DO/MD vs NP/PA in the Family Medicine setting

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KeikoTanaka

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Please, there are countless threads attacking NPs/PAs. I am not interested in hearing those opinions. I can quickly search and find, like I said, countless threads attacking NPs. Please do not make this argument on this thread.

The purpose of this thread, therefore, is to clearly ask and have input from both sides as to how the various degrees function in the primary care field. I'm interested in Primary Care (But who knows?) and I have a lot of debt, like A LOT of debt (6 years of schooling prior to medical school). Therefore, I am slightly nervous about actually pursuing FM out of fear of salaries dropping due to an influx of providers entering the field. I won't be out of residency for 7-8 years, so I have no idea what the medical landscape will be at the time, and while it might be a nice thought that I could work independently, I don't know if I'll have a choice in various jobs. I know NPs have many independent-practice rights across the US. It seems inevitable to work with them with the way trends are going, so here are various questions I have:

1. In states that NPs are independent, do many still work with physicians? Would they have any reason to? Or could it be better for both parties if they still did?

2. What is the upper limit of a NPs ability? And by that I mean, if they work in partnership with a physician, how does the "hand-off" of patient care work?

3. Who decides what patients are "complicated" and should therefore see the physician?

4. As a future physician, what can I do to help separate myself from NPs and therefore be the "expert" on X Y Z and therefore justify seeing X Y and Z patients. I saw a statistic that 49% of NPs work in primary care, but only 18% work in adult primary care solely. Does this mean that, I would mostly be seeing the geriatric population as they are more complicated? Are Internal Medicine PCPs potentially more insulated from mid-level creep?

5. If I did a fellowship in something like Sports Medicine, could that also help attract that patient base to me as well, while the NPs I work with see more acute things that pop up throughout the day if someone comes with an emergent sprained wrist/ankle, for example?

6. How does the physician/scheduling staff decide which patients will see the doctor or the mid-level?

7. Like I said, my biggest fear is seeing salaries drop immensely due to an influx of people entering the field. Other than seeing more complicated cases and seeing more of them per hour, how do we justify our salaries not dropping? If I ever have to work with an NP or PA, I would only ever want to work with 1 at most. I wouldn't want my day consumed by reviewing charts, when what I was trained for was to be seeing patients personally. And to be honest, I feel like that is part of the appeal for patients: To see the "Expert" when they need to see the expert.

I know many people will post like "Do what you love! Don't worry about the money!" And that's all fine and dandy, but I could honestly love a lot of fields that pay more, as long as I'm helping people. But I am intrigued by the variety that family med offers and being someone's "doctor". It just seems working with mid-levels is becoming increasingly more prevalent due to the influx of them into the field. So moving forward, how do we maintain a healthy balance for mid-levels and docs on both sides while ultimately providing the best care for patients, all the while maintaining the integrity of the medical degree and asserting ourselves as experts?

Please, no attacks. I know someone will post "Just don't work with them" or "refuse", but let's pretend due to the economics of it all, this is not an option 10 years down the road, especially if I am not in a position to open up my own office, etc.
 
1. Yes. A large group/hospital system isn't going to let midlevels run around completely on their own. Liability

2. Highly variable. In my group, I have to review 25% of charts and the NP probably discusses an additional 25% of patients with me.

3. Either the midlevel or the practice agreement, whichever is more strict.

4. Be a decent physician. Doesn't take anything more than that.

5. Potentially

6. Whoever sets up how scheduling works

7. Depends on payers more than anything we do.
 
Blue Dog said:
Anyone who thinks midlevel incomes have any effect on physician incomes has no comprehension of how medical reimbursement works.
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You don't think there would be any impact on physician salary if, lets say: suddenly all midlevels could be independent practitioners in the primary care world?
 
KeikoTanaka said:
You don't think there would be any impact on physician salary if, lets say: suddenly all midlevels could be independent practitioners in the primary care world?
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No, because most physicians are paid on production, not salary. Payer fee schedules have nothing to do with how much midlevels are paid.

From an income standpoint, you should be more concerned about single-payer than midlevels.
 
