NMBE sells out the medical profession to the nurses

[fab4fan]

Are they allowed to do everything all by their onesies? They shouldn't be, they don't have the training.

To whom do they go running when they f*ck up? They're nurses, for the love of god, and I never ever thought I'd say this, but it's about f*cking time to put midlevels- NP, PA, CRNA, whatever- back in the middle.

While we're at it, get rid of all this MA, CNA, NA, Certified office assistant BS too. You need a competent office coordinator for the paperwork and and in practice, a PA to do what you tell her to- if she's trained, I have no problem letting a PA do wound check. An RTC visit. But practising on her own, hell no. Liability is one thing, being an idiot is another.

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[nonesuchgirl]

$$$

IDK what this means!!!

 

[Doublecortin]

Sigh, you people are forgetting what the people is demanding and wanting: cheap primary care access. That is why the pharmacy clinics have done well because they provide a needed, wanted service, i.e. cheap urgent care during the weekends and evenings. MDs have already shot themselves in the foot in terms of primary care. Only a third of current doctors are practicing in primary care (IM, FM, Peds). A good managed care program likes to keep people from seeing specialists at all costs. People go to specialists even when they are not needed. In Europe, PCPs make up 2/3s of the MD population.
This trend of decreasing doctor utilization is here to stay. It will be up to you MDs to decide what you want to do about it. Your clout in state legislatures/Congress is not what it used to be. We might see the emergence of the third class of drugs or FDA might cleverly classify them as a subset of OTCs. We might see NPs/PAs/DNPs become the dominant player in Primary Care. We might see independent pharmacist prescribing authority. The list goes on and on.

Jesus, dude, you just keep on stocking the flames and provoking current med students and residents!

 

[fab4fan]

IDK what this means!!!

Sorry. Sometimes I think other people know what my abbreviations mean. (Gee...I should have gone to med. school! j/k)

Meaning, do you want to foot the bill to staff your office with only PAs or licensed nurses? If you can do it, that's great, but most doctors can't. Otherwise, you're going to have to give the shots, draw the blood, etc., etc. yourself, which may not sound like much, but that's going to slow you down, then you won't be able to see as many pts.

Like it or not, most medical offices can't function without medical assistants. A good medical assistant can make an office run efficiently and keep patients happy. A bad one? Bad news for everyone.

 

[oldManDO2009]

Ugh, you just Godwined our argument

first time I heard of this law -

Godwin's Law /prov./ [Usenet] "As a Usenet discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches one." There is a tradition in many groups that, once this occurs, that thread is over, and whoever mentioned the Nazis has automatically lost whatever argument was in progress. Godwin's Law thus practically guarantees the existence of an upper bound on thread length in those groups.


So there are nursing students completing their clinical's and it is VERY different than your average medical student experience.

Nursing students are focusing on technical skills such as passing meds (5 Rights for the nurses out there), documenting patient care, coordinating with other services and providing excellent care I might add. I am impressed with these young (yes I said young) people. They have a good grasp of basic path/physio.

My day; writing a note on my 100th + COPD patient and making sure I covered standards of care for AECOPD (O2, antibiotics, cultures, nebulizer TX, CXR, etc) . Running common organism through my head because I will be pimped in the next 5 minutes on this little fact. Also reviewing antibiotics for empirical TX of AECOPD. Checking labs and reviewing pt history to determine why their K+ is 2.9 and ordering replacement (with my resident), and my attending reminding me that we do not write notes for the sake of note writing but to document assessment and plan of care. This may seem over simplified but my first few notes described the patients condition (lungs, GI, cardio, etc) but lacked assessment and plan which I felt unprepared to develop until I saw 100's of COPDers and looked up the physiology, standards of care and diagnostic criteria. None of my encounter with this patient involved many technical skills.

My long winded point is that we come to the patient from different perspectives, training, and responsibilities. Sometimes AECOPD turns out to be a pleural effusion that is exudative and the differential changes significantly. The responsibility of a physician is to diagnose the patient. A NP sees SBP>160 and thinks HTN sees a Hba1c > 7% and thicks DM. I develop a wide differential and then begin to cross off the possibilities as I prove them wrong - this is the major difference between a MD/DO and a NP/DNP

anyway, test or no test DNP will not approach medicine the same way as MD/DO because they lack the TRAINING and painful clinical servitude....

 

[nonesuchgirl]

Sorry. Sometimes I think other people know what my abbreviations mean. (Gee...I should have gone to med. school! j/k)

Meaning, do you want to foot the bill to staff your office with only PAs or licensed nurses? If you can do it, that's great, but most doctors can't. Otherwise, you're going to have to give the shots, draw the blood, etc., etc. yourself, which may not sound like much, but that's going to slow you down, then you won't be able to see as many pts.

Like it or not, most medical offices can't function without medical assistants. A good medical assistant can make an office run efficiently and keep patients happy. A bad one? Bad news for everyone.

Ok. Gotcha.

The first MA I ever met was the worst one ever invented.

I have no problem with some sort of checkin/blood-draw/vacc person, but I don't think we need 78 different kinds. So, yay assistants, boo lots of pointless ones. One more thing to overhaul, I guess.

