Proposed CMS Mid-Level Pay Parity and Independent Practice Regulations

[Fox800]

Ready to see your hours get cut, your pay get cut, and physicians replaced by fresh-faced midlevels with no ED experience? That's where we're heading. We're staring down a worsening job market with the prospect of physicians being replaced by MLPs while healthcare administrators fluff their bottom line. E-mail them, fill out the AAEM form, or stand by and do nothing. Your choice. Deadline to send open comments to CMS is TOMORROW (1/17).

Have you emailed CMS a little 2-3 sentence e-mail? Have you filled out the pre-made AAEM template (takes about 15 seconds)? If not, you're complicit in the devaluing and destruction of our profession. Apathy is part of the problem that got us here in the first place.

Please email the HHS Secretary Alex Azar and CMS Administrator Seema Verma: [email protected] with "Scope of Practice" in the subject line and state why you OPPOSE removal of supervisory requirements for MLPs seeing Medicare patients and MLP Medicare reimbursement parity with physicians. You can literally write 2-3 sentences. Also please fill out the AAEM form here: https://form.jotform.com/200084358856056

Our profession is under attack from all sides: the AANP, AAPA, insurance companies, and the current administration (re: executive order that got us here in the first place). We need to band together to fight for what's right. Get off your butt and protect our specialty from those that seek to destroy our livelihood.

---

Members don't see this ad.

 

[gamerEMdoc]

From a patient safety perspective, mid-level autonomy is crazy dangerous in the ED. But.... can you imagine if we no longer had to sign midlevel charts or supervise them? Would any of them work in the ED? I mean, I've worked with a lot of very experienced midlevels in my career, and I can't see any of them who have ever wanted to be solely responsible for a sick crashing patient they didn't know what to do with.

Mid-levels who want autonomy and similar pay will reap what they sow. They can't do our jobs, and ultimately most don't want to do our jobs. They think they want autonomy but once they get it, with no oversight and no shared responsibility, they are going to regret it big time. Wait until every mistake they make is constantly thrown back on them, they are sued over and over for their mistakes that aren't caught since they have no supervision for patients they were never trained to see. If I was a trial lawyer, I would be drooling over the possibility of mid-level independent practice. Not only would you sue the hell out of them, but you could target the hospitals for hiring inadequately trained providers into jobs that they weren't qualified for. It would be a trial lawyers dream.

If anything, granting mid-levels autonomy would push them out of EM in my opinion and they'd gravitate towards lower acuity and lower liability fields.

 

[Fox800]

From a patient safety perspective, mid-level autonomy is crazy dangerous in the ED. But.... can you imagine if we no longer had to sign midlevel charts or supervise them? Would any of them work in the ED? I mean, I've worked with a lot of very experienced midlevels in my career, and I can't see any of them who have ever wanted to be solely responsible for a sick crashing patient they didn't know what to do with.

Mid-levels who want autonomy and similar pay will reap what they sow. They can't do our jobs, and ultimately most don't want to do our jobs. They think they want autonomy but once they get it, with no oversight and no shared responsibility, they are going to regret it big time. Wait until every mistake they make is constantly thrown back on them, they are sued over and over for their mistakes that aren't caught since they have no supervision for patients they were never trained to see. If I was a trial lawyer, I would be drooling over the possibility of mid-level independent practice. Not only would you sue the hell out of them, but you could target the hospitals for hiring inadequately trained providers into jobs that they weren't qualified for. It would be a trial lawyers dream.

If anything, granting mid-levels autonomy would push them out of EM in my opinion and they'd gravitate towards lower acuity and lower liability fields.

Sure. Until you can't get a job that you want because a midlevel took it...and your family members and friends are harmed from MLP misadventures. Repeat ad nauseam. Sigh

 

[namethatsmell]

Yeah everybody thinks they can do our job until their feet hit the tile and they’re really responsible for what happens under the fluorescents.

