Anyone using Physician Assistants in their practice?

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Abacab

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The topic of NPs comes up often but I don't hear much about PAs in psychiatry. I have very little experience with mid-levels so forgive me if this is a dumb question. Is there a reason psychiatry relies on NPs so much more heavily than PAs?

PAs are trained within a medical model. I believe their knowledge and training is superior to that of an NP. Neither of them is any less uninitiated than a layperson when it comes to therapy, but I would trust a PA with the medical side of things far more than an NP.

Can anyone please enlighten me as to why we are not supervising PAs instead of NPs?
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Abacab said:
The topic of NPs comes up often but I don't hear much about PAs in psychiatry. I have very little experience with mid-levels so forgive me if this is a dumb question. Is there a reason psychiatry relies on NPs so much more heavily than PAs?

PAs are trained within a medical model. I believe their knowledge and training is superior to that of an NP. Neither of them is any less uninitiated than a layperson when it comes to therapy, but I would trust a PA with the medical side of things far more than an NP.

Can anyone please enlighten me as to why we are not supervising PAs instead of NPs?
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I've seen physicians with pa as well.
 
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Abacab said:
The topic of NPs comes up often but I don't hear much about PAs in psychiatry. I have very little experience with mid-levels so forgive me if this is a dumb question. Is there a reason psychiatry relies on NPs so much more heavily than PAs?

PAs are trained within a medical model. I believe their knowledge and training is superior to that of an NP. Neither of them is any less uninitiated than a layperson when it comes to therapy, but I would trust a PA with the medical side of things far more than an NP.

Can anyone please enlighten me as to why we are not supervising PAs instead of NPs?
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Anecdotally I've supervised only one PA but several NPs. I couldn't tell the difference.
 
I have not had much experience in this but often wondered myself. PAs seem to be better trained medically in general and I think the admissions process to PA school is more rigorous, much more. So the guess is that they may make decent psych prescribers? Some of this is so much dependent on the individual person's character as well. Are they driven to provide really excellent care, read up, be diligent in their work and especially in psychiatry tactful bedside manner with their own set of mature defenses. I've found interesting correlations with the characteristics of a provider and the type of patient population they tend to carry.
 
There are great NPs and great PAs. The best of either will of course be better than the worst physician. That said, in general, PAs do not practice psychiatry. I'm not saying it's impossible. It's just quite rare, in the US, at least. Can't speak for France. I have supervised several PAs doing required mental health rotations and they were not interested, to say the least.
 
Worked with one PA this year. He had no idea what he was doing, and that was fairly obvious. That is the only one ive worked with though.
 
Number of NPs>>number of PAs and probably even more so specifically in mental health. It's the same reason there is more discussion of depression than anti-NMDA encephalopathy. That said, I think if you plunked the average PA and average NP you would do better with the average PA.
 
PAs are superior to ARNPs and DNPs. Clinically, hands down. PAs are superior.
But the independent license of ARNPs to not require physician oversight, and shear volume of RNs and ARNP training programs, they flooded the market.

PAs are trying to catch up by getting independent practice rights too.

Race to the bottom everyone. Hang on tight.
 
One variable that is probably significant - seems that in private practice, reimbursement can be similar/equivalent for NPs. Not a fan of this from the physician perspective, but from a business/financial perspective...more money for the practice for the same amount of work. This is assuming that insurance reimburses less for PA visits/coding but that could be wrong.
 
rjs2131 said:
One variable that is probably significant - seems that in private practice, reimbursement can be similar/equivalent for NPs. Not a fan of this from the physician perspective, but from a business/financial perspective...more money for the practice for the same amount of work. This is assuming that insurance reimburses less for PA visits/coding but that could be wrong.
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I believe with Medicare proceedings, NPs get reimbursed __% of what MDs get reimbursed and the rate is the same between NP and PA. Commercial insurances generally use Medicare's policies at least as a reference point to help determine what is covered and at what rates.

At least with commercial insurances I worked with in PP, I've seen most insurances follow some version of the Medicare model.
 
Sushirolls said:
There are some states passing laws stating they get paid the same from insurance....
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Yes, I'm aware of that. Although at least for patients on Medicare based plans, I wonder if federal policy trumps the state policy. Commercial insurances may be affected though. If it turns out more NP rates are becoming closer to MD, negotiate with each insurance upwards. They need psych prescribers too desperately. At least over here. Unless the laws are passed, I'm not thinking too much about it. Most we can do is lobby against it, although it would be cool if physicians did that more.

