NPs seeing patients primarily and telling the physician which procedure

[deleted993114]

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Has anyone heard of this model? A couple of newbies out of training took over my old practice and are panicking about the high overhead, as they are too slow to be able to crank out enough to pay the overhead (which is very high). Their "solution" is to have two NPs each who see patients, "read the films", examine them, and then determine what procedure (if any) is to be done and schedule said procedure with the physician, who does the ordered procedure.

Has anyone heard of this? It sounds insane to me, as I read all the films myself, look at the history/labs, ect, and examine the patients. I really don't think an NP has the training and thinks in the manner of differential diagnosis to be examining patients and determining the treatment of the patients. I thought that was the role of the physician. I would be terrified of such a "model", as one never knows if undiagnosed cervical stenosis (you would be surprised how few people check reflexes and check for Hoffman's sign) is lurking or another undiagnosed medical condition. I find weird things all the time which are medical disorders that certainly do not need a pain procedure.

Am I missing the boat on something here, or is this crazy?

 

[DOctorJay]

there is a private guy in my local area who has PAs/NPs see all patients for everything. he signs their notes and scripts, and does the procedures they recommend. this is not a good model (unless you want to hand the practice of pain management over to midlevels and destroy the field).

 

[drusso]

Has anyone heard of this model? A couple of newbies out of training took over my old practice and are panicking about the high overhead, as they are too slow to be able to crank out enough to pay the overhead (which is very high). Their "solution" is to have two NPs each who see patients, "read the films", examine them, and then determine what procedure (if any) is to be done and schedule said procedure with the physician, who does the ordered procedure.

Has anyone heard of this? It sounds insane to me, as I read all the films myself, look at the history/labs, ect, and examine the patients. I really don't think an NP has the training and thinks in the manner of differential diagnosis to be examining patients and determining the treatment of the patients. I thought that was the role of the physician. I would be terrified of such a "model", as one never knows if undiagnosed cervical stenosis (you would be surprised how few people check reflexes and check for Hoffman's sign) is lurking or another undiagnosed medical condition. I find weird things all the time which are medical disorders that certainly do not need a pain procedure.

Am I missing the boat on something here, or is this crazy?

 

[deleted993114]

View attachment 274622

Well this is a model initiated by the physician, not NPs themselves, in order to become "more efficient". I think it would do the opposite. I used by NPs for follow-ups, stable med patients, and return patients with identical symptoms.

One of my nurses actually said there is a local practice in my area that uses the same model. They are somewhat of a "mill" and not know for quality.

If physicians consider an NP to be not as well trained as a doc, why would they use them for the most important aspect of their practice- the exam and diagnosis? Perhaps such practices are creating the very problem that physicians decry- giving a less well trained practitioner more and more power and latitude.

 

[drusso]

Well this is a model initiated by the physician, not NPs themselves, in order to become "more efficient". I think it would do the opposite. I used by NPs for follow-ups, stable med patients, and return patients with identical symptoms.

One of my nurses actually said there is a local practice in my area that uses the same model. They are somewhat of a "mill" and not know for quality.

If physicians consider an NP to be not as well trained as a doc, why would they use them for the most important aspect of their practice- the exam and diagnosis? Perhaps such practices are creating the very problem that physicians decry- giving a less well trained practitioner more and more power and latitude.

I think people are emulating what they see the hospitals doing--using mid-levels to stretch capacity. There's a whole mid-level culture evolving before our eyes: "Ask the on-call ortho PA to consult the cardiology PA about a possible MI and if the patient needs the ICU, ask the ICU NP to come write the transfer orders..."

 

[pmrmd]

The extender model is practically the standard for the large groups in these parts. The extender does the E&M and “orders” the procedure and the doc is in fluoro all day. It’s tantamount to healthcare fraud.

 

[bronx43]

This is human incentive 101. Reimburse procedures highly and watch docs do procedures all day and not use their medical knowledge to diagnose and treatment. Literally opposite of what should happen.

 

[Ferrismonk]

As you said, its about the money, not patient care.

