Physicians acting as extenders

[Downbytheicu]

I am on my third year rotations and we typically have one PA student from a nearby school on the team with us. It's getting to be an interesting part of the year because these students are on the 7th of their 8 rotations, and will be graduating in March. Many of the students I have talked to have already signed contracts with a physician, and will have jobs immediately upon graduating. Several--many more than I expected--will be signing on with a dermatologist. One of these students signed a starting $150,000 contract.

Ok, here's the discussion question: Will there be a point in time where some of these family practitioners, and other primary care docs that are having to close their doors because of financial strain, sign up to be a physician extender, or act in that capacity, for higher-pay specialties? Is this even legal? Can an M.D. who is board certified in FP sign on and practice under the licence and specialty of a dermatologist, receive on the job training like a PA, and take the $150,000 with no liability? Does this sort of thing entice any attendings on this forum? If it is legal, would any attendings in a higher pay specialty be willing to take on a physician as an extender rather than a PA?

Thoughts?

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[facetguy]

Just to be clear at the outset, would $150,000 be an attractive offer to many family medicine physicians, or would this be a significant step backward financially?

And in what part of the country are you?

 

[physasst]

I am on my third year rotations and we typically have one PA student from a nearby school on the team with us. It's getting to be an interesting part of the year because these students are on the 7th of their 8 rotations, and will be graduating in March. Many of the students I have talked to have already signed contracts with a physician, and will have jobs immediately upon graduating. Several--many more than I expected--will be signing on with a dermatologist. One of these students signed a starting $150,000 contract.

Ok, here's the discussion question: Will there be a point in time where some of these family practitioners, and other primary care docs that are having to close their doors because of financial strain, sign up to be a physician extender, or act in that capacity, for higher-pay specialties? Is this even legal? Can an M.D. who is board certified in FP sign on and practice under the licence and specialty of a dermatologist, receive on the job training like a PA, and take the $150,000 with no liability? Does this sort of thing entice any attendings on this forum? If it is legal, would any attendings in a higher pay specialty be willing to take on a physician as an extender rather than a PA?

Thoughts?

An MD or DO, or any other provider outside of a graduate from an accredited PA school, is not eligible to take the NCCPA exam, or be licensed as a PA. It would illegal for them to represent themselves as a PA.

As far as workload...gimme a break. There will not be ANY shortage of jobs overall. There may be overloading in certain specialites and/or locales, but to state that a physician could not find a job, particularly rural primary care or general surgery is ludicrous.

Many of my recent projections show that we might, if we continue training providers at the current rate, and estimating generational size, we might reach an overcapacity in about 30 years. Although, due to potential lengthening of life, and increased disease management strategies, it is very hard to get a hard number, it may actually be much longer.

At any rate, for all of us, there will be jobs, and plenty of work for the next several decades.

 

[JaggerPlate]

I am on my third year rotations and we typically have one PA student from a nearby school on the team with us. It's getting to be an interesting part of the year because these students are on the 7th of their 8 rotations, and will be graduating in March. Many of the students I have talked to have already signed contracts with a physician, and will have jobs immediately upon graduating. Several--many more than I expected--will be signing on with a dermatologist. One of these students signed a starting $150,000 contract.

Ok, here's the discussion question: Will there be a point in time where some of these family practitioners, and other primary care docs that are having to close their doors because of financial strain, sign up to be a physician extender, or act in that capacity, for higher-pay specialties? Is this even legal? Can an M.D. who is board certified in FP sign on and practice under the licence and specialty of a dermatologist, receive on the job training like a PA, and take the $150,000 with no liability? Does this sort of thing entice any attendings on this forum? If it is legal, would any attendings in a higher pay specialty be willing to take on a physician as an extender rather than a PA?

Thoughts?

$150,000?? This seems extremely high. These dermatologists must just see an enormous number of patients per day, because to pay a PA 150k a year, I have to imagine they are bringing in a significant amount of $ into the practice, meaning they themselves, which doesn't include the other practitioners or physicians in the practice, are seeing a ton of patients a day.

My guess is that there is a 'catch' somewhere.

Additionally, there really wouldn't be any need for a FP struggling in FP to do something like this. All he/she would really need to do is 'morph' their practice into a 'dermatology-esque' practice. I'm not sure if it would take some sort of informal preceptorship working with a dermatologist, etc, but there is nothing to say a FP can't open a practice geared toward dermatology or even hang a shingle as a 'dermatology expert.'

They will be reimbursed the same for the bread and butter cases (which is the type of stuff the PAs would be doing anyway) and probably just refer a lot of the more complicated stuff. As long as they don't say they are BC in derm or call themselves a dermatologist, to my knowledge, there is technically no restrictions on doing something like this (as long as you were prepped for the potential malpractice). Plus, this would probably bring in must more than 150k.

