IM and midlevels?

[AlbinoHawk DO]

Let’s not generalize . There are bad doctors lazy docs (scorched earth Zpaks and refusal to do prior auth because of perceived difficulty so send to specialist. Or refer to specialist but send zero workup becuase it’s just soooo much effort to press the efax button in the EMR …) out there also

NPs do a great job when under direct physician supervision . They do all the crap we physicians for want to do .

When independent is another story …

In my experience, good NPs are few and far between. I've almost never seen proper supervision. It's more of a cash making situation for these doctors

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[NewYorkDoctors]

If there are bad doctors after 11 yrs of rigorous training, just imagine someone who got an online degree w/ 500-700 hrs preceptorship. It's not a good argument saying that there are bad doctors

perhaps. but at the same time, we cannot just bash all midlevels as garbage filth who should not be allowed to exist. there should be nuances.

my take is having an INDEPENDENT NP or DNP is probably going to create more trouble in the long term. Any healthcare system who tries to replace physicians with midlevels is going to hit a wall sooner than later. this is more a relevant subject to hospitalist physicians like yourself.

but having an NP or DNP work under the supervision of the physician (if only the physician just monitors the labwork, imaging, screening, clinical course, etc... behind the scenes medical work and the NP does the talking with the chatty patient) can only enhance things. some have criticized me in other posts for not hiring other physicians over an NP. well I would do that once revenue really picks up. i'm not in the charity business of giving money to other doctors you know? moreover, you can't exactly have senior attending physicians utilizing junior attending physicians in the role of a resident right? this part is more relevant to a mainly outpatient provider such as myself.

 

[NewYorkDoctors]

In my experience, good NPs are few and far between. I've almost never seen proper supervision. It's more of a cash making situation for these doctors

so you're saying absence of proof is proof of absence?

what is proper supervision in your book? like the resident present in clinic to the attending and both walking in there to talk to the patient again?

what about the busy surgeon who is in the OR most of the time and needs his/her PA to check on the patient on the wards to check on the wound care first before the surgeon can round later on?

I am not a midlevel apologist and I am against the big corporate hospitals trying to replace MD/DOs with DNPs. But some of the takes on here from physicians are illogical and seem to incorporate personal grievances for one reason or another.

Free yourself from the teats of the hospital corporate system. You will never know more happiness than when you do that!

But if you are unable to free yourself from the hospital system (I understand note everyone has the financial wherewithal to do so), then my condolences. Know that I am on the "hospitals should not replace MD/DOs with DNP" train as well.

 

[AlbinoHawk DO]

so you're saying absence of proof is proof of absence?

what is proper supervision in your book? like the resident present in clinic to the attending and both walking in there to talk to the patient again?

what about the busy surgeon who is in the OR most of the time and needs his/her PA to check on the patient on the wards to check on the wound care first before the surgeon can round later on?

I am not a midlevel apologist and I am against the big corporate hospitals trying to replace MD/DOs with DNPs. But some of the takes on here from physicians are illogical and seem to incorporate personal grievances for one reason or another.

Free yourself from the teats of the hospital corporate system. You will never know more happiness than when you do that!

Take it easy. It's okay if you like your NPs. Many of us don't because of what we see. To answer your question, improper supervision is when I see their patients and the mess of medications and lack of coherent plan on notes

 

[NewYorkDoctors]

Take it easy. It's okay if you like your NPs. Many of us don't because of what we see. To answer your question, improper supervision is when I see their patients and the mess of medications and lack of coherent plan on notes

okay i apologize if I sounded antagonistic to you. it's not personal.

right your point reinforces my take that NPs and DNPs should not be fully independent without ... let say... proper physician backup? Supervision is hard to define and probably impossible to ensure.

they should be used in complementary roles. for example in a clinic, they should be the acute / walk in visit provider. after all the physicians all have scheduled patients and need to dedicate the requisite time to the scheduled patients. but not having a proper acute walk in for a clinic will lead to unnecessary hospital visits. if this acute visit is more than URI / sniffles / psychosomatic nonsense, then the physician can step in for the asthma exacerbation, CHF exacerbation, etc....