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Blue Dog said:
Anyone who thinks midlevel incomes have any affect on physician incomes has no comprehension of how medical reimbursement works.
Click to expand...
It would indirectly. If more hospital corporations hire midlevels to staff their primary care offices, then that will drive down the compensation packages for their primary care physicians. Even if doctors work for production, the compensation is still tied to dollars per wRVU, which is determined by the hospital by some opaque method.
 
bronx43 said:
It would indirectly. If more hospital corporations hire midlevels to staff their primary care offices, then that will drive down the compensation packages for their primary care physicians. Even if doctors work for production, the compensation is still tied to dollars per wRVU, which is determined by the hospital by some opaque method.
Click to expand...

I suppose this is my fear but I wasn't sure how to phrase it
 
bronx43 said:
It would indirectly. If more hospital corporations hire midlevels to staff their primary care offices, then that will drive down the compensation packages for their primary care physicians. Even if doctors work for production, the compensation is still tied to dollars per wRVU, which is determined by the hospital by some opaque method.
Click to expand...

Not where I work. And, I'm honestly not sure how you logically get from A to B on that one anyway.
 
bronx43 said:
Supply and demand. Read about it.
Click to expand...

I know all about it, which is why I know that it usually has nothing to do with physician incomes (local recruiting incentives notwithstanding). If it were true across the board, primary care physicians would be better paid than most specialists.
 
Blue Dog said:
I know all about it, which is why I know that it has nothing to do with physician income. If it were true, primary care physicians would be better paid than most specialists.
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Physician compensation is a combination of reimbursement for specific services as well as supply and demand. I’m not saying it’s all supply and demand but I disagree with your assertion that supply and demand doesn’t play a role.
 
bronx43 said:
Physician compensation is a combination of reimbursement for specific services as well as supply and demand. I’m not saying it’s all supply and demand but I disagree with your assertion that supply and demand doesn’t play a role.
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I couldn't care less if you agree with me or not. I never said it doesn't play any role, but the role is minor, and typically confined to local needs.
 
Blue Dog said:
I couldn't care less if you agree with me or not. I never said it doesn't play any role, but the role is minor, and typically confined to local needs.
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All job prospects are local... the more prevalent this trend is, the more localities are affected.

Lol, if you don’t care then don’t respond.
 
bronx43 said:
All job prospects are local... the more prevalent this trend is, the more localities are affected.

Lol, if you don’t care then don’t respond.
Click to expand...

Ditto that.

I'll challenge you to prove your theory by posting physician income trends since midlevel numbers have increased.
 
Blue Dog said:
Ditto that.

I'll challenge you to prove your theory by posting physician income trends since midlevel numbers have increased.
Click to expand...
What's the point? Over the past few decades, the demand for primary care services has outpaced primary care providers of all credentials, therefore by supply and demand alone you would expect pay to go up. This is especially true as hospital systems realize that they need a referral base for their high priced specialty services.

I don't understand how anyone can look at the landscape of mid-level encroachment, and think that it won't have a direct or indirect effect on the physician job market. Every patient that sees a mid-level instead of a physician is detrimental to said job market. Large swaths of the population mistaken their mid-level for a "doctor," and refer to them as such. Even if compensation packages look superficially similar, increased encroachment will push jobs out more and more into less desirable locations. If younger docs are ok with that, then fine. If they're willing to go headfirst with the assumption that supply and demand won't ultimately affect them, then fine.

Perhaps we can look back on this in 15 years and see what the effects are. If I'm wrong by then, I'll eat crow.
 
bronx43 said:
What's the point? Over the past few decades, the demand for primary care services has outpaced primary care providers of all credentials, therefore by supply and demand alone you would expect pay to go up. This is especially true as hospital systems realize that they need a referral base for their high priced specialty services.

I don't understand how anyone can look at the landscape of mid-level encroachment, and think that it won't have a direct or indirect effect on the physician job market. Every patient that sees a mid-level instead of a physician is detrimental to said job market. Large swaths of the population mistaken their mid-level for a "doctor," and refer to them as such. Even if compensation packages look superficially similar, increased encroachment will push jobs out more and more into less desirable locations. If younger docs are ok with that, then fine. If they're willing to go headfirst with the assumption that supply and demand won't ultimately affect them, then fine.

Perhaps we can look back on this in 15 years and see what the effects are. If I'm wrong by then, I'll eat crow.
Click to expand...

I'll be retired.

If anything, the first part of your post refuted the supply and demand argument for physicians. You then went off on a tangent or two about unrelated midlevel stuff, but...whatever. One could more easily argue that midlevels are going to sabotage their own incomes by oversupply (more likely since most of them are actually salaried).

