midlevel referrals

[Gentle_Touch]

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There's a memo from the medical director of our group, regards to inapprioprate referrals made by midlevel practitioners (pa/np). The compliants were made by specialist physicians. i wonder if midlevels really incompetence, whatever, or just some kind of bashing from specialists because of their high status? I am sure these clinicians have the basic knowledge about referring patients out. I once work with an NP, a local urologist refused to patients from her. NP ended up sending the pts to a 50-miles away public university medical ctr, and the wait avg. over 3-month. I dont feel this should be happen in a community.

 

[Faebinder]

This problem will be more evident as more mid levels are added to primary care... Specialists dont want to see the common horses... they want the zebras.

What might look like a zebra for a mid level... can be a horse to a physician...

But there is another factor involved.... insurance. Mid levels are more likely to see uninsured patients than physicians.. So if you send the urologists 6 patients but they are all self pay or on medicaid.... well you can expect the urologist (who is doing well) to tell the mid-level no thanks. Heck they would do it if he/she was a physician as well refering 6 self-pay/medicaid.

 

[deleted6669]

"What might look like a zebra for a mid level... can be a horse to a physician..."

and vis versa....lots of specialty referals from primary care are now seen by specialty pa's....a primary care doc for example might send a strange rash to a derm pa who knows in 3 seconds that it is a classic case of xyz.....

people are good at what they do everyday, regardless of the initials after their names. I spend a lot of my day seeing pts in the e.d. sent in by pcp's for fairly simple stuff that I would assume any physician could see but apparently can't...stuff like finger dislocations, minor lacs and abscesses, fb in the nose, etc

 

[Faebinder]

"What might look like a zebra for a mid level... can be a horse to a physician..."

and vis versa....lots of specialty referals from primary care are now seen by specialty pa's....a primary care doc for example might send a strange rash to a derm pa who knows in 3 seconds that it is a classic case of xyz.....

people are good at what they do everyday, regardless of the initials after their names. I spend a lot of my day seeing pts in the e.d. sent in by pcp's for fairly simple stuff that I would assume any physician could see but apparently can't...stuff like finger dislocations, minor lacs and abscesses, fb in the nose, etc

Now you are defending mid levels for the sake of defending... we are comparing the opinion of a primary care physician to a primary care pa... not to a specialty pa in his specialty who is supposed to pick up the common horses for a specialty physician (or even some zebras). If you get a referal that looks like a horse to you... feel free to refuse to take the referal... would be funny in my opinion....

It's all about the money whether you like it or not.... if the refered patients were valid patients that the specialists could use for reimburisement because they need procedure X Y or Z, then I am sure the specialist would be very happy with the refering primary care mid level....

 

[core0]

There's a memo from the medical director of our group, regards to inapprioprate referrals made by midlevel practitioners (pa/np). The compliants were made by specialist physicians. i wonder if midlevels really incompetence, whatever, or just some kind of bashing from specialists because of their high status? I am sure these clinicians have the basic knowledge about referring patients out. I once work with an NP, a local urologist refused to patients from her. NP ended up sending the pts to a 50-miles away public university medical ctr, and the wait avg. over 3-month. I dont feel this should be happen in a community.

If you are in a multispecialty group that is a problem. We don't have them around here, but one of our physicians who worked in one hated it. The other specialists didn't want to work hard and only wanted to see "rare cases". On the other hand if you have specialist physicians that are not in your group making complaints about your referrals then you have an easy choice, refer to someone else. As a specialist PA I would never complain about a referral from a primary care provider even if I thought it was inappropriate. As a specialist you have two "customers" the referring physician and the patient. You have to keep them both happy. If that means staying late and overbooking for one of their patients thats what you do. Even if you see them committing some horrible misdiagnosis you don't criticize. That gets out very quickly.

Either the specialists need to give specific examples of the problems to the medical director and then the medical director needs to see if this is a real problem (and isn't happening with the physicians). Basically put up or shut up.