Or in a hospital, they can be the hematologist's note writer, order inputter, and patient/family communicator for a hematologist on the leukemia unit. They can be the surgeon's wound checker in the morning and note writer. etc...

but seeing as how hospitals are fully of administrators who want to continue to maintain their personal profits and bonuses in the setting of declining reimbursements, you betcha they are seeing $$ in their eyes when they realize they can hire two NPs for the price of one MD hospitalist. They don't know that a (good) hospitalist does not necessarily fix every problem but have the requisite training to "spot danger a mile away."
Oh that HR of 110? meh looks sinus. patient is anxious! sometime later - rapid response massive blood GI bleeding. something like that.
I guess to an administrator they would want the RRT and the ICU management since more can be billed. shrugs.
maybe the admins think - we know NPs not as good as hospitalists for proper medical are and LOS. But this might lead to more downstream consultations, imaging, procedures, and ICU management (potentially more revenue for the hospital). Ultimately these IM and MICu are not big moneymakers for the hospital. Radiology does not always collect on billing because many times the prior (or should I say post) auth criteria were not met.

 

[AlbinoHawk DO]

okay i apologize if I sounded antagonistic to you. it's not personal.

right your point reinforces my take that NPs and DNPs should not be fully independent without ... let say... proper physician backup? Supervision is hard to define and probably impossible to ensure.

they should be used in complementary roles. for example in a clinic, they should be the acute / walk in visit provider. after all the physicians all have scheduled patients and need to dedicate the requisite time to the scheduled patients. but not having a proper acute walk in for a clinic will lead to unnecessary hospital visits. if this acute visit is more than URI / sniffles / psychosomatic nonsense, then the physician can step in for the asthma exacerbation, CHF exacerbation, etc....

Or in a hospital, they can be the hematologist's note writer, order inputter, and patient/family communicator for a hematologist on the leukemia unit. They can be the surgeon's wound checker in the morning and note writer. etc...

but seeing as how hospitals are fully of administrators who want to continue to maintain their personal profits and bonuses in the setting of declining reimbursements, you betcha they are seeing $$ in their eyes when they realize they can hire two NPs for the price of one MD hospitalist. They don't know that a (good) hospitalist does not necessarily fix every problem but have the requisite training to "spot danger a mile away."
Oh that HR of 110? meh looks sinus. patient is anxious! sometime later - rapid response massive blood GI bleeding. something like that.
I guess to an administrator they would want the RRT and the ICU management since more can be billed. shrugs.
maybe the admins think - we know NPs not as good as hospitalists for proper medical are and LOS. But this might lead to more downstream consultations, imaging, procedures, and ICU management (potentially more revenue for the hospital). Ultimately these IM and MICu are not big moneymakers for the hospital. Radiology does not always collect on billing because many times the prior (or should I say post) auth criteria were not met.

Almost all countries function without any midlevel providers. The problem is access. Many of the things you mention can be done using scribes or special patient educators. Net harm of NPs i think outweighs benefits. PAs could be a conversation to have

 

[NewYorkDoctors]

Almost all countries function without any midlevel providers. The problem is access. Many of the things you mention can be done using scribes or special patient educators. Net harm of NPs i think outweighs benefits. PAs could be a conversation to have

Good points. I agree.

But since there is an access issue for primary care in some parts of the country (think rural areas as well as in underserved areas in the big city. In NYC there are certain neighborhoods which do not have immediate PCP access. Some patients wait on hospital system's clinics for months on end to see a PCP), these DNPs seem to have some role to be an independent provider. But they must have good physician support for the "intermediate and hard" patient cases.


There really is no role for independent NPs in the hospital system outside of admins wanting to axe physicians to save on their profits.

 

[AlbinoHawk DO]

Good points. I agree.

But since there is an access issue for primary care in some parts of the country (think rural areas as well as in underserved areas in the big city. In NYC there are certain neighborhoods which do not have immediate PCP access. Some patients wait on hospital system's clinics for months on end to see a PCP), these DNPs seem to have some role to be an independent provider. But they must have good physician support for the "intermediate and hard" patient cases.


There really is no role for independent NPs in the hospital system outside of admins wanting to axe physicians to save on their profits.

I see patients from these populations treated by these NPs that supposedly help. My experience has been that they do more harm than good. I simply don't trust other doctors "supervising" them. You might be different, but i know so many that aren't that we end up with that saying "this is why we can't have nice things"

 

[hotsaws]

I think the bad doctoring is probably more driven by apathy, although I've certainly trained with some docs that weren't the best clinicians. I think the problem with bad midleveling is more ignorance and simply not knowing what they don't know. No doubt some of the poor practice is also just customer service based. We see plenty of same day sick patients in my A/I practice that have been in the medical system for years and they think when they have a "sinus infection," they need abx and/or steroids. You can end that encounter real quickly and with high pt satisfaction if you just give them their choice abx and send them along. I'm not above that and try not to judge others.

