Mid-levels in Neurohospitalist set up

[sweetsmiles9]

Hi,
I am a neurohospitalist and have worked with mid levels on and off over the last several years. I personally prefer not to have them but some hospitals as well as neurologists seem to prefer having them on the service. I anyways see all new consults myself and have to see the follow ups too so there's not much that the mid level would do except write follow up notes. A mid level with an attitude and making excuses to leave early all the time can be a nightmare (I worked at a hospital where a PA had to be let go by the neurohospitalist group for those reasons). I'm contemplating a new job where there's no mid level which is ok with me. However, there's another neurologist who might join the neurohospitalist team and is absolutely adamant about having a mid level on all days. If I join, I would be the first to come on board and am debating about being firm on the no-mid level stance.
Any thoughts on this matter?

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[xenotype]

Hi,
I am a neurohospitalist and have worked with mid levels on and off over the last several years. I personally prefer not to have them but some hospitals as well as neurologists seem to prefer having them on the service. I anyways see all new consults myself and have to see the follow ups too so there's not much that the mid level would do except write follow up notes. A mid level with an attitude and making excuses to leave early all the time can be a nightmare (I worked at a hospital where a PA had to be let go by the neurohospitalist group for those reasons). I'm contemplating a new job where there's no mid level which is ok with me. However, there's another neurologist who might join the neurohospitalist team and is absolutely adamant about having a mid level on all days. If I join, I would be the first to come on board and am debating about being firm on the no-mid level stance.
Any thoughts on this matter?

Currently do not use midlevels. Correct me if this is wrong but my understanding is that CMS is in the process of making it much, much harder to bill at 100% if the midlevel saw the patient, did the note, and attending did <50% of the time spent seeing the patient.

 

[elanmorin]

why are they so adamant about having a mid-level?

 

[Telamir]

I’ve had some jobs with mid levels and others without.

Besides writing some notes I haven’t seen much benefit. I have to see all new consults anyway, with or without them. For followups it’s sometimes helpful especially for stroke since they can be formulaic and they can be seen by the mid level independently so long as you review the notes/data.

Honestly I don’t care too much but I agree some of them can be difficult to work with as in my experience I’ve heard complaints about hours, scheduling or issues with overconfidence.

 

[deleted1139416]

Hi,
I am a neurohospitalist and have worked with mid levels on and off over the last several years. I personally prefer not to have them but some hospitals as well as neurologists seem to prefer having them on the service. I anyways see all new consults myself and have to see the follow ups too so there's not much that the mid level would do except write follow up notes. A mid level with an attitude and making excuses to leave early all the time can be a nightmare (I worked at a hospital where a PA had to be let go by the neurohospitalist group for those reasons). I'm contemplating a new job where there's no mid level which is ok with me. However, there's another neurologist who might join the neurohospitalist team and is absolutely adamant about having a mid level on all days. If I join, I would be the first to come on board and am debating about being firm on the no-mid level stance.
Any thoughts on this matter?

I’ve had some jobs with mid levels and others without.

Besides writing some notes I haven’t seen much benefit. I have to see all new consults anyway, with or without them. For followups it’s sometimes helpful especially for stroke since they can be formulaic and they can be seen by the mid level independently so long as you review the notes/data.

Honestly I don’t care too much but I agree some of them can be difficult to work with as in my experience I’ve heard complaints about hours, scheduling or issues with overconfidence.

It’s absolutely insane how doctors go through residency working 80+ hour weeks and have to deal with midlevels complaining about having to do more than their regular 9-5. I’m exaggerating but you guys get the point….

 

[sweetsmiles9]

why are they so adamant about having a mid-level?

The other neurologist is currently in an academic set up with residents, fellows and mid levels and is not used to seeing every consult or follow up all by themselves. In their own words, "I don't have to see any consult or follow up and just go and say Hi to the patient before attesting notes".

 

[sweetsmiles9]

It’s absolutely insane how doctors go through residency working 80+ hour weeks and have to deal with midlevels complaining about having to do more than their regular 9-5. I’m exaggerating but you guys get the point….

You're right. I've found the mid levels to be an entitled lot and one of them did not want to do follow up notes since they didn't want to be a scribe.

 

[sweetsmiles9]

I’ve had some jobs with mid levels and others without.

Besides writing some notes I haven’t seen much benefit. I have to see all new consults anyway, with or without them. For followups it’s sometimes helpful especially for stroke since they can be formulaic and they can be seen by the mid level independently so long as you review the notes/data.

Honestly I don’t care too much but I agree some of them can be difficult to work with as in my experience I’ve heard complaints about hours, scheduling or issues with overconfidence.

Thats pretty much how I feel.

 

[sweetsmiles9]

Thank you all for your input. It's good to know that I'm not alone in feeling this way.

 

[sweetsmiles9]

Currently do not use midlevels. Correct me if this is wrong but my understanding is that CMS is in the process of making it much, much harder to bill at 100% if the midlevel saw the patient, did the note, and attending did <50% of the time spent seeing the patient.

I think that is correct

 

[Neurogeneral]

Yes I have also heard that CMS is clamping down on physician billing when the mid-level spent more time with the patient and did most of the note.

I have never worked with a mid-level but I imagine if you have one with good work ethic, it can be helpful in certain situations. When you are a neuro-hospitalist and your list is +30 patients, having a mid-level to write some of the notes, put in some orders, and communicate with the primary team can reduce your workload. At the same time, if you have a busy clinic but are still expected to round everyday at the hospital, having the mid-level can also substantially reduce the workload.

 

[curiousneuro]

Yes I have also heard that CMS is clamping down on physician billing when the mid-level spent more time with the patient and did most of the note.

I have never worked with a mid-level but I imagine if you have one with good work ethic, it can be helpful in certain situations. When you are a neuro-hospitalist and your list is +30 patients, having a mid-level to write some of the notes, put in some orders, and communicate with the primary team can reduce your workload. At the same time, if you have a busy clinic but are still expected to round everyday at the hospital, having the mid-level can also substantially reduce the workload.

If you view midlevels as a scribe+ then this works, but my experience with them is that they don't want this and want to get involved in actual decision making. Which is obviously a problem if you can't see all patients and evaluate them on your own to make sure that they are doing the right thing...because at the end of the day, all the liability is completely on us. For that reason I would never willingly work with a midlevel UNLESS they were completely in a scribe/orders capacity. Using midlevels to see more patients without evaluating them properly is asking for trouble, in my view.