Equal rates for MD/DO & NP Bill Passed in Oregon

[Kj615]

I'm not sure if this has been discussed. I did a search and found nothing. Nothing against NP/DNP, but reimbursing NP's at the same rate as MD/DO for the same procedures?

http://oregoncapitolnews.com/blog/2...-equal-rates-doctors-and-nurse-practitioners/

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[zenman]

If someone with a doctorate painted the front of your house and someone with a lessor degree painted the back but the paint job was of equal quality what would you have to say?

 

[pianoman511]

Give the guy with a doctorate more money. Everybody sees the front, no one cares about the back.

Sent from my PC36100 using Tapatalk

 

[Therapist4Chnge]

If someone with a doctorate painted the front of your house and someone with a lessor degree painted the back but the paint job was of equal quality what would you have to say?

The patient isn't paying for the degree on the wall...they are paying for the expertise that degree helped develop. If one painter just paints every house like the last...that may work some of the time, but what happens if one of those houses has black mold....but they don't catch it?

 

[RDlv]

I'm not sure if this has been discussed. I did a search and found nothing. Nothing against NP/DNP, but reimbursing NP's at the same rate as MD/DO for the same procedures?

http://oregoncapitolnews.com/blog/2...-equal-rates-doctors-and-nurse-practitioners/

We're cost effective.

Say that to yourself 500 times.

"NPs are a cost-effective solution to the health care crisis, providing equal if not better care than physicians."

^^^This is a quote out of my own mind, from having the sentiment drilled OVER and OVER and OVER into my ear over the last two years. I'm very curious what the google results would be for googling the whole phrase? Am I making this up?

EDIT: From the IOM report:

"Since nurse practitioners' education is supported by federal and state funding, we are underutilizing a valuable government investment. Moreover, nurse practitioner training is the fastest and least expensive way to address the primary care shortage. Between 3 and 12 nurse practitioners can be educated for the price of educating 1 physician, and more quickly."

http://www.nejm.org/doi/full/10.1056/NEJMp1012121?activeTab=comments&page=&sort=oldest&

Great, I'm better because I'm a welfare recipient. I'm a cheap date. Great way to boost pride in the profession, folks. Do I also start to look better after you have a six-pack in you?

 

[zenman]

Give the guy with a doctorate more money. Everybody sees the front, no one cares about the back.

Sent from my PC36100 using Tapatalk

What about a proctologist?

 

[ghost dog]

We're cost effective.

Say that to yourself 500 times.

"NPs are a cost-effective solution to the health care crisis, providing equal if not better care than physicians."

^^^This is a quote out of my own mind, from having the sentiment drilled OVER and OVER and OVER into my ear over the last two years. I'm very curious what the google results would be for googling the whole phrase? Am I making this up?

EDIT: From the IOM report:

"Since nurse practitioners' education is supported by federal and state funding, we are underutilizing a valuable government investment. Moreover, nurse practitioner training is the fastest and least expensive way to address the primary care shortage. Between 3 and 12 nurse practitioners can be educated for the price of educating 1 physician, and more quickly."

http://www.nejm.org/doi/full/10.1056/NEJMp1012121?activeTab=comments&page=&sort=oldest&

Great, I'm better because I'm a welfare recipient. I'm a cheap date. Great way to boost pride in the profession, folks. Do I also start to look better after you have a six-pack in you?

Gee, I wonder if NP's will be " cost effective " - now that they will be billing the same as family MDs.

How is this going to work out ?

Time will certainly tell.

The NPs would have you believe that they will see less pts, and treat them more "holistically" (whatever the heck this means).

However, increasing the number of pts seen has already begun:

" Linda Morley, a psychiatric nurse practitioner from Salem, told committee members that decreased reimbursement rates from insurers caused her to increase her patient load by 21 percent. Despite that, Morley said, her income still decreased by 22 percent over the past two years."

http://oregoncapitolnews.com/blog/2...-equal-rates-doctors-and-nurse-practitioners/

Now that this bill has passed - does anyone realistically believe that this practioner is going to reduce her patient load, now that she is being paid more ?

Not . bloody . likely.

 

[Instatewaiter]

Anyone who says the DNP wasn't politically motivated is kidding themselves.

Well thank goodness. For the rest of my life I'm gonna be seeing run-of-the-mill A-fib sent from a DNP that a normal FP MD would take care of. Sweet. Good use of resources.

 

[fab4fan]

Sorry, I don't think mid-levels should bill at the same rate as a physician.

 

[RDlv]

Anyone who says the DNP wasn't politically motivated is kidding themselves.

Well thank goodness. For the rest of my life I'm gonna be seeing run-of-the-mill A-fib sent from a DNP that a normal FP MD would take care of. Sweet. Good use of resources.

