Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare

[AbnormalPsych]

Any of you who work in a medical setting hear about this at the virtual water cooler yet?:

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare|Paperback

Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare exposes a vast conspiracy of political maneuvering and corporate greed that has led to the replacement of qualified medical professionals by lesser trained practitioners. As corporations seek to...

www.barnesandnoble.com

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[WisNeuro]

No, but it's unsurprising. I always prefer to see a doc, but until I see methodologically sound evidence showing discrepancies in patient safety outcomes between the types of practitioners in certain settings, it's all just turf war nonsense.

 

[PsyDr]

As much as I hate it:

curricula are not empirically derived. They are historically derived. We have no idea the exact training needed to produce competent providers. Nor do know the operational definition of competence.

Except chiropractors. The founder said that he learned everything from the ghost of a physician named Dr. Jim Atkinson. Way to go, Iowa. Awesome contribution to the world.

 

[BuckeyeLove]

The founder said that he learned everything from the ghost of a physician named Dr. Jim Atkinson

Wasn't there something about a janitor too? Nothing against janitors...

 

[WisNeuro]

Wasn't there something about a janitor too? Nothing against janitors...

Something about curing a deaf janitor of his deafness through the "magic" of chiropractic care.

 

[cara susanna]

Ooh, interesting. I know that our local VA Primary Care has mostly NPs and PAs now.

Although I know that the data is out on actual outcomes on NPs/PAs vs. MDs, but I think there is definitely a story on how healthcare systems try to save money by hiring people with less advanced degrees in general. We've seen it with psychologists and Masters-level clinicians, after all.

 

[tr]

I used to think this was turf war nonsense (and can find my own posts on this site from a decade ago arguing this) but after some years of clinical interactions with NPs and learning more about what their training actually involves, I do think they are often being put in care settings for which their training is inadequate, putting patients at risk.

There are several papers (research effort driven by Mary Mundinger) that purport to show equivalent outcomes between NPs and MDs; the problem is that the chosen outcomes are invariably not where you would expect to find the differences. For example they will track NPs and MDs in primary care and see whether patients' blood pressure and hemoglobin A1C remain under good control in 6 months or whatever. Or sometimes they will measure outcomes in properly supervised settings, but then cite the results in support of putting NPs in unsupervised settings, which is a rampant and frightening practice.

The concern with NPs is not that they can't measure bp and adjust dosing, but that they may be missing warning signs of rarer conditions that could potentially lead to catastrophic outcomes. (You can find many such anecdotal reports of this all over this site.) This is something that's harder to define and measure.

 

[WisNeuro]

The concern with NPs is not that they can't measure bp and adjust dosing, but that they may be missing warning signs of rarer conditions that could potentially lead to catastrophic outcomes. (You can find many such anecdotal reports of this all over this site.) This is something that's harder to define and measure.

But, these things are also missed by physicians. We'd have to see a difference between the groups to justify anything. The problem with anecdotes is that we tend to remember the ones that support our views, and forget the ones that go against those views. It could very well be the case, but there is no compelling evidence to support that case yet.

 

[AcronymAllergy]

I used to think this was turf war nonsense (and can find my own posts on this site from a decade ago arguing this) but after some years of clinical interactions with NPs and learning more about what their training actually involves, I do think they are often being put in care settings for which their training is inadequate, putting patients at risk.

There are several papers (research effort driven by Mary Mundinger) that purport to show equivalent outcomes between NPs and MDs; the problem is that the chosen outcomes are invariably not where you would expect to find the differences. For example they will track NPs and MDs in primary care and see whether patients' blood pressure and hemoglobin A1C remain under good control in 6 months or whatever. Or sometimes they will measure outcomes in properly supervised settings, but then cite the results in support of putting NPs in unsupervised settings, which is a rampant and frightening practice.

The concern with NPs is not that they can't measure bp and adjust dosing, but that they may be missing warning signs of rarer conditions that could potentially lead to catastrophic outcomes. (You can find many such anecdotal reports of this all over this site.) This is something that's harder to define and measure.

Definitely difficult to measure and needing some large-N studies due to the potential rarity of events. But studying this on the medical sides seems at least potentially more feasible than the MH side, where the outcomes are probably even "softer"/more difficult to operationalize.

