advice on adding PA

[specepic]

Anyone here have a successful PA setup in their practice?

Hospital has offered to hire a PA for me. I am booking out 6-8 weeks and although for chronic pain thats prob ok, and I end up squeezing in acutes, it would be nice to have some breathing room

My thoughts:

Pros:
- better pt access
- potential to use PA as a scribe/help with notes some of the time
- someone to handle scut work (handicap forms)
- PA could be trained to see appts that the PCP can't do but are simple with a little training (some office inj's, some opioid refills)

Cons/pitfalls:
- my pool of pts will be bigger which will make for more calls, etc, and if the PA cant handle it, that will add to rather than lighten my scutwork
- Hosp policy requires I review 25% of PA/NP notes
- $$, currently the orthos in my group dont get an supervisory compensation to speak of, the hosp keeps the diiference b/t what the PA generates and their salary. The justification is that the PAs assist them in the OR and some of those surgeries the hosp does not get paid for the assistant. The PAs do see their own clinic when not in OR

I think the structure of this would require some very specific language to ensure it will make my life better, not worse, as it could go either way. The hosp is not ramming this down my throat, it was thrown out there as: "would you like a PA?"

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[Ducttape]

i was booking out 4 months in advance for new patients before hiring a midlevel.

i would do it, but most on this forum would not, im guessing.

a PA will not take over your practice. a PA does not make you a pill mill by having the PA see your follow ups. you teach the PA what to do, put limitations on their practice ("no opioids unless i already approved and started them", for example).

set it up so the PA sees all the new patients, and you see them "concurrently" (in reality, after they have done a complete H&P). they can do your new eval paperwork with the exception of your concise summary that captures all the requirements for level 3/4 E&M. for example, schedule the patient for 45 min on PA schedule and 15 on yours. Bill under you, not the PA.

PAs can take call for you. since i dont ever call in prescriptions, and ive set up "expectations" that this never happens, the fact you are using a PA to take call every other week doesnt negatively affect you, and gives you some time off. they can and should be doing most of your scutwork. that time you use doing that stuff is better off financially in seeing patients or doing procedures.

 

[jonnylingo]

Anyone here have a successful PA setup in their practice?

- PA could be trained to see appts that the PCP can't do but are simple with a little training (some office inj's, some opioid refills)

Sometimes it's the "simple", straightforward stuff and quick joint injections that get me through the day of chronic pain patients. If a midlevel captured this easier stuff, I'd drown in the complicated chronic pain mass.

 

[jonnylingo]

From a diagnostic standpoint, do you feel that a midlevel would offer less value to the patient and referring provider in terms of exam and diagnosis? Not trying to be inflammatory, but PMR/Pain training arms us with exam and differential skills that I don't feel you can get with a midlevel. May piss off referring doc or patient.

 

[Ducttape]

Whoever said the PA was making the diagnosis, or any decision making in treatment?


The mid level should be clearing you of the wasted not financially productive time - typing in ROS, PSH, lymphatic exam, exacting numbers on buceps reflexes in back pain patients, mri results, getting PT or MRI PAs, setting up psych evaluation for stim's, talking to the other practice mid levels when referred by them, pulling up PMPs, refills on non opioid meds, etc

 

[deleted472101]

Whoever said the PA was making the diagnosis, or any decision making in treatment?


The mid level should be clearing you of the wasted not financially productive time - typing in ROS, PSH, lymphatic exam, exacting numbers on buceps reflexes in back pain patients, mri results, getting PT or MRI PAs, setting up psych evaluation for stim's, talking to the other practice mid levels when referred by them, pulling up PMPs, refills on non opioid meds, etc

Most of that an MA can do right?

 

[BobBarker]

Yea, that is MA work. Just me and a MA and she does all of that.

 

[Ducttape]

not really, especially if you are going to bill appropriately for the PAs services.


one final point, if you are booking out 1 1/2-2 months out, then you need to either radically change your schedule or you need to hire a midlevel. any number of MAs will not fix that.

at one point, i had 3 MAs and 3 nurses. the bottleneck was me. hiring more MAs would not have changed a thing.

 

[specepic]

The pitfalls mentioned above I have also considered:
- since MDs are sending me these cases, will a PA add value?; I think with the right training yes and again have them handle the simpler stuff
- PA sees the simpler stuff leaving me with all the hard / burnout stuff? ; valid concern

A wrinkle here for me is hospital employment as well

 

[geauxg8rs]

In my area the patients don't know the difference between the local ortho spine doc and his PA who sees all of his Mediscare patients. They all refer to the PA as doctor Julie. The old people prefer doctor Julie since she spends more time with the patient. So who knows?

 

[Tenesma]

1) if the PA/NP works in a way to facilitate better patient flow, and gets more of your notes done for you - and you get to keep the revenue generated by the NP - then this is great

2) if the PA/NP evolves into an independent model, and you are supervising them without seeing the majority of the patients - and you don't get to keep the revenue generated by NP - then this sucks.