 

[deleted993114]

The extender model is practically the standard for the large groups in these parts. The extender does the E&M and “orders” the procedure and the doc is in fluoro all day. It’s tantamount to healthcare fraud.

So this is common? It is the first time I have ever heard of it and it sounded bizarre.

I guess I would be a little concerned from a malpractice perspective if the doc did not examine the patients, review the films, and then suggest treatment. What if the pt just needs PT, someNSAIDs and some TLC? Do they still get a procedure?

What do the referring docs say about this? Do they know? I think extenders are fine, but you use them for simple things, like refills and routine follow ups, lab checks, ect......

 

[Agast]

The obvious solution is to figure out why your overhead is so high. There are tons of private practice pain groups that do not resort to weird medical gymnastics to make it work. Probably paying too much in rent.

There is no other procedural specialty that feels the need to do this. Shots don't pay a lot but if you're doing 40+ a week it should more than cover the bills.

 

[Ducttape]

this "model" is often justified as having the physician focus to the highest degree of their training, and from a financial standpoint, this type of approach is most lucrative.

this isn't emulating hospitals. this is "the doc makes a lot more money if he just focuses on the procedures, lets hire someone who costs less to see people first"

pure financial grab. common in private practice block shops.

 

[Ligament]

So this is common? It is the first time I have ever heard of it and it sounded bizarre.

I guess I would be a little concerned from a malpractice perspective if the doc did not examine the patients, review the films, and then suggest treatment. What if the pt just needs PT, someNSAIDs and some TLC? Do they still get a procedure?

What do the referring docs say about this? Do they know? I think extenders are fine, but you use them for simple things, like refills and routine follow ups, lab checks, ect......

This has been common for the past 10 years at least. There was a group here in my state which at one point had one MD and 12+ midlevels. Then the group had around 8 physicians and 50+ midlevels or more amongst many clinics. He just did some of the procedures and pumps. He'd hire MA students from the local MA school to staff the clinics for free, basically. He was then charged with the opioid deaths of around 16 patients and even stlll did not loose his medical license, but of course not before banking millions upon millions. Every doctor in my area, many of whom are on SDN, had to deal with the fall out of thousands of opioid addicted patients calling our clinics after he was shut down. I believe the local university pain clinic is still overwhelmed with the opioid zombies roaming the streets he created. I cannot believe he was allowed to keep his medical license in any context.

https://www.heraldnet.com/news/settlement-restricts-practice-of-former-pain-clinic-director/

I would say over 50% of the pain practices in my area follow this model.

 

[drusso]

So this is common? It is the first time I have ever heard of it and it sounded bizarre.

I guess I would be a little concerned from a malpractice perspective if the doc did not examine the patients, review the films, and then suggest treatment. What if the pt just needs PT, someNSAIDs and some TLC? Do they still get a procedure?

What do the referring docs say about this? Do they know? I think extenders are fine, but you use them for simple things, like refills and routine follow ups, lab checks, ect......

Usually the Pain PA liaisons directly with the PCP’s or Surgeon’s PA about the plan. The doctors are out of the loop.

 

[NJPAIN]

I do some IME work. I see this ALL THE TIME when reviewing charts. Had to call a doc last week to discuss a peer review. This was at HIS request. When I asked him for some details on mechanism of injury, conservative treatment, etc he told me that he didn’t know any of the details because his only contact with patient was to perform the “ injection”. Everything else done by “ my PA”.

 

[drusso]

I do some IME work. I see this ALL THE TIME when reviewing charts. Had to call a doc last week to discuss a peer review. This was at HIS request. When I asked him for some details on mechanism of injury, conservative treatment, etc he told me that he didn’t know any of the details because his only contact with patient was to perform the “ injection”. Everything else done by “ my PA”.

The way for this to get better is for us to collectively shame the Douche-Bag Doctors that do this...

 

[deleted993114]

Usually the Pain PA liaisons directly with the PCP’s or Surgeon’s PA about the plan. The doctors are out of the loop.

This is very eye opening. Apparently I am completely out of the loop, as I have never heard of this until the NP told me the docs in my former practice are planning to work in this fashion.