 

[mypointlesspov]

Wasn't there something about a janitor too? Nothing against janitors...

 

[R. Matey]

I wonder how these writers feel about prescribing psychologists....

 

[PsyDr]

@BuckeyeLove

William Lillard was the mostly- deaf janitor. Palmer claimed that he discovered chiropractic whatever by telling Lillard a joke, slapping him on the back, and that somehow restored Lillard's hearing. Because you tell jokes to deaf people....

@tr

I'd argue that the problem is diagnostics rather than treatment efficacy. Medicine has a very difficult job ahead of them. I don't think focusing on efficacy or even danger is the right approach for your profession. Which I am woefully unqualified to say.

 

[sfgucadoc]

I wonder how these writers feel about prescribing psychologists....

Undoubtedly they think we have even more cooties than NPs and PAs.

 

[tr]

Undoubtedly they think we have even more cooties than NPs and PAs.

Whoa. This is just not personal, and I think taking it personally really introduces all this rancor into a discussion where it doesn't belong.

Not having the training to be an independent practitioner in a given area is not a character flaw. I don't want to run an ICU because I wouldn't have the foggiest idea how to do it and I would 100% kill someone. Lord knows why an NP with 2/5 the amount of general medical (nonpsychiatric) training that I have would want to.

 

[futureapppsy2]

As much as I hate it:

curricula are not empirically derived. They are historically derived. We have no idea the exact training needed to produce competent providers. Nor do know the operational definition of competence.

Except chiropractors. The founder said that he learned everything from the ghost of a physician named Dr. Jim Atkinson. Way to go, Iowa. Awesome contribution to the world.

I'm legitimately curious as to if anyone has studied if pimping is truly the best way to learn clinical medicine, or if people just do it that way because that's how it's always been done.

 

[WisNeuro]

I'm legitimately curious as to if anyone has studied if pimping is truly the best way to learn clinical medicine, or if people just do it that way because that's how it's always been done.

My money is on the latter.

 

[medium rare]

I wonder how these writers feel about prescribing psychologists....

They are vehemently opposed and make the same patient safety concern allegations.

This debate is nothing new. There are bad NPs/PAs just like there are bad physicians and bad psychologists.

 

[tr]

I'm legitimately curious as to if anyone has studied if pimping is truly the best way to learn clinical medicine, or if people just do it that way because that's how it's always been done.

Haven't seen any kind of formal study but I'd guess it's one of the worst ways to learn clinical medicine (or anything for that matter). It just makes people anxious and afraid to reveal their thought processes for fear of public shaming, and that's not at all conducive to learning.

But it also constitutes a vanishingly small portion of the overall knowledge transfer that takes place in medical training.

 

[PsyDr]

Some might say that nerds, who got picked on, may end up picking on others once they are in positions of power. It's almost like there is a compulsion to repeat something... maybe we could get a name for it... like....repeaty compulsy.

 

[nexus73]

They are vehemently opposed and make the same patient safety concern allegations.

This debate is nothing new. There are bad NPs/PAs just like there are bad physicians and bad psychologists.

I think this is granting a false equivalency. While there are certainly good and bad physicians or nps or pas or psychologists, expecting this to be the same percentage across the board is an unfounded assumption. It makes more sense to assume that if there are "bad" providers of medical care, the degree program with the least amount of training would have a higher percentage amongst their ranks.

I just find it irrational to dismiss these arguments as turf battles, or rationalize that all fields have good and bad providers, so we shouldn't be critical of NPs or PAs, or prescribing psychologists. (and BTW, if psychologists want to prescribe meds why not just go through PA school?)

 

[PsyDr]

I think this is granting a false equivalency. While there are certainly good and bad physicians or nps or pas or psychologists, expecting this to be the same percentage across the board is an unfounded assumption. It makes more sense to assume that if there are "bad" providers of medical care, the degree program with the least amount of training would have a higher percentage amongst their ranks.

I just find it irrational to dismiss these arguments as turf battles, or rationalize that all fields have good and bad providers, so we shouldn't be critical of NPs or PAs, or prescribing psychologists. (and BTW, if psychologists want to prescribe meds why not just go through PA school?)