Ask you medical director who you should refer to if the specialists don't want the business. Here is a similar problem. One of the local hospitals would not take an order for a radiology exam from a NPP. The upshot was all my radiology studies went to my supervising physician with obvious delays. My response was to move all my studies somewhere else. Within a few weeks the radiology supervisor called to find out why we were doing so few studies. I replied that it was a simple matter of patient safety. If I could not count on getting the study in a timely manner, then I would not do business with them. I do not allow other peoples inability to follow directions to impact my patient care or liability. I showed them several examples of where this had delayed patient care and explained that since in several cases they had put my orders under my SP's name they were probably committing medicare fraud since they did not have a valid order. I explained that until their policy changed they didn't get my business. Sure enough the policy changed a few days later.

If you are referring to someone they should appreciate it. If they don't find someone else.

David Carpenter, PA-C

 

[deleted6669]

"Now you are defending mid levels for the sake of defending... "

and you are bashing midlevels for the sake of bashing.....

your post implies that the primary care pa would not only miss something simple but they would be stupid enough to refer on to a specialist without consulting with their supervising physician who is generally in the same building while the pt is being seen.....

"If you get a referal that looks like a horse to you... feel free to refuse to take the referal... would be funny in my opinion...."

I can't refuse pts, I work in the e.d., remember?

 

[deleted6669]

If you are referring to someone they should appreciate it. If they don't find someone else.

David Carpenter, PA-C

agree- I know of a few pa unfriendly docs and I don't send them ANY pts....

 

[Gentle_Touch]

thanks all, I really getting excellent replies. This is a large HMO/IPA medical group consists of 250+ independent providers, from PCP to specialists. It also could have been the group is capitation from various health plans. Specialists trying to bursh-off non-urgent patients, and blaming on the midlevels would be easier. However, on the primary care side, agreed, to ruled-out suspect Dx or assurance from a specialist etc. a referral need to made. core0, I agreed too, not too many people know that np/pa has upin that must indicating on their orders not the SP. This is why HIPAA requires one simple NPI coming soon to your billing paper, regardless private, or government payors.

 

[Faebinder]

"Now you are defending mid levels for the sake of defending... "

and you are bashing midlevels for the sake of bashing.....

your post implies that the primary care pa would not only miss something simple but they would be stupid enough to refer on to a specialist without consulting with their supervising physician who is generally in the same building while the pt is being seen.....

"If you get a referal that looks like a horse to you... feel free to refuse to take the referal... would be funny in my opinion...."

I can't refuse pts, I work in the e.d., remember?

You are seeing fire in my replies where there is none.... Not all primary care mid levels are supervised the way you see it. Many setups around the country are set to have the mid level simply consult the physician on special cases... Sometime the physician only needs to check their charts occasionally... so it's up to the mid level to refer. And don't put words in my mouth claiming that i said anyone is stupid just because they jump to referring... everyone has field limits.

 

[deleted6669]

fair enough- I agree that everone has limits, regardless of the initials after their names

 

[Beau Geste]

If I am understanding the op correctly, I think this is an issue more regarding reimbursement than who refers.

Issue 1: Do insurance (or other 3rd party) companies pay the same regardless of who does the referring?

Issue 2: Is the referral necessary or redundant?

For Issue 1, unfortunately there is a very large discrepancy in reimbursement depending on what payor source you have. Public aid typically pays the least, and if the midlevels were referring lots of PA pts., the specialists can defer. He/she has the right to run a business as much as anyone else.

For Issue 2, maybe this is the stem of the memo. If the specialists are getting a lot of redundant or inappropriate referrals mostly from NPs or PAs, rather than primary care docs, then maybe the NPs and PAs in that particular practice are over-referring. It happens a lot, and not only in medicine. I have over-zealous county health departments that refer at least 2-3 kids a week for speech evals because some 2-year-old doesn't have 400 words yet. If they were speech-language trained, they'd know that wasn't the norm (and still don't listen despite the inservices I've given!).

