Utilizing Midlevels in the practice...

[bluehighlighter]

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Currently we are a 3 doc practice. We each see our individual set of patients. In efforts to help accommodate / boost volume , we are thinking about hiring an NP.

For those who have midlevels, can you please shed some light on how you utilize them in your day to day practice ( i.e do they see follow ups vs. new patients vs. post procedure patients, etc). ?

Do they adjust patient's opioids without conferring with you? How does it work in your setting?

I appreciate any insight

 

[drusso]

Currently we are a 3 doc practice. We each see our individual set of patients. In efforts to help accommodate / boost volume , we are thinking about hiring an NP.

For those who have midlevels, can you please shed some light on how you utilize them in your day to day practice ( i.e do they see follow ups vs. new patients vs. post procedure patients, etc). ?

Do they adjust patient's opioids without conferring with you? How does it work in your setting?

I appreciate any insight

Use use a team-based model of care: Just like this...

 

[lobelsteve]

They write the narcs at escalating doses and order the procedures. You just go along and collect the money, do all the shots. Own the ASC and UDS company.

 

[Ferrismonk]

If you want a midlevel, I would recommend a PA instead of a NP. In my experience they have a completely different attitude towards the physician. Also, I have a serious problem hiring/supporting anyone who's professional organizations are actively trying to push out physician-directed healthcare. Usually it's the nurses.

Practically speaking, use your PA as what they are; an "assistant". Each PA should have a provider agreement where they follow established guidelines you give them. I use mine to see routine follow-ups on low-dose opiate refill patients. I've made my practice guidelines clear to him and he follows them. He will also answer messages in my patient portal. You don't need a fellowship trained anesthesiologist to determine if a neurontin refill is appropriate. I also have him do practice-improvement projects from time to time such as redoing patient-information handouts, etc.

Don't let money or more procedures be the reason you hire a PA, hire a PA so you can see more new patients and focus your time on the more complex/difficult patient problems and work at the top of your skill set.

 

[nvrsumr]

We have several practices in my area where the NPs do all procedures in physician owned asc (except stim trials) and write narcs with q monthly uds in physician owned “lab”.

Practices started out hiring bottom of barrel pain docs but have slowly replaced them all with NPs. Seems like much simpler to manage nurses and very successful financially. The referring pcps could care less as long as narcotic scripts taken off their plate.

This is the future of pain med imho.

 

[drusso]

We have several practices in my area where the NPs do all procedures in physician owned asc (except stim trials) and write narcs with q monthly uds in physician owned “lab”.

Practices started out hiring bottom of barrel pain docs but have slowly replaced them all with NPs. Seems like a much simpler to manage nurses and very successful financially. The referring pcps could care less as long as narcotic scripts taken off their plate.

This is the future of pain med imho.

NP's provide the additional benefit of not being tied to the MD/DO's license. They stand on their own from a liability perspective. They are also more "controllable" in the sense that older generations of NP's still feels some fealty to the medical hierarchy. This is eroding quickly.

On the other hand, having a PA is like owning a race-horse: Barn rent, feed costs, etc. They are tied to you professionally. If you maintain medical staff privileges at a hospital, then most med staff by-laws state that you are directly responsible for their activities and if they f*ck up it can be grounds for a peer review action on YOU. Plus, if you're concerned about your license, you actually have to sit down and talk to them at defined intervals and monitor their overall health & "wellness," submit supervision agreements with the medical board, etc.

Missouri just passed a law allowing non-residency trained MD/DO's to function as "assistant physicians."

Missouri Advisory Commission for Physician Assistants

You might want to look at these kind of candidates. Could also consider an Occ Med/FP type individual. You pay a little more, but you can set them on auto-pilot and if they get sued it all on them.

 

[bluehighlighter]

We have several practices in my area where the NPs do all procedures in physician owned asc (except stim trials) and write narcs with q monthly uds in physician owned “lab”.