Been waiting 16 years for that flood of patients harmed by prescribing psychologists to start...

 

[WisNeuro]

Been waiting 16 years for that flood of patients harmed by prescribing psychologists to start...

I mean, there have only been millions of patient encounters in that time span. Such a small n, how could we possibly do research with such a small sample?

 

[Sanman]

It may or may not just be a turf war, but the idea that it matters anymore is a bit silly. The horse that is PA/NPs have already left the gate. So has prescribing psychology (albeit much more slowly). Even if they are worse, the question becomes worse compared to what? Physicians or no access to care? The AMA is very good at limiting med school and residency spots compared to psychology. You cannot restrict supply and simply not meet demand in healthcare. Other fields took advantage of physicians wanting to keep the high salary party going as long as possible. The studies on outcomes are bit unrealistic when it comes to the real world, IMO. It matters more by setting, specialty. years of experience, and patient volume. Would a physician seeing 24 patients in a day be better than an NP seeing 15 patients? Hell at my VA, the students certainly write the most comprehensive notes regardless of field. The staff and attendings get lazy, myself included. I am presently outsourcing all of my assessment work via VVC to interns because I find it a headache and they are motivated to get it done.

 

[AbnormalPsych]

Some might say that nerds, who got picked on, may end up picking on others once they are in positions of power. It's almost like there is a compulsion to repeat something... maybe we could get a name for it... like....repeaty compulsy.

New V code.

I am going to write it into my DSM-5 with crayon (I don't know why, but this feels appropriate).

 

[medium rare]

The horse that is PA/NPs have already left the gate. So has prescribing psychology (albeit much more slowly).

Agreed. That horse fled the barn a while ago and is not coming back.

I have been on the receiving end of the anti-RxP, anti-NP/PA arguments as both a clinical psychologist supportive of RxP (did my dissertation on the topic) and as a PMHNP. I’ve found if you do your due diligence, know your stuff and stay abreast of research, prioritize good continuing education, recognize your limits, continually strive for excellence in clinical practice, and value multidisciplinary collaboration, patients benefit.

Physicians will always play a vital role in healthcare but they are not healthcare - healthcare is substantially broader than medicine alone.

 

[clausewitz2]

I have been on the receiving end of the anti-RxP, anti-NP/PA arguments as both a clinical psychologist supportive of RxP (did my dissertation on the topic) and as a PMHNP. I’ve found if you do your due diligence, know your stuff and stay abreast of research, prioritize good continuing education, recognize your limits, continually strive for excellence in clinical practice, and value multidisciplinary collaboration, patients benefit.

There is a lot of truth in this. So much of being a solid clinician is about how much you are committed to the things you mention, and that's independent of degree. Doing that consistently requires a great deal of intrinsic motivation and dedication, because standard of care is so low out in the community that no one is going to force you to do those things. To the extent there is a gap between physicians and mid-levels I think it may have to do to the extent the training pathways select for people who tend to be driven to constantly be upping their game and relentlessly improving their practice. I think you are going to have a greater proportion of people who can be described this way emerging from a post-graduate training pathway that takes 8 years with periods of hellish workload than a training pathway that can take, like, 2 years post-graduate and in some cases is not...um...overly taxing in terms of required clinical exposure. So one would actually expect someone who did a clinical psychology degree and then became a PMHNP to pattern more with the physicians than NPs under this account.

If this is even a bit true it's going to complicate the empirical research comparing outcomes based on degree types, at least until we start operationalizing arete.

 

[WisNeuro]

If this is even a bit true it's going to complicate the empirical research comparing outcomes based on degree types, at least until we start operationalizing arete.

Took me a second to think of the other definition. I was wondering why you were using a climbing term. My climbing competition days had me primed,

 

[Sanman]

Took me a second to think of the other definition. I was wondering why you were using a climbing term. My climbing competition days had me primed,

It means fish bones in French, which I think lends to the most hilarious reading in context.