So many times have consultants or hospitalists whispered “I don’t know how you work in this place with all these patients.”

As I’ve said before, giving midlevels undifferentiated patients is the exact opposite of how they should be used. And now our government wants to incentive this? Madness. When it came to health policy Obama certainly had his faults, but this garbage executive order from Trump is lunacy.

And so the race to the healthcare bottom continues.


Sent from my iPhone using SDN mobile

 

[gamerEMdoc]

Sure. Until you can't get a job that you want because a midlevel took it...and your family members and friends are harmed from MLP misadventures. Repeat ad nauseam. Sigh

Right, I don't believe that will happen. Because of what I said. In the same way that I don't think little leaguers would suddenly take all of the MLB contracts away from big leaguers if a law passed that said MLB could sign 12 year olds. I don't believe they can do our job. And I believe if they were given the opportunity to do so with complete independence and no oversight, they'd fail to do so and would quickly get out of EM altogether. I agree this is bad for patients in the short run, which is why I oppose it. But I also don't believe they will takeover our field and we won't have a job.

Honestly, if midlevels COULD do our job as well as us (they can't), then we are way overpaid (we aren't).

 

[KeikoTanaka]

My questions are:

1. In states with already independent mid-level providers, how is the ED job market for physicians?

2. If their is "pay parity" for midlevels - Won't this drastically increase the cost of healthcare by making them bill the same amount as physicians?

3. Won't hospitals be the only ones to benefit from this because a mid level provider will now be able to bill (arbitrary numbers incoming) 500,000$ as opposed to their old 200,000$, but still only get paid 130k?

4. If somehow you DO need to pay the midlevel the same as a physician, why would you EVER hire a midlevel over a physician? Less bang for your buck

 

[rokshana]

My questions are:

1. In states with already independent mid-level providers, how is the ED job market for physicians?

2. If their is "pay parity" for midlevels - Won't this drastically increase the cost of healthcare by making them bill the same amount as physicians?

3. Won't hospitals be the only ones to benefit from this because a mid level provider will now be able to bill (arbitrary numbers incoming) 500,000$ as opposed to their old 200,000$, but still only get paid 130k?

4. If somehow you DO need to pay the midlevel the same as a physician, why would you EVER hire a midlevel over a physician? Less bang for your buck

Your mistake is that you think payment would go up...

 

[Dr Mantis Toboggan]

Plenty would stay and plenty new ones will take these jobs. The most dangerous ones.

From a patient safety perspective, mid-level autonomy is crazy dangerous in the ED. But.... can you imagine if we no longer had to sign midlevel charts or supervise them? Would any of them work in the ED? I mean, I've worked with a lot of very experienced midlevels in my career, and I can't see any of them who have ever wanted to be solely responsible for a sick crashing patient they didn't know what to do with.

Mid-levels who want autonomy and similar pay will reap what they sow. They can't do our jobs, and ultimately most don't want to do our jobs. They think they want autonomy but once they get it, with no oversight and no shared responsibility, they are going to regret it big time. Wait until every mistake they make is constantly thrown back on them, they are sued over and over for their mistakes that aren't caught since they have no supervision for patients they were never trained to see. If I was a trial lawyer, I would be drooling over the possibility of mid-level independent practice. Not only would you sue the hell out of them, but you could target the hospitals for hiring inadequately trained providers into jobs that they weren't qualified for. It would be a trial lawyers dream.

If anything, granting mid-levels autonomy would push them out of EM in my opinion and they'd gravitate towards lower acuity and lower liability fields.

 

[Fox800]

My questions are:

1. In states with already independent mid-level providers, how is the ED job market for physicians?

2. If their is "pay parity" for midlevels - Won't this drastically increase the cost of healthcare by making them bill the same amount as physicians?

3. Won't hospitals be the only ones to benefit from this because a mid level provider will now be able to bill (arbitrary numbers incoming) 500,000$ as opposed to their old 200,000$, but still only get paid 130k?