A NP/PA can probably handle the bread and butter follow up just fine. They make more sense in a subspecialty field than in a primary field. I'm not sure how much an MD can realistically supervise them beyond being available any time they have questions. I am always available if a PA wants to run something by me but how can I know what they're missing or not telling me? I think the best structure for midlevel utilization is that all new patients are seen by the physician and midlevels are used to reinforce or slightly modify treatment plans. Phyisicans should continue to see the patient every now and then and make sure nothing has gone wild in the plan. Any new or strange complaints probably should go to the physician.

 

[AlbinoHawk DO]

I think the bad doctoring is probably more driven by apathy, although I've certainly trained with some docs that weren't the best clinicians. I think the problem with bad midleveling is more ignorance and simply not knowing what they don't know. No doubt some of the poor practice is also just customer service based. We see plenty of same day sick patients in my A/I practice that have been in the medical system for years and they think when they have a "sinus infection," they need abx and/or steroids. You can end that encounter real quickly and with high pt satisfaction if you just give them their choice abx and send them along. I'm not above that and try not to judge others.

A NP/PA can probably handle the bread and butter follow up just fine. They make more sense in a subspecialty field than in a primary field. I'm not sure how much an MD can realistically supervise them beyond being available any time they have questions. I am always available if a PA wants to run something by me but how can I know what they're missing or not telling me? I think the best structure for midlevel utilization is that all new patients are seen by the physician and midlevels are used to reinforce or slightly modify treatment plans. Phyisicans should continue to see the patient every now and then and make sure nothing has gone wild in the plan. Any new or strange complaints probably should go to the physician.

Mid-levels should be presenting like interns and each one of their notes read thoroughly. When I see their notes being written worse than an attending, I know it's all bull****

 

[dozitgetchahi]

All the outpatient ones I've seen do flag. The thing is these people probably don't look at that bar or just instinctively click X on the pop up. NPs sincerely don't care about patients. I overheard a call of a patient telling the NP she started having headaches with amlodipine and if she could switch to another drug. The NP said "well, amlodipine is a good medicine. You'll have to decide if you want to have good blood pressure or no headaches"

Exactly.

I use Epic. It flags this stuff. However, if nobody reacts to the flags, it never gets done.

 

[NewYorkDoctors]

so a one of my chronic pulmonary patients have told me they recently changed PCPs. I find out they changed to NPs have opened up totally independent primary care practices. he said he did this due to far shorter wait times.

for this patient it's not a big deal since im doing the heavy lifting anyway for his COPD and IPF. I also noticed pancytopenia with monocytosis and just took care of the heme referral and communication with heme and I also diagnosed cardiovascular limitation and abnormal EKG stress test with CPET and referred to interventional cardiology and he ended up with a stent and medical management... so the NP just does the screening and vaccinations. Not a bad deal.

As long as a patient has good and immediate subspecialty support, then why not see an NP who has far shorter wait times for something elementary like vaccines or screening.

But this reinforces the point that there should be easy physician access.

 

[AlbinoHawk DO]

so a one of my chronic pulmonary patients have told me they recently changed PCPs. I find out they changed to NPs have opened up totally independent primary care practices. he said he did this due to far shorter wait times.

for this patient it's not a big deal since im doing the heavy lifting anyway for his COPD and IPF. I also noticed pancytopenia with monocytosis and just took care of the heme referral and communication with heme and I also diagnosed cardiovascular limitation and abnormal EKG stress test with CPET and referred to interventional cardiology and he ended up with a stent and medical management... so the NP just does the screening and vaccinations. Not a bad deal.

As long as a patient has good and immediate subspecialty support, then why not see an NP who has far shorter wait times for something elementary like vaccines or screening.

But this reinforces the point that there should be easy physician access.