The OP is referring (by using italics) that the specialists were being elitist in their memo, but there is probably a LOT more going on and not a conspiracy against the mid-levels in the practice.

 

[core0]

If I am understanding the op correctly, I think this is an issue more regarding reimbursement than who refers.

Issue 1: Do insurance (or other 3rd party) companies pay the same regardless of who does the referring?

Insurance pays the same no matter who refers.

Issue 2: Is the referral necessary or redundant?

Not sure. Even in specialty care I practice more defensive medicine than my SP's. They are responsible for their own actions where I have my own actions to worry about and the other maxim which is don't set up the physician for failure.

For Issue 1, unfortunately there is a very large discrepancy in reimbursement depending on what payor source you have. Public aid typically pays the least, and if the midlevels were referring lots of PA pts., the specialists can defer. He/she has the right to run a business as much as anyone else.

For Issue 2, maybe this is the stem of the memo. If the specialists are getting a lot of redundant or inappropriate referrals mostly from NPs or PAs, rather than primary care docs, then maybe the NPs and PAs in that particular practice are over-referring. It happens a lot, and not only in medicine. I have over-zealous county health departments that refer at least 2-3 kids a week for speech evals because some 2-year-old doesn't have 400 words yet. If they were speech-language trained, they'd know that wasn't the norm (and still don't listen despite the inservices I've given!).

The OP is referring (by using italics) that the specialists were being elitist in their memo, but there is probably a LOT more going on and not a conspiracy against the mid-levels in the practice.

If this is a large HMO (actually 250 + isn't that big) then its probably a case where certain specialties are feeling overworked and lashing out at the NPP's since they would never consider criticizing their fellow physicians . I would ask the medical director to review all referals to the complaining physicians from both NPP's and physicians. See if there is any difference. See what the referral load is really like. I will say that this is unlikely to happen.

David Carpenter, PA-C

 

[megsMS]

I had a patient who was changing his PCP to an actual physician b/c the NP he had been seeing had referred him to a chronic pain clinic for his gout (which flared up approximately every 6 months). This is a perfect example of an inappropriate referral. Gout is definitely not a "zebra" but I agree that many mundane medical problems look like zebras to NPs. BTW, the NP had been in practice for something like 20 years.

There's a memo from the medical director of our group, regards to inapprioprate referrals made by midlevel practitioners (pa/np). The compliants were made by specialist physicians. i wonder if midlevels really incompetence, whatever, or just some kind of bashing from specialists because of their high status? I am sure these clinicians have the basic knowledge about referring patients out. I once work with an NP, a local urologist refused to patients from her. NP ended up sending the pts to a 50-miles away public university medical ctr, and the wait avg. over 3-month. I dont feel this should be happen in a community.

 

[Gentle_Touch]

The memo is DIRECTLY to mid level practitioners advised to check with their Phyisician before sending pt out. It could also be incentives, providers do get more money by the end of the year depends what left on the pot, beside their fee-for-service charges.

However, this different case involving a NP serves in a surburb area no HMO just fee-for-service pts (owns her own office) and rare local specialist like nephrologist and urologist refusing to take patients from her. Probably she is not a physician and doesnt have privileges to the local hospital. The NP and her employees (pa/np) either trying to be buddies with other family doctor to refer/admit pts. I can understand about the hospital admission, but not the refusal of the referral. Certainly, not a repeat but something similar. Another personal experience, by work part-time with an ophthalmologist, this ophth's not in a hurried to send a consultation report back to a mid level vs a physician.

 

[Beau Geste]

If this is a large HMO (actually 250 + isn't that big) then its probably a case where certain specialties are feeling overworked and lashing out at the NPP's since they would never consider criticizing their fellow physicians . I would ask the medical director to review all referals to the complaining physicians from both NPP's and physicians. See if there is any difference. See what the referral load is really like. I will say that this is unlikely to happen.