 

[clausewitz2]

Took me a second to think of the other definition. I was wondering why you were using a climbing term. My climbing competition days had me primed,

Foolish of me not to write it as ἀρετή

 

[manwelio]

I think this is granting a false equivalency. While there are certainly good and bad physicians or nps or pas or psychologists, expecting this to be the same percentage across the board is an unfounded assumption. It makes more sense to assume that if there are "bad" providers of medical care, the degree program with the least amount of training would have a higher percentage amongst their ranks.

I just find it irrational to dismiss these arguments as turf battles, or rationalize that all fields have good and bad providers, so we shouldn't be critical of NPs or PAs, or prescribing psychologists. (and BTW, if psychologists want to prescribe meds why not just go through PA school?)

Because PA school doesn't emphasize what a PhD in clinical psychology emphasizes, including research. It's not a mistake on the part of the provider that the educational institutions gatekeep their information instead of sharing and merging programs so practitioners can get what they need to be the best they can be.

You wouldn't tell someone who wants to work as a guidance counselor to become a teacher just because it'll get them in the room with students.

People who become clinical psychologists and work with scripting duties don't get into the job because they just want to write scripts all day. If the appeal is prescriptions, become a pharmacist.

Otherwise, there is value to being in charge of both therapeutic treatments and biochemical treatments that will help support the patient, especially if you work in private practice or in research.

 

[nexus73]

Because PA school doesn't emphasize what a PhD in clinical psychology emphasizes, including research. It's not a mistake on the part of the provider that the educational institutions gatekeep their information instead of sharing and merging programs so practitioners can get what they need to be the best they can be.

You wouldn't tell someone who wants to work as a guidance counselor to become a teacher just because it'll get them in the room with students.

People who become clinical psychologists and work with scripting duties don't get into the job because they just want to write scripts all day. If the appeal is prescriptions, become a pharmacist.

Otherwise, there is value to being in charge of both therapeutic treatments and biochemical treatments that will help support the patient, especially if you work in private practice or in research.

But a nights and weekends medical course over a year or two hardly seems adequate to grant authority of independent medical practice to psychologists (medication management, physical exam, laboratory assessments, awareness of non-psychiatric medical conditions and non psychiatric medications and how they contribute to complicate mental health conditions and the psychiatric medications being prescribed).

As a psychiatrist the branding of “med checks” or “med management” is frustrating as it makes the work sound very simple when it is not.

 

[nowaysanjose]

No, but it's unsurprising. I always prefer to see a doc, but until I see methodologically sound evidence showing discrepancies in patient safety outcomes between the types of practitioners in certain settings, it's all just turf war nonsense.

You cannot be serious. These people have less training than a dog groomer. The default is that they cannot do the job of a physician, not the other way around. All of the ‘studies’ they propagate to suggest otherwise are low power, flawed methodology, and frequently comparing physician-led NPs v physicians, so of course there would be little to no difference. Just wait until yourself and/or someone you know/love is hurt by these people. And yes, docs also make mistakes, and that’s the exact reason you wouldn’t want someone with less than 1/10th the training of a doctor to be making life or death decisions.

 

[WisNeuro]

You cannot be serious. These people have less training than a dog groomer. The default is that they cannot do the job of a physician, not the other way around. All of the ‘studies’ they propagate to suggest otherwise are low power, flawed methodology, and frequently comparing physician-led NPs v physicians, so of course there would be little to no difference. Just wait until yourself and/or someone you know/love is hurt by these people. And yes, docs also make mistakes, and that’s the exact reason you wouldn’t want someone with less than 1/10th the training of a doctor to be making life or death decisions.

Oh, I am very serious. If you want to provide evidence that they are not as efficacious, Do. The. Work. The data is there, methods are there. The AMA could spend less money doing a methodologically sound study, than they spend lobbying year after year in quixotic efforts. Perhaps there is a reason they choose not to go the way of data...

 

[nowaysanjose]

There is no evidence that suggests their “outcomes” are equal or superior to physicians. The VA compiled comparison studies and found all to have insufficient or low strength of evidence, and all with evidence of bias. You would never get a direct comparison between actual physicians and NPs through an IRB to begin with. Next time we need to refer for psychological testing, we’ll just send the patient to a middle school guidance counselor. Until you have methodologically sound evidence showing discrepancies in patient care, your opposition would just be turf war nonsense.