So in the end you're the primary care doctor here. At most practices, the MA does the screening stuff and offers vaccinations based on the EMR. This patient is paying for multiple doctors and an NP that does nothing. The sad thing is this person will end up with something that they actually need a primary care physician and if they don't see you, nothing will be done. This also adds to the bloat in our medical system. Any abnormality? Refer to specialist

 

[NewYorkDoctors]

So in the end you're the primary care doctor here. At most practices, the MA does the screening stuff and offers vaccinations based on the EMR. This patient is paying for multiple doctors and an NP that does nothing. The sad thing is this person will end up with something that they actually need a primary care physician and if they don't see you, nothing will be done. This also adds to the bloat in our medical system. Any abnormality? Refer to specialist

Pretty much . I tried to pull the “have your pcp take care of it …” , I call over no response (not just NPs but a lot of private pcps don’t feel the need to pick up , send notes , leave messages but it’s just all therapeutic inertia in the community .

I’m not confident this NP will handle things . But hey at least the NP got this patient his prevnar 20 so I didn’t have to . Whoop de do

 

[greatnt249]

As long as a patient has good and immediate subspecialty support, then why not see an NP who has far shorter wait times for something elementary like vaccines or screening.

I didn't go into my subspecialty to be the patient's surrogate primary physician. If I wasn't salary-based, I might be singing a different tune.

 

[NewYorkDoctors]

I didn't go into my subspecialty to be the patient's surrogate primary physician. If I wasn't salary-based, I might be singing a different tune.

yep I agree with that. I am totally fee for service so whatever. "win-win"

 

[dozitgetchahi]

So in the end you're the primary care doctor here. At most practices, the MA does the screening stuff and offers vaccinations based on the EMR. This patient is paying for multiple doctors and an NP that does nothing. The sad thing is this person will end up with something that they actually need a primary care physician and if they don't see you, nothing will be done. This also adds to the bloat in our medical system. Any abnormality? Refer to specialist

Exactly!

I see so many patients like this and it drives me freaking crazy.

You’ve been having chest pain for years and your PCP hasn’t worked it up?

You’ve been short of breath for years and there’s been no workup?

You can barely swallow solid foods and this has been going on for years?

What has your PCP been doing all this freaking time?

I can and do get a lot of workup for these patients and make a lot of referrals. But my god - some of these people have been complaining about this stuff to their PCP for years, and the PCP notes even talk about it, and yet even the basic steps of working it up somehow haven’t happened.

It’s wasteful and stupid. I’m fee for service too, but still. I trained as a rheumatologist and rheumatology is what I want to be dealing with. I get that PCPs are busy, but so am I - and I need to run on time and keep up with my rapidly enlarging panel of rheumatology patients, not get way off into the weeds dealing with issues that are only peripherally related to rheumatology (at best). The fact that some PCPs seem to excel at this sort of stuff means that it’s not impossible to accomplish all of this as a PCP in the current environment. Put out some effort for Pete’s sake. I see way too many PCPs out there basically just going through the motions and collecting a paycheck. It’s not ok.

(This phenomenon usually also leads to patients calling your office as a specialist for issues that aren’t relevant to you. I’ve had patients call for an appointment saying, among other things, “I have anxiety and you’re the only doctor that listens.” That’s a no-go. If your PCP sucks, it’s time for you to find another one, but I’m not becoming your surrogate PCP.)

 

[NewYorkDoctors]

Exactly!

I see so many patients like this and it drives me freaking crazy.

You’ve been having chest pain for years and your PCP hasn’t worked it up?

You’ve been short of breath for years and there’s been no workup?

You can barely swallow solid foods and this has been going on for years?

What has your PCP been doing all this freaking time?

I can and do get a lot of workup for these patients and make a lot of referrals. But my god - some of these people have been complaining about this stuff to their PCP for years, and the PCP notes even talk about it, and yet even the basic steps of working it up somehow haven’t happened.

It’s wasteful and stupid. I’m fee for service too, but still. I trained as a rheumatologist and rheumatology is what I want to be dealing with. I get that PCPs are busy, but so am I - and I need to run on time and keep up with my rapidly enlarging panel of rheumatology patients, not get way off into the weeds dealing with issues that are only peripherally related to rheumatology (at best). The fact that some PCPs seem to excel at this sort of stuff means that it’s not impossible to accomplish all of this as a PCP in the current environment. Put out some effort for Pete’s sake. I see way too many PCPs out there basically just going through the motions and collecting a paycheck. It’s not ok.