 

[zenman]

Sigh, you people are forgetting what the people is demanding and wanting: cheap primary care access. That is why the pharmacy clinics have done well because they provide a needed, wanted service, i.e. cheap urgent care during the weekends and evenings. MDs have already shot themselves in the foot in terms of primary care. Only a third of current doctors are practicing in primary care (IM, FM, Peds). A good managed care program likes to keep people from seeing specialists at all costs. People go to specialists even when they are not needed. In Europe, PCPs make up 2/3s of the MD population.
This trend of decreasing doctor utilization is here to stay. It will be up to you MDs to decide what you want to do about it. Your clout in state legislatures/Congress is not what it used to be. We might see the emergence of the third class of drugs or FDA might cleverly classify them as a subset of OTCs. We might see NPs/PAs/DNPs become the dominant player in Primary Care. We might see independent pharmacist prescribing authority. The list goes on and on.

This is why docs are losing. They tout their superior, top-of-the heap knowledge but do not listen to what their customers want. From a business perspective, docs are frankly, nuttier than sh**. Look at all the people using CAM and all docs do is whine. You guys really have no clue...

 

[oldManDO2009]

about time zenman pipe in...

genisis09 -look cheap has nothing to do with primary care because the cost is covered by insurance unless you are wanting free? and this idea that you imply that pharmacist should have independent prescribing authority is another play on what is traditionally MD/DO turf - a pharmacist is not qualified by virtue of their training to prescribe for disease management. now if you want a recommendation for one of the bazzillion cold remedies then that is within the scope of your training. This is another group trying to down play the importance of what a physician does - it look easy I can do that mentality is dangerous and should be prevented with laws that protect patients from inadequately trained professionals that want to play doctor.

as for zenman - your experience alone should allow you to play doctor I mean how does a PCP function without your helping them diagnose everything?

Zenman has a long history on studentDOCTOR and he will spout his top of the heap superior knowledge any moment now

Hey Z I know what patients want - a well trained physician who provides healthcare not your chicken sacrificing, chanting, goat skin chapped drumming

Are you allowed back in the USA yet??

 

[fab4fan]

My plan had been to work toward NP, but if this is where the profession is headed, I don't know if I can handle it.

I have no intention of being solo--ever. Guess I should have looked into PA but they're aren't many programs around here, I'm not in a position to relocate and most important, you don't see them used like you do NPs.

I guess it may be back to the drawing board.

 

[oldManDO2009]

My plan had been to work toward NP, but if this is where the profession is headed, I don't know if I can handle it.

I have no intention of being solo--ever. Guess I should have looked into PA but they're aren't many programs around here, I'm not in a position to relocate and most important, you don't see them used like you do NPs.

I guess it may be back to the drawing board.

I think if you hook up with a good doctor then you can have a great working environment and a much needed and respected position. I have worked with some good NP's that work for different practices and they do a great job but have the physician as a back up in case things go south. So throw out the drawing board - it will take years to get this DNP thing main streamed by then I don't think you will care (you probably have as many years in healthcare as I do...)

The contention is with the few that are out to practice independently and play doctor when they are clearly not qualified to do so...

 

[fab4fan]

I think if you hook up with a good doctor then you can have a great working environment and a much needed and respected position. I have worked with some good NP's that work for different practices and they do a great job but have the physician as a back up in case things go south. So throw out the drawing board - it will take years to get this DNP thing main streamed by then I don't think you will care (you probably have as many years in healthcare as I do...)

The contention is with the few that are out to practice independently and play doctor when they are clearly not qualified to do so...

I hope I don't have too many years. I'm 45. I for one do not intend to die with my boots on, be they OR boots or any other boots for that matter.

Thanks for the advice. That was my plan all along, but reading here made it sound like no one wanted to do that, so I started getting a little fretful.

 

[zenman]

about time zenman pipe in...

as for zenman - your experience alone should allow you to play doctor I mean how does a PCP function without your helping them diagnose everything?

Zenman has a long history on studentDOCTOR and he will spout his top of the heap superior knowledge any moment now

Hey Z I know what patients want - a well trained physician who provides healthcare not your chicken sacrificing, chanting, goat skin chapped drumming

Are you allowed back in the USA yet??

Don't start a personal attack now unless you have no valid arguments left. I've been here only a year longer than you...

I don't have your knowledge base in medicine, nor do I want it. What I do have is some knowledge of business and marketing...which is why I wonder why physicians (some) are wondering down the wrong road. What I do have is an ability so see all sides of the picture, something you might want to develop. Especially since Dr. Oz is on Oprah touting CAM and you're here on SDN. Who's gonna win here, lol!

The PCP I work with is a fresh one, which is why she knows little.

 

[oldManDO2009]

just having some fun....,

I have a master in healthcare administration and understand the business implications and still could careless about CAM Dr. Oz is about his personal money and not healthcare.....

 

[zenman]

just having some fun....,

I have a master in healthcare administration and understand the business implications and still could careless about CAM Dr. Oz is about his personal money and not healthcare.....