"NPs are a cost-effective solution to the health care crisis, providing equal if not better care than physicians."

My contrary opinions are starting to cost me points in my clinical-based courses, since I can't lose the points in the "discussion" course since all opinions are welcome, don'tcha know. My diagnoses and plans of care are spot on, but still losing a few points here and there. Hmmm.

So, I am learning to repeat the above phrase over and over and over:

"NPs are a cost-effective solution to the health care crisis, providing equal if not better care than physicians."

......................

Luke: ... Is the dark side stronger?
Yoda: No, no, no. Quicker, easier, more seductive.

 

[Kj615]

......say it 500 times!

 

[deleted432032]

......say it 500 times!

Still won't make it true

 

[Denatured]

I'm sorry, I don't see the problem with this. 1) same fee for same service. If you think that's wrong then you have entitlement issues. 2) it is actually rare that NPs practice completely independent (owning their practice). So really this just means more money for the doctors they work for and maybe more for the NP if they receive a productivity bonus.

 

[Kj615]

I'm sorry, I don't see the problem with this. 1) same fee for same service. If you think that's wrong then you have entitlement issues. 2) it is actually rare that NPs practice completely independent (owning their practice). So really this just means more money for the doctors they work for and maybe more for the NP if they receive a productivity bonus.

....evidently, your lack of knowledge on the issue. I suggest you recheck your facts or read the link in it entirety.

 

[sector9]

The title is misleading. The bill has passed out of committee and has been sent to the full House. It hasn't been passed as law in Oregon yet.

 

[physicsnerd42]

Yeah, the bill is dead.

 

[Denatured]

....evidently, your lack of knowledge on the issue. I suggest you recheck your facts or read the link in it entirety.

I have read it and I am knowledgable. I have years of experience in healthcare and I'm not a proponent of NPs in there current form practicing independently the day they graduate. However, if the NP can perform the task and use the same code then why shouldn't they get the same pay. The argument that a specialist using the same code should get more is a straw man argument. A specialist's training should allow him to do things that others without his training cannot. If he isn't learning more and different skills, then why is he a specialist?

Increase healthcare costs? Passing the savings on to the consumer? What a crock. I've denials for the most ridiculous things and they have the balls to say they are looking after the consumer?

Ask emedpa how many NPs own their practice. Not many. The percentage wasn't even in the double digits last I looked.

Last tidbit, I really don't care which way it goes because it does not affect me in the least, but I do sense that was is occurring is not fair.

 

[Kj615]

Yeah, the bill is dead.

Yeah..Thanks to the burst of last minute lobbying by the OMA.

According to the report "“ONA and our partners are committed to returning to this issue in the future and working hard to ensure that nurse practitioners receive the payment parity that they deserve.” It appears the ONA had vow to return in full force. I bet, they'll encourage other states to do the same.

 

[Kj615]

I have years of experience in healthcare

...as an NP/PA/MD/DO or as an educator?

 

[IlDestriero]

I'm sorry, I don't see the problem with this. 1) same fee for same service. If you think that's wrong then you have entitlement issues. 2) it is actually rare that NPs practice completely independent (owning their practice). So really this just means more money for the doctors they work for and maybe more for the NP if they receive a productivity bonus.

I could take my Jaguar to the Ford dealer for basic service at $85 an hour, but it's probably best to pay the $145/hr at the Jag dealer. I pay more for the same service because one is an expert in his field (Jaguar) and one is not. But they both could change my oil, brakes, filters, hoses, etc. You pay for expertise. An independent attorney with his own shop might ask $150/hr for some work that the big firm full of experts charges $600/hr. Same work, not the same pay. You pay for experience.
I'm told independent CRNAs bill the same as MD/care team for procedures. We'll see how long the insurance companies keep paying out MD fees for care provided by solo nurses. I do know that they pay the same total amount if I do a case myself, have a resident doing it, or supervising a CRNA. So much for the decreased cost argument. Zero cost savings after training. If they're employed by a management company or the facility, they're taking all the profits off of their sweat.

 

[sarjasy]

...as an NP/PA/MD/DO or as an educator?

Who cares? How is that relevant? You don't have to be a cow to know what milk is.

 

[sarjasy]

I could take my Jaguar to the Ford dealer for basic service at $85 an hour, but it's probably best to pay the $145/hr at the Jag dealer. I pay more for the same service because one is an expert in his field (Jaguar) and one is not. But they both could change my oil, brakes, filters, hoses, etc. You pay for expertise. An independent attorney with his own shop might ask $150/hr for some work that the big firm full of experts charges $600/hr. Same work, not the same pay. You pay for experience.