(This phenomenon usually also leads to patients calling your office as a specialist for issues that aren’t relevant to you. I’ve had patients call for an appointment saying, among other things, “I have anxiety and you’re the only doctor that listens.” That’s a no-go. If your PCP sucks, it’s time for you to find another one, but I’m not becoming your surrogate PCP.)

I am PCP for a few patients who primarily have major subspecialty issues and just need a few minor screening and back pain isssues addressed now and then.

Whenever I refer to another physician, I outline very clearly what I spoke about and recommended but patient declined, nver followed up, etc...

I'm not letting any patient slander my name for not doing the fundamentals! plus it brings clarity to the consulting physician.

I often try to assume the PCP probably did address certain issues but ...

but I lose hope when I review patient's inhaler technique and find out no one taught them how to use it.

I also lose hope with that when I attend some PCP meetings sometimes in the local IPA group and find out what screening rates for the basics mammo, colon, DEXA, pap, DM/eye, HBV HCC, are not 90+%.... that just makes me think many PCPs (MD/DO) dont give a you know what.

If MD/DOs arent doing this, we can bet most DNPs/NPs probably arent either...


Maybe its the subspecialty training that has conditioned me to "go get stuff done."
I do recall IM (GIM + hospitalist) training was a lot of risk adverse mental gymnastics half the time and calling consultants most of the time anyway....

 

[VA Hopeful Dr]

I am PCP for a few patients who primarily have major subspecialty issues and just need a few minor screening and back pain isssues addressed now and then.

Whenever I refer to another physician, I outline very clearly what I spoke about and recommended but patient declined, nver followed up, etc...

I'm not letting any patient slander my name for not doing the fundamentals! plus it brings clarity to the consulting physician.

I often try to assume the PCP probably did address certain issues but ...

but I lose hope when I review patient's inhaler technique and find out no one taught them how to use it.

I also lose hope with that when I attend some PCP meetings sometimes in the local IPA group and find out what screening rates for the basics mammo, colon, DEXA, pap, DM/eye, HBV HCC, are not 90+%.... that just makes me think many PCPs (MD/DO) dont give a you know what.

If MD/DOs arent doing this, we can bet most DNPs/NPs probably arent either...


Maybe its the subspecialty training that has conditioned me to "go get stuff done."
I do recall IM (GIM + hospitalist) training was a lot of risk adverse mental gymnastics half the time and calling consultants most of the time anyway....

You underestimate how many patients don't want to do screenings and will just flat out refuse.

They are a huge part of my quality bonus so I will flat out threaten patients to make sure stuff gets done.

Seriously, at least one/week who refuses an AWV because "it's not Medicare's business".

 

[NewYorkDoctors]

You underestimate how many patients don't want to do screenings and will just flat out refuse.

They are a huge part of my quality bonus so I will flat out threaten patients to make sure stuff gets done.

Seriously, at least one/week who refuses an AWV because "it's not Medicare's business".

I hear you. But there is a icd10 code z28.21 to refuse vaccines and z53.20 procedure not carried out due to patient refusal of screening

I believe if these are inputted and documented one can “get credit” and “eliminate the denominator .”

Anyway , patients have the right to choose not to do anything . I’m fully in line with that . It’s just annoying as I have to write an infinitely longer note to document to cover my behind and squarely pin the onus on the patient . I’m certain to document our conversation verbatim so I don’t get any future “that’s not what I said … exactly .”

 

[Splenda88]

It's easy to criticize PCP, but after being in that business for 5 years (3 yrs residency and 2 yrs as an attending), I realize most patients do NOT do what their PCPs advise them to do. As a hospitalist, I have become skeptical about what most patients tell me about their outpatient PCP.

 

[NewYorkDoctors]

It's easy to criticize PCP, but after being in that business for 5 years (3 yrs residency and 2 yrs as an attending), I realize most patients do NOT do what their PCPs advise them to do. As a hospitalist, I have become skeptical about what most patients tell me about their outpatient PCP.

right. I did not wish to sound like "specialist talking down to PCP."

I do practice some PCP (as mentioned) so I get those challenges also and I do walk the walk (though to a lesser degree as a full time PCP).

I am stating I only wish it is conveyed to me what is or is not done by the patient
(something like PMHx: patient refused this refused that or patient decline this or decline that)

Anyway, I often "take full ownership" of subspecialty issues and make it clear to PCP that "i got this . you can do you now" and I tell the patient "stop bothering your PCP about this issue. ill be available to you for this issue."

