiable. why wouldnt they (the insurers) try to find ways to pay less. Its what they do. Also, medicare has been working and planning on paying 85% on all pa cases unless physician involvement was required. That fight is ahead.

I would love to be able to negotiate those terms. Unfortunately with 70-80% of the market share, BCBS effectively has a monopoly in our state at present and they know the groups (especially in hospital based specialties) aren't going to walk away over an issue like this. That said their reimbursement has been pretty reasonable as a whole, but monopolies leave the door open for a lot of bad behavior.

I am not looking forward to a CMS fight over which cases require physician involvement. That sounds a lot like the CT issue where a negative CT meant retrospectively that the test wasn't indicated.

 

[gro2001]

While I greatly enjoy Greg Henry's books and lectures, I think it's important to remember that his livelihood largely depends on perpetuating the culture of fear. I don't mean to say that it's all made up and we have nothing to fear in terms of weird and unexpected sources of liability. A certain amount of fear is healthy. But after a point it stops being productive and makes us want to do counterproductive things (ordering those MRIs, not signing PA notes, not hiring PAs, etc).