 

[deleted6669]

150 k is a bit high for a new grad pa in derm but not unheard of. they do LOTS of procedures and usually get salary + production. I know a local derm pa 5 yrs out of school who makes 187k/yr working 4.5 days/week.
The derm md in the practice is only there 2 days/week to do MOHS and other surgery. his pa basically runs the non-operative and cosmetic aspects of the practice.

 

[JaggerPlate]

The derm md in the practice is only there 2 days/week to do MOHS and other surgery.

 

[JackADeli]

...Can an M.D. ...sign on and practice under the licence ...of...[another physician]...and take the $150,000 with no liability?...

No.

 

[deleted6669]

...however...what is stopping a derm md from hiring another md for 150k/yr who has a license(who has completed at least an internship and whatever the state requires for min practice) and letting them run (for example) only the cosmetic/non-surgical aspects of the practice? the derm md could buy the non-derm md his own malpractice policy to cover him in the event of a suit. so doc #2 still has liability(you can never get away from that) but is covered under his own policy...the derm doc could then advertise that his practice only has "physician level providers". one of the places that I work is run by an em md group. the em md's are "partners" and the fp docs and pa's are "associates". the fp docs are practicing emergency medicine under their own licenses but have full malpractice and other benefits paid by the em md partners.
currently a physician (who is not a resident) can not work "under the license of another physician".
as discussed elsewhere it would not be difficult to create a new category of physician, the "supervised physician", who is a grad from a U.S. md/do program and has passed step 1-3 but not matched (yet). presumably most of these folks would go on to later match/scramble in another yr.

 

[facetguy]

...however...what is stopping a derm md from hiring another md for 150k/yr who has a license(who has completed at least an internship and whatever the state requires for min practice) and letting them run (for example) only the cosmetic/non-surgical aspects of the practice? the derm md could buy the non-derm md his own malpractice policy to cover him in the event of a suit. so doc #2 still has liability(you can never get away from that) but is covered under his own policy...the derm doc could then advertise that his practice only has "physician level providers". one of the places that I work is run by an em md group. the em md's are "partners" and the fp docs and pa's are "associates". the fp docs are practicing emergency medicine under their own licenses but have full malpractice and other benefits paid by the em md partners.
currently a physician (who is not a resident) can not work "under the license of another physician".
as discussed elsewhere it would not be difficult to create a new category of physician, the "supervised physician", who is a grad from a U.S. md/do program and has passed step 1-3 but not matched (yet). presumably most of these folks would go on to later match/scramble in another yr.

Would this (bold) be a barrier to getting hired? What MD would hire a 'supervised physician', expending time, energy and probably some money knowing that employee would be gone in a year?

 

[deleted6669]

What MD would hire a 'supervised physician', expending time, energy and probably some money knowing that employee would be gone in a year?

someone who thought they would return as a (pre-trained and oriented) partner after residency.

 

[facetguy]

someone who thought they would return as a (pre-trained and oriented) partner after residency.

Perhaps.

 

[Downbytheicu]

Sorry I posted this and then went AWOL for a bit. The $150k number is legit. I don't know if there are any "catches" to the arrangement, but I am sure that the "lifestyle" of it are something that many desire. As far as workload goes, my implication was not that these docs who close their doors did not have the "work load" to keep them open. I believe that these docs are overworked by patients whose insurance reimburses so poorly that they can't keep their doors open. The problem may in fact be too much work load.

Also, I am not suggesting that residents get out and do something like this... I am wondering aloud whether the tired and spent family practitioner or the jaded internist that we have all seen at some point in our training will find a situation like this to be enticing and whether or not it is possible.

For instance, derm is an extraordinarily competitive residency. Not all the people who wish to practice derm can do so, and I think we all recognize that. However, would it be possible, or plausible, for a physician to sign up as an "associate" (as someone else called it) at a derm clinic, and essentially practice dermatology in affiliation or supervision of another physician without having done a dermatology residency? This then raises again the question of whether a derm attending would prefer a newly graduated PA to a residency trained FP. I don't know.

Or, perhaps to put another spin on it, one of the things I envy in the PA field is the ability to change fields all together. Could, for instance, an internist who loved surgery in school but avoided it because of the malignancy of many of the programs decide to switch ships and be a permanent 1st assist to a CT surgeon, the way that another of my PA friends will be when she graduates in a few months?