 

[NewYorkDoctors]

anyway I have another anecdote about a patient (that perhaps dozegatchi might find amusing) and is overall relevant to the idea of this thread

i see a patient for chronic cough and dyspnea.
she is very hard to focus on the clinical history because she is all over the place and hard to focus
i eventually get to ROS and try to make sense of things but everything is all over the place
the one thing I do NOT get the sense of is malingering or primary gain as she does not want pills but "wants to get better." She also "hears me out" and does not seem to enjoy being sick.
she keeps a very thorough note book and notes of all her doctors visits and her prior workup. this already signifies that she probably feels "real symptoms" but sometimes it's hard to get things done.

she had an internist who would refer her everywhere. this is fine as it's unfair for internist to solve the world's problems like this.

the patient is "labelled as having SLE." I am not sure why as it is unclear 4/11 ACR criteria were ever met. her PCP did an "arthritis panel" and found ANA 1:160 but no other consistent serologies. The patient probably self diagnosed herself with SLE based on "ANA only" and she seems to have demanded hydroxychloroquine. but she is quite insistent on not taking prednisone due to weight gain and her mood going haywire.

anyway I do my workup over time and everything is normal. she claims she had asthma but I put an end to that quite quickly after a few visits with PFTs, bronchoprovocation testing, CPET and EIB testing. everything pulmonary wise was normal.
the cough was probably GERD. I TLC'd her into buying a bed wedge pillow and over time TLC'd her into getting her GERD cough better.

but since I did so much TLC she began to come to me discuss other issues. I slowly began to tell her return to PCP return to PCP.
one day she said she "fired her PCP" and "fired three rheumatologists" because they told her she did not have SLE and would not give her hydroxychloroquine anymore (because the ophthalmologist said there were some retinal issues).

She put a mountain of prior labwork in my desk begging me to just look for the magical cure...


luckily I did notice hey one of your labs showed Ca of 11.4 one time. and you're always seemingly high normal or 10.6 most of the time.
I asked if she saw endocrine before - they said they told her to leave. then I realize it was because she tried to pressure these endocrine's into "treating her thyroid disease." On getting the full story, she has elevated TPOAb but was euthymic. She wanted treatment for the TPOAb itself because she read online that thyroidectomy for euthymic hashimoto might improve her whole body pain and some of her neuropsychiatric symptoms. maybe the way she presented herself was wrong

I take an interest in her calcium has no one else has. ultimately diagnose with primary hyperparathyroidism with an adenoma. while neuropsychiatric symptoms are not an indication for parathyroidectomy per the guidelines, she did reach over 1.0 over normal once.. her urine calcium is boderline at 380mg/day, and she has osteopenia (but not osteoporosis), and she is.. 49...

after 4 surgeons (endocrine, H&N, and ENTs x 2), she made her way to MSKCC and bugged the heck out of a H&N surgeon who did the parathyroid adenoma removal... she had hungry bones syndrome for a bit but is now doing fairly well.

she comes say hello to me now and then and state her neuropsychiatric symptoms are better but she still has joint aches.

anyway the NP part is she found a new primary care NP and has hydroxychloroquine again now. 'doh.

 

[dozitgetchahi]

It's easy to criticize PCP, but after being in that business for 5 years (3 yrs residency and 2 yrs as an attending), I realize most patients do NOT do what their PCPs advise them to do. As a hospitalist, I have become skeptical about what most patients tell me about their outpatient PCP.

There’s a difference between offering the patient something and them declining (and the PCP documenting that) and the PCP never offering it or, even worse, neglecting to do something about it despite the patient asking for solutions (and the PCP even documenting this in the note!). I see way too much of the latter going on, and as I said, it tends to be the same “usual suspects” who otherwise don’t seem to be giving the best care.

Some docs seem to almost always do it right.

 

[NewYorkDoctors]

moreover the PCP bonuses for getting all the screening done is really not that much. i mean its not nothing dont get me wrong. But an annual near perfect (>90% adherence) screening for PCPs nets a bonus of about $10,000-$20,000 from the IPA (derived from all the insurances) in my neck of the woods. certainly not bad

but when a PCP is opening up a 99213 mill and the goal is to get more volume (quality be damned), then you can see how giving up that screening bonus to see more patients for quick Zpaks is more lucrative.

