How can CVS hire Nurse practitioners and PAs in their MinuteClinics?

[gothamsfinest]

As a pharmacy based business how can NPs and PAs be hired without MD oversight?

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[Dred Pirate]

Depending on the state. NPs don't need md oversight

 

[gothamsfinest]

So NPs can open there own clinics and pharmacists can hire them if they desire?

 

[Dred Pirate]

I am sure they could - but you need to remember there is a big difference in owning a practice vs owning a building and renting space to a provider. You also have to make sure you don't violate any kickback provisions when you do something like that. (providing any incentive whatsoever to the provider that they send the patients to do).

Like was stated on the other thread - it will be really hard for a provider to want to work for a practice owned by something "less than them" (not saying a RPh is less than a rph, but in the hierarchy of prescribing we are). Example, I knew a GP who owned a practice, he employed one MD and one NP. He then rented space to a GI specialist. The GI specialist did not work for the PCP MD, he had a separate practice - he actually made a lot more money than the PCP who owned the practice. There was also a pharmacy in the building - again the MD did not own the pharmacy business, he rented space to a RPh who owned the business. That avoids a lot of the kick back provisions - you just rent for fair market value.

 

[mgarph]

In my state at least, the NPs are under a protocol with a physician who is obviously not on site. Rx's would be called in under nurse's name and they would have a supervising MD. I would assume a single MD would be supervising all Clinics in the town or up to a maximum if there is any type of ratio, etc

 

[Vandalia]

In my state, NPs must be supervised by a physician and have a formal collaboration agreement. However, there is no requirement that the physician be in any geographic proximity to where the NP practices, let alone by physically present in the clinic. As long as he is licensed in the state, I believe he can physically be located in China or anywhere else. Prescribing is a slightly different matter, the collaborating physician must within 7 days review 5% of the charts where medicine was prescribed . The GME requirement for a physician license for a graduate of a US medical school is one year (aka an internship year). So it is pretty easy to find a way to implement all this, you find someone who has a state medical license, probably had only an internship and couldn't get a residency, pay him $60K/year to review charts all day for every location in the state, and they are set. I don't know that is exactly what these places do, only that it is what they legally could do. And I would be shocked if one of these chains spent even a penny more than the minimum requirement.

 

[allantois]

So NPs can open there own clinics and pharmacists can hire them if they desire?

You need to educate yourself on what physician “supervision” entails.

 

[lord999]

In my state, NPs must be supervised by a physician and have a formal collaboration agreement. However, there is no requirement that the physician be in any geographic proximity to where the NP practices, let alone by physically present in the clinic. As long as he is licensed in the state, I believe he can physically be located in China or anywhere else. Prescribing is a slightly different matter, the collaborating physician must within 7 days review 5% of the charts where medicine was prescribed . The GME requirement for a physician license for a graduate of a US medical school is one year (aka an internship year). So it is pretty easy to find a way to implement all this, you find someone who has a state medical license, probably had only an internship and couldn't get a residency, pay him $60K/year to review charts all day for every location in the state, and they are set. I don't know that is exactly what these places do, only that it is what they legally could do. And I would be shocked if one of these chains spent even a penny more than the minimum requirement.

Most states have dialed that back due to pill mills (FL and CA used to be exactly as you describe, but imposed more onerous oversight requirements after seeing what happened), I'd be surprised if your state is that extreme. States do impose some level of oversight, and the practice of not being geographically located in the same area almost always requires some explanation (for example, a physician might not be physically at the 4 Corners because it doesn't justify it there). PA's have more supervision requirements than NP's, and in certain states, NP's can more or less be independent, but if they are overseen by a practitioner, it has to be at a demonstrable level.

Also, all states retain a review process for practice beneath standards which is situational. So, any physician can technically do neurosurgery given the medical license, however, if you are not an ABMS-boarded Neurosurgeon, you'd have to explain yourself if anything went wrong why someone of that standard wasn't the practitioner doing the procedure. Emergent situations are reasonably justified (so, you'll see Trauma and General Surgeons doing Neurosurgery work when there's something like a car accident and not operating would be clearly detrimental), but standing situations would probably hold to the same practice standard as specialists. An untenable supervisory situation is not going to survive the first incident. There's standards for telehealth/telemedicine that preclude the China example because it is hard to believe effective oversight is given when out of the country.