My MBA trumps (no pun intended) your niche MHA as hospitals and healthcare are years behind any successful business practice...and we see the results don't we?

 

[genesis09]

I'm just telling you about trends which are happening in health care. Pharmacists already have limited independent prescribing authority in a couple states, and dependent in many more. Long term goal is to require more information on prescriptions. In hospitals, pharmacists already do a lot of the prescribing. So many times do you see prescription per pharmacy. This is already happening. At the UIC clinics, doctors will sign blank prescription pads and hand them to the pharmacists, and tell them to fill it out with what they believe is best for the patient.
Insurance can make it in people's interest to see a NP/PA first. Look at prescription drugs, the copay for generics is always cheaper than for the brand. Insurance cares about costs. Doctors visits are one of the biggest pieces of the pie. If you can cut that down, you'll save a lot of money.
We have always been told to justify your existance. I can bring out any number of studies showing active pharmacist involvement will decrease the numbers of ADRs, etc. Primary care physicians will have to show that their extra costs are worth it to the insurance company.

 

[Miami_med]

I'm just telling you about trends which are happening in health care. Pharmacists already have limited independent prescribing authority in a couple states, and dependent in many more. Long term goal is to require more information on prescriptions. In hospitals, pharmacists already do a lot of the prescribing. So many times do you see prescription per pharmacy. This is already happening. At the UIC clinics, doctors will sign blank prescription pads and hand them to the pharmacists, and tell them to fill it out with what they believe is best for the patient.
Insurance can make it in people's interest to see a NP/PA first. Look at prescription drugs, the copay for generics is always cheaper than for the brand. Insurance cares about costs. Doctors visits are one of the biggest pieces of the pie. If you can cut that down, you'll save a lot of money.
We have always been told to justify your existance. I can bring out any number of studies showing active pharmacist involvement will decrease the numbers of ADRs, etc. Primary care physicians will have to show that their extra costs are worth it to the insurance company.

Ah, but this is where's you're touting a common misconception, doctor's visits are a relatively SMALL portion of the pie. All doctor pay, including in hospital pay is ~20% of the entire pie.

P.S. Stopping ADRs and knowing which drug to prescribe are NOT equal.

 

[oldManDO2009]

I'm just telling you about trends which are happening in health care. Pharmacists already have limited independent prescribing authority in a couple states, and dependent in many more. Long term goal is to require more information on prescriptions. In hospitals, pharmacists already do a lot of the prescribing. So many times do you see prescription per pharmacy. This is already happening. At the UIC clinics, doctors will sign blank prescription pads and hand them to the pharmacists, and tell them to fill it out with what they believe is best for the patient.
Insurance can make it in people's interest to see a NP/PA first. Look at prescription drugs, the copay for generics is always cheaper than for the brand. Insurance cares about costs. Doctors visits are one of the biggest pieces of the pie. If you can cut that down, you'll save a lot of money.
We have always been told to justify your existance. I can bring out any number of studies showing active pharmacist involvement will decrease the numbers of ADRs, etc. Primary care physicians will have to show that their extra costs are worth it to the insurance company.

I would NEVER hand a blank signed prescription to anyone. It is a prescription for disaster. You signature means you are responsible for the drug. The argument "I can't be responsible someone else filled out my signed prescriptions" will not cut it in court. The doctor is an idiot that would do that. As for independent prescribing authority - will you as a pharmacist review xrays, labs and examine the patient to ensure the right drug is being prescribed our will you be another high blood pressure means anti-hypertensive med, next?

Active pharmacist involvement does reduce complications associated with medications - does not mean your are qualified to prescribe. Again, back to the OP implication that mid-levels and other professionals invasion of traditionally medical responsibilities...

 

[Faebinder]

I know one resident that used to be the CHIEF of the service. Whenever an attending would want to leave for a vacation, he would ask him for some blank signed scripts for the patients he would need to discharge. He would use some of the scripts and the rest he would fill and sell or use (unsure which).

You can't trust anyone you dont know very well with blank scripts and even then think twice. And if I can't trust my fellow physicians with a script, there is no way in hell I will trust a pharmacist with one.

 

[Doublecortin]

I'm just telling you about trends which are happening in health care. Pharmacists already have limited independent prescribing authority in a couple states, and dependent in many more. Long term goal is to require more information on prescriptions. In hospitals, pharmacists already do a lot of the prescribing. So many times do you see prescription per pharmacy. This is already happening. At the UIC clinics, doctors will sign blank prescription pads and hand them to the pharmacists, and tell them to fill it out with what they believe is best for the patient.
Insurance can make it in people's interest to see a NP/PA first. Look at prescription drugs, the copay for generics is always cheaper than for the brand. Insurance cares about costs. Doctors visits are one of the biggest pieces of the pie. If you can cut that down, you'll save a lot of money.
We have always been told to justify your existance. I can bring out any number of studies showing active pharmacist involvement will decrease the numbers of ADRs, etc. Primary care physicians will have to show that their extra costs are worth it to the insurance company.

are you freakin' serious? Who's going to be responsible(sued) if the pharmacist "prescribes" the wrong medication for the patient? Ouch!

