Missouri bill to license "Assistant Physicians" awaiting governor's signature

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I don't see why MD/DO grads shouldn't have the option to work as midlevels if they are unable to match or do not wish to do residency. I mean, 4 years of medical school should at least put one on level with PA's. A big downside though could be an influx of poorly qualified FMG's.
 
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I wonder if it would play out even of the law is signed. I wonder how insurance reimbursements and employers would handle it. No law is stopping docs with one year of GME from practicing in most states, yet they rarely do.
 
NurWollen said:
I wonder if it would play out even of the law is signed. I wonder how insurance reimbursements and employers would handle it. No law is stopping docs with one year of GME from practicing in most states, yet they rarely do.
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Third party payers are - who want you to be board certified.
 
NurWollen said:
Exactly. That's what I meant. If this law is signed into law I'm wondering how third party payers would handle these 'assistant physicians."
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The way the law is written, they are supposed to be treated identically to physician assistants. Since they aren't practicing independently, they could always use one of the many routes available for midlevels to bill through their supervising physician anyway.
 
user3 said:
I don't see why MD/DO grads shouldn't have the option to work as midlevels if they are unable to match or do not wish to do residency. I mean, 4 years of medical school should at least put one on level with PA's. A big downside though could be an influx of poorly qualified FMG's.
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If we let that happen, imagine how much worse primary care will pay.
 
user3 said:
I don't see why MD/DO grads shouldn't have the option to work as midlevels if they are unable to match or do not wish to do residency. I mean, 4 years of medical school should at least put one on level with PA's. A big downside though could be an influx of poorly qualified FMG's.
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It's probably just for American graduates.
 
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Wouldnt be too concerned unless you know someone who is a PA in the state. Then this PA vs AP thing can get tricky. This already exists in pretty much every state in america. They're called "doctors". When you get to do a geriatrics rotation (or if you spend some time at a nursing home) you'll find out many "physicians" who work at nursing homes are actually doctors who didnt complete residency and they work UNDER the head physician of the facility. They cant write Rx or bill, but they can do everything for the head physician who can bill and prescribe as advised by the guy on the ground at the nursing home. A few of them can be paid as employees and the prescribing doctor effectively increases his productivity and throughput many-fold. Its seen almost exclusively in geriatrics and nursing homes because these people pretty much never sue, since they are circling the drain anyway. The lower risk population for lawsuits means that the prescribing doctor can feel okay outsourcing all of the work and decision making.

What perhaps makes this significantly unique is that it is a push to have these people go out and work in rural areas in primary care of normal-aged people. Which I think it will have a big issue with. Medicare (and thus all insurances) have rules as to what every single class of billing provider must do in order to be able to bill. Creating a new class doesnt clarify that medicare doesnt recognize them. Now if the state recognizes them, it could push it a bit for the fed to recognize them. But its the same reason why all residents dont run out and perform independantly: We can't bill anyone for anything (unless they want to pay cash) until we are licensed, and we cant be licensed until about a year into residency. And PAs and NPs have their own criteria to be able to bill (independently or through an MD/DO, as decided by the states).
 
DocEspana said:
Wouldnt be too concerned unless you know someone who is a PA in the state. Then this PA vs AP thing can get tricky. This already exists in pretty much every state in america. They're called "doctors". When you get to do a geriatrics rotation (or if you spend some time at a nursing home) you'll find out many "physicians" who work at nursing homes are actually doctors who didnt complete residency and they work UNDER the head physician of the facility. They cant write Rx or bill, but they can do everything for the head physician who can bill and prescribe as advised by the guy on the ground at the nursing home. A few of them can be paid as employees and the prescribing doctor effectively increases his productivity and throughput many-fold. Its seen almost exclusively in geriatrics and nursing homes because these people pretty much never sue, since they are circling the drain anyway. The lower risk population for lawsuits means that the prescribing doctor can feel okay outsourcing all of the work and decision making.
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In practice, is this as exploitative and dubious as it sounds or are patients benefiting? I feel bad for older people :(.
 