 
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Blue Dog said:
I'll be retired.

If anything, the first part of your post refuted the supply and demand argument for physicians. You then went off on a tangent or two about unrelated midlevel stuff, but...whatever. One could more easily argue that midlevels are going to sabotage their own incomes by oversupply (more likely since most of them are actually salaried).

Click to expand...
Um no it didn’t. Just because supply and demand favors physicians at this present time doesn’t mean you’re immune to it.

Mid levels are likely going to sabotage their own incomes by oversupply, but the effects are going to bleed into physician job markets.

Most physicians are salaried now as well.
 
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Generally, when becoming a physician you understand what you can do in terms of scope of practice, for mid levels this becomes more dependent on location/specialty and is changing

In my experience, limited as it may be, income potential of mid levels is capped, where I can take on additional roles not offered to mid levels and my RVU reimbursement is several times higher. These differences may be locally dependent, taking on supervisory roles is not typically offered to mid levels (directorships including).
Practice in whatever role you feel comfortable in - if you’re happy in what you do/enjoy it, then it isn’t work.
 
VA Hopeful Dr said:
Prove it, because I'm fairly certain this isn't true.
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I don’t mean salaried without production bonus. I mean salaried as in employed, where someone else determines what your income is.

Bluedog and I are in physician owned groups without a "base salary"," "production bonus" or "wRVUs." Money in, money out, you keep the difference.

264861
 
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bronx43 said:
I don’t mean salaried without production bonus. I mean salaried as in employed, where someone else determines what your income is.

Bluedog and I are in physician owned groups without a "base salary"," "production bonus" or "wRVUs." Money in, money out, you keep the difference.

View attachment 264861
Click to expand...
So by salaried you didn't actually mean salaried? Got it.
 
VA Hopeful Dr said:
So by salaried you didn't actually mean salaried? Got it.
Click to expand...
Salary with a bonus structure is still salaried by definition, but whatever. I don't see the point of this argument over semantics.
 
bronx43 said:
Salary with a bonus structure is still salaried by definition, but whatever. I don't see the point of this argument over semantics.
Click to expand...

Well, the word "salary" does have a specific meaning. I try to avoid using it unless I'm talking about a fixed amount (e.g., the way our midlevels are paid).

Screen Shot 2019-05-29 at 8.37.59 AM.png
 
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Blue Dog said:
Well, the word "salary" does have a specific meaning. I try to avoid using it unless I'm talking about a fixed amount (e.g., the way our midlevels are paid).

View attachment 264863
Click to expand...
Fair enough, though it does get murky when physicians are paid a “base salary” with a production bonus after a predetermined threshold.
I mean, many industries (corporate, sales, finance, etc) have salaried employees who get bonuses if they go above and beyond. I would consider them all salaried.
 
bronx43 said:
Fair enough, though it does get murky when physicians are paid a “base salary” with a production bonus after a predetermined threshold.
I mean, many industries (corporate, sales, finance, etc) have salaried employees who get bonuses if they go above and beyond. I would consider them all salaried.
Click to expand...
And they would be under the definition.

Most employed physicians I know aren't like that. In the last 3 places I've worked that were production based, your pay was based on the previous quarter's productivity. If you under-earned, you had to pay them back. That's not really how salaries work.
 
VA Hopeful Dr said:
Most employed physicians I know aren't like that. In the last 3 places I've worked that were production based, your pay was based on the previous quarter's productivity. If you under-earned, you had to pay them back. That's not really how salaries work.
Click to expand...

That's more like a draw (we have that option, too, but practically nobody uses it).
 
DoubleBogey said:
Curious as to why they wouldn’t take that option?
Click to expand...

Most of us are used to the monthly variability, and plan accordingly. The people who tend to want consistent monthly checks also tend to be the ones who are living beyond their means (IMO). They're also the ones who usually wind up paying the company back at some point. As the saying goes, "If you give someone a floor, they'll sit on it."
 
Patient care is not easy. Being comfortable takes time and skill. We have PA and NP that most would never want to be without a physician... its scares them. They want the safety net. Plus FM is so much more then clinic, all the skills outside clinic setting scares PA and NP even more and rightly so. It takes training to feel comfortable. Sure there are exceptions but at least 70% would say the hell with going independent with no physician, at least in my experience. Our high skill job will always need us.
 