4. If somehow you DO need to pay the midlevel the same as a physician, why would you EVER hire a midlevel over a physician? Less bang for your buck

Hospitals can pay them less, while they bill CMS for the same amount as a physician. Hospital makes the same money but has a smaller expense.

 

[Fox800]

Right, I don't believe that will happen. Because of what I said. In the same way that I don't think little leaguers would suddenly take all of the MLB contracts away from big leaguers if a law passed that said MLB could sign 12 year olds. I don't believe they can do our job. And I believe if they were given the opportunity to do so with complete independence and no oversight, they'd fail to do so and would quickly get out of EM altogether. I agree this is bad for patients in the short run, which is why I oppose it. But I also don't believe they will takeover our field and we won't have a job.

Honestly, if midlevels COULD do our job as well as us (they can't), then we are way overpaid (we aren't).

I respectfully feel that your head might be in the clouds in academia. You're insulated.

There are already EDs near me paying $85-125 an hour because that's the money that MLPs (or an FM/IM physician) will take. They're staffed by an MLP with a supervising physician "available by phone" (i.e. they never get called). These hospitals refuse to pay more for a BC/BE EM physician, because they don't have to. Hence, no physicians at these places. Hence, lower demand for physicians. Hence, our bargaining power goes down, and we make less money. This is happening across my state. I'm not saying you'd want to work at these places, but you see my point.

My state is saturated with docs, and a flood of MLPs that are cheaper to employ, get reimbursed the same as us, and have no supervisory requirement will make things worse.

 

[GeneralVeers]

I respectfully feel that your head might be in the clouds in academia. You're insulated.

There are already EDs near me paying $85-125 an hour because that's the money that MLPs (or an FM/IM physician) will take. They're staffed by an MLP with a supervising physician "available by phone" (i.e. they never get called). These hospitals refuse to pay more for a BC/BE EM physician, because they don't have to. Hence, no physicians at these places. Hence, lower demand for physicians. Hence, our bargaining power goes down, and we make less money. This is happening across my state. I'm not saying you'd want to work at these places, but you see my point.

My state is saturated with docs, and a flood of MLPs that are cheaper to employ, get reimbursed the same as us, and have no supervisory requirement will make things worse.

That's a license waiting to be pulled by a board. I already got threatened over a midlevel patient I didn't see (but was in the ED at the time) and signed the chart. Can't imagine the medical boards being so forgiving of a "supervising physician" who is asleep at home while the midlevels run amuck.

 

[Fox800]

That's a license waiting to be pulled by a board. I already got threatened over a midlevel patient I didn't see (but was in the ED at the time) and signed the chart. Can't imagine the medical boards being so forgiving of a "supervising physician" who is asleep at home while the midlevels run amuck.

Recruiters here are offering $85-135 an hour to staff rural EDs. "I know the pay is low, but they're really slow!". Yeah, 1PPH for 24 hours isn't busy, but it isn't slow. Slow is like 2000-3000 visits per year. Slow is seeing 6 patents in 24 hours and napping, watching movies, etc. Not 1 PPH.

 

[gamerEMdoc]

I respectfully feel that your head might be in the clouds in academia. You're insulated.

There are already EDs near me paying $85-125 an hour because that's the money that MLPs (or an FM/IM physician) will take. They're staffed by an MLP with a supervising physician "available by phone" (i.e. they never get called). These hospitals refuse to pay more for a BC/BE EM physician, because they don't have to. Hence, no physicians at these places. Hence, lower demand for physicians. Hence, our bargaining power goes down, and we make less money. This is happening across my state. I'm not saying you'd want to work at these places, but you see my point.

My state is saturated with docs, and a flood of MLPs that are cheaper to employ, get reimbursed the same as us, and have no supervisory requirement will make things worse.