DocEspana said:
Wouldnt be too concerned unless you know someone who is a PA in the state. Then this PA vs AP thing can get tricky. This already exists in pretty much every state in america. They're called "doctors". When you get to do a geriatrics rotation (or if you spend some time at a nursing home) you'll find out many "physicians" who work at nursing homes are actually doctors who didnt complete residency and they work UNDER the head physician of the facility. They cant write Rx or bill, but they can do everything for the head physician who can bill and prescribe as advised by the guy on the ground at the nursing home. A few of them can be paid as employees and the prescribing doctor effectively increases his productivity and throughput many-fold. Its seen almost exclusively in geriatrics and nursing homes because these people pretty much never sue, since they are circling the drain anyway. The lower risk population for lawsuits means that the prescribing doctor can feel okay outsourcing all of the work and decision making.

What perhaps makes this significantly unique is that it is a push to have these people go out and work in rural areas in primary care of normal-aged people. Which I think it will have a big issue with. Medicare (and thus all insurances) have rules as to what every single class of billing provider must do in order to be able to bill. Creating a new class doesnt clarify that medicare doesnt recognize them. Now if the state recognizes them, it could push it a bit for the fed to recognize them. But its the same reason why all residents dont run out and perform independantly: We can't bill anyone for anything (unless they want to pay cash) until we are licensed, and we cant be licensed until about a year into residency. And PAs and NPs have their own criteria to be able to bill (independently or through an MD/DO, as decided by the states).
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DocE, that seems horrible. Unqualified "doctors" working in NHs. I wonder why working in NHs isn't popular. No residency required, 9-5 hrs, no lawsuits.
As far as the AP Missouri law, DermViser is correct it's geared toward USMGs from ACGME schools. Another reason for the merger and complete absorption of DO to MD.
 
NontradCA said:
In practice, is this as exploitative and dubious as it sounds or are patients benefiting? I feel bad for older people :(.
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Why doesn't the government inspect these places. The government inspects hospitals regularly, why can't it be done in NHs?
 
Apprands31 said:
DocE, that seems horrible. Unqualified "doctors" working in NHs. I wonder why working in NHs isn't popular. No residency required, 9-5 hrs, no lawsuits.
As far as the AP Missouri law, DermViser is correct it's geared toward USMGs from ACGME schools. Another reason for the merger and complete absorption of DO to MD.
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It's not assumed toward ACGME. That's poppycock. This is a poorly worded news article. "Four year degree bearing school or equivalent " is the terminology.
 
Apprands31 said:
Why doesn't the government inspect these places. The government inspects hospitals regularly, why can't it be done in NHs?
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There is nothing wrong with this. These people are doctors. In 90% of other countries this is where they would start practice. It's the residency having countries that look at this as odd. And or rules state they can practice medicine, but not bill insurances. This is simply a loophole. One that everyone is well aware of, but there is no reason to close. We train PAs the same way; on the job training with continued supervision.

And why would it be advantageous to those docs? Let's say they are older. Residency isn't as appealing as 80% pay ceiling but working right now.
 
But DocE, you know people in the government, why don't they inspect NHs ?
DocEspana said:
There is nothing wrong with this. These people are doctors. In 90% of other countries this is where they would start practice. It's the residency having countries that look at this as odd. And or rules state they can practice medicine, but not bill insurances. This is simply a loophole. One that everyone is well aware of, but there is no reason to close. We train PAs the same way; on the job training with continued supervision.

And why would it be advantageous to those docs? Let's say they are older. Residency isn't as appealing as 80% pay ceiling but working right now.
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Apprands31 said:
DocE, that seems horrible. Unqualified "doctors" working in NHs. I wonder why working in NHs isn't popular. No residency required, 9-5 hrs, no lawsuits.
As far as the AP Missouri law, DermViser is correct it's geared toward USMGs from ACGME schools. Another reason for the merger and complete absorption of DO to MD.
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So this proposed law doesn't allow DOs the same residency-free practice privileges? Well now I'm for sure against it.
 
NurWollen said:
So this proposed law doesn't allow DOs the same residency-free practice privileges? Well now I'm for sure against it.
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But why? It's only MDs who don't match. DOs have a 100% match rate.
Which leads to another thing, if you can't match then you shouldn't be allowed to practice medicine . Survival of the fittest!
 
Apprands31 said:
But why? It's only MDs who don't match. DOs have a 100% match rate.
Which leads to another thing, if you can't match then you shouldn't be allowed to practice medicine . Survival of the fittest!
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Because the law essentially codifies DO discrimination. I'm realistic. I know that DO discrimination exists and I accept that, but I know it consists mostly of subjective bias. I can't support a law that treats MDs and DOs differently.
 