 

[tantrum]

People should be careful and observe REAL practices. I've had staff members forge my signature because of drug addiction. Pill addiction is VERY COMMON and this will make you liable especially after issuing SIGNED prescription pads.

 

[genesis09]

are you freakin' serious? Who's going to be responsible(sued) if the pharmacist "prescribes" the wrong medication for the patient? Ouch!

A good number of the drugs prescribed either in the hospital or in the clinics are prescribed by the pharmacists.
Anyway, Illinois just approved dependent prescribing for pharmacists, and so, once the rules are settled, they will have their own pads.
I also knew a MD who did the same with their NP before they were granted dependent prescribing privileges.
You must understand, MDs do regularly discuss drug therapies with pharmacists. In a regular out-patient pharmacy, you do run across some bad prescriptions. So, you call the prescriber, and almost always they will automatically accept your recommendation.
There actually is a lot of uncertainty about liability about dispensed prescription drugs. Slowly, more liability is being transferred from prescriber to pharmacist. This is an entirely different issue and discussion.

 

[core0]

A good number of the drugs prescribed either in the hospital or in the clinics are prescribed by the pharmacists.
Anyway, Illinois just approved dependent prescribing for pharmacists, and so, once the rules are settled, they will have their own pads.
I also knew a MD who did the same with their NP before they were granted dependent prescribing privileges.
You must understand, MDs do regularly discuss drug therapies with pharmacists. In a regular out-patient pharmacy, you do run across some bad prescriptions. So, you call the prescriber, and almost always they will automatically accept your recommendation.
There actually is a lot of uncertainty about liability about dispensed prescription drugs. Slowly, more liability is being transferred from prescriber to pharmacist. This is an entirely different issue and discussion.

I've always believed that leaving written evidence that you are comitting a crime is a bad idea. If the state health department ever comes and checks your clinic one of the first things they usually do is open a few drawers looking for signed scrip pads (N= 1 state).

David Carpenter, PA-C

 

[Doublecortin]

A good number of the drugs prescribed either in the hospital or in the clinics are prescribed by the pharmacists.
Anyway, Illinois just approved dependent prescribing for pharmacists, and so, once the rules are settled, they will have their own pads.
I also knew a MD who did the same with their NP before they were granted dependent prescribing privileges.
You must understand, MDs do regularly discuss drug therapies with pharmacists. In a regular out-patient pharmacy, you do run across some bad prescriptions. So, you call the prescriber, and almost always they will automatically accept your recommendation.
There actually is a lot of uncertainty about liability about dispensed prescription drugs. Slowly, more liability is being transferred from prescriber to pharmacist. This is an entirely different issue and discussion.

good

 

[soeagerun2or]

A good number of the drugs prescribed either in the hospital or in the clinics are prescribed by the pharmacists.

Unfortunately in the ivory tower that is academic pharmacy, physicians are perceived as not knowing about drugs and pharmacists must protect their patients from these egocentric dolts.

In reality, however, pharmacists merely stand on their little platform behind a counter and hand out the pills they so dutifully counted out.

Many states have laws about Rx pads and the physician's license can be revoked for such practices as leaving pads where they can be stolen let alone pre-signing blank pads.

 

[oldManDO2009]

a little off topic but germane to the OP's point - that everyone wants a piece of the physicians responsibility...


Why would pharmacist want to prescribe medications and what medications would they prescribe in a hospital and clinic??? You have no clinical training let alone the ability to diagnose a disease???????

Now for consultation - I call the pharmacy if I have a question that is not handled by my epocrates drug guide. Typically some one off contradiction compatibility issue. Genesis09, I realize you are a student but what kind of crap are they spewing that makes you think a physician is not necessary to dispense a drug, and/or that a pharmacist should dispense medications?

just my opinion but it seems everyone does not feel they get enough respect and can only be respected if they do the job traditionally in the physician realm - "I also dispense medication..."

I tried to find a copy of the IL law you were referring to and if you mean "the morning after pill" I have no opinion - it would seem that you would be liable for adverse reaction due to a lack of physical exam and history. If you think your life is better being able to dispense a drug without a physician have at it and enjoy the liability exposure....

 

[Faebinder]

I have no idea why a pharmacist thinks they should adjust medications. So many times we use medications for off-label dosages, or special indications that the pharmacist might not be aware of. Some ABX have different dosages for the different bacteria and location being covered. Will the pharmacist know I am covering a skin wound even though i operated on the colon and instinct tells you its GI flora when it's not?

I would advise not to be too thrilled about being able to alter a prescription without knowing the mind of the prescriber.

 

[fab4fan]

I have no idea why a pharmacist thinks they should adjust medications. So many times we use medications for off-label dosages, or special indications that the pharmacist might not be aware of. Some ABX have different dosages for the different bacteria and location being covered. Will the pharmacist know I am covering a skin wound even though i operated on the colon and instinct tells you its GI flora when it's not?

LOL. Do you know what "SCIP protocols" are? Nurses are supposed to call surgeons if they don't order the "right abx for the right procedure" and tell them what to order. Cough, cough.

