NPs in the hospitalist group

[Red Beard]

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I was recently rotating in a mid-sized community hospital in the west, and got to talking to a woman on the hospitalist service. After a minute I noticed that hiding under the lapel of her long white coat was the title 'nurse practitioner', and asked her about that. She responded "yeah, its pretty uncommon out here [the west] but much more common back east. I did an acute care fellowship after my master's and thankfully the hospital was willing to give me a shot. We can do all the same things, and we are cheaper, so why wouldn't hospitals want to hire us?"

This is something I was unaware of. If you think about the number of hospitalists that are employed by hospitals rather than a private group contracting with a hospital, and the universal reality that hospitals will look to cut costs wherever possible, then...

Thoughts?

 

[Good Solutions]

Welcome to the future. The minimum standards to practice autonomous medicine have been lowered. It is now time for primary care physicians to be the first to make it know they are not to be equated with the new minimum. Opting out of the sytem and not taking insurance. Specialists may eventually need to do the same, too.

We will have a two tiered system based not just on government/universal health vs. private, we will also have mid-level vs. physician.

 

[DrJosephKim]

NP privileges vary in each state. In some states, NPs can work completely autonomously with no physician supervision. They have full prescription rights in such states and can open their own office/practice and work independently in an outpatient or inpatient setting.

 

[mig26x]

NP privileges vary in each state. In some states, NPs can work completely autonomously with no physician supervision. They have full prescription rights in such states and can open their own office/practice and work independently in an outpatient or inpatient setting.

pretty sad!!!

 

[Tigerz_Fan]

NP privileges vary in each state. In some states, NPs can work completely autonomously with no physician supervision. They have full prescription rights in such states and can open their own office/practice and work independently in an outpatient or inpatient setting.

I did not know this. Do they do a residency like we do?

 

[iatrosB]

I did not know this. Do they do a residency like we do?

😆


In a word...no.

 

[adam6]

Dr. Stephen Wachter (the "father of the hospitalist movement" who coined the term and is from USCF) gave a lecture during my residency and talked about mid-level practitioners and the hospitalist movement. He said that the hospitalist group sat down with their practice/group manager, crunched the numbers, and realized it was more economical to hire a few more physicians and let the mid-level practitioners go from their group -- and that's what they did.

 

[Red Beard]

A physician friend of mine is involved in hospital administration, recently attended a meeting discussing the concept of the 'medical home.' Apparently a number of bigwigs from various industry think-tanks were in attendance and the consensus vision was of out patient primary care being largely delivered by mid-levels with physician managers who would themselves have a small panel of more complicated patients. In addition, there was much talk about a similar model for inpatient care.

I suppose it makes sense in many ways, but I for one am not excited at the prospect of spending even half of my paid time managing other people.

 

[dragonfly99]

One of the hospitalist services at my teaching hospital (one of the nonteaching services) is staffed by an NP or two plus one medicine attending. This is supposed to be the service for patients with more routine complaints, etc. who do not have a personal physician. The sicker patients go to the teaching service. The NP's round on the patients and then along with the attending they formulate a plan...I think they write a lot of the notes, etc. but the attending is involved and probably cosigns the notes. I think it works all right.

 

[Taurus]

One of the hospitalist services at my teaching hospital (one of the nonteaching services) is staffed by an NP or two plus one medicine attending. This is supposed to be the service for patients with more routine complaints, etc. who do not have a personal physician. The sicker patients go to the teaching service. The NP's round on the patients and then along with the attending they formulate a plan...I think they write a lot of the notes, etc. but the attending is involved and probably cosigns the notes. I think it works all right.

Does anybody here think that a hospital would hire DNP with like 20 years of inpt experience as an attending? There will always be those who aren't happy playing second fiddle for their entire careers.

 

[BlackNDecker]

Does anybody here think that a hospital would hire DNP with like 20 years of inpt experience as an attending? There will always be those who aren't happy playing second fiddle for their entire careers.

More importanly, does anybody here think that a hospital would hire a DNP over a physician (regardless of experience) due to cost containment? The writing is on the wall...

Glad to see that many are now aware of the DNP movement. The AMA failed us by not raising awareness YEARS ago when the DNP curriculum was only a thought.

 

[BlackNDecker]

Taurus, the link you posted as "NP report" is sobering....

 

[Taurus]

Glad to see that many are now aware of the DNP movement. The AMA failed us by not raising awareness YEARS ago when the DNP curriculum was only a thought.

The AMA can't do anything about the development of the DNP.

We as physicians need to unite on this issue. Only physicians at the individual level can do something about it. Voice your displeasure by not hiring NP/DNP's. Hire PA's. That will send a clear and loud message to nursing.

 

[BlackNDecker]

I repeat, the AMA failed us by not raising awareness...and I would further argue that we as physicians are much more powerful collectively than we are individually. The scope of NP/DNP practice needs to be clearly defined on a national level...not just in your particular practice.

 

[Shah_Patel_PT]

One of the hospitalist services at my teaching hospital (one of the nonteaching services) is staffed by an NP or two plus one medicine attending. This is supposed to be the service for patients with more routine complaints, etc. who do not have a personal physician. The sicker patients go to the teaching service. The NP's round on the patients and then along with the attending they formulate a plan...I think they write a lot of the notes, etc. but the attending is involved and probably cosigns the notes. I think it works all right.

Cosigning notes are not required by attendings. They can do what they want...but when the patient crashes...of course they get help from the real docs...

 

[core0]

NP privileges vary in each state. In some states, NPs can work completely autonomously with no physician supervision. They have full prescription rights in such states and can open their own office/practice and work independently in an outpatient or inpatient setting.

Outpatient services are governed by state law. Inpatient services are governed by state law and hospital bylaws. I don't know any hospital that allows NPs (or PAs) to practice independently in the inpatient setting. There may be some small rural hospitals that allow this but its purely anectdotal. Every hospital I have ever worked in requires a sponsoring physician and the physician to sign off on any parts of inpatient practice. This is based on federal hospital regulations that require every patient in the hospital be under the care of a physician. Here is an overview of NP practice issues (medscape registration required):
http://www.medscape.com/viewarticle/531035_3

If you use NPPs for initial patient visit you will give up about 15% of reimbursement. Follow up E/M can be billed at either 85% if the NPP does all the work or 100% under shared visits. Depending on the practice it may be a reasonable tradeoff or not. Some hospitalist groups have all admissions done by the physician then have the NPP follow the patient. Some work up the patient in a team manner. Some do not differentiate between the physician and NPP allowing whomever is up next to take the next patient.

David Carpenter, PA-C

 

[core0]

Dr. Stephen Wachter (the "father of the hospitalist movement" who coined the term and is from USCF) gave a lecture during my residency and talked about mid-level practitioners and the hospitalist movement. He said that the hospitalist group sat down with their practice/group manager, crunched the numbers, and realized it was more economical to hire a few more physicians and let the mid-level practitioners go from their group -- and that's what they did.

With the growth of NPP salaries and the desire of more IM physicians to turn to hospital medicine I think this is more common. A lot of the time it comes down to call. If you are doing home call and the physicians are not comfortable with the NPPs taking home call then either the physicians are going to take a lot of call or it makes more sense to have an all physician practice.

The issue is that a lot of hospitals cannot find enough hospitalists to fully staff their groups. In this case either the physicians have to work more or you find someone else to do the work like NPPs. The other place that I see NPPs used more is when hospital groups are contracted to follow patients in an attached LTAC. You see a lot of NPPs here.

David Carpenter, PA-C