Frankly, I think it would not be entertaining, as I like the work up and diagnosis more than doing the procedures. The procedures are just monkey work, as they are routine, and not as much variability as the work ups.

Oh well.......................... I learned something new today. Nothing I would want to do, but I am surprised it is so prevalent. I am a little surprised that referring physicians would sent their patients into a mill like that.

 

[pmrmd]

This is very eye opening. Apparently I am completely out of the loop, as I have never heard of this until the NP told me the docs in my former practice are planning to work in this fashion.

Frankly, I think it would not be entertaining, as I like the work up and diagnosis more than doing the procedures. The procedures are just monkey work, as they are routine, and not as much variability as the work ups.

Oh well.......................... I learned something new today. Nothing I would want to do, but I am surprised it is so prevalent. I am a little surprised that referring physicians would sent their patients into a mill like that.

In big, corporatist medicine no one cares. The doc works for some suit and gets a check for working 40 hours a week. Heck the doc may be replaced next week. The referral coordinator doesn’t care, just that the patient was given a disposition. The patient doesn’t care as long as the meds keep coming. Some are appalled and hear about outside experiences and transfer but most presume their experience is the norm. It’s sad really, but make no mistake part of this is rooted in Big Medicine.

 

[SommeRiver]

Yall are sitting here kicking this around about pain management, with ortho doing this for years...Midlevels scheduling joint replacements and pts only seeing the MD for the surgery. No preop or postop visits. This happens AT MY PRACTICE. I do not have a PA by choice; God knows I truly need one for follow ups and routine visits.

 

[Needlejockeys]

Yall are sitting here kicking this around about pain management, with ortho doing this for years...Midlevels scheduling joint replacements and pts only seeing the MD for the surgery. No preop or postop visits. This happens AT MY PRACTICE. I do not have a PA by choice; God knows I truly need one for follow ups and routine visits.

100% spot on. Only a matter of time before the pain apocalypse

 

[drusso]

100% spot on. Only a matter of time before the pain apocalypse

I'm imagining my elderly mother calling me and saying, "I saw the ortho NP and she signed up for a hip replacement." I think we'd be having a conversation about that.

 

[SommeRiver]

I'm imagining my elderly mother calling me and saying, "I saw the ortho NP and she signed up for a hip replacement."

This happens every day.

I had a pt who needed a TKR maybe Jan of this year. His back was doing well after an RFA and some PT, maybe an epidural, and I had been doing some visco for his knees. He said a certain knee guy in my practice had replaced a few knees in friends of his and he wanted to go ahead and get it done. I rarely send my knees to this guy bc I don't like him as a person, and I prefer another guy in my group.

I said something like, "Well...If you specifically want to see him I'll make it happen but I've gotten to know you pretty good and you'd probably do better with another guy in our group. Nothing against this surgeon's skills, but I don't think yall would jive as people."

I saw him again maybe 3 weeks ago and he says he has no idea what the surgeon looks like and he's never met him. He's had probably 5 visits with that guy's service not including surgery. Never had a face to face.

I sent the internal referral, he saw the PA within probably 2 weeks, had his TKR maybe 2 weeks after that, and he's been seen postop several times for persistent postop pain, and never met the MD. Knee is finally coming along and he's going to be fine, but pretty infuriating to me bc I get a copy of every MD's monthly numbers and their midlevels. I see what every person collects, bills, number of surgical cases, etc...That surgeon is a very, very wealthy individual who has two PA's scheduling beaucoup surgeries.

He also rarely sends me patients for some reason. He actually sends them out to another group believe it or not. Not sure why that is, but then again if you're dumping persistent post surgical pain on the referral sheet I'm fine not to see those pts bc genicular RFA doesn't reimburse and I hate doing them.

 

[Needlejockeys]

I'm imagining my elderly mother calling me and saying, "I saw the ortho NP and she signed up for a hip replacement." I think we'd be having a conversation about that.