 

[WisNeuro]

The absence of evidence is not the evidence of absence. There was never an emprircally established standard of training. It's all just historical precedent. If you'd like to suggest otherwise, show me the data. If you are the one making an assertion, the burden of proof is on you.

As far as our own field, you can look back on my past posts. I fully admit that we also do not have the data to suggest we are superior to midlevels. As far as psychological testing, for the most part, that guidance counselor can't bill for most of it anyway, so I don't think you'll have too much luck there. And yes, as long as we don't have the data, it is a turf war. I'm at least honest about it.

 

[PikminOC]

Because PA school doesn't emphasize what a PhD in clinical psychology emphasizes, including research. It's not a mistake on the part of the provider that the educational institutions gatekeep their information instead of sharing and merging programs so practitioners can get what they need to be the best they can be.

You wouldn't tell someone who wants to work as a guidance counselor to become a teacher just because it'll get them in the room with students.

People who become clinical psychologists and work with scripting duties don't get into the job because they just want to write scripts all day. If the appeal is prescriptions, become a pharmacist.

Otherwise, there is value to being in charge of both therapeutic treatments and biochemical treatments that will help support the patient, especially if you work in private practice or in research.

Many of the rxp psychologist are just prescribing meds as they make much more money doing that

 

[PikminOC]

There is a lot of truth in this. So much of being a solid clinician is about how much you are committed to the things you mention, and that's independent of degree. Doing that consistently requires a great deal of intrinsic motivation and dedication, because standard of care is so low out in the community that no one is going to force you to do those things. To the extent there is a gap between physicians and mid-levels I think it may have to do to the extent the training pathways select for people who tend to be driven to constantly be upping their game and relentlessly improving their practice. I think you are going to have a greater proportion of people who can be described this way emerging from a post-graduate training pathway that takes 8 years with periods of hellish workload than a training pathway that can take, like, 2 years post-graduate and in some cases is not...um...overly taxing in terms of required clinical exposure. So one would actually expect someone who did a clinical psychology degree and then became a PMHNP to pattern more with the physicians than NPs under this account.

If this is even a bit true it's going to complicate the empirical research comparing outcomes based on degree types, at least until we start operationalizing arete.

Yes and intrinsic motivation gets Physicians thru difficult undergrad, mcat, med school, residency, three licensing exams and board certifications. That drive is strong with Physicians

 

[PsyDr]

Many of the rxp psychologist are just prescribing meds as they make much more money doing that

It pays a whole $24.05 more per hour than outpatient psychotherapy. You could make more by adding one group psychotherapy thing per week.

 

[PikminOC]

It pays a whole $24.05 more per hour than outpatient psychotherapy. You could make more by adding one group psychotherapy thing per week.

Here 50 minute therapy is between 100 to 150. Insurance reimbursement is less than that. Versus 4 med check. Please walk me through the numbers

 

[AcronymAllergy]

Relating to a prior point, in general, I do think it's generally incumbent upon the "newcomer" to demonstrate equivalence (or at least adequacy) relative to the existing standard, particularly in situations where there's a significant departure from that existing standard.

But I also think it's incumbent upon those in the existing standard to be perpetually evaluating their own (in this case training) methods to evaluate necessity, efficiency, efficacy, etc. Which certainly occurs, but perhaps not as much when there's an absence of an alternative.

 

[WisNeuro]

Relating to a prior point, in general, I do think it's generally incumbent upon the "newcomer" to demonstrate equivalence (or at least adequacy) relative to the existing standard, particularly in situations where there's a significant departure from that existing standard.

But I also think it's incumbent upon those in the existing standard to be perpetually evaluating their own (in this case training) methods to evaluate necessity, efficiency, efficacy, etc. Which certainly occurs, but perhaps not as much when there's an absence of an alternative.

In this situation, I wonder what that existing standard would be? What patient outcome data would be examined? Because, it seems that the proposed existing standard by the AMA would be education/training. Which is problematic as it is based on precedence rather than empiricism, and has not yoked itself to any meaningful patient outcome data from which a newcomer would demonstrate such equivalence.