Apprands31 said:
But why? It's only MDs who don't match. DOs have a 100% match rate.
Which leads to another thing, if you can't match then you shouldn't be allowed to practice medicine . Survival of the fittest!
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DOs don't have a 100% match rate. They don't even have a 100% GME placement rate. Whoever told you that doesn't know what they're talking about. Match rate is <90%, and the placement rate is at best 98-99% (roughly the same as MDs).
 
Apprands31 said:
Which leads to another thing, if you can't match then you shouldn't be allowed to practice medicine . Survival of the fittest!
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It's ridiculous to argue that everyone who didn't match is unfit to ever practice medicine.
 
Here's the actual text:
334.036. 1. For purposes of this section, the following terms shall
2 mean:
3 (1) "Assistant physician", any medical school graduate who:
4 (a) Is a resident and citizen of the United States or is a legal
5 resident alien;
6 (b) Has successfully completed Step 1 and Step 2 of the United
7 States Medical Licensing Examination or the equivalent of such steps
8 of any other board-approved medical licensing examination within the
9 two-year period immediately preceding application for licensure as an
10 assistant physician, but in no event more than three years after
11 graduation from a medical college or osteopathic medical college;
12 (c) Has not completed an approved postgraduate residency and
13 has successfully completed Step 2 of the United States Medical
14 Licensing Examination or the equivalent of such step of any other
15 board-approved medical licensing examination within the immediately
16 preceding two-year period unless when such two-year anniversary
17 occurred he or she was serving as a resident physician in an accredited
18 residency in the United States and continued to do so within thirty
19 days prior to application for licensure as an assistant physician; and
20 (d) Has proficiency in the English language;
21 (2) "Assistant physician collaborative practice arrangement", an
22 agreement between a physician and an assistant physician that meets
23 the requirements of this section and section 334.037;
24 (3) "Medical school graduate", any person who has graduated
25 from a medical college or osteopathic medical college described in
26 section 334.031.
27 2. (1) An assistant physician collaborative practice arrangement
28 shall limit the assistant physician to providing only primary care
29 services and only in medically underserved rural or urban areas of this
30 state or in any pilot project areas established in which assistant
31 physicians may practice.
32 (2) For a physician-assistant physician team working in a rural
33 health clinic under the federal Rural Health Clinic Services Act, P.L.
34 95-210, as amended:
35 (a) An assistant physician shall be considered a physician
36 assistant for purposes of regulations of the Centers for Medicare and
37 Medicaid Services (CMS); and
38 (b) No supervision requirements in addition to the minimum
39 federal law shall be required.
40 3. (1) For purposes of this section, the licensure of assistant
41 physicians shall take place within processes established by rules of the
42 state board of registration for the healing arts. The board of healing
43 arts is authorized to establish rules under chapter 536 establishing
44 licensure and renewal procedures, supervision, collaborative practice
45 arrangements, fees, and addressing such other matters as are necessary
46 to protect the public and discipline the profession. An application for
47 licensure may be denied or the licensure of an assistant physician may
48 be suspended or revoked by the board in the same manner and for
49 violation of the standards as set forth by section 334.100, or such other
50 standards of conduct set by the board by rule.
51 (2) Any rule or portion of a rule, as that term is defined in
52 section 536.010, that is created under the authority delegated in this
53 section shall become effective only if it complies with and is subject to
54 all of the provisions of chapter 536 and, if applicable, section
55 536.028. This section and chapter 536 are nonseverable and if any of
56 the powers vested with the general assembly under chapter 536 to
57 review, to delay the effective date, or to disapprove and annul a rule
58 are subsequently held unconstitutional, then the grant of rulemaking
59 authority and any rule proposed or adopted after August 28, 2014, shall
60 be invalid and void.
61 4. An assistant physician shall clearly identify himself or herself
62 as an assistant physician and shall be permitted to use the terms
63 "doctor", "Dr.", or "doc". No assistant physician shall practice or attempt
64 to practice without an assistant physician collaborative practice
65 arrangement, except as otherwise provided in this section and in an
66 emergency situation.
http://www.senate.mo.gov/14info/pdf-bill/tat/SB716.pdf
 
GUH said:
It's ridiculous to argue that everyone who didn't match is unfit to ever practice medicine.
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Indeed. Most people who don't match do end up matching somewhere, later on, even if they have to take a year off to build up their CV a bit.