Ironheme said:
This is my favourite thread in this forum. bronx43 and BlueDog you two are like an old married couple. Thanks for the chuckle.
Click to expand...
It's always good to hear opposing opinions. As a physician to be I always like the banter on this site, I learn the things.
 
FWIW, we had two doctors leave my office before I was there to work at the VA. Within 5 years they’re back with the network.

I know nothing beyond that. Please don’t ask me why 😉.
 
KeikoTanaka said:
Like I said, my biggest fear is seeing salaries drop immensely due to an influx of people entering the field. Other than seeing more complicated cases and seeing more of them per hour, how do we justify our salaries not dropping? If I ever have to work with an NP or PA, I would only ever want to work with 1 at most. I wouldn't want my day consumed by reviewing charts, when what I was trained for was to be seeing patients personally. And to be honest, I feel like that is part of the appeal for patients: To see the "Expert" when they need to see the expert.
Click to expand...
I'm not sure I understand you here
Can you elaborate
DO you see no difference in the level of care an MD/DO can provide vs a APN/PA ?
 
I work with the Physician group affiliated with Kaiser. In many of our regions, NP/PA are not employed in the primary care setting at all, it is 100% MD/DO. They are exclusively used to help the surgeons/dermatologists with minor procedures or in surgical assist roles. They might do weekly phone call appts with CHF patients with cardiology. This is the extent. They used to be used in the PCP role but Kaiser needed PCPs to be able to manage a great deal and not refer for every minor BS ailment and be able to tell the patient why that is the case so they dont feel like care is being deferred/declined. Guess what happened...

We are now desperate for FM trained individuals. Starting salary has gone from 205k to 265k in a 6 year time frame for a 45-50 (35 patient care hours) hour workweek with no weekends/call and vacation time that starts at 4 weeks -> 5 weeks at 3 years service -> 6 weeks at 10 years.
 
anthroguy said:
We are now desperate for FM trained individuals. Starting salary has gone from 205k to 265k in a 6 year time frame for a 45-50 (35 patient care hours) hour workweek with no weekends/call and vacation time that starts at 4 weeks -> 5 weeks at 3 years service -> 6 weeks at 10 years.
Click to expand...
265K for northern cali ?
 
scharnhorst said:
265K for northern cali ?
Click to expand...

Yes. T

They'll also give you a forgivable loan as a sort of signing bonus and help to buy a home as well. The catch is, to really get both the forgivable loan and downpayment assist and never have to pay it back,you have to stay 5-7 years.
5% 401k match
pension (5 years to vest)
you pay zero salary towards healthcare (you do pay for meds and copays)
 
anthroguy said:
We are now desperate for FM trained individuals. Starting salary has gone from 205k to 265k in a 6 year time frame for a 45-50 (35 patient care hours) hour workweek with no weekends/call and vacation time that starts at 4 weeks -> 5 weeks at 3 years service -> 6 weeks at 10 years.
Click to expand...

Vacation time is on the low side compared to anesthesiologists or Radiologists (~10 wks).
 
Splenda88 said:
Vacation time is on the low side compared to anesthesiologists or Radiologists (~10 wks).
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Both of those groups work nights and weekends.

I would wager I work fewer hours per year than them even with their larger amount of vacation days.
 
VA Hopeful Dr said:
Both of those groups work nights and weekends.

I would wager I work fewer hours per year than them even with their larger amount of vacation days.
Click to expand...
Not sure what that means but I agree that most FM docs work fewer hours...
 
VA Hopeful Dr said:
Seriously?

You had just posted that radiologists and anesthesiologists got more vacation time than FPs in anthroguy's group.
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I was semi drunk when I read your post 😛. I agree that you guys have one of the best lifestyles in medicine (residency included)... I am jealous of my FM colleagues who will we be off almost every weekend as a PGY2.
 
Splenda88 said:
I was semi drunk when I read your post 😛. I agree that you guys have one of the best lifestyles in medicine (residency included)... I am jealous of my FM colleagues who will we be off almost every weekend as a PGY2.
Click to expand...

In what world are FM residents off almost every weekend as PGY2? Our cat PGY2 residents work almost as hard as interns in PGY2 and have weekend call on the FM service half the time on outpatient rotations.

Sure PGY3 has plenty of electives/outpatient subspecialty time, but still. FM life is better as an attending, but at least at my hospital, 2nd year is pretty rough.
 
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