 

[PsyDr]

Here 50 minute therapy is between 100 to 150. Insurance reimbursement is less than that. Versus 4 med check. Please walk me through the numbers

I. Looking at actual numbers from the past years, with some admittedly bad math, and some outdated CPT spreadsheets, because I'm doing other things and that's what I have in front of me:

a. CPT 99213= $50.52. Per descriptor, 99213 should usually last 15 minutes. I am assuming that transitioning from patient to patient takes at least 3 minutes. That makes 9 minutes of transition per hour, and 45 minutes of services. for a total of 54 minutes per hour. 3X$50.52= $151.56/hr. Yields approximately $1057.00 for a 7 hour day. Add in an hour of admin work, charting, phone calls, pre-auths, etc after the end for an 8 hr day. Never seen someone get paid for that stuff, but what do I know?

b. CPT 90837= $127.51. Statistically this is the most commonly used psychotherapy CPT code. Descriptor says length is between 52-60 minutes of service. I am assuming 3-8 minutes to transition between hourly patients is roughly equivalent to the transitions between 3 med checks.


c. $151.56- $127.05= $24.05/hr differential.

d. That same timeframe, I could perform neuropsych testing on one patient while having a technician testing another patient in a separate room. 7 units per day for each of us is approximately $1259.00/day. Less $20/hr to the tech who gets a paid lunch, yields approximately $1099.00 for the day. That practice structure gets you better hours, payment for a lot of admin work, has almost no malpractice risk, and almost zero call ever.

e. Comparing the finances of those, if you did 7hrs of rxp work, you'd make approximately $1060 gross (3 units of 99213 per hour, yields approximately $151.52/hr, X 7hrs is approximately $1,060.00.). In neuropsych, that same 7 hr day with one tech would yield approximately $1099 . Therefore it's about $40/day better to be a neuropsych .


II. Now, I know you're saying that you can work harder and see FOUR 99213s, or throw in the odd 99214. That's fair. Let's compare that to actually working hard in neuropsych.

a) 4 units of 99213 at $50.52 per unit= $202.08/hr. You'd likely need a scribe and/or staff to help, as the documentation requirements for 99213 include at least a few vitals and one mention of the MSK system. Let's say you cheap out, get some poor MA for $10/hr, and you never have to pee, and never eat, and you have no overhead. You work a 10hr day. That grosses approximately $2020.80 for the day, less $100.00 for the MA, leaving you about $1920.80, or $9604.00 for the week, or $460,992.00 for the year, assuming 48 weeks working per year ( 2 weeks vacation, one week sick time, one week CME time). Daaaaaaaaaaang, baller. Not bad for someone before overhead.

b) Let's compare that to having 3 neuropsych techs. I bring in 10 new patients on Monday, interview all of them, add in a brief neuro exam. I get $969.90 for that day. Techs each test a patient for 7 hours, which includes scoring after the patient is gone. Three tech can process 10 patients in about 3 days, with one or two of them taking over a slow patient on a 4th day. That takes care of Monday, Tuesday, Wednesday. They can be repurposed to do scheduling, or admin work, or marketing, or talk crap about me behind my back, and still have an hour lunch break. Their work yields approximately $1602 per day, or $8010 per week, less $2400/week for $20/hr at 8hrs/day , 5 days per week for their pay. "Net" is about $5610.00/week. Notice we haven't even talked about what I am doing after Monday? I have 10 new patients a week. Let's say I am a god, and can write reports in 3hrs. So that is 30hrs of report writing, which yields approximately $2908.00 per week , in addition to my work on Monday's, for a total of $3878.00 for my own work. Total is approximately $9480.00 per week, or $455,500 per year, after paying staff's hourly, but before other expenses including payroll and overhead. That makes Monday a 10hr day, and Tuesday-Friday 8hr days. Still not even really working hard.

c) Comparing those two practice areas: Revenue for working 10hr days in rxp yields approximately $460,992.00. Revenue for working 10hr days in neuropsych=$455,578. Approximate annual increase in gross income for rxp= $5,400.00 per year. Or about 1%.

d) If you're wise, you're gonna mention hiring a PA, or NP as a counter argument for why you can make a ton of money. That's not a bad argument, but it's not accurate. Psychologists don't really have extenders that can work independently like that. We can have techs administer stuff, but we have to see the patients, face to face, and we have to write everything.