David Carpenter, PA-C

Your response about insurance is interesting. My experience in the therapy field is inconsistent reimbursement across insurance companies. I'm a preferred provider with BC/BS, but at any given time I also have other companies like HUmana, Aetna, etc. to bill too.

Say I bill $150/hr, sometimes I get paid that amount, sometimes (well usually) I get less than that, but it's never consistent from company to company. But then again, Speech-Language Pathology is the bastard child of therapy - insurance companies hate to pay us because they deem us "unnecessary".

So I based that response on my own experience.

 

[guetzow]

I think both explanations for that situation are good. 'Zebra' and 'people are good at what they do everyday, regardless of the initials after their names'. Perhaps there was some bias, and perhaps the referring mid-level thought he/she saw a zebra. In either case, the specialist should stop whining and be happy for the business. I do that, and the money is a-flowin'......








Or.......Hire a PA to take care of the overflow 🙂

 

[primadonna22274]

I think there is a learning curve for PAs and NPs in when to refer, and to whom. (Probably such a learning curve exists for new FPs and internists as well, although the internists to a lesser degree.)
In my first year of (PA) practice, I embarrassed myself tremendously by referring a 50-something lady to uro for stress urinary incontinence s/p vag hyst/bladder suspension (I don't remember the exact procedure). The surgery had been done 8 mos prior by one of our clinic GYNs (a very good surgeon too). Why didn't I send her back to the GYN? Because the patient was mad at her and wanted to see someone else. So she went to see the uro who called the GYN and said, "gee, you should talk to your PA about sending your own patients back to you"...thankfully the GYN was very didactic about it and I learned my lesson. So the patient was mad at her--the GYN should have had the opportunity to talk it out with the patient and see what could be done.
I think in a perfect system, the PA or NP has a supervising physician who knows more than the PA/NP so when there's an issue of knowledge, the PA can refer TO the SP, and then the SP can refer on if s/he can't handle it. This is just not always the case, or the SP is already overloaded and wants to hand it off anyway, so the PA/NP learns quickly to skip that step. And then you end up with unhappy consultants.
My last job was actually a very nice multispecialty mix--FP, IM, peds, gen surg--and I had 14 people with different skill sets to bounce ideas around with, and certain people I could refer to within the group for particular problems. We didn't have to send every complicated diabetic to endo because we had a very skilled internist who loved the stuff (not to mention endo was a 30-minute drive away and for some of these people that might as well have been across the state). Some of the internists would send me their GYN stuff because they didn't do GYN anymore, and it all worked out well. God, I miss that job....
I'm in EM now where there is definitely a wide range of talent between attending docs. When I'm with a good one, I feel very comfortable in my practice. When not-so-good, it's a very frustrating shift to get through with a scatterbrained easily flustered doc who gets defensive at every question. Sheesh.
Um, back to the original question....

 

[guetzow]

"Why didn't I send her back to the GYN? Because the patient was mad at her and wanted to see someone else".

Actually, You did the right thing!!... Medicine is a business now, and many docs have not caught on to that concept yet. If one of my patients wants a different neuro referral (I work in Ortho), for whatever reason (Even if they have been worked up before, and their might be another component to their sx), we give it to them . My SP agrees with this approach 100% (Give the patient what they want). Because he looks at the business end (Patient as Customer), we have a thriving practice. As long as you document your medical advice (The standard of care, of course), and that the patient understands what you are recommending, they are free to go and act like a five-year-old once they leave the clinic. The days of you must do this, and you must do that are longgggggg gone in medicine. It is what it is, denial will only hurt your bottom line...


Now EM is a Captive Audience, so it seems you don't have do deal with that at this point in your career😉

 

[primadonna22274]

What happened to my post? 😡 It was a good one!