I lived this last month. Couldnt believe it

 

[Aether2000]

The primary model for medicine is for NPs and PAs to perform the initial patient evaluation and determine a treatment plan. The physician has become subsidiary to this process and in effect is totally dependent on the least well trained to make the diagnosis. It happens in all specialties now, and is a symptom of the avarice of physicians coupled with the avarice of corporate medicine.

 

[BobBarker]

My NP is very nice but she does not
order very many procedures. Maybe after successful MBB she will order the RFA on follow up. She also still orders procedures in ways that don’t make sense, like the cpt for interlaminar cesi but the description “bilateral c7-t1”. It would be best to have a non interventional physiatrist. But no residency in my state, so not many around.

 

[drusso]

My NP is very nice but she does not
order very many procedures. Maybe after successful MBB she will order the RFA on follow up. She also still orders procedures in ways that don’t make sense, like the cpt for interlaminar cesi but the description “bilateral c7-t1”. It would be best to have a non interventional physiatrist. But no residency in my state, so not many around.

Occ med doctors are also good options. For a little more than a PA you can hire a less than full-time Occ Med Mommy-doc.

 

[SommeRiver]

My first nurse used to put "transformational ESI" on all TFESI orders. She would pop gum too. Jewelry clanging around...She lasted 3 months and forced me to fire her.

 

[Ferrismonk]

I'm imagining my elderly mother calling me and saying, "I saw the ortho NP and she signed up for a hip replacement." I think we'd be having a conversation about that.

Except she won't say she saw the "Ortho NP", she'll say "I saw Dr. X", not even knowing it's a DNP.

 

[Extralong]

My first nurse used to put "transformational ESI" on all TFESI orders. She would pop gum too. Jewelry clanging around...She lasted 3 months and forced me to fire her.

Hilarious!!

 

[Crybaby]

My NP is very nice but she does not
order very many procedures. Maybe after successful MBB she will order the RFA on follow up. She also still orders procedures in ways that don’t make sense, like the cpt for interlaminar cesi but the description “bilateral c7-t1”. It would be best to have a non interventional physiatrist. But no residency in my state, so not many around.

I have ortho surgeons that refer to me for B/L ILESI and will ask for multiple levels....... Also a new sports med guy that will ask for a 5 level cervical tfesi. So, that may not be solved.

 

[Ferrismonk]

To be fair, I've overhead orthopedic surgeons in the OR talk about their patient in the ICU who is "on the intubator".

 

[geauxg8rs]

To be fair, I've overhead orthopedic surgeons in the OR talk about their patient in the ICU who is "on the intubator".

I always thought it was incubated

 

[clubdeac]

Our group's NPs order bilateral TFESIs for everything, even if it's unilateral pain which I find out after reviewing the chart. The kicker however is that my hospital does not recognize the -50 modifier. Therefore I only get paid for a unilateral procedure. It's so messed up!

 

[lobelsteve]

Our group's NPs order bilateral TFESIs for everything, even if it's unilateral pain which I find out after reviewing the chart. The kicker however is that my hospital does not recognize the -50 modifier. Therefore I only get paid for a unilateral procedure. It's so messed up!

Then you are wrong for doing what is not necessary.

 

[SSdoc33]

Our group's NPs order bilateral TFESIs for everything, even if it's unilateral pain which I find out after reviewing the chart. The kicker however is that my hospital does not recognize the -50 modifier. Therefore I only get paid for a unilateral procedure. It's so messed up!

then you have to bill it as lt and rt. some indurances accept different ways of coding it. i GUARANTEE that you can get paid for both sides, although the hospital may only give you 50% of the first side. so, a 64483 + 64484 will pay you more than a 64483 x 2. you need to look into this. you/the hospital is leaving a lot of money on the table

 

[callmeanesthesia]

So, I’m getting busy enough that I’m thinking of adding a mid-level soon. How would you guys recommend incorporating them ethically? I don’t do opioid management so no routine med refills for them to see. My partner uses mid levels who see new patients and order procedures but he only does basic lumbar interventions (in high volume) and having done some procedures for his patients while he’s on vacation, they don’t always order the right thing.