Another thought I had is, let's say insurances do make reimbursement rates equal between NP, PA, DO, and MD. The rates can either be adjusted up to meet the MD rate or down to meet the mid level rate. With inflation going steady for a number of years, I don't think it will be the latter. Insurances need providers too much. Just my thoughts. We'll see what happens! At least we know with a market saturated with psych NPs, we're still sitting pretty. At least that's my opinion.
 
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randomdoc1 said:
I have not had much experience in this but often wondered myself. PAs seem to be better trained medically in general and I think the admissions process to PA school is more rigorous, much more. So the guess is that they may make decent psych prescribers? Some of this is so much dependent on the individual person's character as well. Are they driven to provide really excellent care, read up, be diligent in their work and especially in psychiatry tactful bedside manner with their own set of mature defenses. I've found interesting correlations with the characteristics of a provider and the type of patient population they tend to carry.
Click to expand...
They get a total of 4 weeks of psych training. Pa and np both have much less training than a physician
 
randomdoc1 said:
I believe with Medicare proceedings, NPs get reimbursed __% of what MDs get reimbursed and the rate is the same between NP and PA. Commercial insurances generally use Medicare's policies at least as a reference point to help determine what is covered and at what rates.

At least with commercial insurances I worked with in PP, I've seen most insurances follow some version of the Medicare model.
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comp1 said:
There are great NPs and great PAs. The best of either will of course be better than the worst physician. That said, in general, PAs do not practice psychiatry. I'm not saying it's impossible. It's just quite rare, in the US, at least. Can't speak for France. I have supervised several PAs doing required mental health rotations and they were not interested, to say the least.
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The best of either still has minimal training and less standardizes education than the worst physician.
 
Abacab said:
Can anyone please enlighten me as to why we are not supervising PAs instead of NPs?
Click to expand...
There are more nurses/NPs than PAs.

It’s also self selection. Those who choose an "assistant" occupation are more likely to listen to the professionals they are assisting. They are less likely to have the heart (and ego) of a nurse and run off to open clinics with zero experience. But both NPs and PAs are meh. Even when I was a med student, we knew enough psych to have a good laugh at the inpatient psych PAs’ plans and med choices.

There is probably a sexist/gender component too. NPs are more likely female, and practice owners and fulltime inpatient psychiatrists are more likely male. There appears to be a preference for such males to surround themselves with younger, giggling NPs. I call them "tee-hee" NPs.
 
I appreciate all the insight.
Anecdotally, I've found patients referred to me after being started on medication by their midlevel PCP are broken down as follows:

NP put patient on benzos for anxiety.
PA put patient on SSRI for anxiety (but never optimized/adjusted the dose)
 
Where could I find PA's with an interest in psychiatry. I heard there was a few programs but can't find them easily from search. I'm considering trying to hire 1 or 2 if they're available and interested. Thanks for the general topic OP.
 
Sushirolls said:
There are some states passing laws stating they get paid the same from insurance....
Click to expand...

randomdoc1 said:
Yes, I'm aware of that. Although at least for patients on Medicare based plans, I wonder if federal policy trumps the state policy. Commercial insurances may be affected though. If it turns out more NP rates are becoming closer to MD, negotiate with each insurance upwards. They need psych prescribers too desperately. At least over here. Unless the laws are passed, I'm not thinking too much about it. Most we can do is lobby against it, although it would be cool if physicians did that more.

Another thought I had is, let's say insurances do make reimbursement rates equal between NP, PA, DO, and MD. The rates can either be adjusted up to meet the MD rate or down to meet the mid level rate. With inflation going steady for a number of years, I don't think it will be the latter. Insurances need providers too much. Just my thoughts. We'll see what happens! At least we know with a market saturated with psych NPs, we're still sitting pretty. At least that's my opinion.
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More and more NPs are opening their own clinics. It's incredibly insulting to think about being reimbursed at the same rate as these clowns. Few disagree that physicians are >>> NPs or PAs in terms of quality of care, yet we somehow have states and insurers reimbursing them equally. Sure, large healthcare orgs currently pay the docs better. For those in private practice, though, it's absolutely crazy that insurance-based setups can lead to equal reimbursement between the two.