No I fully understand your fear, but I just don't believe it's the likely final outcome if this were to happen. I can tell you I've never seen a situation like you describe in your state where MLPs are practicing in EDs with a supervisor by phone. I'm pretty certain that isn't legal in my state. Medicine is regional, state laws are different in terms of supervision, etc. Ultimately, I just don't believe that independence of MLPs will mean the end of EM physicians, I really don't. I believe it will be a major medical-legal threat to hospitals, one they won't want to be burdened with.

Look at it this way. Residents aren't terribly expensive labor. Why not have all the IM interns start doing heart caths that they don't know how to do instead of paying for an interventional cardiologist? There will come a point where the outcomes will be bad enough that the hospital won't want to face the liability of staffing their places with only MLPs.

 

[RuralEDDoc]

I filled out the AAEM form. Thread BUMP for others to do the same.

 

[swamprat]

Anyone consider insurance companies may not want to insure or cover independent mid levels ? Or that the cost will be extremely high making hospitals not bother

 

[TheComebacKid]

Much of this discussion is predicated on answering the question of how much risk as a SOCIETY we are willing to accept.

In some places, a mid level will send home a ruptured ectopic with some famotidine for gastritis, and there will be outrage. Patients will say, "I was not treated by a DOCTOR". In other places, nobody will bat an eye.

In an era where people are traumatized by vaccines and other seemingly benign medical interventions, I'm not sure how much tolerance there will be for idiotic misses.

I think places with serious crashing patients that require emergent interventions are not in danger of being overrun by mid levels. But the lazy community ED with ankle sprains and "GERD" are the places where midlevels will thrive, and is arguably the more dangerous place for them to be. How much risk are those hospitals and communities willing to accept?

 

[Tenk]

Right, I don't believe that will happen. Because of what I said. In the same way that I don't think little leaguers would suddenly take all of the MLB contracts away from big leaguers if a law passed that said MLB could sign 12 year olds. I don't believe they can do our job. And I believe if they were given the opportunity to do so with complete independence and no oversight, they'd fail to do so and would quickly get out of EM altogether. I agree this is bad for patients in the short run, which is why I oppose it. But I also don't believe they will takeover our field and we won't have a job.

Honestly, if midlevels COULD do our job as well as us (they can't), then we are way overpaid (we aren't).

Or will they.....

 

[Winter2014]

Ask For A Physician

Not all healthcare providers in the United States have the same training. Know the difference. Ask for a physician.

www.askforaphysician.com

This was posted on the medicine subreddit forums where there is quite the conversation.

 

[KGflyboy]

Ask For A Physician

Not all healthcare providers in the United States have the same training. Know the difference. Ask for a physician.

www.askforaphysician.com

This was posted on the medicine subreddit forums where there is quite the conversation.

Although I like the idea of this campaign, look at the "ask for a physician" lapel pins. Can you imagine what would happen if a doctor wore that to work in the ED? NPs followed by the administration would lose their minds.

 

[Winter2014]

Although I like the idea of this campaign, look at the "ask for a physician" lapel pins. Can you imagine what would happen if a doctor wore that to work in the ED? NPs followed by the administration would lose their minds.

Yeah, same thoughts. Would definitely create tension in that environment. Private practice on the other hand.....

 

[TooMuchResearch]

Well, yeah, but his arm was broken and that somehow made him an amazing pitcher. (Unless I'm confusing that with another childhood classic?)

Or will they.....

 

[TooMuchResearch]

Man I got to get me some single cause cash generating website.

Ask For A Physician

Not all healthcare providers in the United States have the same training. Know the difference. Ask for a physician.

www.askforaphysician.com

This was posted on the medicine subreddit forums where there is quite the conversation.

 

[Tenk]

Well, yeah, but his arm was broken and that somehow made him an amazing pitcher. (Unless I'm confusing that with another childhood classic?)

Yeah... just like how their MCAT and undergrad gpa were broken so they became amazing NPs.