 

[core0]

Sorry I posted this and then went AWOL for a bit. The $150k number is legit. I don't know if there are any "catches" to the arrangement, but I am sure that the "lifestyle" of it are something that many desire. As far as workload goes, my implication was not that these docs who close their doors did not have the "work load" to keep them open. I believe that these docs are overworked by patients whose insurance reimburses so poorly that they can't keep their doors open. The problem may in fact be too much work load.

Also, I am not suggesting that residents get out and do something like this... I am wondering aloud whether the tired and spent family practitioner or the jaded internist that we have all seen at some point in our training will find a situation like this to be enticing and whether or not it is possible.

For instance, derm is an extraordinarily competitive residency. Not all the people who wish to practice derm can do so, and I think we all recognize that. However, would it be possible, or plausible, for a physician to sign up as an "associate" (as someone else called it) at a derm clinic, and essentially practice dermatology in affiliation or supervision of another physician without having done a dermatology residency? This then raises again the question of whether a derm attending would prefer a newly graduated PA to a residency trained FP. I don't know.

Or, perhaps to put another spin on it, one of the things I envy in the PA field is the ability to change fields all together. Could, for instance, an internist who loved surgery in school but avoided it because of the malignancy of many of the programs decide to switch ships and be a permanent 1st assist to a CT surgeon, the way that another of my PA friends will be when she graduates in a few months?

In theory you could but in reality its going to be difficult. The issue is that Medicine has essentially two types of license (omitting training licenses). Restricted and unrestriced. Physicians (barring having done something naughty) have an unrestricted license to practice medicine and surgery. The concept is that once you are licensed you alone are responsible for your practice. PAs have a restricted license to practice medicine. The exact wording varies from state to state but essentially the restriction is that the PAs scope of practice is limited to that of the supervising physician.

Now to the assisting part. It used to be (and still is at some small hospitals) that anyone could assist in surgery. However, with bad outcomes and liability being dumped on the hospital when they ran through the physicians malpractice (and the JC), hospitals have limited this to those they deemed "qualified". Notice the quotes. Now there is no reason that a BC FP could not be "qualified" to assist in CT surgery. However, the way the rules are written, since the FP is a physician they have to be qualified in a manner similar to a physician doing the surgery. The have to be credentialled showing that they have been trained to assist in CT surgery. Even though they may be more "qualified" than a PA whose training is whatever surgery experience they have in school, the PA is within the scope of practice because they have a supervising physician that essentially accepts responsibility for their actions. There is no way under current BOM or hospital regulations for another physician to accept responsibility for a fully licensed physicians actions.

This is the essential trade off that more than a few of us have made. Physicians have true independence of license but its constrained within their training. PAs have a limited license but its transferable within the limits of their supervising physicians training. You give up "independence" and to some extent salary for lateral mobility.

Bottom line there is no place in American Medicine for a supervised physician. Practicing physicians and the BOMs like it and want it that way. Any other method threatens the guild system of certain specialties and creates a licensing nightmare.

 

[morning]

$150,000?? This seems extremely high. These dermatologists must just see an enormous number of patients per day, because to pay a PA 150k a year, I have to imagine they are bringing in a significant amount of $ into the practice, meaning they themselves, which doesn't include the other practitioners or physicians in the practice, are seeing a ton of patients a day.

It's not like PAs get paid on a flat scale no matter what specialty they're in. PA earnings correspond to the specialty of the physician they work with. Derms make a LOT of money, so PAs in derm make a lot of money. One of the lowest-paying specialties is pediatrics, just like for physicians. A peds PA probably makes around 70k.

 

[JaggerPlate]

It's not like PAs get paid on a flat scale no matter what specialty they're in. PA earnings correspond to the specialty of the physician they work with. Derms make a LOT of money, so PAs in derm make a lot of money. One of the lowest-paying specialties is pediatrics, just like for physicians. A peds PA probably makes around 70k.

I know, but 150k sounds high regardless. This is probably more than a lot of guys (DO/MDs) in academics or fields like peds make period.

 

[drift]

I know, but 150k sounds high regardless. This is probably more than a lot of guys (DO/MDs) in academics or fields like peds make period.

Yeah 150k is probably on the upper-end of PAs. I find it odd that a new grad PA being offered 150k. The higher paid PAs are generally due to experience in the field and not simply being a PA graduate. I think derm PAs are the highest paid PAs (even more than surgery if I'm not wrong), compared to peds/academics which would certainly be the lower paying physician specialties. While it's not the norm, I can definitely see how an experienced derm PA could make more then a peds/FP physician. I personally know of a derm pa who makes more than 150k, but that's only after ~5 years of being in derm. I don't think new grads would be "worth" that initially to a practice.

