Midlevel encroachment on PAIN

[Pain Applicant1]

Can we hijack the thread a little and discuss how physicians can begin billing for PT services? Does anyone have experience with this? Maybe I should begin a new thread. Nonetheless, I think the following are the basic CPT codes and the link is a bit more extensive.

97001 - Initial Evaluation
97750 - Physical performance test or measurement, with written report
97110 - Therapeutic procedure, 1 or more areas, each 15 minutes, therapeutic exercises to develop strength, endurance,
range of motion and flexibility.
97112 - Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and
proprioception, each 15 minutes
97116 - Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing), each 15
minutes
97140 - Manual therapy techniques, 1 or more regions, each 15 minutes


http://www.physicaltherapytoolbox.com/pdfs/cpt.pdf

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[Fiveoboy11]

#1 I'm not sure anyone said this and I don't think there are any studies on this.


#2 Again, I don't think that a single person here thinks that PTs actually pay attention to our scripts with the exception of precautions. I know that PT is independently in the military and many other countries. However, comparing our health care system against any other country's is likely apples to oranges. This is the system we are in. It's not perfect and in many states a physician directed script is required by many payors. So, that being said, a physician directed script is effective and improves outcome for patients if it means no therapy at all. A physician directed script actually leads to poorer outcomes and more costly care not to mention a headache for me and a dependent patient, so how do you figure it is effective and improves outcomes. What in the world are you basing that on? It's physical therapy provided by a PT, not physician therapy provided by a PTA.

State law trumps payor requirements. As far as I know, payors only require a script, referral, orders, or whatever you want to call it for physical therapy that says "evaluate and treat" along with a diagnosis that is amenable to physical therapy. Personally, I like to read physician reports and take everything into consideration, including any precautions as a result of the medical problems.


See #1


The Childs' is the main study that shows that OCS certified PTs score higher than "orthopedists and staff physicians." However, if we go by the logic that whoever "scores higher" should treat musculoskeletal conditions "best" then that still leaves it to "orthopedists and staff physicians." I don't think that's best either though.

The point is that PT's are far more competent in MSK conditions than non PT's seem to realize.

See #2

Support for US healthcare system in terms of MSK outcomes and cost vs other countries with direct access to PT
See #2

Countries with better access to healthcare are overall better systems of healthcare. In addition to this, it has been proven in this country that direct access to physical therapists leads to better care and less cost. They are not exactly the same, but if you think about it, any time you compare one thing to another you're comparing apples to oranges.

 

[Fiveoboy11]

Can we hijack the thread a little and discuss how physicians can begin billing for PT services? Does anyone have experience with this? Maybe I should begin a new thread. Nonetheless, I think the following are the basic CPT codes and the link is a bit more extensive.

97001 - Initial Evaluation
97750 - Physical performance test or measurement, with written report
97110 - Therapeutic procedure, 1 or more areas, each 15 minutes, therapeutic exercises to develop strength, endurance,
range of motion and flexibility.
97112 - Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and
proprioception, each 15 minutes
97116 - Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing), each 15
minutes
97140 - Manual therapy techniques, 1 or more regions, each 15 minutes


http://www.physicaltherapytoolbox.com/pdfs/cpt.pdf

I invite you to bill for physical therapy so you can be exposed for the unprofessional, quack hack that you are. Hopefully someday there will be a giant lawsuit because of BS like this, i'll be there.

 

[Pain Applicant1]

I invite you to bill for physical therapy so you can be exposed for the unprofessional, quack hack that you are. Hopefully someday there will be a giant lawsuit because of BS like this, i'll be there.

Enough of your foolish name calling. You know nothing of me or of my training. My post does not concern you and I will now ignore you. Poof, you are gone (unless of course you'd like to give me tips on billing for PT). As for everyone else, please post any tips on how to bill for PT. I did review the codes and it doesn't really seem like it makes much financial sense as reimbursement is relatively low. Also, is it really necessary to hire a PT to do the PT? I spent a year training with PT and it just is not that difficult. I feel I can train an Athletic Trainer, PTA, or even my MA to do the treatment if I set the protocols up for them. I'm sure that the PT lobby, however, has worked hard to prevent that from happening. I trained my MAs to do my fluoro, get vitals, start IVs, etc, and they're doing great. No techs or nurses required.