 

[cara susanna]

@PsyDr - this is unrelated to the overall thread, but can I ask what code you would use to bill for a psychotherapy session that lasts fewer then 16 min? Like if the pt comes in and says "I'm fine, nothing to talk about today" or ends early for any other reason? Or would you not bill for that?

Not so much worried about finances as I'm in the VA, but I am trying to boost my RVUs.

 

[PikminOC]

I. Looking at actual numbers from the past years, with some admittedly bad math, and some outdated CPT spreadsheets, because I'm doing other things and that's what I have in front of me:

a. CPT 99213= $50.52. Per descriptor, 99213 should usually last 15 minutes. I am assuming that transitioning from patient to patient takes at least 3 minutes. That makes 9 minutes of transition per hour, and 45 minutes of services. for a total of 54 minutes per hour. 3X$50.52= $151.56/hr. Yields approximately $1057.00 for a 7 hour day. Add in an hour of admin work, charting, phone calls, pre-auths, etc after the end for an 8 hr day. Never seen someone get paid for that stuff, but what do I know?

b. CPT 90837= $127.51. Statistically this is the most commonly used psychotherapy CPT code. Descriptor says length is between 52-60 minutes of service. I am assuming 3-8 minutes to transition between hourly patients is roughly equivalent to the transitions between 3 med checks.


c. $151.56- $127.05= $24.05/hr differential.

d. That same timeframe, I could perform neuropsych testing on one patient while having a technician testing another patient in a separate room. 7 units per day for each of us is approximately $1259.00/day. Less $20/hr to the tech who gets a paid lunch, yields approximately $1099.00 for the day. That practice structure gets you better hours, payment for a lot of admin work, has almost no malpractice risk, and almost zero call ever.

e. Comparing the finances of those, if you did 7hrs of rxp work, you'd make approximately $1060 gross (3 units of 99213 per hour, yields approximately $151.52/hr, X 7hrs is approximately $1,060.00.). In neuropsych, that same 7 hr day with one tech would yield approximately $1099 . Therefore it's about $40/day better to be a neuropsych .


II. Now, I know you're saying that you can work harder and see FOUR 99213s, or throw in the odd 99214. That's fair. Let's compare that to actually working hard in neuropsych.

a) 4 units of 99213 at $50.52 per unit= $202.08/hr. You'd likely need a scribe and/or staff to help, as the documentation requirements for 99213 include at least a few vitals and one mention of the MSK system. Let's say you cheap out, get some poor MA for $10/hr, and you never have to pee, and never eat, and you have no overhead. You work a 10hr day. That grosses approximately $2020.80 for the day, less $100.00 for the MA, leaving you about $1920.80, or $9604.00 for the week, or $460,992.00 for the year, assuming 48 weeks working per year ( 2 weeks vacation, one week sick time, one week CME time). Daaaaaaaaaaang, baller. Not bad for someone before overhead.

b) Let's compare that to having 3 neuropsych techs. I bring in 10 new patients on Monday, interview all of them, add in a brief neuro exam. I get $969.90 for that day. Techs each test a patient for 7 hours, which includes scoring after the patient is gone. Three tech can process 10 patients in about 3 days, with one or two of them taking over a slow patient on a 4th day. That takes care of Monday, Tuesday, Wednesday. They can be repurposed to do scheduling, or admin work, or marketing, or talk crap about me behind my back, and still have an hour lunch break. Their work yields approximately $1602 per day, or $8010 per week, less $2400/week for $20/hr at 8hrs/day , 5 days per week for their pay. "Net" is about $5610.00/week. Notice we haven't even talked about what I am doing after Monday? I have 10 new patients a week. Let's say I am a god, and can write reports in 3hrs. So that is 30hrs of report writing, which yields approximately $2908.00 per week , in addition to my work on Monday's, for a total of $3878.00 for my own work. Total is approximately $9480.00 per week, or $455,500 per year, after paying staff's hourly, but before other expenses including payroll and overhead. That makes Monday a 10hr day, and Tuesday-Friday 8hr days. Still not even really working hard.

c) Comparing those two practice areas: Revenue for working 10hr days in rxp yields approximately $460,992.00. Revenue for working 10hr days in neuropsych=$455,578. Approximate annual increase in gross income for rxp= $5,400.00 per year. Or about 1%.

d) If you're wise, you're gonna mention hiring a PA, or NP as a counter argument for why you can make a ton of money. That's not a bad argument, but it's not accurate. Psychologists don't really have extenders that can work independently like that. We can have techs administer stuff, but we have to see the patients, face to face, and we have to write everything.