These are invalid comparisons for several reasons, one of which is that healthcare is not a free market and what you describe above are free market principles. You are free to willingly pay more for the same service by taking you car to the Jaguar dealer for "peace of mind" if you wish - it is your money. Insurance companies can't/won't operate on similar principles. As for attorneys, you pay $600 per hour precisely because you believe, not that you will get the same work, but SUPERIOR work. If someone pays $600/hr for the same work that could have been gotten for $150/hr, well, they are idiots.

Answer this: is the nephrologist who effectively treats a simple UTI entitled to more reimbursement than the FP physician who effectively treats the exact same simple UTI?

 

[RDlv]

Wow, that is scary. Is this really what they emphasize in NP/DNP school? It almost sounds like brainwashing...

In the non-clinical courses, yeah. "Role of NPs," (1st semester), "Health Policy," (3rd semester), "Entry to Practice," (4th semester).

Clinically based courses have been "pure," i.e. pharm is pharm, path is path, physical assessment is physical assessment, etc.

AANP and ANCC write our cert exams, so their position papers have weight. They put on our national conventions, accredit our CEUs, etc. One can certainly practice as an NP without getting too deep into that side (and most NPs I dare say do just that, do their job and skip the Ivory Tower crap), but the national policies are driven by the big orgs.

As for brainwashing...it may very well be that my student peers are simply smart enough to parrot what they know the prof wants to hear, unlike dumb me who has to call BS when I smell it. There are a few that I'm sure buy into it with the attendant logical inconsistencies (e.g. how we are cost effective but need to pay for a DNP and have the gov't pay for the degree and pay for more faculty and reimburse at 100% and pay for primary care so we make more money and pay for more screening tests so we can save the patient money and...), and trying to point out where 2+2 /= 6 leads to a blank (on-line) stare. Oh well.

My standard disclaimer: I like being an RN, I'm liking being an NP student. It's fun, challenging, and satisfying. I don't want to dog my profession or my peers, I just don't want political/academic BS to drag us down.

 

[IlDestriero]

Answer this: is the nephrologist who effectively treats a simple UTI entitled to more reimbursement than the FP physician who effectively treats the exact same simple UTI?

Probably. They're both physicians and you're paying for twenty minutes of their time, not the diagnosis. I don't know what's customary for these office fees. (yet) I would bet that insurance pays the specialist significantly more though. That's fair. You went to the nephrologist, you pay the nephrologist what he bills, not what the NP gets at CVS for a visit. Though they may actually get MORE at CVS. (being out of network, etc.)
You can add barriers to my seeing the nephrologist, but I pay more for premium insurance allowing me to bypass that trip to my pcp and just book an appointment with the appropriate specialist. I'm paying my insurance company more for better access to care. If it costs them more to have the dermatologist treat my kids acne that my pcp can treat just as well, oh well.
Do you think all physicians should be paid the same rate? Maybe by the hour? The busy FP working 70 hours a week making as much or more than the neuro and ortho spine surgeon and even less for the lowly anesthesiologist doing their cases, accepting significant liability, but only working 50 hours a week? If you want to pay me what a primary care physician makes, it's probably time for me to stop doing high risk patients, covering multiple rooms, etc. The risk is not worth the reward. But I guess the CRNAs will just fill in on those peds liver transplants and super sick neonates, etc. Right? Their leadership would have them practice independently with me as partners, with me doing the sick ASA 3-5 patients while they do the healthy ASA 1 and 2 patients for the same money, and we should also be available to jump in during an emergency and play fireman (accepting more unreinbursed liability). Sure man, sure. But we're all equal doing the same job with "equivalent" training...

 

[Kj615]

Who cares? How is that relevant? You don't have to be a cow to know what milk is.

Obviously, you can't answer just a simple question. You're all hyped. Calm down my friend. No punch intended. Yes, it's indeed very relevant. If you're a cow, you know how it feels/painful to been milked! Do you see my point? Probably not. Then, forget it. Let just be friends. Staying on the issue. Oh, I forgot, it was recently killed! The bill, was killed!! It's dead!!! I bet, it would probably show up somewhere else in the U.S of A. It's a constant lobbying/flexing of muscle. The AMA are powerful. Believe that! Maybe, they are not!

 

[Kj615]

Who cares? How is that relevant? You don't have to be a cow to know what milk is.

Already responded.

These are invalid comparisons for several reasons, one of which is that healthcare is not a free market and what you describe above are free market principles. You are free to willingly pay more for the same service by taking you car to the Jaguar dealer for "peace of mind" if you wish - it is your money. Insurance companies can't/won't operate on similar principles. As for attorneys, you pay $600 per hour precisely because you believe, not that you will get the same work, but SUPERIOR work. If someone pays $600/hr for the same work that could have been gotten for $150/hr, well, they are idiots.