 

[Ducttape]

Agree with Tenesma. Option 1 is you being "captain of the ship." you see all the new evals, decide on the treatment course, and the PA follows up. if he sees a follow up that is too complicated, then he can grab you to go over the patient. it will free you up to do more procedures and injections.

you and the PA should not be working in vacuums, like #2.

 

[paindoctn]

Make sure the PA goes through a trial period. I was hired out of the fellowship to oversee an office in the middle of nowhere with 1 PA running it for a couple of years essentially unsupervised before I came on board. Well, he turned out to be an old PA "set in his ways" whose favorite combo was Roxi 30's + generic Oxymorphone ER 40 tid. My life way a daily struggle and screaming matches and eventual threat to the employing group "either he or I". Finally, they fired this guy. And I was very new at the time.
Then they listened to me and all my complaints about the 1st PA and hired his complete opposite. The second PA was conservative all right. If pt was 2 pills short or had 3 extra pills during a monthly visit, she'd just go off on them, made them fill like a junkie and would dismiss them. She ran a police station out of that office. We easily lost ~ 25% of business in a matter of months. A crazy PA ran ruin your office and reputation.
So to make long story short, be careful who you hire. Don't hire a total nut on either extreme of the PA spectrum.

 

[Tenesma]

best is to hire somebody out of training - so you can mold them
2nd best is to hire a PA/NP from a different specialty - so you can mold them
3rd best is to hire a PA/NP from a similar specialty - so they have somewhat of an understanding, but are still open to molding
worst is to hire a PA/NP from same specialty unless you have worked w/ them before and know them welll - this bucket is usually most problematic.

 

[Doctodd]

Im considering hiring a PA to see hospital consults only. Want to feed the office and keep the other pain docs away.

 

[Pacman27]

I am booked out about 2 weeks and I am not sure if my PA adds anything to increase patient volume, but she def makes my life easier and I can leave the office earlier.

Sometimes its worth paying for a piece of my mind, assuming the PA can handle that

I still at least say hello to every patient

 

[Tenesma]

best part of a PA is that on days that you are sick or otherwise can't function/be in the office, the whole office doesn't come to a screaching halt....

 

[specepic]

do any of you teach the PAs to do relatively simple fluoro inj's? ILESI on non-complex anantomy, MBB LS, SIJ ? USGI of TPI/joints? I also dont want to train my replacement.... maybe just have them see OV

 

[DOctorJay]

do any of you teach the PAs to do relatively simple fluoro inj's? ILESI on non-complex anantomy, MBB LS, SIJ ? USGI of TPI/joints? I also dont want to train my replacement.... maybe just have them see OV

Please don't do that

TPIs only (if that)

 

[deleted472101]

do any of you teach the PAs to do relatively simple fluoro inj's? ILESI on non-complex anantomy, MBB LS, SIJ ? USGI of TPI/joints? I also dont want to train my replacement.... maybe just have them see OV

What! No. Follow ups. Consults etc yes.
But flouro procedures?!

 

[lobelsteve]

In Georgia there is an attorney general letter regarding these non delegable tasks. Similar to letting your PA take out a gallbladder or uterus.

 

[Stim4me]

Make sure the PA goes through a trial period. I was hired out of the fellowship to oversee an office in the middle of nowhere with 1 PA running it for a couple of years essentially unsupervised before I came on board. Well, he turned out to be an old PA "set in his ways" whose favorite combo was Roxi 30's + generic Oxymorphone ER 40 tid. My life way a daily struggle and screaming matches and eventual threat to the employing group "either he or I". Finally, they fired this guy. And I was very new at the time.
Then they listened to me and all my complaints about the 1st PA and hired his complete opposite. The second PA was conservative all right. If pt was 2 pills short or had 3 extra pills during a monthly visit, she'd just go off on them, made them fill like a junkie and would dismiss them. She ran a police station out of that office. We easily lost ~ 25% of business in a matter of months. A crazy PA ran ruin your office and reputation.
So to make long story short, be careful who you hire. Don't hire a total nut on either extreme of the PA spectrum.

PAs tend to want to serve their master, NPs can go rogue... A np in CT was recently arraigned for writing subsys willy nilly on every patient... She made the list of most subsys pills in the USA... As a consequence Of her 80k per year in speaking fees, age is looking at possible jail time. She is also being sued for several wrongful death suits... The MD owner is taking no responsibility...

 

[drusso]

You need to train them. It's like having a permanent resident working with you....and, it's fine to have them see new patients and dictate the note, but you MUST get your face in front of EVERY new patient and double check everything.