Portending the near future for doctors: I'm currently treated as an equal to the numerous NPs in my organization, despite one of them literally asking me for my template for new intakes. I told her, "It's in my head because I've already done 100s of these assessments." I somehow got the 5th degree when I declined to let an NP student shadow despite telling administrators that I don't believe NPs' admission or graduation requirements are nearly rigorous enough.

Plus, we shouldn't forget that physicians can't own hospitals. I'm not sure the same is true for nurses.

As for the PA issue, I'm not convinced they provide any better psychiatric care. They might have a better understanding of our medications, but they don't necessarily know when or why to use them.
 
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As an insight:

France is having a huge shortage of psychiatrists, so they re relying more and more to NP and PA.

The NPs we work with are only able to renew a prescription thats been done first by a psychiatrist, thats about it really theyre not supposed to start a new drug or question diagnosis. Most nurses dont want to be a NP at all.

As for PA, here anyone can be a PA really, the job is so new there isnt even any requirement.
So I ll be starting with a nurse I ve been working with for the past 2 years at the hospital. Guy is a nurse but couldve been a doctor if he wasnt born in a poor ass family.
PAs arent allowed to prescribe drugs but can basically fill out the whole medical record.
Hes been working in psych for 10 years and is hands down better than the majority of psychiatrists collegues I ve worked with.
Plan is I see my patients, he attends to his, and when hes done I come in and take over the prescribing/deprescribing part of the interview.

Main advantages are:
- I wont be working solo as thats one thing that could burn me out quicky
- He can handle and spend time with "simple patients" who are basically remited and come every 3 months for a fill up
- Slightly better income but I ll see less patients to attend to his so overall quite similar

Will be interesting to see how it goes.

But yeah there is no way in hell I would do that with an NP. We had two in the psychiatric hospital who were embarassingly clueless. Seems like their NP training just gave them confidence. Thank god they are given very few things to do - so far.
 
Kirby said:
Plus, we shouldn't forget that physicians can't own hospitals. I'm not sure the same is true for nurses.
Click to expand...
It is very interesting and troubling that there was a lot of legislation specifically aimed at physicians that don't impact NPs. This includes the ACA's prohibition against medicare-funded hospitals from being physician owned (with some exceptions), Sunshine Act reporting (NPs don't have their pharma money publicly reported), and Stark Law. In fact, it may be because NPs are exempt from Stark Law that they might be a cash cow for hospitals.
 
Kirby said:
More and more NPs are opening their own clinics. It's incredibly insulting to think about being reimbursed at the same rate as these clowns. Few disagree that physicians are >>> NPs or PAs in terms of quality of care, yet we somehow have states and insurers reimbursing them equally. Sure, large healthcare orgs currently pay the docs better. For those in private practice, though, it's absolutely crazy that insurance-based setups can lead to equal reimbursement between the two.

Portending the near future for doctors: I'm currently treated as an equal to the numerous NPs in my organization, despite one of them literally asking me for my template for new intakes. I told her, "It's in my head because I've already done 100s of these assessments." I somehow got the 5th degree when I declined to let an NP student shadow despite telling administrators that I don't believe NPs' admission or graduation requirements are nearly rigorous enough.

Plus, we shouldn't forget that physicians can't own hospitals. I'm not sure the same is true for nurses.

As for the PA issue, I'm not convinced they provide any better psychiatric care. They might have a better understanding of our medications, but they don't necessarily know when or why to use them.
Click to expand...
Np have a great lobby, united, with tons of people in it. Physicians are fractured and eat each other

Of course the organization wants everyone to be seen as the same, interchangeable. Physicians cost them too much
 
I have a problem with how NP's (and less so PA's) are used in specialty care. Rather than following-up/continuing a treatment plan for a diagnosis made by a physician, they are usually slotted in as being equal to physicians. I do have to say that there may be a bit of a patient dissatisfier especially in mental health with doing an intake with a doc but then being followed by someone else. But other specialties get away with similar patterns of care with no problem.

I have considered suggesting that we hire an NP but only if the organization and the NP are accepting of the model where the NP exists to treat patients specifically sent to them because they are so straightforward. (Never tried an SSRI for depression, new pure-ADHD patients, etc.)
 