 

[specepic]

Mods, I respectfully request that Fiveboy be banned from SDN. Yes, there has been plenty of back and forth but he is clearly seeking out trouble, and has w/o a doubt behaved unprofessionally and violated SDN policy, specifically unprofessional name calling such as "arrogant dick" and "quack". Shut him down as he is dragging down the quality of this board, please

 

[Fiveoboy11]

Mods, I respectfully request that Fiveboy be banned from SDN. Yes, there has been plenty of back and forth but he is clearly seeking out trouble, and has w/o a doubt behaved unprofessionally and violated SDN policy, specifically unprofessional name calling such as "arrogant dick" and "quack". Shut him down as he is dragging down the quality of this board, please

Yea, I'm the only one being unprofessional. No bashing of the PT profession at all. I apologize to everyone who's been offended as it wasn't my intention and I will leave this forum and not come back.

 

[physasst]

I think you are right on. My next venture will be teaming up with lawyers in their attempts to sue para medical professionals -aka midlevels. Can you imagine the headlines? Where you treated by an *NP/PA/CRNA* -where you not given the option of a dr? Then call me! I will fight for you! Lol. I can see this happening. I am personally very annoyed by midlevels who have little community college/online courses and think they know everything bc an MD/DO gives them orders and they carry them out. Such a sad state of our medical profession.

I also a very frustrated by this 2 tiered system we have. We should probably take a number of things to the supreme court and say hey-do you want drs practicing or midlevels? We should not have both. But this is my opinion.

Not quite. In fact, there is research looking at the relative malpractice exposures and rates of filings amongst providers. Not surprisingly physicians have higher rates than either PAs or NPs but that isn't surprising, as they tend to take on sicker, more complicated patients.

Bottom line is, money talks. We are cheaper to train and cheaper to employ, and we bring in revenue that is similar to physicians. (reimbursement is the same with the exception of a couple of insurers, mainly Medicare, which is 85%...STILL, at roughly 50% salary, the group makes MORE money off of their PAs)

Does that mean we can do EVERYTHING, or that physicians aren't needed....no, of course not, and that is a laughable thought. But we can be used to a greater degree than we are for the most part, and numerous studies, including the IOM piece as well as the Macy Foundation study 2 years ago suggested letting us practice at the top of our licensure.

We aren't going anywhere, and while I cannot speak for NPs, there is only one PA program that I am aware of that is partially online....(BTW, I am completely and utterly opposed to that program as well). Many PA programs are located at medical schools and they take clinical medicine classes with their med school colleagues. There is even a combined PA/PhD program now at Wake Forest. We don't take "community college" level classes.

I'm not mentioning this to be combative or start a war, but merely to try and point out some basic facts and correct some misconceptions.

Additionally, there has not been ONE study showing poorer outcomes with PA managed patients versus MD patients. Outcomes have always been similar. The only exception was in one study comparing PAs to NPs to MDs in the care of several outpatient primary care diagnoses, where PAs and MDs were equivalent in diabetic management, but NPs actually scored better.

If you have some studies or data showing worse outcomes, poorer care delivery, decreased patient satisfaction, or increased rates of tort filings, please provide it. Otherwise, your comments are grossly incorrect.

BTW, spoke with a PA out east the other night, and he actually started his own pain practice about 6 years ago. He hired the 3 physicians that work there, and while one of them is his "supervising physician", he owns and runs the practice himself.

 

[facetguy]

Mods, I respectfully request that Fiveboy be banned from SDN. Yes, there has been plenty of back and forth but he is clearly seeking out trouble, and has w/o a doubt behaved unprofessionally and violated SDN policy, specifically unprofessional name calling such as "arrogant dick" and "quack". Shut him down as he is dragging down the quality of this board, please

"Quack" rings a bell. I wonder if perhaps I've heard that term tossed around in reference to chiropractors...perhaps even on SDN?? Nah, couldn't be.

 

[specepic]

"Quack" rings a bell. I wonder if perhaps I've heard that term tossed around in reference to chiropractors...perhaps even on SDN?? Nah, couldn't be.

I believe SDN makes a distinction between characterizing an individual versus a profession. I seem to recall a pain physician being recently banned for merely stirring up trouble (I think they were doing some pimping) on a mid-level (NP?) board. It is also my recollection that personal name calling/etc. is out of bounds; general heated discussion/debates are allowed, I think folks try to avoid getting personal however. I think if you read through this thread these lines of distinction are fairly clear. If someone cannot debate in a productive and civil manner then they need to step away, if unable to do that, they should be removed.