Answer this: is the nephrologist who effectively treats a simple UTI entitled to more reimbursement than the FP physician who effectively treats the exact same simple UTI?

IIDestriero had provided you with a clear explanation as an insider (the cow who knows how painful it feels to be milked). No offend IIDestriero; you're not a cow. Just trying to put my point across to he who claims to have significant experience in healthcare.

Probably. They're both physicians and you're paying for twenty minutes of their time, not the diagnosis. I don't know what's customary for these office fees. (yet) I would bet that insurance pays the specialist significantly more though. That's fair. You went to the nephrologist, you pay the nephrologist what he bills, not what the NP gets at CVS for a visit. Though they may actually get MORE at CVS. (being out of network, etc.)
You can add barriers to my seeing the nephrologist, but I pay more for premium insurance allowing me to bypass that trip to my pcp and just book an appointment with the appropriate specialist. I'm paying my insurance company more for better access to care. If it costs them more to have the dermatologist treat my kids acne that my pcp can treat just as well, oh well.
Do you think all physicians should be paid the same rate? Maybe by the hour? The busy FP working 70 hours a week making as much or more than the neuro and ortho spine surgeon and even less for the lowly anesthesiologist doing their cases, accepting significant liability, but only working 50 hours a week? If you want to pay me what a primary care physician makes, it's probably time for me to stop doing high risk patients, covering multiple rooms, etc. The risk is not worth the reward. But I guess the CRNAs will just fill in on those peds liver transplants and super sick neonates, etc. Right? Their leadership would have them practice independently with me as partners, with me doing the sick ASA 3-5 patients while they do the healthy ASA 1 and 2 patients for the same money, and we should also be available to jump in during an emergency and play fireman (accepting more unreinbursed liability). Sure man, sure. But we're all equal doing the same job with “equivalent" training...

sarjay; are you taking note. He who knows it feels it!

Thank you IIDes

 

[IlDestriero]

Obviously, you can't answer just a simple question. You're all hyped. Calm down my friend. No punch intended. Yes, it's indeed very relevant. If you're a cow, you know how it feels/painful to been milked! Do you see my point? Probably not. Then, forget it. Let just be friends. Staying on the issue. Oh, I forgot, it was recently killed! The bill, was killed!! It's dead!!! I bet, it would probably show up somewhere else in the U.S of A. It's a constant lobbying/flexing of muscle. The AMA are powerful. Believe that! Maybe, they are not!

The AMA doesn't represent the interests of most practicing physicians. I will never be a member. The anesthesia PAC is far better funded. Think about that. One small specialty PAC is better funded than the AMA PAC who SHOULD be representing ALL practicing physicians, not bending over to politicians and struggling to try to remain relevant.
They're a disgrace. We should form and/or join an organization who's going to actually represent our interests in Congress. Everyone's worried about their little slice of the pie, and they don't even know it's already been eaten.

 

[Denatured]

Obviously, you can't answer just a simple question. You're all hyped. Calm down my friend. No punch intended. Yes, it's indeed very relevant.

Why would Sarjasy be able to answer a question you asked me?

Really, it's not relevant because how much we believe someone should be paid is opinion and because you are going to be distrustful of my opinion regardless of what I am. In fairness, I'm a PA and former Nurse. Like I said, I don't care about the bill specifically because I'm not affected by the issue and I'm not for NP independence with their current training. I do believe in same fee for same service.

Your arguement doesn't really make a lot of sense. My 4th year med student or intern can do the same work as my NP in taking an H+P and diagnosing/managing a UTI but they certainly don't get compensated similarly and I'm sure you wouldn't like it if you were taxed more to allow Medicare to pay a resident approrpriately based on your own logic. The reality is the compensation should be based on the knowledge of the provider not just the simple act/code; sure a simple UTI might be managed by an NP (I certaintly wouldn't advocate for this) but I would argue the training of the MD is far better in picking the one case that isn't a simple UTI and requires further workup, etc.

Actually, residency programs receive federal monies. So I am paying plenty for that service.

Because it helps defines who the opinon is coming from...an NP advocating for equal billing doesn't hold a lot of weight in my book

I'm guessing since I am a PA my opinion doesn't count either.