FlowRate said:
I have a problem with how NP's (and less so PA's) are used in specialty care. Rather than following-up/continuing a treatment plan for a diagnosis made by a physician, they are usually slotted in as being equal to physicians. I do have to say that there may be a bit of a patient dissatisfier especially in mental health with doing an intake with a doc but then being followed by someone else. But other specialties get away with similar patterns of care with no problem.

I have considered suggesting that we hire an NP but only if the organization and the NP are accepting of the model where the NP exists to treat patients specifically sent to them because they are so straightforward. (Never tried an SSRI for depression, new pure-ADHD patients, etc.)
Click to expand...

At my current job, one thing I do is chart review minimum 20% of their charts. I do a word document each one and write things that I reccomend for each patient and email it back to them. its exhausting but because of this i have seen some drastic improvements in cleaner prescribing, giving less meds, dosing appropriately, etc. They are actually receptive to this because a lot of them have no experience with CYP interactions, SE profile, monitoring requrements, etc.
 
DrAmazingishere said:
At my current job, one thing I do is chart review minimum 20% of their charts. I do a word document each one and write things that I reccomend for each patient and email it back to them. its exhausting but because of this i have seen some drastic improvements in cleaner prescribing, giving less meds, dosing appropriately, etc. They are actually receptive to this because a lot of them have no experience with CYP interactions, SE profile, monitoring requrements, etc.
Click to expand...
Sounds like responsible supervision.

I guess to put my main gripe straightforwardly, NP's are not trained to diagnose and IMO should not be pretending to provide specialty-level diagnostic services.

I can see their role in primary/urgent/emergency care being a bit different/better slotting in as a generalist especially the latter settings when they're pretty much staffing every pt with an attending immediately.
 
FlowRate said:
Sounds like responsible supervision.

I guess to put my main gripe straightforwardly, NP's are not trained to diagnose and IMO should not be pretending to provide specialty-level diagnostic services.

I can see their role in primary/urgent/emergency care being a bit different/better slotting in as a generalist especially the latter settings when they're pretty much staffing every pt with an attending immediately.
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I wish they worked this way. Far as I can tell, they walk into rooms, declare themselves as “PCPs” and take on all the responsibility without telling anyone they have 1.5 years of “prescribing” education.

Primary care is incredibly hard to do well.

Don’t forget that many of them can practice independently.
 
splik said:
It is very interesting and troubling that there was a lot of legislation specifically aimed at physicians that don't impact NPs. This includes the ACA's prohibition against medicare-funded hospitals from being physician owned (with some exceptions), Sunshine Act reporting (NPs don't have their pharma money publicly reported), and Stark Law. In fact, it may be because NPs are exempt from Stark Law that they might be a cash cow for hospitals.
Click to expand...
Makes me wonder if that's why NPs are the only ones using Vrylar, Latuda, Caplyta, Aztarys, and Qelbree despite absent evidence of superiority.
 
Kirby said:
I wish they worked this way. Far as I can tell, they walk into rooms, declare themselves as “PCPs” and take on all the responsibility without telling anyone they have 1.5 years of “prescribing” education.

Primary care is incredibly hard to do well.

Don’t forget that many of them can practice independently.
Click to expand...
Yeah impossible to forget when so much of my practice is fixing the mistakes of independent NP's. There's a practice here "Psychiatry %CityName%" that is 100% NP's and one of the major sources of those issues, no psychiatrists on staff. Should be considered false advertising to have a name like that. Every pt I get from them calls their former nonphysician prescriber "Dr. so and so."
 
FlowRate said:
Yeah impossible to forget when so much of my practice is fixing the mistakes of independent NP's. There's a practice here "Psychiatry %CityName%" that is 100% NP's and one of the major sources of those issues, no psychiatrists on staff. Should be considered false advertising to have a name like that. Every pt I get from them calls their former nonphysician prescriber "Dr. so and so."
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It's disgusting. Many of my referrals describe their previous provider as doctor or psychiatrist such and such. They come to me feeling terrible because of akathisia and/or insomnia from inappropriate antipsychotic regimens (usually characterological issues diagnosed as bipolar), but can't comprehend what I'm saying when I tell them, "You've actually been seeing a nurse practitioner who may have completed as little as one-and-a-half-years of training before treating you." Literally had someone tell me, "But I can text them whenever I need to!" She literally texted her provider every day as late as 10PM.