 

[facetguy]

I believe SDN makes a distinction between characterizing an individual versus a profession. I seem to recall a pain physician being recently banned for merely stirring up trouble (I think they were doing some pimping) on a mid-level (NP?) board. It is also my recollection that personal name calling/etc. is out of bounds; general heated discussion/debates are allowed, I think folks try to avoid getting personal however. I think if you read through this thread these lines of distinction are fairly clear. If someone cannot debate in a productive and civil manner then they need to step away, if unable to do that, they should be removed.

I'm not defending anyone. But "quack" might be too low a threshold for banning; I've been called that more than once here on SDN.

 

[RUOkie]

I'm not defending anyone. But "quack" might be too low a threshold for banning; I've been called that more than once here on SDN.

if the shoe fits...

 

[Baritonebass]

That pain clinic out east... Would that be in fl by chance???

 

[Pain Applicant1]

It's interesting that non-physicians post in the physician forums. Not that I'm necessarily against it by why is it? I can't help but think it's due to wanting to gain respect, perhaps due to an inferiority complex. Am I wrong?

I don't think physicians typically go and post in the non-physician forums. There is a chiro, a PA, and a PT posting in here. I don't ever feel the need to post, or even to read for that matter, anything in one of those forums. Please shed some light.

 

[facetguy]

It's interesting that non-physicians post in the physician forums. Not that I'm necessarily against it by why is it? I can't help but think it's due to wanting to gain respect, perhaps due to an inferiority complex. Am I wrong?

I don't think physicians typically go and post in the non-physician forums. There is a chiro, a PA, and a PT posting in here. I don't ever feel the need to post, or even to read for that matter, anything in one of those forums. Please shed some light.

There's a chiro forum around here?

 

[physasst]

That pain clinic out east... Would that be in fl by chance???

Nope, northeast. Maine to be precise.

 

[physasst]

I don't think physicians typically go and post in the non-physician forums. There is a chiro, a PA, and a PT posting in here. I don't ever feel the need to post, or even to read for that matter, anything in one of those forums. Please shed some light.

Well, first off, they do. And good, they should. Just like we should post here as well.

We need to IMPROVE interprofessionalism and teamwork, not worsen it. These kinds of forums provide some opportunity, albeit limited, to discuss professional issues that affect all of us.

Based on some of the misconceptions about PAs that I've read in just this thread, we should be posting here more often. Just as we (PAs) can learn more about our physician colleagues by reading and participating here.

Those are some reasons at least.

 

[Pain Applicant1]

There's a chiro forum around here?

Why not? Love it or hate it, chiro is a part of the health care system and this forum is for health care providers.

Well, first off, they do. And good, they should. Just like we should post here as well.

We need to IMPROVE interprofessionalism and teamwork, not worsen it. These kinds of forums provide some opportunity, albeit limited, to discuss professional issues that affect all of us.

Based on some of the misconceptions about PAs that I've read in just this thread, we should be posting here more often. Just as we (PAs) can learn more about our physician colleagues by reading and participating here.

Those are some reasons at least.

So, you want to change the misconceptions about PAs, in other words to gain more respect from us. What can a physician learn from a PA thread? If you post a link of a PA thread here that you feel will be helpful to me, I will read it. Not to be contentious but If I wanted to learn more about Neurology, I would prefer to learn from a Neurology attending as opposed to a Neurology PA.

 

[physasst]

Why not? Love it or hate it, chiro is a part of the health care system and this forum is for health care providers.



So, you want to change the misconceptions about PAs, in other words to gain more respect from us. What can a physician learn from a PA thread? If you post a link of a PA thread here that you feel will be helpful to me, I will read it. Not to be contentious but If I wanted to learn more about Neurology, I would prefer to learn from a Neurology attending as opposed to a Neurology PA.

Not contentious at all. There is a good deal more variability in a PAs background and knowledge base.

One PA on the west coast owns his own headache practice. He has written several headache books, and knows more about headache management than most physicians.....including neurologists. NOW, that does NOT MEAN that he knows more about general neurology, epilepsy, stroke, etc., but his expertise in refractory headache management is really good.