Probably. They're both physicians and you're paying for twenty minutes of their time, not the diagnosis. I don't know what's customary for these office fees. (yet) I would bet that insurance pays the specialist significantly more though. That's fair. You went to the nephrologist, you pay the nephrologist what he bills, not what the NP gets at CVS for a visit. Though they may actually get MORE at CVS. (being out of network, etc.)
You can add barriers to my seeing the nephrologist, but I pay more for premium insurance allowing me to bypass that trip to my pcp and just book an appointment with the appropriate specialist. I'm paying my insurance company more for better access to care. If it costs them more to have the dermatologist treat my kids acne that my pcp can treat just as well, oh well.
Do you think all physicians should be paid the same rate? Maybe by the hour? The busy FP working 70 hours a week making as much or more than the neuro and ortho spine surgeon and even less for the lowly anesthesiologist doing their cases, accepting significant liability, but only working 50 hours a week? If you want to pay me what a primary care physician makes, it's probably time for me to stop doing high risk patients, covering multiple rooms, etc. The risk is not worth the reward. But I guess the CRNAs will just fill in on those peds liver transplants and super sick neonates, etc. Right? Their leadership would have them practice independently with me as partners, with me doing the sick ASA 3-5 patients while they do the healthy ASA 1 and 2 patients for the same money, and we should also be available to jump in during an emergency and play fireman (accepting more unreinbursed liability). Sure man, sure. But we're all equal doing the same job with “equivalent" training...

If a FP did anesthesia for surgery, I would expect him to be paid the same. This won't happen (well it actually does rarely with older GPs who did anesthesia before credentialing and Board certification became so big) because no hospital would dare hire him to do such a thing and no insurance company would pay for it. So really it's not relevant.

What is relevant is that would should be paying for outcomes. If we could pay people based on how well they performed (and I'm talking in ratios, not paying based on one individual patient) then I'm sure it would balance out and those with more training and fewer poor outcomes would be paid more. I'm sure their are problems with this idea, such as it providing and incentive for providers to cherry pick patients, but with some tweaks I think it would be optimal.

Anesthesiologist receives stipends from hospitals to be able to acquire their current level of income, therefore they cost more healthcare dollars.

And I'm sure if peds liver transplants were done at places that weren't huge academic centers with anesthesiology residencies and residents given first dibs, I'm sure there would be CRNAs doing them. I've seen claims that CRNAs don't independently do CABGs and TEE, but I've seen that too.

Anyway, this is not about independence. So that's the last I have to say on that matter. This is about pay. It's not about private insurance either, as you allude to. While CRNAs can bill 100% of medicaid/medicare, they often cannot with private insurance companies.

 

[IlDestriero]

Anesthesiologist receives stipends from hospitals to be able to acquire their current level of income, therefore they cost more healthcare dollars.

A couple points.
Not all practices receive stipends, or significant ones, and groups with minimal stipends are at an advantage when it comes to competition for contracts and they prove their value when compared to averages during negotiations.
The stipends usually pay for unreinbursed services, like 24/7 trauma coverage, 24 hour L&D services, etc. Someone has to be available, not able to work, waiting for something to come in. They also pay to get providers to work at places with poor payer mix and/or undesirable locations. Is anyone going to work at less than 1/2 private rates in high percentage Medicaid hospitals without a subsidy? CRNAs won't either.
When CRNAs are my partners, they will want to be paid for these unreimbursed services as well. Nobody works for free.
There are a few practices I recently heard about in a couple less desirable states where CRNAs and MDs are equal partners. Believe me, they're not saving anyone any money and they're getting an equal share of those stipends that the MD partners used to get. CRNA making over $500k? YES! Still think they're providing savings? We were discussing this in the anesthesia forum, and there have been ads in the job board for these equal arrangements. Sadly people will choose to work there as the fireman because they're lazy or bad.

 

[Kj615]

denature: consider that the question/response were meant for you then. you must be a newly PA graduate per your thought process or prior to becoming a PA you have worked many years as an RN. it time you move to the right (is there a right or left to the debate? oh well).

 

[IlDestriero]

About the paying for outcomes stuff.
You really think that an NP/PA should get payed the same for their time as an FP who should make the same as a nephrologist for their UTI patient?
How about when nobody wants to see the sick as stool kidney patient who always sees the nephrologist and has worse outcomes. I guess he should get less, obviously.

 

[sarjasy]

Because it helps defines who the opinon is coming from...an NP advocating for equal billing doesn't hold a lot of weight in my book

You still miss the point. A 5 year old can tell you the grass is green, you don't need a horticulturist to tell you that. An argument stands or falls on its own merit -- the one making it is irrelevant. Logic 101.

 

[sarjasy]

Depends on what the nephrologist does. If they use of more of their knowledge and skill and bill for a more advanced consult than an FP who treats this as a routine follow up, absoultely the reimbursement will be different.

I told you what the nephrologist does in my example. I said "the same simple UTI," i.e. the FP physician and nephrologist provide the exact same physical and utilize the exact same resources.