99213 PCP mills in NYC make over $1M easy. but the quality usually suffers. for most patients... that's okay.... its very hard to get a patient worse off , especially when specialists are everywhere

 

[VA Hopeful Dr]

I hear you. But there is a icd10 code z28.21 to refuse vaccines and z53.20 procedure not carried out due to patient refusal of screening

I believe if these are inputted and documented one can “get credit” and “eliminate the denominator .”

Anyway , patients have the right to choose not to do anything . I’m fully in line with that . It’s just annoying as I have to write an infinitely longer note to document to cover my behind and squarely pin the onus on the patient . I’m certain to document our conversation verbatim so I don’t get any future “that’s not what I said … exactly .”

There are ways to get patients out of the quality cohort but it's usually very difficult to do.

Those codes you have definitely won't do it, at least not for Medicare.

 

[end stage fibro]

Maybe its the subspecialty training that has conditioned me to "go get stuff done."
I do recall IM (GIM + hospitalist) training was a lot of risk adverse mental gymnastics half the time and calling consultants most of the time anyway....

this is so accurate. it's sad because that milquetoast attitude gets carried into attendighood. then you get effete hospitalists that just get stomped on by the specialists and admin.


Anyways, to add some fuel to the fire:

Source
Kaufman Hall is probably the consulting company in healthcare. If they talk, you should listen.

 

[CptNemo]

I feel that NPs and PAs are at their best when they are in a subspecialty clinic with a special/narrow focus where they get really good at a few things with repetition. I've seen terrific APPs in wound care clinic, doing basic ortho exams, and even doing dialysis rounding (2-3 visits/month with the physician doing 1-2 visits).

Primary care fields or inpatient fields such as hospitalist and critical care are so broad that with their limited training and limited exposure to cases during their training, it is not really fair to expect APPs to be adept at them. They will most definitely miss lots of things and over-refer. Especially since in most case they are not willing to put in extra time and work >40 hours per week to really get good at a broad field (for better or worse, I feel that people coming from a nursing culture have a much different attitude towards after-hours unreimbursed work as compared to physicians who spend many years on after hours studying or working in med school and residency). They have more of a tendency to want to clock out and check out at the end of the shift - just my observation.

I always find it amusing when over-confident APPs give me suggestions how to manage my CRRT in the ICU or try to argue with me about basic physiology that they clearly do not understand... we've even had some instances where they've tried to change our CRRT orders with nearly catastrophic results (if the bedside nurse had actually followed the changed orders). My favorite is when a patient was running -100 mL/hr on CVVH, but the Critical Care APP thought that they were getting "too overloaded" from all the replacement fluids that they were getting on CVVH and thus decided to delete the order...

 

[NewYorkDoctors]

I feel that NPs and PAs are at their best when they are in a subspecialty clinic with a special/narrow focus where they get really good at a few things with repetition. I've seen terrific APPs in wound care clinic, doing basic ortho exams, and even doing dialysis rounding (2-3 visits/month with the physician doing 1-2 visits).

Primary care fields or inpatient fields such as hospitalist and critical care are so broad that with their limited training and limited exposure to cases during their training, it is not really fair to expect APPs to be adept at them. They will most definitely miss lots of things and over-refer. Especially since in most case they are not willing to put in extra time and work >40 hours per week to really get good at a broad field (for better or worse, I feel that people coming from a nursing culture have a much different attitude towards after-hours unreimbursed work as compared to physicians who spend many years on after hours studying or working in med school and residency). They have more of a tendency to want to clock out and check out at the end of the shift - just my observation.

I always find it amusing when over-confident APPs give me suggestions how to manage my CRRT in the ICU or try to argue with me about basic physiology that they clearly do not understand... we've even had some instances where they've tried to change our CRRT orders with nearly catastrophic results (if the bedside nurse had actually followed the changed orders). My favorite is when a patient was running -100 mL/hr on CVVH, but the Critical Care APP thought that they were getting "too overloaded" from all the replacement fluids that they were getting on CVVH and thus decided to delete the order...

but where is the ICU attending? Sleeping perhaps. But usually the tightest ICUs have a clear hierarchical structure and APPs ultimately should run things by the intensivist...

 

[Osteoth]

but where is the ICU attending? Sleeping perhaps. But usually the tightest ICUs have a clear hierarchical structure and APPs ultimately should run things by the intensivist...