Practices started out hiring bottom of barrel pain docs but have slowly replaced them all with NPs. Seems like much simpler to manage nurses and very successful financially. The referring pcps could care less as long as narcotic scripts taken off their plate.

This is the future of pain med imho.

This is an interesting thought but not the path that we're trying to take...

 

[bluehighlighter]

NP's provide the additional benefit of not being tied to the MD/DO's license. They stand on their own from a liability perspective. They are also more "controllable" in the sense that older generations of NP's still feels some fealty to the medical hierarchy. This is eroding quickly.

On the other hand, having a PA is like owning a race-horse: Barn rent, feed costs, etc. They are tied to you professionally. If you maintain medical staff privileges at a hospital, then most med staff by-laws state that you are directly responsible for their activities and if they f*ck up it can be grounds for a peer review action on YOU. Plus, if you're concerned about your license, you actually have to sit down and talk to them at defined intervals and monitor their overall health & "wellness," submit supervision agreements with the medical board, etc.

Missouri just passed a law allowing non-residency trained MD/DO's to function as "assistant physicians."

The nuances b/w NP and PA were not something I was aware of...I'll definitely bring this to the group and do more research as you have recommended

 

[bluehighlighter]

If you want a midlevel, I would recommend a PA instead of a NP. In my experience they have a completely different attitude towards the physician. Also, I have a serious problem hiring/supporting anyone who's professional organizations are actively trying to push out physician-directed healthcare. Usually it's the nurses.

Practically speaking, use your PA as what they are; an "assistant". Each PA should have a provider agreement where they follow established guidelines you give them. I use mine to see routine follow-ups on low-dose opiate refill patients. I've made my practice guidelines clear to him and he follows them. He will also answer messages in my patient portal. You don't need a fellowship trained anesthesiologist to determine if a neurontin refill is appropriate. I also have him do practice-improvement projects from time to time such as redoing patient-information handouts, etc.

Don't let money or more procedures be the reason you hire a PA, hire a PA so you can see more new patients and focus your time on the more complex/difficult patient problems and work at the top of your skill set.

Have you given the PA written guidelines or is it more of a discussion regarding your expectations?

 

[Ducttape]

regardless of hiring an NP or PA, remember that you need to be the one driving the ship.

teach them how to make appropriate differentials, for you to make diagnoses. dont just throw them out there and expect to be in the procedure room 4-5 days a week, just doing procedures - that is the making of block shop.

you have to be in the office seeing patients with them, at least to start, and available to help them if they have questions. one model would be to have him follow you in to see new patients for the first 4-6 months, to learn how to examine patients and what H&P findings one would see with common pain conditions.

make ground rules. they never start opioids. they never increase doses of opioids, without direct consultation with you (and that might force you to see the patient before authorizing any changes, but thats the right way to do things).

after they get comfort with knowing what common conditions look like, you can have them see your follow ups and your med refills. it will take a while...

 

[drusso]

The nuances b/w NP and PA were not something I was aware of...I'll definitely bring this to the group and do more research as you have recommended

Strongly consider a FP or Occ Med MD.

 

[nvrsumr]

Strongly consider a FP or Occ Med MD.

Would you teach them to do injections?

 

[lobelsteve]

Hire no one. DO it yourself. Or get a partner.

 

[drusso]

Would you teach them to do injections?

No.

 

[drusso]

Hire no one. DO it yourself. Or get a partner.

Not everyone is partnership material.

 

[drpainfree]

let's face, PA or NP, it's just for additional $$$.

if you were the patient, will you go to see a doctor who feeds you to PA/NP?

but I know I'm old-fashioned...

 

[Yo GabbaPentin]

let's face, PA or NP, it's just for additional $$$.

if you were the patient, will you go to see a doctor who feeds you to PA/NP?

but I know I'm old-fashioned...

My NP actually loses money for me monthly. However she specializes is seeing my tramadol refill patients and telling my fibromyalgia patients that they don’t need norco. This saves my sanity and is worth every penny. Plus if someone calls in with a “flare up” and needs to be seen TODAY, then she is available without a three week wait.