 

[deleted6669]

Fields with pa's i have known who make > 150k
derm
ortho
surg( ct, neuro)
em
fp (owns practice)
bariatrics(owns practice)
Urgent care(owns practice)

 

[SirNeaps]

My wife recently needed to see a Dermatologist urgently. She could only get a PA appointment. After the visit, she felt it was a complete waste of her time. She saw a Dermatologist MD a few days later and was elated to have a diagnosis and treatment which made sense and worked. PA's and NP's need to be supervised. Luckily in some states only a physician can own a medical practice.

 

[PharmBound2011]

Fields with pa's i have known who make > 150k
derm
ortho
surg( ct, neuro)
em
fp (owns practice)
bariatrics(owns practice)

emed, are these PA owned practices overseen by MD/DOs?

 

[deleted6669]

emed, are these PA owned practices overseen by MD/DOs?

yes, but the docs are employees of the practice, not partners or owners( or in some cases the docs are minority owners). if the practice does well everyone makes money. if the practice does poorly the pa loses a huge amt of money and ruins his credit(just like a doc in a solo practice that fails would) and the doc walks away. don't confuse "business ownership" with "medical supervision". either way(doc owner or pa owner) the legal supervisory requirements still need to be met.
I should also add that I know pa's who own and operate urgent care ctrs as well- slipped my mind before.
all 50 states require pa's to work with physicians. there is no such thing as a fully independent pa(the military, peace corps and disaster teams come close but there are still docs involved ).I know several very happy and well paid docs who work in this type of arrangement.

 

[deleted6669]

in some states only a physician can own a medical practice.

fewer states every day.
I think as long as a physician is involved in a collaborative/supervisory role in the practice and meets all legal requirements there is no reason a pa or np can't be the business owner.
it's actually a nice gig for the docs: no overhead or office hassles, full benefits and malpractice paid as an employee of the practice. just like working for an hmo.

 

[deleted87716]

it's actually a nice gig for the docs

Only if they're complete *****s.

All of the liability, none of the control...? Yeah, sign me up. Not.

 

[deleted6669]

Only if they're complete *****s.

All of the liability, none of the control...? Yeah, sign me up. Not.

ACTUALLY....SAME liablility, none of the business related hassles. no mtgs, no wondering if you have enough overhead to buy a new fax machine or hire another MA, etc
the docs get a malpractice policy paid as part of the benefits package. all they have to do is show up a few times a week, see a few pts, review a few charts and collect a check.
this is actually quite a popular gig for semiretired docs....a few thousand/mo for a few hrs/week....how sweet is that....

 

[deleted87716]

ACTUALLY....SAME liability

No.

There's no way you can convince me (or a jury) that these docs are really "supervising" their employers.

 

[deleted6669]

I guess we will have to agree to disagree about this issue and move on.

 

[JackADeli]

...There's no way you can convince me (or a jury) that these docs are really "supervising" their employers.

I guess we will have to agree to disagree about this issue and move on.

ACTUALLY....SAME liablility...

I'm with BD on this one. It depends on what you are comparing when saying, "the same"....

...none of the business related hassles. no mtgs, no wondering if you have enough overhead to buy a new fax machine or hire another MA, etc...

This is a general reality of many employed positions. However, as the employed physician in this scenario, the lack of "business related hassles" comes at a price. Yes, no meetings. But, what sort of business plan are they discussing that you are not a part of? Is the business plan within the ethics you as a physician upheld? They are planning strategies for profits. This means the mid-levels (i.e. owners) are designing the practice structure. This is of course the practice you are supposed to be supervising... but your not there. You are not particularly involved in the business decisions relative to what meds are prescribed, pricing, ?industry reps involvement, etc...

...the docs get a malpractice policy paid as part of the benefits package...

That is standard of just about any employed situation.

...all they have to do is show up a few times a week, see a few pts, review a few charts and collect a check...

That description does NOT equate supervision of a practice. In theory, the mid-levels (i.e. owners, practice managers, practice designers, etc...) are seeing far more patients then just a few a week during just a few hours. It sounds like the model design is one in which the physician is a hollow figure head and an occasional chart reviewer. Again, a couple hours, a couple patients, and a few charts does not represent supervision in a busy practice; a practice designed and managed by someone other then the "supervisor".

I understand all the business desire to make a profit. I applaud it. However, I am not going to applaud a set up that claims a product/service that is false.

 

[deleted87716]

The whole idea of a PA employing their SP is ass-backwards, and an obvious conflict of interest.

This letter from the Texas Medical Association sums it up pretty well.

Source: http://www.texmed.org/Template.aspx?id=8395

A physician assistant (PA) cannot legally "employ," even as an "independent contractor," his or her supervising physician. The scope of practice of the PA is set out in Section 2004.202, Occupations Code. In particular, Subsection (e) states:

(e) A physician assistant is the agent of the physician assistant's supervising physician for any medical services that are delegated by that physician and that:

(1) are within the physician assistant's scope of practice; and
(2) are delineated by protocols, practice guidelines, or practice directives established by the supervising physician.