How can I compete with that? I understand the value of boundaries and appropriate coping skills.
 
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Kirby said:
It's disgusting. Many of my referrals describe their previous provider as doctor or psychiatrist such and such. They come to me feeling terrible because of akathisia and/or insomnia from inappropriate antipsychotic regimens (usually characterological issues diagnosed as bipolar), but can't comprehend what I'm saying when I tell them, "You've actually been seeing a nurse practitioner who may have completed as little as one-and-a-half-years of training before treating you." Literally had someone tell me, "But I can text them whenever I need to!" She literally texted her provider every day as late as 10PM.

How can I compete with that? I understand the value of boundaries and appropriate coping skills.
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This is the inherent problem. Why am I spending months getting people off of problematic regimens of multiple antipsychotics, benzos, stimulants and mood stabilizers, just to come to the conclusion that they could get better results from an SRI and DBT (even the broken DBT I can offer), when they love their NP as much or more for "always listening" despite causing them weight gain, anxiety, irritability, and mental fog? I just can't...
 
Kirby said:
Makes me wonder if that's why NPs are the only ones using Vrylar, Latuda, Caplyta, Aztarys, and Qelbree despite absent evidence of superiority.
Click to expand...

Disagree on the first two, vraylar and latuda have good support programs, mainly vraylar. If you have low income then you can basically get it for free each month. The metabolic profile of these drugs make them desireable. Symbyax and seroquel both cause significant weight gain. Latuda I can get with a decent number of commercial insurances and medicare if I remember correctly, esp if they failed other agents.

Caplyta is a lot harder to get covered. I have 3 people on it, because they failed everything else, and they responded well to it. But im only able to get it to them because no insurance/limited income. The two desireable aspects of it are minimal if any weight gain and no dose titration.

I try to use weight friendly stuff whenever possible and seroquel is abused a ton in community psychiatry, its traded/mixed with drugs frequently.

I think you're missing out if you dont consider vraylar or latuda because SE profile they work well. Captlyta is a bipolar depression drug for the people who have a lot of money and don't give a ****, or have no income and get it for free.

Utilize patient support programs whenever possible, they're super useful.

I personally dislike lamictal because of slow titration so people get discouraged, and in my experience people are not good at following easy instructions. Not everyone, but a significant number of people. Plus the ones with comorbid borderline or borderline masquerading as bipolar 2 may OD on it
 
FlowRate said:
I have a problem with how NP's (and less so PA's) are used in specialty care. Rather than following-up/continuing a treatment plan for a diagnosis made by a physician, they are usually slotted in as being equal to physicians. I do have to say that there may be a bit of a patient dissatisfier especially in mental health with doing an intake with a doc but then being followed by someone else. But other specialties get away with similar patterns of care with no problem.

I have considered suggesting that we hire an NP but only if the organization and the NP are accepting of the model where the NP exists to treat patients specifically sent to them because they are so straightforward. (Never tried an SSRI for depression, new pure-ADHD patients, etc.)
Click to expand...
This is maybe a fine model in surgical specialties where the diagnosis is very clear from imaging/physical exam but really does not work well in outpatient medicine/psychiatry. These patients are not going to want to follow up with NP/PA if their first evaluation is with a psychiatrist. Plus we all know that their diagnoses might very well change with subsequent appointments
 
CB5T said:
Where could I find PA's with an interest in psychiatry. I heard there was a few programs but can't find them easily from search. I'm considering trying to hire 1 or 2 if they're available and interested. Thanks for the general topic OP.
Click to expand...
There are no PA programs in psych as all PA programs are geared towards general medicine. You would just want to look for somebody with an interest or experience in psych
 
I've used PAs. It depends on the state. In my own state the rules of PAs and NPs are the same in terms of oversight except that I have to review 20% of the cases an NP does that are controlled substances, 10% othewise. For PAs it's 10% across the board.

Other than this the rules are the exact same.

So I can tell you all about it but it depends on the state, so it's kind of moot outside this state, Missouri.

The bottom line is there's good and bad NPs and PAs out there. You got a good one you're solid. If they suck get rid of them.
 
allantois said:
There are no PA programs in psych as all PA programs are geared towards general medicine. You would just want to look for somebody with an interest or experience in psych
Click to expand...
There are PA psychiatry "residencies" that are basically one year of psych clerkships at some institutions. Some people have completed those.
 
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