No matter how much they run by you unless you’re looking through the notes and orders of every patient, which even the conscientious ones don’t, things will get missed.

 

[NewYorkDoctors]

this all comes back to how the "best" APPs are those who literally are the extension of the physician. This returns full circle in that APPs are valuable members of the medical team... just not as solo independent practitioners.

 

[dozitgetchahi]

Primary care fields or inpatient fields such as hospitalist and critical care are so broad that with their limited training and limited exposure to cases during their training, it is not really fair to expect APPs to be adept at them. They will most definitely miss lots of things and over-refer. Especially since in most case they are not willing to put in extra time and work >40 hours per week to really get good at a broad field (for better or worse, I feel that people coming from a nursing culture have a much different attitude towards after-hours unreimbursed work as compared to physicians who spend many years on after hours studying or working in med school and residency). They have more of a tendency to want to clock out and check out at the end of the shift - just my observation.

It’s my observation too.

In fact, I’ve generally noticed that nobody else associated with medicine seems to put in the level of time and after hours effort that doctors do. There’s a very widespread “clock puncher” mentality among most other types of workers in medicine (nurses, CNAs, whatever) - when the shift ends, it’s time to go and they’re all super unhappy at the idea of staying longer to figure anything out. They also look at me like I have two heads when they hear that I’ve been there hours after everyone else left, doing notes and everything else necessary to keep the whole production going. (The worst thing is that because we often work when nobody else sees us working, it’s like everyone else assumes that we weren’t working at those times. A lot of our long hours are simply invisible to everyone else, including management.)

On one hand, I think this level of dedication that has been drilled into us over the years is really important, and distinguishes us from almost everyone else in “allied health”. On the other hand, I think it has been exploited by hospitals and the rest of the American healthcare system to ensure they squeeze every single drop of work and effort out of us.

 

[dozitgetchahi]

In my experience, good NPs are few and far between. I've almost never seen proper supervision. It's more of a cash making situation for these doctors

Ditto.

 

[dozitgetchahi]

99213 PCP mills in NYC make over $1M easy. but the quality usually suffers. for most patients... that's okay.... its very hard to get a patient worse off , especially when specialists are everywhere

Just remember that somewhere down the line, some specialist is getting stuck with the super messed up case from these 99213 idiots where a patient comes in talking about 5-10 years of chest pain, dyspnea, rashes, dysphagia, etc etc…”I don’t really get much out of my PCP, they don’t really care about this stuff” etc.

It makes me hopping mad sometimes to watch these docs make fistfuls of cash while specialists like myself have to clean up the messes they should have attended to years ago. I don’t care how much money you’re making as a doc - if the quality of your care is no better than a midlevel, then my level of respect for you drops as such. (That said, most of these docs seem to have no sense of shame and don’t remotely care about their ****ty reputations…they’re laughing all the way to the bank.) What I’ve started doing lately with these patients is handing out referrals to a PCP in our group who I know will actually put in the work and give a damn. “I’ll help get the workup started, but your PCP sucks and I’m not doing all their homework for them anymore. Go see this one instead.”

 

[NewYorkDoctors]

Just remember that somewhere down the line, some specialist is getting stuck with the super messed up case from these 99213 idiots where a patient comes in talking about 5-10 years of chest pain, dyspnea, rashes, dysphagia, etc etc…”I don’t really get much out of my PCP, they don’t really care about this stuff” etc.

It makes me hopping mad sometimes to watch these docs make fistfuls of cash while specialists like myself have to clean up the messes they should have attended to years ago. I don’t care how much money you’re making as a doc - if the quality of your care is no better than a midlevel, then my level of respect for you drops as such. (That said, most of these docs seem to have no sense of shame and don’t remotely care about their ****ty reputations…they’re laughing all the way to the bank.) What I’ve started doing lately with these patients is handing out referrals to a PCP in our group who I know will actually put in the work and give a damn. “I’ll help get the workup started, but your PCP sucks and I’m not doing all their homework for them anymore. Go see this one instead.”

yep. i never said it was a good system... just putting it out there what happens. Those PCPs are NOT reporting their salaries to Medscape lol.

right I also have some cards for other PCPs (usually younger and tech saavy and who were trained in the modern residency programs and thus taught to want to get things done) which I hand out to patients when they ask me "can you be my PCP?" (i say no)