This provision of the Physician Assistant Licensing Act clearly establishes that the PA is the agent of the physician. The law of agency allows one person to employ another to do her or his work, sell her or his goods, and acquire property on her or his behalf as if the employer were present and acting in person. The principal may authorize the agent to perform a variety of tasks or may restrict the agent to specific functions, but regardless of the amount, or scope, of authority given to the agent, the agent represents the principal and is subject to the principal's control. More important, the principal is liable for the consequences of acts that the agent has been directed to perform. The agent does not and cannot employ or control the principal.

Perhaps the most important element of a principal-agent relationship is the concept of control: the agent agrees to act under the control or direction of the principal. The extent of the principal's control over the agent distinguishes an agent from an Independent Contractor, over whom control and supervision by the principal may be relatively remote.

In effect, the proposed rule turns agency law upside down and is in direct contradiction of the Physician Assistant Licensing Act.

...

The proposed rule of the Physician Assistant Licensing Board is an attempt to circumvent the Medical Practice Act by permitting a non physician to employ or use a physician to control the authority of a physician to direct the activities of the person he is employed to supervise. A physician cannot meaningfully supervise the person paying his salary or fees as an independent contractor. The physician will know that if he or she does not accede to the wishes of the person paying his salary or fees, he or she will be fired or the contract terminated. It is an effort to do indirectly that which cannot be done directly.

The biblical adage from Matthew 6:24 rings true. "One cannot serve two masters."

 

[JackADeli]

The whole idea of a PA employing their SP is ass-backwards, and an obvious conflict of interest.

This letter from the Texas Medical Association sums it up pretty well.

Source: http://www.texmed.org/Template.aspx?id=8395

Your posting probably illustrates it far better then my previous post. As you have illustrated probably better then I, it defies reason to even suggest/imply/etc.... that you are "supervising" your employer under the best of circumstances. However, the example of just a few days, few hours, few patients, few charts per week, hassle free, no involvement in the management of the practice... well that is ludicrous to say it is "supervising".

PS: BD, what was the end result/decision on that issue by TMA?

 

[deleted87716]

BD, what was the end result/decision on that issue by TMA?

I don't know what the proposed rule actually said, but this is the current rule: http://secure.sos.state.tx.us/pls/pub/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=185&rl=16

I don't see anything in it relating to PAs employing physicians.

 

[JackADeli]

I don't know what the proposed rule actually said, but this is the current rule: http://secure.sos.state.tx.us/pls/p...=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=185&rl=16

I don't see anything in it relating to PAs employing physicians.

Thank you. I did a web search and didn't find much more then that either. Didn't know if there was any responses or published debate relative to the TMA letter.

 

[deleted6669]

so how does it work in the military when a pa/np is of higher rank than their supervisor? is this a conflict of interest if a 1st lt. supervises a major who could transfer them?

and how is the supervision any better if the doc owns the practice and is there 4 hrs/week(to meet the state min requirement) and the pa does all the work( 60 hrs/week) but has no say in how the practice is run?

 

[JackADeli]

so how does it work in the military when a pa/np is of higher rank than their supervisor? is this a conflict of interest if a 1st lt. supervises a major who could transfer them?...

The military is a whole different ball of wax and these two things, i.e. mid-level owning the practice and hiring a physician vs higher ranking officer being a mid-level and the more junior officer being the physician, are not the same thing. The junior officer is NOT the employee of the senior officer or the higher ranking ward nuirse, etc.... The military has too many nuances and formal regs to even start trying to equate the two or even discuss at any length.

...and how is the supervision any better if the doc owns the practice and is there 4 hrs/week(to meet the state min requirement) and the pa does all the work( 60 hrs/week) but has no say in how the practice is run?

Nobody is saying a physician failing to supervise is a good thing. The discussion is not about saying how equivalent negligence in responsibility in same way makes the conduct better. But, the physician that owns the practice is actually in a position to supervise with some degree of authority. Not so in the situation described earlier, i.e. a few days, few hours, few patients, few charts per week, hassle free, no involvement in the management of the practice...

 

[drift]

The military is a whole different ball of wax and these two things, i.e. mid-level owning the practice and hiring a physician vs higher ranking officer being a mid-level and the more junior officer being the physician, are not the same thing. The junior officer is NOT the employee of the senior officer or the higher ranking ward nuirse, etc.... The military has too many nuances and formal regs to even start trying to equate the two or even discuss at any length.Nobody is saying a physician failing to supervise is a good thing. The discussion is not about saying how equivalent negligence in responsibility in same way makes the conduct better. But, the physician that owns the practice is actually in a position to supervise with some degree of authority. Not so in the situation described earlier, i.e. a few days, few hours, few patients, few charts per week, hassle free, no involvement in the management of the practice...