He actually gets referrals from all kinds of physicians to his practice for him to manage their patients refractory headaches.

Does that mean ALL PAs are like that? No. Not in the least, but to assume that you can't learn anything from a PA is pretty arrogant. I've always felt that I can learn from everyone. I hope to correct misconceptions so that they are not perpetuated. Most PAs once they've spent at least 5 years in a specialty become really good. Some become exceptional, some will never be great...just like physicians. Doesn't mean that we can replace the physician completely on EVERY patient, but it does mean that we can function rather independently with MOST patients.

FWIW, when I was in Orthopedics, the attending I worked with would often ask me to teach the fellows and residents. He would also listen to me and ask my judgment frequently, as more than once my EM background caught some events occuring post operatively...

As far as learning from each other, that's the reason I am here, to learn from you and our PM&R colleagues. We can always learn from each other.

 

[Pain Applicant1]

Not contentious at all. There is a good deal more variability in a PAs background and knowledge base.

One PA on the west coast owns his own headache practice. He has written several headache books, and knows more about headache management than most physicians.....including neurologists. NOW, that does NOT MEAN that he knows more about general neurology, epilepsy, stroke, etc., but his expertise in refractory headache management is really good.

He actually gets referrals from all kinds of physicians to his practice for him to manage their patients refractory headaches.

Does that mean ALL PAs are like that? No. Not in the least, but to assume that you can't learn anything from a PA is pretty arrogant. I've always felt that I can learn from everyone. I hope to correct misconceptions so that they are not perpetuated. Most PAs once they've spent at least 5 years in a specialty become really good. Some become exceptional, some will never be great...just like physicians. Doesn't mean that we can replace the physician completely on EVERY patient, but it does mean that we can function rather independently with MOST patients.

FWIW, when I was in Orthopedics, the attending I worked with would often ask me to teach the fellows and residents. He would also listen to me and ask my judgment frequently, as more than once my EM background caught some events occuring post operatively...

As far as learning from each other, that's the reason I am here, to learn from you and our PM&R colleagues. We can always learn from each other.

If that's the case then med school and subsequent training should be changed so we are all trained as PAs are trained. If the training of med school is not required for most patients then no need to waste time and resources on the training. Let PA schools become more competitive from an increased applicant pool and let money be saved for med students. No need to waste all those hours and sleepless nights.

Nonetheless, I still feel no need to change anything about the way PAs, NPs, chiros, or PTs perceive the physician profession, yet midlevels seem to have this feeling as evidenced in this forum.

 

[pmr4life]

In the minor defense of physasst's assessment, how much current, clinically applicable material did we learn in med school? Think about your daily work...how much of it is related to the Kreb's cycle or diastolic murmurs? Most of the MSK/Neuro knowledge is picked up through residency. Honestly, I think PA's/NP's, whoever, can take care of 90% of the stuffy noses, HTN, diabetes management out there....it's the other 10% that need doctors. The depth of our training, while prolonged and sleepless, gives us the critical depth of knowledge needed for the tough cases...thus handing us the liability and increased salary (most of the time). In my brief history of working with NP's and PA's, they can function very well with straight forward stuff....thinking outside of the box tends to get tricky since they might not know that there is another world outside of the box. Hence, that's where we come in.

 

[Taus]

The big key there is having the knowledge to recognize when one is dealing w/ the other 10%. In other words.... "knowing what you don't know"

In the minor defense of physasst's assessment, how much current, clinically applicable material did we learn in med school? Think about your daily work...how much of it is related to the Kreb's cycle or diastolic murmurs? Most of the MSK/Neuro knowledge is picked up through residency. Honestly, I think PA's/NP's, whoever, can take care of 90% of the stuffy noses, HTN, diabetes management out there....it's the other 10% that need doctors. The depth of our training, while prolonged and sleepless, gives us the critical depth of knowledge needed for the tough cases...thus handing us the liability and increased salary (most of the time). In my brief history of working with NP's and PA's, they can function very well with straight forward stuff....thinking outside of the box tends to get tricky since they might not know that there is another world outside of the box. Hence, that's where we come in.

 

[specepic]

The OP here was 'mid level encroachment' in Pain, i.e. Pain specialty. What Pain docs do (not the pill mills or needle jockeys but boarded real deal pain docs) is figure out, or at least try, pts that no on else could. We typically see patients who have seen several physical therapists, several chiropractors, several surgeons, several internists, specialists, etc.