And then there's Nevada...

 

[gothamsfinest]

I am sure they could - but you need to remember there is a big difference in owning a practice vs owning a building and renting space to a provider. You also have to make sure you don't violate any kickback provisions when you do something like that. (providing any incentive whatsoever to the provider that they send the patients to do).

Like was stated on the other thread - it will be really hard for a provider to want to work for a practice owned by something "less than them" (not saying a RPh is less than a rph, but in the hierarchy of prescribing we are). Example, I knew a GP who owned a practice, he employed one MD and one NP. He then rented space to a GI specialist. The GI specialist did not work for the PCP MD, he had a separate practice - he actually made a lot more money than the PCP who owned the practice. There was also a pharmacy in the building - again the MD did not own the pharmacy business, he rented space to a RPh who owned the business. That avoids a lot of the kick back provisions - you just rent for fair market value.

How can being hired by a pharmacist be less than working for CVS, which is controlled by MBAs? But back to the original question. So CVS also hires physicians to have a collaborative agreement?

 

[Vandalia]

Most states have dialed that back due to pill mills (FL and CA used to be exactly as you describe, but imposed more onerous oversight requirements after seeing what happened), I'd be surprised if your state is that extreme. States do impose some level of oversight, and the practice of not being geographically located in the same area almost always requires some explanation (for example, a physician might not be physically at the 4 Corners because it doesn't justify it there). PA's have more supervision requirements than NP's, and in certain states, NP's can more or less be independent, but if they are overseen by a practitioner, it has to be at a demonstrable level.

Also, all states retain a review process for practice beneath standards which is situational. So, any physician can technically do neurosurgery given the medical license, however, if you are not an ABMS-boarded Neurosurgeon, you'd have to explain yourself if anything went wrong why someone of that standard wasn't the practitioner doing the procedure. Emergent situations are reasonably justified (so, you'll see Trauma and General Surgeons doing Neurosurgery work when there's something like a car accident and not operating would be clearly detrimental), but standing situations would probably hold to the same practice standard as specialists. An untenable supervisory situation is not going to survive the first incident. There's standards for telehealth/telemedicine that preclude the China example because it is hard to believe effective oversight is given when out of the country.

And then there's Nevada...

Everything that you say is true in the abstract, however healthcare politics muddles things a bit in actual practice. There are two very powerful competing forces when it comes to NP (and to a much lesser extent PA) prescribing: the rampant abuse of controlled substances, and the very powerful lobby supporting complete independence for nurse-practitioners. Here, it has essentially led to a complete stalemate and the rules I describe above (the current ones) have remained stable for several years. The collaboration agreement must be reviewed by the state board of medicine, but in my biased opinion they are afraid of picking a fight, and do their best (or worst) to keep at least the "status quo" and therefore will approve any collaboration agreement that meets the minimum standards imposed by law and regulation. I see a lot of these collaboration agreements form my healthcare system, and I can't recall one instance where they were ever questioned or returned for more information, let alone denied. I like to think that is because we are doing a good job, but I am more influenced by what I hear from colleagues across the state.

While a physician can legally do just about anything under his/her license, the limiting factor is basically the employment situation not fear of the state board. A physician can attempt to practice neurosurgery, but without hospital privileges, s/he is not going to get very far. There are potential liability issues related to a non-specialist physician being the supervisor for a "specialist" NP, but here we are talking about an urgent care staffed by a NP. That would be considered the scope of practice of any licensed physician. The reality is that if there is a lawsuit, the plaintiff is not going to care about the NP or the collaborating physician, they are going to go after CVS or Walgreens. The other reality is that there are a number of physicians who have a license (or are at least eligible for a license) who were not able to get a residency slot and are essentially unemployable in "traditional" medicine. This is especially true as "healthcare systems" suck up the independent practices to control the market.

(As an example of the above, I went to look at the blocked spam in my email account and there were four looking for a physician for "NP Supervision": $1000 a month, a couple of hours a week, only requirement is a state license, do not need to reside in that state.)