I agree. I have no problem with PA owned clinics, but not the one stated above. Honestly, there is no clinical difference whether the PA who is seeing a patient owns the clinic or is an employee, assuming that adequate physician supervision is present (either are better than sole NP owned/operated clinics in my eyes). I have seen successful PA owned clinics that I would have no problems sending my loved ones to, because despite all/most of the clinic being owned by a pa, there is adequate physician involvement and supervision. I fail to see any clinical difference in an employed PA or an owner PA providing care, provided that the same physician supervision requirements are there. The overall theme is that regardless of owner, adequate supervision of the PA must be maintained, according to their state.

What I do take issue with is inexperienced PAs trying to go around trying to open a clinic. While I haven't heard of any such cases, but suppose a nutcracker new grad PA is adamant on opening a clinic, there is nothing stopping him from hiring a doc and opening a practice. I wish legislation would be put forward that said something like "the PA may get clinic ownership rights after X years of practice in their particular specialty/field."

 

[deleted6669]

I agree. I have no problem with PA owned clinics, but not the one stated above. Honestly, there is no clinical difference whether the PA who is seeing a patient owns the clinic or is an employee, assuming that adequate physician supervision is present (either are better than sole NP owned/operated clinics in my eyes). I have seen successful PA owned clinics that I would have no problems sending my loved ones to, because despite all/most of the clinic being owned by a pa, there is adequate physician involvement and supervision. I fail to see any clinical difference in an employed PA or an owner PA providing care, provided that the same physician supervision requirements are there. The overall theme is that regardless of owner, adequate supervision of the PA must be maintained, according to their state.

What I do take issue with is inexperienced PAs trying to go around trying to open a clinic. While I haven't heard of any such cases, but suppose a nutcracker new grad PA is adamant on opening a clinic, there is nothing stopping him from hiring a doc and opening a practice. I wish legislation would be put forward that said something like "the PA may get clinic ownership rights after X years of practice in their particular specialty/field."

I agree 100% with all of the above. new grads should not be working solo.all the folks I know who own practices have been working pa's for > 10 yrs, many > 20 yrs before undertaking this. it would be a stupid or very greedy doc who would agree to work for a new grad. generally the docs who do this work have already worked with the pa for an extended period of time in another setting so they know the pa's practice style and are comfortable with it. a friend of mine is setting up a practice right now and is hiring a doc he has worked with for the last 9 yrs who is semi-retired and will not be working anywhere else. there is already trust there, which is what makes it work. the doc knows the pa isn't an idiot and will consult him as needed and the pa knows he can bounce anything off the doc without fear of being considered an idiot and will seriously consider any input given.
FWIW my pcp is a pa at a clinic he owns. he has 2 physicians, 1 pa, and 1 np as other clinical employees of the practice. bright guy. former military(interestingly enough ALL of the pa clinic owners I know are former military( N=10 or so). )

 

[JaggerPlate]

The whole idea of a PA employing their SP is ass-backwards, and an obvious conflict of interest.

Does it really matter if the PA was simply a business owner though, or are you referring to a PA who owned the business and also practiced with the DO/MD in the clinic. The reason I ask is because my dad knew a guy who was a PA and after a few years of practice, he essentially decided to give up on clinical medicine and just purchased practices and medical buildings/offices. It's my understanding that he was simply the owner of the practice and didn't really do anything clinical. In this sense, I really don't see an issue with it, but it may be something entirely different than what you're referring to.

 

[deleted87716]

Does it really matter if the PA was simply a business owner though, or are you referring to a PA who owned the business and also practiced with the DO/MD in the clinic. The reason I ask is because my dad knew a guy who was a PA and after a few years of practice, he essentially decided to give up on clinical medicine and just purchased practices and medical buildings/offices. It's my understanding that he was simply the owner of the practice and didn't really do anything clinical. In this sense, I really don't see an issue with it, but it may be something entirely different than what you're referring to.

I'm referring to PAs employing their supervising physicians.

Practice ownership isn't the issue.

 

[JaggerPlate]

I'm referring to PAs employing their supervising physicians.

Practice ownership isn't the issue.

Yeah, that makes no sense ... my comments were definitely with regard to practice ownership.