We not only deal regularly with the "10%" mentioned above, but often the 1% of the 1%. For me, med school, plus residency and fellowship was a total of 10 years. that was after 4 years of college. I strongly firmly believe there is no substitute for depth and quality of training, prior to practice. There are some things you can just not learn on the fly on your own, or at a wkd course.

Can a mid-level do an epidural injection. Of course. Should they do these injections on patient's who are directly referred to them for the procedure either by other mid levels or even by physicians who are not specialists, absolutely not. If they do not have the training to assess a full differential diagnosis, read the MRI yourself to know where it is safe to inject, understand all the side effects of precautions and how those impact on the chronic medical problems, etc. Put down the needle and send them to us (board-certified pain physicians).

Where would you send your mother?

I should add, in case the above is not clear, that not all pain docs walk on water. In my state there are dedicated pain practices which I would not send a relative to. One of these (the biggest in the state) has lots of ads and an army of midlevels doing totally independent care (from consult to cervical epidural). The other big group does not use mid levels but also appears to not be fellowship trained, lots of series of 3, and almost everyone gets L5-S1 x 3 ILESI. Maybe I should be grateful as most patients are quite insightful and come see me after them

 

[facetguy]

The OP here was 'mid level encroachment' in Pain, i.e. Pain specialty. What Pain docs do (not the pill mills or needle jockeys but boarded real deal pain docs) is figure out, or at least try, pts that no on else could. We typically see patients who have seen several physical therapists, several chiropractors, several surgeons, several internists, specialists, etc.

We not only deal regularly with the "10%" mentioned above, but often the 1% of the 1%. For me, med school, plus residency and fellowship was a total of 10 years. that was after 4 years of college. I strongly firmly believe there is no substitute for depth and quality of training, prior to practice. There are some things you can just not learn on the fly on your own, or at a wkd course.

Can a mid-level do an epidural injection. Of course. Should they do these injections on patient's who are directly referred to them for the procedure either by other mid levels or even by physicians who are not specialists, absolutely not. If they do not have the training to assess a full differential diagnosis, read the MRI yourself to know where it is safe to inject, understand all the side effects of precautions and how those impact on the chronic medical problems, etc. Put down the needle and send them to us (board-certified pain physicians).

Where would you send your mother?

I should add, in case the above is not clear, that not all pain docs walk on water. In my state there are dedicated pain practices which I would not send a relative to. One of these (the biggest in the state) has lots of ads and an army of midlevels doing totally independent care (from consult to cervical epidural). The other big group does not use mid levels but also appears to not be fellowship trained, lots of series of 3, and almost everyone gets L5-S1 x 3 ILESI. Maybe I should be grateful as most patients are quite insightful and come see me after them

I'm happy to see that you added that clarification there at the end, because it's been my experience that the process used by many "real boarded pain docs" to figure out the 10% (or 1% or whatever) is to do 3 epidurals, see what happens, then do facets on one side, see what happens, then do the other side, see what happens, and down the line.

Obviously, this doesn't include all pain docs, and my example only applies to spine and you guys do more than that. But if you're honest, you'll agree that what I described above happens all the time and looks a lot more like guesswork than knowing what others don't know.

 

[ghost dog]

Not contentious at all. There is a good deal more variability in a PAs background and knowledge base.

One PA on the west coast owns his own headache practice. He has written several headache books, and knows more about headache management than most physicians.....including neurologists. NOW, that does NOT MEAN that he knows more about general neurology, epilepsy, stroke, etc., but his expertise in refractory headache management is really good.

He actually gets referrals from all kinds of physicians to his practice for him to manage their patients refractory headaches.

Does that mean ALL PAs are like that? No. Not in the least, but to assume that you can't learn anything from a PA is pretty arrogant. I've always felt that I can learn from everyone. I hope to correct misconceptions so that they are not perpetuated. Most PAs once they've spent at least 5 years in a specialty become really good. Some become exceptional, some will never be great...just like physicians. Doesn't mean that we can replace the physician completely on EVERY patient, but it does mean that we can function rather independently with MOST patients.

FWIW, when I was in Orthopedics, the attending I worked with would often ask me to teach the fellows and residents. He would also listen to me and ask my judgment frequently, as more than once my EM background caught some events occuring post operatively...