 

[Faebinder]

LOL. Do you know what "SCIP protocols" are? Nurses are supposed to call surgeons if they don't order the "right abx for the right procedure" and tell them what to order. Cough, cough.

Oh I would have a blast with that one... My attending would take it all the way to the CEO if he has to on that one. Don't muck with a surgeon's ABXs preop or postop unless you are the Sith Lord of Infectious Disease himself AND you were actually consulted..... and even then beware of vengeful angry surgeons.

 

[genesis09]

Legally, most physicians do not dispense medications. Dispensing medications means you are actually giving the physical drug to the patient.
Right now, IL pharmacists are in between practice acts, and I haven't checked which practice act they currently have posted.
I have never said physicians don't have the ability to prescribe medications, but that pharmacists are playing more of role
In hospitals, prescribing habits are controlled by the P&T committee than anyone else.
There is also a move by insurances to stop reimbursement of drugs for unapproved indications. You can easily look up standard off label indications.
What do you think they teach us in pharm school; to look at the pretty drug structure? We are taught how to pick the correct drug for the patient. I more than certainly know that antibiotics are active in different areas and different bacteria; be they gram neg, gram pos, etc.

 

[Coastie]

Screw steps 1 and 2? At this point I can't take you seriously anymore. You are just trying to rile us up, right?



Hilarious.

The AMA should get on this pronto. I would love to hear the nurses squeal when every CNA, EMT, and phlebotomist is trying to take the NCLEX to cure the nursing shortage. It is almost exactly what they are doing to us.

Call the AMA. They are VERY interested in hearing from med students and residents.

The sticky is on top of the general residency forum.

 

[fab4fan]

Oh I would have a blast with that one... My attending would take it all the way to the CEO if he has to on that one. Don't muck with a surgeon's ABXs preop or postop unless you are the Sith Lord of Infectious Disease himself AND you were actually consulted..... and even then beware of vengeful angry surgeons.

Yeah. Well, guess how many calls I've made so far...

ETA: In any case, SCIP trumps your CEO:

SCIP

I'd be willing to bet your OR follows the protocols. "If you only knew the power of the Dark Side"....Bwah!

 

[oldManDO2009]

genesis09 ...you need to finish school. Go to any FP office and doctors are giving patients drugs everyday. Though "big bad pharm" is not giving docs as many samples. As a physician I can label a medication and provide instructions to the patient - which is what you will do one day.

As for turf stomping DNP's time will tell if people want real doctors or nurse doctors. In the mean time give to an organization that will support physician practice rights and I don't know if the AMA is going to be that organization. Isn't there some group of motivated pre-med/med/resident/attending kinds out there that want to get militant and mid-evil on the ANA????

 

[genesis09]

I didn't say physicians don't dispense. The giving of samples is not true dispensing as in my state's definition of it because most physicians do not go through the true labeling process. Every time I've received a drug sample, it's not labeled, and sometimes, they think because I'm a pharmacy student, I can figure out my own directions. It's just a legal gray area. I actually went to a physician's office which didn't have drug samples, but when he moved to another practice, they have samples.

In terms of where Primary care practice is headed, you can't forget the 500 ton gorilla in the room, the payer-insurance. They want to save as much money as possible. In general, the cost to see a NP/PA is half of what it is to see a MD/DO. In their minds, you are going to have to prove you are worth double their cost. You have to show their care is so terrible, that they will spend more money in secondary procedures. The public will not be sympathetic to MDs protecting their turf. The people view MDs as well-paid. The MD-God complex won't help; it alienates many people in and out of health care.
The AMA does not have as much clout as it once had. The other health care professionals have been winning their battles over them in the past few years. In Illinois, during the past year, NPs were able to amend their practice act to allow them to prescribe C-2s, pharmacists got dependent prescribing authority and dropped the minimum age for pharmacist immunization to 13, and ODs got expanded prescriptive authority.
If it comes down to people choosing the AMA or the insurance company, they will pick the insurance. I see this all the time. They will do what their insurance company tells them is the cheapest option.

 

[primadonna22274]

Wrong. I don't know why there is such a misconception that it's cheaper to see a PA/NP. If I see a person with a sinus infection, the bill is the same as if the doctor sees/treats the patient. Now there is a decrease in REIMBURSEMENT from the third party payor; 85% of the physician's fee is usual (this follows Medicare reimbursement). However, we get around this by billing under the doctor's number if the doctor is present on-site (does not require the doctor to physically see the patient).
Now, lots of insurance companies slash the reimbursement so much for ALL providers that we're lucky to get half of what we bill, but the charge up front for PAs/NPs is not discounted.
The patient doesn't get a break on the copay or deductible. They don't pay "half". Administrators and employers get a break in terms of what it costs to employ us...usually half of what the physicians are paid. Honestly though where I work I'm sure the docs make 3 times what I make--at MINIMUM.
My FP group billed $137k last month for my services. I'm just floored by that number. I've been in primary care several years and the typical billing for me 4 days/week was around $33-36k/month. Granted we're in a practice that has tons of ancillary services--CT/MRI, US, nuclear medicine stress tests, xray, lab, the gamut, so these services artificially inflate the billed amounts because they charge the highest possible charge and take what they get paid. Unfortunately the collections suck as for that $137k they COLLECTED $31k which means my bonus is not so good. (I agree the failure of billing to collect what they bill is not my fault but there's not much I can do with that end.) This was the height of the worst flu season I've seen in eight years and there were many days I saw 48 people. I am still tired. I remember one Saturday that about killed me the front office staff told me they collected $1500 in COPAYS alone. Not kidding. You can bet I'm a bargain because they certainly didn't pay me a third of that for that shift.
Lisa PA-C