I can get onion soup at Panera or the French Bistro. On paper they look the same and serve the same basic function of filling my stomach but at the end of the day the quality of the preparation is obviously different and hence I pay more for it.

"Different" is a key word you use here. In my example of the nephro and FP physician, there is no difference. The nephrologist provided the exact same service with the exact same outcome, utilizing the same resources and both accomplished exactly what the patient wanted and needed.

 

[sarjasy]

Do you think all physicians should be paid the same rate? Maybe by the hour?

Of course not. Specialized work should be compensated at a higher level. A nephro treating a diabetic with recurrent UTI's and decreased kidney function should get more. But a nephrologist treating a simple UTI should get paid what every other physician would get paid for treating it. I saw an ENT write a script for hypertension a few months back on patient he'd never seen before. Should he get paid more or less than a FP or cardiologist for doing so?

 

[Pleepl3us]

YOU still missed the point. Congrats, now ask that 5 year old how the proper levels of nitrogen affect growth for all plants and which chemicals are safe for a farmer to use on his crops and how those chemicals work/differ from one another and if he/she were to use said chemicals how would that affect the pH of the soil and which physical characteristics the crops would show if the treatments weren't working.

Medicine is not 1st order logic, and from the NP students/practioners I have come in contact with that is all their online open book curriculum prepared them for.

 

[sarjasy]

YOU still missed the point. Congrats, now ask that 5 year old how the proper levels of nitrogen affect growth for all plants and which....Medicine is not 1st order logic, and from the NP students/practioners I have come in contact with that is all their online open book curriculum prepared them for.

My point about the 5 year old (and the cow) had nothing to do the capabilities of NP's vs MD's. My point was that one's background has no bearing a whether an argument is a valid one or not (in this case pertaining to reimbursements). Try reading the thread first.

 

[Kj615]

My point about the 5 year old (and the cow) had nothing to do the capabilities of NP's vs MD's. My point was that one's background has no bearing a whether an argument is a valid one or not (in this case pertaining to reimbursements). Try reading the thread first.

Sarjasy...you strongly need to rest your argument. You've continuously demonstrated your lack of knowledge on the issue as evidence by your analogies thus far. Your points doesn't stick!

 

[IlDestriero]

Of course not. Specialized work should be compensated at a higher level. A nephro treating a diabetic with recurrent UTI's and decreased kidney function should get more. But a nephrologist treating a simple UTI should get paid what every other physician would get paid for treating it. I saw an ENT write a script for hypertension a few months back on patient he'd never seen before. Should he get paid more or less than a FP or cardiologist for doing so?

Why? You're paying for his time and his time is valued more than the FP or "doc in the box" (with no actual physician to be found).
Again, the dermatologist can treat simple acne as well as the school nurse. Should the dermatologist turn my kids away because they only have a couple random pimples and not scarring acne requiring retinA and laser resurfacing? Or should they bill their customary charge for a 20 min consult and/or followup. Their time is worth what it is worth, acne or melanoma followup with skin check. Though they many not have to bill the same depending on what they actually did. What about all the providers who "up charge" by doing more comprehensive evaluations than absolutely required? I'm sure that happens all the time.

 

[Kj615]

...just got tipped off by s/one that sarjasy pmhx = significant for post duplication in an attempt to inflame war here on sdn. Hence, it is my personal decision to ignore her/him. I sincerely hope Medicaid/Medicare and all other private insurance will follow-suit.

Oh **** Just realized I had 3-venti pike just today alone! The star-coffee eating up my $$.

 

[sarjasy]

Should the dermatologist turn my kids away because they only have a couple random pimples and not scarring acne requiring retinA and laser resurfacing? Or should they bill their customary charge for a 20 min consult and/or followup.

Neither. He should bill what any other physician would bill for treating it, as his specialized expertise is not utilized in such a case.

And you did not answer my question about the ENT. He wrote a script for hypertension. Should he bill more, less, or the same as an FP physician or a cardiologist?

Look, I really don't have a lot of interest in the this topic, though I think the idea of a salaried, supervised NP or PA being able to bill the same as their collaborating MD/DO can be a good thing if it meant that the MD/DO made more money, especially in family practice. But the arguments put forward stating that specialized expertise alone dictates higher reimbursement makes no sense in cases where that specialized expertise is not utilized.

In the end, the healthcare payment model is fundamentally broken. Insurance for non-catastrophic health events has created this mess and helped drive healthcare costs through the roof. If basic care were a true market (free of insurance), the consumer could choose to payer higher amounts to the derm for what could have just as easily been treated by a PCP if they so choose. But when they are using insurance, everyone else in the pool is paying for it all the while driving up insurance rates.