As far as learning from each other, that's the reason I am here, to learn from you and our PM&R colleagues. We can always learn from each other.

Can this PA admit his headache patients if they are truly refractory to the traditional treatments ?

For example: if the motivated headache patient has medication overuse headache complicated by opioid dependence this will not infrequently call for an inpatient admission for opioid detoxification. In this type of scenario, this is an extremely important management step.

I'm not sure if PAs have the ability to get admitting privileges.

 

[specepic]

I'm happy to see that you added that clarification there at the end, because it's been my experience that the process used by many "real boarded pain docs" to figure out the 10% (or 1% or whatever) is to do 3 epidurals, see what happens, then do facets on one side, see what happens, then do the other side, see what happens, and down the line.

Obviously, this doesn't include all pain docs, and my example only applies to spine and you guys do more than that. But if you're honest, you'll agree that what I described above happens all the time and looks a lot more like guesswork than knowing what others don't know.

I would be curious if the block shops you describe are actual boarded pain docs who are ACGME fellowship trained. Send me links via PM to a couple of those groups. I would liek to vett their cred's. Most of the "BC" pain docs in my state have pseudo-BC, not ABMS BC

 

[lobelsteve]

I would be curious if the block shops you describe are actual boarded pain docs who are ACGME fellowship trained. Send me links via PM to a couple of those groups. I would liek to vett their cred's. Most of the "BC" pain docs in my state have pseudo-BC, not ABMS BC

I'd offer the majority of practicing pain docs are ACGME cert but not fellowship trained.

And given the current quality of fellowship, I'm unsure it adds anything more than 365 days listening to some idiot babble about the golden age of series of 3.

Patients don't know, referring docs dont care. Pain specialty is dying, not growing.

 

[specepic]

I'd offer the majority of practicing pain docs are ACGME cert but not fellowship trained.

And given the current quality of fellowship, I'm unsure it adds anything more than 365 days listening to some idiot babble about the golden age of series of 3.

Patients don't know, referring docs dont care. Pain specialty is dying, not growing.

Do you mean ACGME residency or ABMS boarded who grandfathered in before fellowship required? We both know fellowship is important and valuable, though may some may need refining. Take a Savella, go for a run, and/ or get l*id and then check back....

 

[lobelsteve]

Do you mean ACGME residency or ABMS boarded who grandfathered in before fellowship required? We both know fellowship is important and valuable, though may some may need refining. Take a Savella, go for a run, and/ or get l*id and then check back....

I mean the grumpy old men first and foremost.

Then idiot's like me training people second.

 

[deleted6669]

Can this PA admit his headache patients if they are truly refractory to the traditional treatments ?

For example: if the motivated headache patient has medication overuse headache complicated by opioid dependence this will not infrequently call for an inpatient admission for opioid detoxification. In this type of scenario, this is an extremely important management step.

I'm not sure if PAs have the ability to get admitting privileges.

I know the pa in question. he and his md partner have admitting privileges at several facilities. He knows all about dealing with medication overuse headaches. he coauthored one of the first journal articles on it while working with a doc who at the time was considered among the world's top experts in headache management, including inpatient tx.. he has done exclusively headache related practice for over 30 years.

 

[Poetic Silence]

The headache PA also authors a rather fascinating blog.

 

[Louisville04]

I know the pa in question. he and his md partner have admitting privileges at several facilities. He knows all about dealing with medication overuse headaches. he coauthored one of the first journal articles on it while working with a doc who at the time was considered among the world's top experts in headache management, including inpatient tx.. he has done exclusively headache related practice for over 30 years.

So does the PA "own his own headache practice", 50/50 partner with a physician, or is an employee? Does he need a physician collaborator? Does he pay more in malpractice than most PA's since is more independent?

I don't doubt his knowledge base for headaches if he has been doing it for over 30 years.

 

[deleted6669]

So does the PA "own his own headache practice", 50/50 partner with a physician, or is an employee? Does he need a physician collaborator? Does he pay more in malpractice than most PA's since is more independent?

I don't doubt his knowledge base for headaches if he has been doing it for over 30 years.

he owns the practice.
the doc is his employee and collaborator(as required by law). he pays his own malpractice(and the docs) at the specialty rate. he also pays the overhead on the facility, pays all the staff, etc. it's his practice.
he worked here for may years:
http://www.mhni.com/