In general, the cost to see a NP/PA is half of what it is to see a MD/DO. In their minds, you are going to have to prove you are worth double their cost. .

 

[Faebinder]

The billing codes are the same for NP/PA/MD/DO. Heck I even hear chiropractors use our billing codes.

 

[oldManDO2009]

Wrong. I don't know why there is such a misconception that it's cheaper to see a PA/NP. If I see a person with a sinus infection, the bill is the same as if the doctor sees/treats the patient. Now there is a decrease in REIMBURSEMENT from the third party payor; 85% of the physician's fee is usual (this follows Medicare reimbursement). However, we get around this by billing under the doctor's number if the doctor is present on-site (does not require the doctor to physically see the patient).
Now, lots of insurance companies slash the reimbursement so much for ALL providers that we're lucky to get half of what we bill, but the charge up front for PAs/NPs is not discounted.
The patient doesn't get a break on the copay or deductible. They don't pay "half". Administrators and employers get a break in terms of what it costs to employ us...usually half of what the physicians are paid. Honestly though where I work I'm sure the docs make 3 times what I make--at MINIMUM.
My FP group billed $137k last month for my services. I'm just floored by that number. I've been in primary care several years and the typical billing for me 4 days/week was around $33-36k/month. Granted we're in a practice that has tons of ancillary services--CT/MRI, US, nuclear medicine stress tests, xray, lab, the gamut, so these services artificially inflate the billed amounts because they charge the highest possible charge and take what they get paid. Unfortunately the collections suck as for that $137k they COLLECTED $31k which means my bonus is not so good. (I agree the failure of billing to collect what they bill is not my fault but there's not much I can do with that end.) This was the height of the worst flu season I've seen in eight years and there were many days I saw 48 people. I am still tired. I remember one Saturday that about killed me the front office staff told me they collected $1500 in COPAYS alone. Not kidding. You can bet I'm a bargain because they certainly didn't pay me a third of that for that shift.
Lisa PA-C

Thanks Lisa,

such silly ignorance when it comes to this subject. Genesis just wants to validate his position. When pt's get misdiagnosed by Doctor Nurse and a few high profile cases hit the media - people will be inclined to chose a real doctor.

People think doctors are so over paid or "well paid" in genesis09's mind. But as you pointed out you may bill 137K good luck collecting it. I am on an ortho rotation and there are "cash" customers that the physician will never collect from. In the ER 20-40 % may be "cash" and so again free care....

Genesis09 - just state your position - you feel as a pharm student you should have more responsibility in the form of writing prescriptions and giving shots? If that makes you feel more important or give you the ability to say "oh we also write scripts" - ok. But as physicians we complete a physical exam, take a history, and then make a diagnosis prior to prescribing a medication. How do you plan to do that? Other than the morning after pill what in the heck would you prescribe. You have yet to state your position or list what kinds of medications you are talking about. IMHO - pharmacist are not qualified to diagnose and prescribe meds. The only health care professionals I can think about are MD/DO, dentist, PA's and reluctantly NP's - who have the training to diagnose and prescribe. Please reply if you think differently but list some specifics instead of people want cheap care yet Lisa pointed out they are shielded from the billing process....

Lisa you office soulnds like your local ER

 

[soonereng]

However, we get around this by billing under the doctor's number if the doctor is present on-site (does not require the doctor to physically see the patient).

Your billing practices aren't on super firm ground there. They're using the incident-to practice, but to really fall under the letter of the law, the physician must make the initial diagnosis and treatment plan which can be followed up by a midlevel at subsequent visits and a physician has to be in the clinic at the time (although not necessarily the physician who initially treated the pt and they don't even have to be in the same specialty).

I wouldn't worry too much about it because lots of practices do this, but I just wouldn't necessarily want to go through a Medicare audit. I don't know how it applies to private insurance though. Probably different for every carrier.