Youre comparing to neuropsych. Many therapist do not have neuropsych.

 

[nowaysanjose]

In this situation, I wonder what that existing standard would be? What patient outcome data would be examined? Because, it seems that the proposed existing standard by the AMA would be education/training. Which is problematic as it is based on precedence rather than empiricism, and has not yoked itself to any meaningful patient outcome data from which a newcomer would demonstrate such equivalence.

Can you define “outcome data”? Is a doc telling an NP to start metformin + glipizide and getting an a1c of 6.9 v a doc starting metformin and glyburide and getting an a1c of 7.1 evidence of anything at all? As said previously, a newcomer (NP) would never be able to demonstrate such equivalence, because a true comparison would literally be unethical as the training difference is so vast it would unequivocally lead to patient harm. If you opened a hospital ran entirely by NPs—that means everything, NP ER, surgical NP, rads and path NP, and compared “outcomes” to a physician-only hospital, do you really think patients would not suffer tremendously with the former? You guys don’t understand the difference in training because you’re not physicians. You don’t see NPs running services who don’t understand basic things that a first year Med student would. We see it every day. No one is out here reporting all the times they screw up. Malpractice hasn’t caught up yet from the myriad of laws and rules on who gets sued when s*** goes down. This entire thing is a joke.

 

[WisNeuro]

@PsyDr - this is unrelated to the overall thread, but can I ask what code you would use to bill for a psychotherapy session that lasts fewer then 16 min? Like if the pt comes in and says "I'm fine, nothing to talk about today" or ends early for any other reason? Or would you not bill for that?

Not so much worried about finances as I'm in the VA, but I am trying to boost my RVUs.

Look into 96152 for more brief things. We used these codes when on spinal cord units, H&B codes

 

[WisNeuro]

Can you define “outcome data”? Is a doc telling an NP to start metformin + glipizide and getting an a1c of 6.9 v a doc starting metformin and glyburide and getting an a1c of 7.1 evidence of anything at all? As said previously, a newcomer (NP) would never be able to demonstrate such equivalence, because a true comparison would literally be unethical as the training difference is so vast it would unequivocally lead to patient harm. If you opened a hospital ran entirely by NPs—that means everything, NP ER, surgical NP, rads and path NP, and compared “outcomes” to a physician-only hospital, do you really think patients would not suffer tremendously with the former? You guys don’t understand the difference in training because you’re not physicians. You don’t see NPs running services who don’t understand basic things that a first year Med student would. We see it every day. No one is out here reporting all the times they screw up. Malpractice hasn’t caught up yet from the myriad of laws and rules on who gets sued when s*** goes down. This entire thing is a joke.

If it "unequivocally led to patient harm" you would now have millions of examples of this harm. It's got to be out there, document it and compare it to MD/DO outcomes. Seriously, you have tens of millions, if not more, data points. I've been working more than a decade with MDs/DOs/NPs.PAs, and I have yet to see the sky fall Chicken Little.

 

[PsyDr]

Youre comparing to neuropsych. Many therapist do not have neuropsych.

I was literally comparing the most common psychotherapy CPT code with the most common E/M code.....

 

[WisNeuro]

I was literally comparing the most common psychotherapy CPT code with the most common E/M code.....

Redirect Notice

Edit- I'm a Luddite with gif pasting, but you get the picture

 

[Sanman]

Look into 96152 for more brief things. We used these codes when on spinal cord units, H&B codes

96152 is now replaced by 96158, which is a 30 min code. You should have the patient in the room for at least 15 min to bill it now, same as a 90832. For a sub 16 min interaction currently, I would opt for a telephone code. For a sub 16 min outpatient interaction in real life, discharge the patient.