 

[Instatewaiter]

There is a major issue in the arguement that there should be the same fee for the same service;
1) illness is too heterogenous to define what is simiple and
2) you cannot define what the same service because of heterogeneity of knowledge and of patient populations. Let me explain and also explain why more knowledgible providers should be paid according to their education levels.

What is simple often is not
How illness present is heterogeneous as are the co-morbidities of patients. This makes it impossible to define what is a "simple." Patients do not present with a sign that says, "Giant cell arteritis with right ventricular failure" they present with nausea. Is it simple nausea caused by something innocuous or is it right heart failure? To make many life saving diagnoses it is this complex and often massive knowledge base that is needed. What is seen as simple often is very complex and dangerous.

Laypeople do not have the required knowledge to diagnose and treat illness. if they did, you could just go to your neighbor's house for diagnosis/treatment. Instead, people go to the doctor specifically for the doctor's knowledge base. It is this knowledge base that you pay for. An NP's education and therefore knowledge base is much, much smaller than a physicians. It makes sense from this point of view that the pay should be based on expertise and knowledge base

Same service
Now let's discuss the other issue, that you cannot define what is the same service because of heterogeneity of both the patient population and provider knowledge. First the population: One person with a UTI is not the same as another because of co-morbidities. This makes no treatment the same and no service based on illness the same.

More importantly, the difference in knowledge between an NP and physician make the "same service" essentially an impossibility. It is this extra knowledge that gives the doctor the ability to consider many more possiblities than an NP. Much of the "service" is the consideration and ability to rule out dangerous things. Again it is the knowledge base you are paying for.

 

[Instatewaiter]

Equal Pay for Equal Education and Equal Knowledge base
It is not as if this knowledge base is clandestine or occult. You just need the depth of classes and length of clinical education to get it. Currently NP education does not give this depth and breadth. If it did, that would be quite different and this argument would be moot.

All pre-NP and current NPs have the opportunity to get this education by going through medical school and residency. It's not as if they were kept from going to med school. They made a choice to take the shorter route than medical school and residency and the choice come out with a smaller knowledge base. There's nothing wrong with this. But, the difference in education is what you are and should be paying for.

So the arguments that an NP should treat the simple things and that there should be the same fee for the same service are bunk. It is near impossible to tell what is simple because most complex things present identically to the simple things. The "same fee for same service" argument is also bunk because it is the knowledge base that makes the same service an impossiblity.

 

[Charles_Carmichael]

There is a major issue in the arguement that there should be the same fee for the same service;
1) illness is too heterogenous to define what is simiple and
2) you cannot define what the same service because of heterogeneity of knowledge and of patient populations. Let me explain and also explain why more knowledgible providers should be paid according to their education levels.

What is simple often is not
How illness present is heterogeneous as are the co-morbidities of patients. This makes it impossible to define what is a "simple." Patients do not present with a sign that says, "Giant cell arteritis with right ventricular failure" they present with nausea. Is it simple nausea caused by something innocuous or is it right heart failure? To make many life saving diagnoses it is this complex and often massive knowledge base that is needed. What is seen as simple often is very complex and dangerous.

Laypeople do not have the required knowledge to diagnose and treat illness. if they did, you could just go to your neighbor's house for diagnosis/treatment. Instead, people go to the doctor specifically for the doctor's knowledge base. It is this knowledge base that you pay for. An NP's education and therefore knowledge base is much, much smaller than a physicians. It makes sense from this point of view that the pay should be based on expertise and knowledge base

Same service
Now let's discuss the other issue, that you cannot define what is the same service because of heterogeneity of both the patient population and provider knowledge. First the population: One person with a UTI is not the same as another because of co-morbidities. This makes no treatment the same and no service based on illness the same.

More importantly, the difference in knowledge between an NP and physician make the "same service" essentially an impossibility. It is this extra knowledge that gives the doctor the ability to consider many more possiblities than an NP. Much of the "service" is the consideration and ability to rule out dangerous things. Again it is the knowledge base you are paying for.

That's an excellent point and along the lines of what I was thinking. Because of the physician's ability to generate large differentials and rule out dangerous/complex conditions, physicians and NPs are not providing the same service. The final outcome may be similar, but the process of getting there is not.

Like Instatewaiter said, patients don't come with a sign that says "I'm an easy case. Here's what I have."

 

[sarjasy]

So the arguments that an NP should treat the simple things and that there should be the same fee for the same service are bunk. It is near impossible to tell what is simple because most complex things present identically to the simple things. The "same fee for same service" argument is also bunk because it is the knowledge base that makes the same service an impossiblity.

That's an excellent point and along the lines of what I was thinking. Because of the physician's ability to generate large differentials and rule out dangerous/complex conditions, physicians and NPs are not providing the same service. The final outcome may be similar, but the process of getting there is not.