 

[genesis09]

The cash price to see my local MD for an office visit is about $130, assuming no complications. The cost to go to one of those clinics at a pharmacy is about $60. The average NP/PA makes in the high 5 figures. The average primary care MD makes about $150-$175k. The billing codes are standardized, but the base cash price is not. We all use the same codes for ease.
I've never said pharmacists are able to diagnose. I know a number of the basic diagnostic procedures, and understand the results from them. Pharmacists assume a diagnosis.
In case some of you didn't get it, I've been trying to play devil's advocate with you. You took a random list of trends, and made something of it. Do I want independent prescribing, no, I can't diagnose that much more than basic ailments. I do know when it is time for you to go beyond the OTC section and into a MD's care. I do believe we will probably see a third class of medications in the coming years. Drugs which have been discussed for such a class include albuterol inhaler, migraine medications, statins, birth control pills, erectile dysfunction medications, amongst others. The reason why I thought of that was first, I just read something about pharmacists prescribing in Canada and two, I had to go to some speech by the ASHP president, and he was talking about that. When provoked, I feel the need to support what I wrote.
I do believe there is a coming crisis in primary care. Someone is going to have to pick up the slack because there aren't enough primary care MD/DOs, and that is an issue of their own making.
I've heard horror stories about Medicare/Medicaid audits.
People with insurance, don't know the true cost of their healthcare, but their insurance does know the cost. They will do whatever they can to get people to the low cost option. A lot of insurances do not cover prescription PPIs without prior authorization, and so on. You need to sometimes think about this from another perspective, like a payer.
When an office is paid, the majority of the money goes to the MDs.

 

[fab4fan]

Yeah, think of the poor insurance companies. Those greedy doctors taking the bread out of the mouths of their shareholders.

Give me a break. I worked for a couple of years in Purgatory, I mean, pre-certification. It's all about making a bigger profit. If you want to think about health care in terms of business only, that's fine, but I couldn't stomach it.

 

[Miami_med]

The cash price to see my local MD for an office visit is about $130, assuming no complications. The cost to go to one of those clinics at a pharmacy is about $60. The average NP/PA makes in the high 5 figures. The average primary care MD makes about $150-$175k. The billing codes are standardized, but the base cash price is not. We all use the same codes for ease.
I've never said pharmacists are able to diagnose. I know a number of the basic diagnostic procedures, and understand the results from them. Pharmacists assume a diagnosis.
In case some of you didn't get it, I've been trying to play devil's advocate with you. You took a random list of trends, and made something of it. Do I want independent prescribing, no, I can't diagnose that much more than basic ailments. I do know when it is time for you to go beyond the OTC section and into a MD's care. I do believe we will probably see a third class of medications in the coming years. Drugs which have been discussed for such a class include albuterol inhaler, migraine medications, statins, birth control pills, erectile dysfunction medications, amongst others. The reason why I thought of that was first, I just read something about pharmacists prescribing in Canada and two, I had to go to some speech by the ASHP president, and he was talking about that. When provoked, I feel the need to support what I wrote.
I do believe there is a coming crisis in primary care. Someone is going to have to pick up the slack because there aren't enough primary care MD/DOs, and that is an issue of their own making.
I've heard horror stories about Medicare/Medicaid audits.
People with insurance, don't know the true cost of their healthcare, but their insurance does know the cost. They will do whatever they can to get people to the low cost option. A lot of insurances do not cover prescription PPIs without prior authorization, and so on. You need to sometimes think about this from another perspective, like a payer.
When an office is paid, the majority of the money goes to the MDs.

Um.... There was no shortage of PCPs until Medicare mucked up the reimbursement systems in the late 60s and 70s, and the shortage has slowly developed thereafter, with specialist billing at first skyrocketing and then everyone going down, so that the PCPs are now all underpaid. This has nothing to do with the MDs outside of the obvious ignorance of the originial generation that let Uncle Sam get involved in a major way in the first place.

Insurance companies largely follow Medicare, which is a bigger payer now than all of them combined.

PCP offices often have overhead that equal their own take from the office. They also collect a tiny fraction of what's billed. We may get to the point (as we're seeing now with the flurry of cash and concierge practices) where patients start to say "you know what, why am I paying $1k/month to be see an occasional nurse and have all of my procedures denied?"

 

[oldManDO2009]

you make an EXCELLENT point. "I can't diagnose that much more than basic ailments....Pharmacists assume a diagnosis" - you are not qualified to do even that and you could miss deadly conditions assuming a diagnosis.

So what this comes down to and I think many other groups see this the same way. Physician make to much or most of the money. Well, doctors spend 4 years in medical school and then 3 - 10 years finishing residencies and fellowships and are UNDERPAID. Yes I said it! While these young doctors are giving up jobs in corporate America and 401k contributions for medicine their counterparts are earning good salaries and saving for their retirement. An FP doctor makes 150k for 7 years of little or nothing in pay and has to pay back massive debt and has a great deal of responsibility.

You talk about cheap as if it was a good thing - do you want an under-trained person taking care of you and your family? No - but you want that specialist there to treat that heart disease or cancer but condemn doctors for making to much. So a specialist is okay but an FP should be replace by an under-trained DNP I just don't get it????

FP make valuable contributions to health care and you well understand this when you have to decide is this a serious medical problem and I need to see a doctor (REAL) or is this just a cold and a nurse doctor will do?? When a serious disease comes up and a family members life is now on the line was that choice worth it?


Someone will reply that doctors misdiagnose and miss diagnosis's - this may be the case but DNP's have not been trained nor will they with the current curriculum and I will not entrust my daughters life to an untried process. Will you?