 

[primadonna22274]

Well, G, not quite, because: this was a multispecialty group practice and the GYN got my notes since we worked in the same practice (granted, a 40-doc plus practice, but eventually....) AND the referring uro called her (the GYN) about it. Politically, I did the absolute WRONG thing.
Patient care wise, I think you're right that my heart was in the right place to send her somewhere else, but this was a very closed community where everybody talks to everybody else. The only way to have sidestepped this issue would be to send her out of town and I was a relatively new PA who hadn't figured out all the subtleties yet.
Damn, I hate politics in medicine.
L.

"Why didn't I send her back to the GYN? Because the patient was mad at her and wanted to see someone else".

Actually, You did the right thing!!... Medicine is a business now, and many docs have not caught on to that concept yet. If one of my patients wants a different neuro referral (I work in Ortho), for whatever reason (Even if they have been worked up before, and their might be another component to their sx), we give it to them . My SP agrees with this approach 100% (Give the patient what they want). Because he looks at the business end (Patient as Customer), we have a thriving practice. As long as you document your medical advice (The standard of care, of course), and that the patient understands what you are recommending, they are free to go and act like a five-year-old once they leave the clinic. The days of you must do this, and you must do that are longgggggg gone in medicine. It is what it is, denial will only hurt your bottom line...


Now EM is a Captive Audience, so it seems you don't have do deal with that at this point in your career😉

 

[corpsmanUP]

Primary care docs make "inappropriate" referrals also. But what this comes down to as many have eluded is that the capitated specialist is getting bi$ch slapped by the who capitated model, and just wants to reduce the workload likely.

I used to work as a primary care PA in a place that had little capitation, and the best gifts I ever received came from the specialist physicians I sent patients to. Never once did I get told that I was sending patients indiscriminantly. In fact, looking back, some of my referrals were probably unnecessary and still I ended up with a bottle of wine at Christmas time from these specialists.

Capitation is the antichrist!!!! It encourages physicians to shave a little off the care they dish out because it affects their bonuses at the end of a quarter or year.

 

[guetzow]

Working in specialty clinic, I get to decapitate others😀 As far as the multispecialty thing goes, it sounds like a battle of egos (The patient vs the Docs); BADDDDD Business model. Shame on all of them. Good thing you moved to EM.

 

[lloydchristmas]

I rarely get these problems and never because it's unnecessary. I've referred out people who it could've easily been argued as overkill and it ended up saving their lives. (future response coverage: "But how many did you inappropriately refer out to find the one that needed it? None. I'd rather have their heart stressed/cathed to know it's clear. Have I referred out clear hearts? Absolutely. And those patients were just as happy as the sick ones.)

If a NP/PA has trouble with a specialist, then that specialist is busy enough to be a picky arrogant prick. Just ignore them and move on. Or, as in the case of the urologist, write a letter to the board of healing arts and newspaper explaining the patient suffering that is going on all because he won't play with kids that look different. I guarantee that if a few more urologists moved in he'd change his tone in a hurry.

 

[guetzow]

I rarely get these problems and never because it's unnecessary. I've referred out people who it could've easily been argued as overkill and it ended up saving their lives. (future response coverage: "But how many did you inappropriately refer out to find the one that needed it? None. I'd rather have their heart stressed/cathed to know it's clear. Have I referred out clear hearts? Absolutely. And those patients were just as happy as the sick ones.)

If a NP/PA has trouble with a specialist, then that specialist is busy enough to be a picky arrogant prick. Just ignore them and move on. Or, as in the case of the urologist, write a letter to the board of healing arts and newspaper explaining the patient suffering that is going on all because he won't play with kids that look different. I guarantee that if a few more urologists moved in he'd change his tone in a hurry.

Exaaaaactly. Sound similar to my earlier comment ("the specialist should stop whining and be happy for the business".)

 

[lloydchristmas]

Exaaaaactly. Sound similar to my earlier comment ("the specialist should stop whining and be happy for the business".)

Yes, you and I are on the same page. Some specialists are lucky enough to be able to be arrogant piss ants and not have an empty clinic and therefore pocketbook.