Again, I don't have strong feelings on this matter, and I could be convinced one way or another, but this still doesn't add up, especially in a world in which healthcare is funded by insurance.

I'll ask the two of you my question about the (real life) ENT who wrote a script for hypertension. How much reimbursement does he deserve vs. family physician or cardiologist?

How about the ENT writing the script vs. a cards NP who'd been practicing for 10 years? Who do you think possesses the more valuable, specialized knowledge in treating HTN?

 

[Maybeknot]

And you did not answer my question about the ENT. He wrote a script for hypertension. Should he bill more, less, or the same as an FP physician or a cardiologist?

Is the ENT following the patient purely for hypertension? Why was the patient referred to ENT in the first place?

An ENT visit is fundamentally different from your typical health maintenance PCP visit. Absent an ENT indication, that patient should not be seeing -- and being billed for-- an ENT, period.

In the end, the healthcare payment model is fundamentally broken. Insurance for non-catastrophic health events has created this mess and helped drive healthcare costs through the roof. If basic care were a true market (free of insurance), the consumer could choose to payer higher amounts to the derm for what could have just as easily been treated by a PCP if they so choose. But when they are using insurance, everyone else in the pool is paying for it all the while driving up insurance rates.

Funny you mention that, as utilization studies have shown that NP's in primary care order more radiographic and laboratory tests and consult to specialists more often than MD's and PA's. Given that this helps "drive healthcare costs through the roof," shouldn't we be paying the NP's less than they are getting now?

 

[sarjasy]

Is the ENT following the patient purely for hypertension? Why was the patient referred to ENT in the first place?

Don't remember the exact reason the patient was there, but it was ENT related. ENT uncovered HTN and wrote the script.

An ENT visit is fundamentally different from your typical health maintenance PCP visit. Absent an ENT indication, that patient should not be seeing -- and being billed for-- an ENT, period.

Your obfuscating. What sort of reimbursement does the ENT deserve relative to an FP or cards physician?

Funny you mention that, as utilization studies have shown that NP's in primary care order more radiographic and laboratory tests and consult to specialists more often than MD's and PA's.

This is not directly related to the conversation at hand, but if you are referring to the study I think you are, the study only found statistical significance in 3/17 items measured and did not account for the lower labor costs of NP's. It also did not include PA's in the study.

 

[Instatewaiter]

Again, I don't have strong feelings on this matter, and I could be convinced one way or another, but this still doesn't add up, especially in a world in which healthcare is funded by insurance.

I'll ask the two of you my question about the (real life) ENT who wrote a script for hypertension. How much reimbursement does he deserve vs. family physician or cardiologist?

How about the ENT writing the script vs. a cards NP who'd been practicing for 10 years? Who do you think possesses the more valuable, specialized knowledge in treating HTN?

There are a few things here:
First the ENT should not be writing a script for hypertension unless that medication was already prescribed by a primary care doctor, internist or someone in an internal medicine subspecialty. They just don't have much experience to chose the right medicine.

If we assume that you would get reimbursed for only the disease you are treating rather than lumping it into the visit- I would say that a cards NP should get paid more than an ENT for treating hypertension but less than a cardiologist. That said, an ENT really should not be treating hypertension except under very rare circumstances just like a PCP or cardiologist should not be treating something like vocal cord paresis.

 

[Kj615]

...never heard of ENT rx antihypertensive..mostly likely the patient was already taking med.

 

[IlDestriero]

Your continued referenced to the ENT writing for a beta blocker is irrelevant.
He came to the ENT for a consult, got his consult, was given an eval and sent home with an rx. He should get paid whatever an ENT clinic visit is customarily worth. It's not like he's going to take over the job of his PCP and schedule monthly bp checks. It doesn't matter what he was there for or what his diagnosis ultimately was. If the cards guy saw him he should be paid at the rate of a cardiologist not an FP or NP, because that's what he is, and that's what he customarily charges for an appointment. If it's a straight forward hypertension dx in a reasonably healthy patient, he should recommend followup with his PCM.
Here's a question, if the patients premium insurance allows him to schedule appointments with specialists directly, as mine does, should the cardiologist refuse to see this patient, who they now have a relationship with, for his followup care just because it's a straight forward disorder that could be competently managed by the quack at the free clinic? I would think not.

 

[Kj615]

ENT in my neck of the woods wouldn't lay their hands on a patient with an uncontrolled HTN. They ship them back to PCP. Though, they lay their hands and pray if you're healthy (adequately/well controlled malignant hypertension). Is like an Orthopod telling a patient to loss wt, else They will not touch you/operate on them. That must be painful. Am so sorry!