 

[primadonna22274]

You're so right my office is like our local ER, except more of our patients pay their bills
I honestly don't think I could work in this office unless I had worked in the ED first. I worked in outpatient FP for six years prior to moving from Oregon to SC but it was really a very "insular" practice--no one got in the door without going through the triage nurse. And man, she was good. Where we are now my supervising doc has the idea that we see all comers--and it makes me very nervous sometimes. I've transported more than a few people out of our office and to the ED where they belong. And I'm not a newbie PA.
I also agree that the "incident to" billing is frequently misunderstood. Unfortunately I'm not privy to all the ins and outs of our billing department. I really do need to sit down with the billing ladies and see how it's done because I've heard far too many horror stories of PAs/NPs getting audited and getting slapped for improper billing practices that were done without their knowledge. I think in my setting it would be the clinic that got the fine but how do we know for sure?
I realize we're off on a few tangents here. Wasn't this thread about NBME offering a licensing exam for DNPs? I'm not necessarily pro-DNP (don't get me started on DPA, which doesn't exist...yet) but wouldn't it lend credibility to the DNP movement if the DNPs DID pass a USMLE-style exam? Remember the NBME helped us PAs develop PANCE thirty-odd years ago and the AMA is still involved in the credentialing process for PAs. We often point out that one of the strengths the PA profession has over NPs is that we have ONE credentialing body so you know what you get when you hire a PA-C.
L.

 

[core0]

snip
I realize we're off on a few tangents here. Wasn't this thread about NBME offering a licensing exam for DNPs? I'm not necessarily pro-DNP (don't get me started on DPA, which doesn't exist...yet) but wouldn't it lend credibility to the DNP movement if the DNPs DID pass a USMLE-style exam? Remember the NBME helped us PAs develop PANCE thirty-odd years ago and the AMA is still involved in the credentialing process for PAs. We often point out that one of the strengths the PA profession has over NPs is that we have ONE credentialing body so you know what you get when you hire a PA-C.
L.

This doesn't really answer the question. According to the article, the DNP is supposed to make up for the lack of primary care providers. Ideally the proper test would measure the knowledge necessary to practice primary care, which is primarily outpatient and split between acute minor illness and chronic conditions. Having never taken the step III I'll be happy to be corrected, but the residents describe it as primarily focused on inpatient medicine with very little testing on chronic conditions. Is this the true way to evaluate nurses who wish to practice "primary care". If you look at the board certifications, they are conducted in a manner similar to the PANCE and PANRE (PA certifications). A roadmap of the knowledge base for the specialty is mapped out. It is validated by practitioners in the field. Questions are written based on that road map and then again validated by people actually working in the field. This is the proper way to do a certification and the steps that the DNP are completely skipping.

The other issue is that while the step III is supposed to assess the physician for independent practice, in reality that is not the case. Information from this board seems to indicate that it is required for FMGs before they can apply for internship. So in this case, it would seem to be more a requirement for non-independent practice (ie internship). In addition there is no state that I am aware of that will allow a physician to get an unrestricted license with a degree and step III (not discussing COMLEX here). This tells me that the people that license physicians do not consider it a complete measure of physician independent practice.

On the other hand what are the chances that a bunch of academic NPs are able to pass a test that primarily measures inpatient medicine knowledge? Hopefully the NMBE will release the test results regardless of the outcome. Hopefully the results will be graded as they would be for physicians not some sort of "curve". The devil here is not only in the test but the details.

David Carpenter, PA-C

 

[zenman]

"Minnesota lawmakers should approve legislation to create the dental equivalent of a nurse practitioner to help address gaps in dental care access in underserved parts of the state, this editorial says. The position would allow the practitioner to fill cavities, pull teeth and administer medications." ...Star Tribune

 

[Mythos219]

"Minnesota lawmakers should approve legislation to create the dental equivalent of a nurse practitioner to help address gaps in dental care access in underserved parts of the state, this editorial says. The position would allow the practitioner to fill cavities, pull teeth and administer medications." ...Star Tribune

el oh el

 

[primadonna22274]

Few recent threads on this. See this one:
http://forums.studentdoctor.net/showthread.php?t=502094

"Minnesota lawmakers should approve legislation to create the dental equivalent of a nurse practitioner to help address gaps in dental care access in underserved parts of the state, this editorial says. The position would allow the practitioner to fill cavities, pull teeth and administer medications." ...Star Tribune

 

[Punchap]

I liked that DrNP curriculum the first time I saw it when it was called and MPH.

LOL

You are sooo right.

 

[Punchap]

Unfortunately, however, what is really being proposed here is a parallel pathway to achieving MD privileges (much like DO or foreign graduates).

Not cool. DOs are the equivalent to MDs.

 

[soeagerun2or]

Not cool. DOs are the equivalent to MDs.

I totally agree with you iff they pass Step I-III and are trained in an American allopathic medical residency. Otherwise they might as well be snake-oil salesmen.

 

[Punchap]

I totally agree with you iff they pass Step I-III and are trained in an American allopathic medical residency. Otherwise they might as well be snake-oil salesmen.

Ignorant.