 

[Socrates25]

http://www.texmed.org/Template.aspx?id=8395 (courtesy of blue dog) I'm sick and tired of hearing this nonsense that PAs are "different" than NPs and have no desire to fight docs. This link makes it absolutely clear that they are a threat as well, and anybody who says otherwise is a fool. Dont believe the PAs on this forum who keep lying and telling everybody "we want to be friends" with the docs. They are two-faced manipulators, telling everybody one thing and then secretly going behind our backs to try to change the rules (EXACTLY like the NPs)

 

[deleted6669]

deleted

 

[JackADeli]

...nonsense that PAs are "different" than NPs ...PAs on this forum who keep lying ...They are two-faced manipulators, telling everybody one thing and then secretly going behind our backs to try to change the rules (EXACTLY like the NPs)

I work with very skilled and talented mid-levels, both NPs & PAs. Do I disagree with some of the political agendas and ludicrous comparisons from NPs & PAs as well as from MDs? Yes. However, I am not in support of any blanket generalizations or condemnations of mid-levels. IMHO, mid-levels are an important part of the well organized/structured healthcare team.

 

[physasst]

so how does it work in the military when a pa/np is of higher rank than their supervisor? is this a conflict of interest if a 1st lt. supervises a major who could transfer them?

and how is the supervision any better if the doc owns the practice and is there 4 hrs/week(to meet the state min requirement) and the pa does all the work( 60 hrs/week) but has no say in how the practice is run?

In the military, the PA cannot outrank their SP. One of my better friends is a Commander in the Coast Guard, and actually is in the executive command structure of a Coast Guard medical center. His SP is actually stationed at Coast Guard HQ in DC, as he outanks all of the MD's at the center.

He has an interesting story, in that he was a CFO for a fortune 500 company and had his MBA at the time, went back and finished his PA, joined the Coast Guard, and over the years has also completed a DHA and a separate PhD. He says that new physicians will often say "Okay, so....I'm a physician, and you're a PA, how is this going to work?" To which, he usually replies, "When I am seeing patients, if you have some clinical directive for me, or recommendations for a patient, please tell me.....Otherwise, I am in charge."

Of course, another friend of mine, is a PA, and is a Rear Admiral....so...I'm not quite sure who his SP is....

I know of a few PA's who own their own practice....it's not really that hard. Clinically, the MD is the SP, and is in charge of patient care issues. The PA who owns the practice is in charge of the business aspect and pays the SP a salary. It's merely a matter of clearly delineating where each professionals leadership ends, and where it begins.

 

[physasst]

http://www.texmed.org/Template.aspx?id=8395 (courtesy of blue dog) I'm sick and tired of hearing this nonsense that PAs are "different" than NPs and have no desire to fight docs. This link makes it absolutely clear that they are a threat as well, and anybody who says otherwise is a fool. Dont believe the PAs on this forum who keep lying and telling everybody "we want to be friends" with the docs. They are two-faced manipulators, telling everybody one thing and then secretly going behind our backs to try to change the rules (EXACTLY like the NPs)

Hyperbolic fear....is well, hyperbolic fear....

 

[deleted6669]

I know of a few PA's who own their own practice....it's not really that hard. Clinically, the MD is the SP, and is in charge of patient care issues. The PA who owns the practice is in charge of the business aspect and pays the SP a salary. It's merely a matter of clearly delineating where each professionals leadership ends, and where it begins.

yup, no brainer. obviously you find a doc who practices in a style similar to your own so their will be minimal conflicts.and as a doc you don't supervise a pa you are not comfortable with.

 

[altap]

I completely agree with BD and the TMA regarding this issue. A physician who signs up with this business model is for lack of a better word insane. The physician is still the captain of the ship in this regard. So when the PA is sued and found guilty, the physician will also be found liable in that he is the "supervisor" of the PA. Lest we forget that PAs can only practice under the supervision of a physician. Business wise why would a physician make lesser amount of money than the PA?

 

[JackADeli]

...Business wise why would a physician make lesser amount of money than the PA?

Do not get distracted by the money and/or who "deserves" more. The scenario described, I would say the physician should not be getting paid any sort of fortune. The physician in that scenario is little more then a figure head and has not invested into the enterprise. Rather, he/she has rented their license to the enterprise and is, by description not actually performing much clinical labor. The ethics issues not withstanding, the finacial arrangement is, to the unscrupulous, quite a nice arrangement. Let us not take an already shady and greedy deal and cry over more money!

But, for s hort and simple answer, because the physician is not actually doing much work or investing any firm assets in the enterprise.