Someone with a 550 COMLEX who applies ortho is probably more likely to go unmatched that someone with a 450 who applies FM. Who is more fit to practice medicine?
 
NurWollen said:
Because the law essentially codifies DO discrimination. I'm realistic. I know that DO discrimination exists and I accept that, but I know it consists mostly of subjective bias. I can't support a law that treats MDs and DOs differently.
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NurWollen said:
So this proposed law doesn't allow DOs the same residency-free practice privileges? Well now I'm for sure against it.
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You're out of your damn mind. The bill explicitly states this is open to graduates of osteopathic schools.

http://legiscan.com/MO/text/SB716/2014
 
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Apprands31 said:
But DocE, you know people in the government, why don't they inspect NHs ?
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I guess I should address this. The practice is entirely legal. They're doctors and they're doing what their degree allows them too. Billing (and thus culpability) and practice shouldn't be separated, but it's not illegal to do so. So NHs being reviewed won't find anything wrong with this. There is one doctor who takes all the responsibility and gets all the money and he pays other doctors to work for him doing what they're legally allowed to do (as long as they run every billable action by him). This would qualify as non-autonomous practice. Like a PA. Or a NP would be in most states.

And reconnecting the NH trend with this, you are seeing Missouri basically say that the previous bar for semi-autonomous practice (intern year, passed step 3, and paying for a medical license) would be lowered if you sequestered yourself to rural medicine.
 
DocEspana said:
I guess I should address this. The practice is entirely legal. They're doctors and they're doing what their degree allows them too. Billing (and thus culpability) and practice shouldn't be separated, but it's not illegal to do so. So NHs being reviewed won't find anything wrong with this. There is one doctor who takes all the responsibility and gets all the money and he pays other doctors to work for him doing what they're legally allowed to do (as long as they run every billable action by him). This would qualify as non-autonomous practice. Like a PA. Or a NP would be in most states.

And reconnecting the NH trend with this, you are seeing Missouri basically say that the previous bar for semi-autonomous practice (intern year, passed step 3, and paying for a medical license) would be lowered if you sequestered yourself to rural medicine.
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Doc E, is that what most unmatched med students do, they work in NHs? I read it costs $84,000 a year to stay in a NH. That explains why some FPs are paid one million dollars by Medicare.
DocE , how do you become the head doctor in a NH? Do you have to be certified in geriatrics? It seems like a good job: a bunch of people working for you, no call, no lawsuits, 9-5 etc
 
Apprands31 said:
Doc E, is that what most unmatched med students do, they work in NHs? I read it costs $84,000 a year to stay in a NH. That explains why some FPs are paid one million dollars by Medicare.
DocE , how do you become the head doctor in a NH? Do you have to be certified in geriatrics? It seems like a good job: a bunch of people working for you, no call, no lawsuits, 9-5 etc
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From all I've seen its unmatched foreign doctors. And to head a NH? I imagine it's as much connections as anything else (e.g. geriatrics fellowship)
 
DocEspana said:
From all I've seen its unmatched foreign doctors. And to head a NH? I imagine it's as much connections as anything else (e.g. geriatrics fellowship)
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So these are doctors without an internship? Right? No medical license? I imagine that kind of job is a big break for some foreign doctors. I've heard of them working as phlebotomists or MA's. Neurosurgeons come here and are lucky to find a psych or an FM residency.
 
NurWollen said:
So these are doctors without an internship? Right? No medical license? I imagine that kind of job is a big break for some foreign doctors. I've heard of them working as phlebotomists or MA's. Neurosurgeons come here and are lucky to find a psych or an FM residency.
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Correct on every point
 
In Florida, at least my neck of the woods, IMG's who didn't complete residency could practice under an ACN "area of clinical need" license. This allowed them to write prescriptions and generally practice as family physicians under a clinic director. Of course, they were pretty much used and abused in most cases as they are considered expendable. Not an ideal situation at all.
 
Back 5 said:
In Florida, at least my neck of the woods, IMG's who didn't complete residency could practice under an ACN "area of clinical need" license. This allowed them to write prescriptions and generally practice as family physicians under a clinic director. Of course, they were pretty much used and abused in most cases as they are considered expendable. Not an ideal situation at all.
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I worked with a couple of these physicians (they were FMG) at a county health department in FL and the other physicians were saying that these ACN physicians were better than the NP/PA at that clinic...
 