 

[specepic]

Before everyone gets their dander up about PAs doing fluoro procedures, it was merely a question, and already happens at length in my state. Was curious what others here were doing on here. My primary PA needs are in the office

 

[Jcm800]

The pitfalls mentioned above I have also considered:
- since MDs are sending me these cases, will a PA add value?; I think with the right training yes and again have them handle the simpler stuff
- PA sees the simpler stuff leaving me with all the hard / burnout stuff? ; valid concern

A wrinkle here for me is hospital employment as well

in a hospital environment, with no compensation for it, i would not do it. If there is a bunch of stuff you have to do that you DONT want to do, and the PA could do that, then its worth it.

 

[Ducttape]

in a hospital environment, with no compensation for it, i would not do it. If there is a bunch of stuff you have to do that you DONT want to do, and the PA could do that, then its worth it.

The compensation would come in terms of reduced E&M and increased wRVUs with greater procedures. More patients, more procedures...

Additionally, overall revenue by the pain center as a whole would increase without as significant an increase in expenses - PAs cost a system less than a third the cost of another physician.

 

[SSdoc33]

Additionally, overall revenue by the pain center as a whole would increase without as significant an increase in expenses - PAs cost a system less than a third the cost of another physician.

wonderful. your chairman and the CEO make more money and you get increased risk. if the books are completely open to you (which they NEVER are) then you can make this claim.

 

[Jcm800]

The compensation would come in terms of reduced E&M and increased wRVUs with greater procedures. More patients, more procedures...

Additionally, overall revenue by the pain center as a whole would increase without as significant an increase in expenses - PAs cost a system less than a third the cost of another physician.

i dont believe this to be the case. I have an NP. She does not generate me more procedures becasue the patients she sees, dont generate procedures. Plus, i dont like to do procedures on patients i havent seen, so i STILL need to the see that patient, if the NP saw them and "set them up" so i still need to do the EM. So its worse for me, because that patient is on their schedule, but i end up having to see them too and was not planning on it. I could have just seen them by myself. Granted i dont have to do the whole chart, but that doesnt take me that long anyway, since the MAs put in all the BS.

its not like I can do MORE procedures because the PA/NP is seeing EMs, because i still need to the see the E and Ms to generate the procedures.

I dont think it makes more money, but it makes me BETTER money. so if you have to see bogus waste of time hospital consults, they are awesome. Because that visit is now a quick 1 minute bedside visit and a sign of a chart. If you want to use them to set up a block shop and pill mill, then they are worth their weight in gold. But if you run a good practice, or at least what i consider good, for me, they are not money makers, they are sanity savers. but if i was in a hospital, and it creates more work, then i would not do it. But like i said, if it can keep the riff raff away, it may be worth it.

 

[SSdoc33]

ive trained a bunch of fellows. by the end of the year, i still cant get them to make the right decisions (or the decisions that I would make) regarding treatment, site of injections, etc. that might say more about me than anything, but there really isnt a role for a PA or NP to make the real decisions in our field. and i wouldnt want them seeing opioid follow ups if im responsible for them. so, besides hospital consults and phone calls, you arent getting much bang for your buck...

 

[Ducttape]

admin has been pretty open with the books, up until a year ago, as far as i can tell. i see everyone's salary, the amount spent on benefits, supplies, equipment, parking for patients, etc. i get a breakdown of the insurances, the procedures, the AR, the recieved payments. i dont think they would like it if i posted the excel documents online. anyways, you guys would laugh at how few procedures i do - stim or lobel probably does more procedures in a week that i do in a year (that is not a snipe at either of them - i just know they do a lot of injections).

i see all new patient evals. where i get benefit with the midlevel is the routine follow up - my current ratio of follow up to injection on an average patient runs 3:1. only so many appointment slots in the day. the only time the NP/PA "orders" an injection is on someone who had clinically meaningful improvement on their prior injection and requests another, but that adds up...


and ironic you mention CEO. the administrator that hired me (and started the pattern of providing all the records up until a year ago) moved up the ranks, and is now currently the President of the hospital system...

 

[PMR2008]

I have 2 PA's and about to hire my third. I have a very unique practice model (Rehab/Pain subacute and inpatient consults+2 days a week clinic). My PA's are both former orthopedic PA's and can easily manage peripheral joint injections, trigger point injections, peripheral nerve blocks. I don't allow them to perform anything more complicated than that. I see all the initial consults and it works out really well. I am never going to hire a NP for the same reasons listed above.

 

[Tenesma]

again, the money generated from a NP is peanuts compared to the income we generate --- HOWEVER, I still would argue that a mid-level is worth their weight in gold when for unforeseen circumstances I am out of the office, and don't need to close the office... ie: when i am sick, doing a deposition, what not... other than that, I can totally do without a mid-level

re: mid-levels and procedures.. they love algorithms and wash/repeat thought processes - i had one mid-level, who saw a patient who did fantastic with an SI joint injection, he quickly scheduled SI joint injections on every patient with back/buttock/leg pain --- i knew this was a problem when i walked into my procedure suite and had 8 SI joint injections back to back -- never allowed mid-levels to make injection decisions again for me... so all patients that require injections need eval by me first.