 

[SSdoc33]

So, I’m getting busy enough that I’m thinking of adding a mid-level soon. How would you guys recommend incorporating them ethically? I don’t do opioid management so no routine med refills for them to see. My partner uses mid levels who see new patients and order procedures but he only does basic lumbar interventions (in high volume) and having done some procedures for his patients while he’s on vacation, they don’t always order the right thing.

have them see the injection f/u patients with a clear plan in place. it takes a good year or so to be confident in them not completely wasting your time and having to redo everything they have done/told the patient. most NPs/PAs get zero training in what we do, so the learning curve is steep. once they get the hand of your practice, then having them see new medicare/caid patients would be the next step, but be prepared to have them completely mismanage and order injections incorrectly.

i suppose letting them do knee, subacromial, GTB, TPIs, lateral epicondyle injections wouldnt be unreasonable.

also, you should try to find someone who will stay on for a while. you dont want to invest a year only to have them bolt right away.

maybe im a control freak, but i really couldnt figure out a way to make it work because i was routinely frustrated about their lack of knowledge and ability to make the correct decisions. i just felt like i was offering bad care

 

[Ducttape]

The best way that the system will not let you do is to have them shadow you for a year. Essentially a Pain fellowship guided by... you.

They don’t see any new patients. They see injection fu patients after a few months. Start with simple ones - ie routine fu after rfa, or fu after 2nd successful Mbb to set up RFA.

I don’t ever want new patients seen only by an NP - they should see them with you to start to see how you like to proceed and what initial treatments you like.

 

[clubdeac]

Then you are wrong for doing what is not necessary.

If it’s unilateral pain I’ll just do one side. Why would I do the other side when it’s not indicated and won’t reimburse

 

[drusso]

So, I’m getting busy enough that I’m thinking of adding a mid-level soon. How would you guys recommend incorporating them ethically? I don’t do opioid management so no routine med refills for them to see. My partner uses mid levels who see new patients and order procedures but he only does basic lumbar interventions (in high volume) and having done some procedures for his patients while he’s on vacation, they don’t always order the right thing.

You're going to see that there's a very wide spectrum of ability in mid-levels. Best one I ever had was a former Marine who was both a surgical tech and paramedic before going to PA school. He had mad skills. The worst was a NP who didn't know the three nerves in the hand...she didn't last long. Plan on regular didactics with them to orient them to specialty-specific topics. Remember they are there to make your life easier. I always have started with scribing visits so that they know my vocabulary and terminology. Teach them YOUR physical exam.

 

[clubdeac]

then you have to bill it as lt and rt. some indurances accept different ways of coding it. i GUARANTEE that you can get paid for both sides, although the hospital may only give you 50% of the first side. so, a 64483 + 64484 will pay you more than a 64483 x 2. you need to look into this. you/the hospital is leaving a lot of money on the table

I know the hospital’s collecting the 50% fee when I do bilaterals but they don’t pay me for it. I’ve looked into adding the Rt and Lt modifiers and from what I can tell they don’t directly affect reimbursement

 

[geauxg8rs]

The best way that the system will not let you do is to have them shadow you for a year. Essentially a Pain fellowship guided by... you.

They don’t see any new patients. They see injection fu patients after a few months. Start with simple ones - ie was routine fu after rfa, or fu after 2nd successful Mbb to set up RFA.

I don’t ever want new patients seen only by an NP - they should see them with you to start to see how you like to proceed and what initial treatments you like.

I would imagine midlevels could
Help with the endless paperwork, peer to peers, phone calls. Simple follow ups, gabapentin refills

 

[Paingas]

pure trash

 

[lobelsteve]

I would imagine midlevels could
Help with the endless paperwork, peer to peers, phone calls. Simple follow ups, gabapentin refills

MA can handle 99% of that.

 

[Cryc_to_the_point]

View attachment 274622

Ahhh... the patriarchy, or the imagination of feminists. I'm not sure which sums it up better .

 

[Paingas]

Ahhh... the patriarchy, or the imagination of feminists. I'm not sure which sums it up better .

bahahahahaah that is a joke.