@Apprands31 ... To be the head of a NH, you don't need to be a BC in geriatrics... You can be a BC in FM/IM... My cousin is the medical director of one... In FL, is it not necessarily a 9-5 job... The way it works for my cousin is like they give him a stipend every month (I think it's over 2k/month) and he has most of the patients in the facility and he does visits like 3-4 times/week and he bills medicare/medicaid whenever he sees a patient whether he writes H/P, progress notes or orders etc...
 
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BestDoctorEver said:
I worked with a couple of these physicians (they were FMG) at a county health department in FL and the other physicians were saying that these ACN physicians were better than the NP/PA at that clinic...
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They are good doctors, but they are expendable because (in my experiences) if they didn't like the long hours and low pay, there were leagues of others willing to take their place.
 
BestDoctorEver said:
@Apprands31 ... To be the head of a NH, you don't need to be a BC in geriatrics... You can be a BC in FM/IM... My cousin is the medical director of one... In FL, is it not necessarily a 9-5 job... The way it works for my cousin is like they give him a stipend every month (I think it's over 2k/month) and he has most of the patients in the facility and he does visits like 3-4 times/week and he bills medicare/medicaid whenever he sees a patient whether he writes H/P, progress notes or orders etc...
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When your cousin works in the NH, how many hours does he spend there ? It seems like a sweet deal. $24,000 guaranteed plus extra from Medicare/Medicaid . Looking at the medicare website that comes to about $80,000 to 90,000. So your cousin makes about 105-115,000 working 3 days a week. Sounds sweet!
 
DocEspana said:
From all I've seen its unmatched foreign doctors. And to head a NH? I imagine it's as much connections as anything else (e.g. geriatrics fellowship)
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DocE, this is good to know. My neighbor was a doc in the Philippines and can't pass the Exams here. He's going into nursing with the hope of being an NP. I'll tell him he can find work as a doctor in a NH.
 
Apprands31 said:
When your cousin works in the NH, how many hours does he spend there ? It seems like a sweet deal. $24,000 guaranteed plus extra from Medicare/Medicaid . Looking at the medicare website that comes to about $80,000 to 90,000. So your cousin makes about 105-115,000 working 3 days a week. Sounds sweet!
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He usually spend 3-4 hours there. I would say he spend on average 12 hours/week at that place. By the way, I used to work part time at that place as a RN. He mentioned to me once that he make over 350k/year as a physician. He had over 50 patients at that place when I was working there, so sometimes the nurses call him for nonsense such as if they can give a patient tylenol. This can also be an annoying job...He also has a nice practice and he seems to be very smart with money too..
 
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BestDoctorEver said:
He usually spend 3-4 hours there. I would say he spend on average 12 hours/week at that place. By the way, I used to work part time at that place as a RN. He mentioned to me once that he make over 350k/year as a physician. He had over 50 patients at that place when I was working there, so sometimes the nurses call him for nonsense such as if they can give a patient tylenol. This can also be an annoying job...He also has a nice practice and he seems to be very smart with money too..
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What is your cousin's specialty if I may ask?
 
Apprands31 said:
Sweet! Did he train at a top tier place like MGH or UCSF?
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Lol... My cousin went to med school in Argentina right out of high school (6 year program) in the early 90s and he did his residency in NY... He told me him and his brother (a pediatrician) did the whole med school stuff (tuition, housing, food etc...) for less than 100k combined...
 
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BestDoctorEver said:
Lol... My cousin went to med school in Argentina right out of high school (6 year program) in the early 90s and he did his residency in NY... He told me him and his brother (a pediatrician) did the whole med school stuff (tuition, housing, food etc...) for less than 100k combined...
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Awesome! I was thinking about being a nocturnist and doing urgicare on the side. But now hearing about NHs I may look into that a little bit more!
 
user3 said:
I don't see why MD/DO grads shouldn't have the option to work as midlevels if they are unable to match or do not wish to do residency. I mean, 4 years of medical school should at least put one on level with PA's. A big downside though could be an influx of poorly qualified FMG's.
Click to expand...

You didn't read the article did you? That's pretty much exactly what it does.

It gives you the option of becoming an assistant physician to another physician after you graduate without a residency. In fact, the article said that the Missouri PA academy opposes the bill because it pretty much allows docs to do PA work without a residency.

This isn't something to get worked up over. In fact it's a good thing.
 
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