 

[deleted6669]

because the physician is not actually doing much work or investing any firm assets in the enterprise.

exactly..I have several friends who have done this successfully. one is my pcp.
the pa leases the facility, buys all the equipment, pays all the insurance, pays all the salaries/benefits of all employees, lab fees. equipment maintenance, etc
if the practice does well the pa should make a profit. if it does poorly the pa loses lots of money, often their life savings. so yes, they deserve more than a doc who is merely an employee....
one of the pa's I know who runs his own practice probably clears 300k/yr, drives a mercedes, etc and has a few docs on staff he pays 150k or so to be present a few days/week. in his practice model one of his physician employees is almost always physically on site seeing their own pts(and available for consult obviously), although this is not the norm for pa owned practices.
I understand this model doesn't work for lots of docs like bluedog. that's fine. don't do it. it's a personal choice but one that works well for many others. there are pa practice arrangements out there in em that I wouldn't be comfortable with either like presenting every single pt and having the doc see every pt.( some-rare- hospital er's do this- at that point why have a pa at all if the doc has to repeat everything they have already done?)

 

[Dr Oops]

exactly..I have several friends who have done this successfully. one is my pcp.
the pa leases the facility, buys all the equipment, pays all the insurance, pays all the salaries/benefits of all employees, lab fees. equipment maintenance, etc
if the practice does well the pa should make a profit. if it does poorly the pa loses lots of money, often their life savings. so yes, they deserve more than a doc who is merely an employee....
one of the pa's I know who runs his own practice probably clears 300k/yr, drives a mercedes, etc and has a few docs on staff he pays 150k or so to be present a few days/week. in his practice model one of his physician employees is almost always physically on site seeing their own pts(and available for consult obviously), although this is not the norm for pa owned practices.
I understand this model doesn't work for lots of docs like bluedog. that's fine. don't do it. it's a personal choice but one that works well for many others. there are pa practice arrangements out there in em that I wouldn't be comfortable with either like presenting every single pt and having the doc see every pt.( some-rare- hospital er's do this- at that point why have a pa at all if the doc has to repeat everything they have already done?)

I agree with emedpa. The owning PA has put together all the resources and thus owns the practice, what to do with the profits should be that PAs decision. However, I dont think the SP should be an employee of that PA if that PA works there clinically. Instead they should have an independent contractor type deal. If the PA has no clinical duties under the SP employee, then I see no problems.

 

[deleted6669]

Most often this is set up in such a way that the physician doesn't "work for the pa", they work for a corporation as does the pa.
the pa might happen to be the primary(or only) stockholder in the corporation however or the pa's non-medical spouse "owns" the corporation and hires the pa and the doc. in those states that require an md be a partner it is not uncommon to give the doc a 1% share in the business(which they are contractually required to sell back if they leave). I know of a group with 3 pa's who each are 33% shareholders who hired an sp who gets 1%.
many pa owned groups however hire at least 2 docs so there is a backup in case one quits/dies/moves/etc.
most pa's in these settings continue to work at least part time in a clinical capacity but the more successful ones sometimes quit working clinically at all and just work as practice managers.

 

[JackADeli]

Most often this is set up in such a way that the physician doesn't "work for the pa", they work for a corporation as does the pa.
the pa might happen to be the primary(or only) stockholder in the corporation however or the pa's non-medical spouse "owns" the corporation and hires the pa and the doc. in those states that require an md be a partner it is not uncommon to give the doc a 1% share in the business(which they are contractually required to sell back if they leave). I know of a group with 3 pa's who each are 33% shareholders who hired an sp who gets 1%.
many pa owned groups however hire at least 2 docs so there is a backup in case one quits/dies/moves/etc.
most pa's in these settings continue to work at least part time in a clinical capacity but the more successful ones sometimes quit working clinically at all and just work as practice managers.

The description is very shady, i.e.:

...the physician doesn't "work for the pa", they work for a corporation...[the PA just happens to own said corporation] ...or the pa's non-medical spouse "owns" the corporation...

or


...in those states that require an md be a partner it is not uncommon to give the doc a 1% share in the business(which they are contractually required to sell back if they leave)"...

I have always found it easy to recognize a problem in ethics. Simply look for complex or convaluted structuring designed to "meet requirements". If something takes a lot of loop holing, it probably is not very up and up. That 1% is giving alot of management authority to the supervising physician

 

[deleted6669]

hey, I don't write the laws or work in a setting like this, I'm just sharing reality with y'all. I bet there are even arrangements like this in the "great " state of texass.
the issue most of the docs are having here is with the degree of supervision. I would submit it's not that different than a lot(or most) of the arrangements where a pa works for a doc. for example in many states the pa submits 5-10% of their charts for review within 1 month and the doc physically sees 0% of the pa's pts unless requested to do so.
isn't this less supervision than a pa owned clinic with a doc there a few days/week in person for consults AND reviewing charts. Mandatory full time physician on site supervision is a thing of the past in the vast majority of practice settings in 2010.