What are your thoughts on the proposed 2021 CMS policy changes

kirktodd0

2+ Year Member
Feb 23, 2017
6
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And specifically this line is what I'm wondering about

In the FY 2021 IRF PPS proposed rule, CMS is proposing to allow non-physician practitioners to perform any of the IRF coverage service and documentation duties that are currently required to be performed by a rehabilitation physician, provided that the duties are within the non-physician practitioner’s scope of practice under applicable state law. CMS is also soliciting comments from stakeholders on further ideas to reduce provider burden, as well as on proposals to codify subregulatory guidance on preadmission screening documentation and certain other IRF coverage requirements.

As a disclaimer I am not a PM&R physician (yet) but does this look like a worrying trend? As midlevels' scope of practice continues to expand will IRFs just hire them instead of physicians to save money? We've already seen the VA decide to allow CRNAs to work unsupervised, a decision which was strongly opposed by the ASA.
 

DMBandFan86

7+ Year Member
Aug 5, 2011
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I'd expect it to happen at some time, if not this year or the next. This proposal isn't going to go away even if we fight it off year to year.

In my opinion, IPR is going to the hospitalists. Partially due to sicker patients, but also due to years of many physiatrist refusing to treat basic medical conditions or take call for medical issues. I think PM&R will eventually just be a consultant on patients only when the primary team needs help in management.

To be honest, when I was working as a consultant in IPR in residency I usually felt like I wasn't doing anything. TBI and some SCI can benefit from being see 3-4 times per week depending on their condition. But most of the time we would even defer bowel/bladder and pain management to medicine services. All I felt like we did as consultant was say hello to the patients, call family, and run panel meetings. Unfortunately I'm pretty sure a NP can be trained to do that. Obviously that's not reflective of how everyone practices, but I've seen it quite a bit.

On the other side, the hospitals that have PM&R as the primary service currently probably won't change much even if the rules change.

Some advice to a medical student going into PM&R: it is always a good idea to ensure you develop the skills in residency that will put you above a mid-level so they can't replace you in the future. Whether that is mastering ultrasound MSK diagnosis, EMG, interventional procedures, getting fellowship trained in TBI or SCI, cancer rehab, sports, spasticity, baclofen pumps etc it just sets you a bar above the mid-levels. Remember it is mostly business people and politicians who set these rules and not physicians, so they are looking to cut costs at every corner.
 
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PMR2008

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Some advice to a medical student going into PM&R: it is always a good idea to ensure you develop the skills in residency that will put you above a mid-level so they can't replace you in the future. Whether that is mastering ultrasound MSK diagnosis, EMG, interventional procedures, getting fellowship trained in TBI or SCI, cancer rehab, sports, spasticity, baclofen pumps etc it just sets you a bar above the mid-levels. Remember it is mostly business people and politicians who set these rules and not physicians, so they are looking to cut costs at every corner.
Could not have said it better myself. Competition is good. We need to stop complaining and prove our worth. Show better outcomes for a lower price. Unfortunately for inpatient rehab it is too late now.
 
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Kissmyabjj

5+ Year Member
Mar 18, 2014
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I treated a lot of medicine issues with my patients during residency. So I was surprised to moonlight at a IRF earlier during my fellowship where the physiatrist I was covering for did essentially nothing. Didn't typically order labs or imaging, and had medicine see all of his patients daily. It was actually a tough adjustment because I felt like I had to run everything by the NP on the medicine service before I ordered anything in order to avoid duplicating efforts.

I honestly don't see how this kind of practice is going to remain viable. Even if you are TBI or SCI fellowship trained, unless you work in academics doing research or perform procedures in clinic, there is really nothing that you do on a daily basis on inpatient that can't be done by a NP or PA. Even treating the medical issues unique to these populations can be learned in a few months by someone with a lot of medicine experience.

I have tried to spend as much of my time during my sports fellowship doing fluoro, electromyography, TONS of ultrasound, and learning acute MSK/fracture care. If all you can do as an outpatient physiatrist is rule out red flags, order imaging, and prescribe NSAIDs and gabapentinoids for neck and back pain; and perform knee and shoulder injections for chronic arthritic pain, I don't think you are safe either.
 

PMR2008

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If all you can do as an outpatient physiatrist is rule out red flags, order imaging, and prescribe NSAIDs and gabapentinoids for neck and back pain; and perform knee and shoulder injections for chronic arthritic pain, I don't think you are safe either.
Strongly agree! I personally know a few Physiatrists who were replaced by PA's in ortho practices for the exact same reason. Bring a skill to the table that is not easily replaceable.
 
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blue.jay

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Feb 5, 2014
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I'm not PM&R but don't you think the goal of medschool+residency is not to be replaced by someone with half the training? Midlevels always claim they aren't there to take any doctors job blah blah blah. I don't think 1 yr or 2 yr fellowship should be needed to get a job in any field. It's easier to train midlevels to do simple procedural task than complex thinking. Are we wasting more time learning concepts we don't need or more training which doesn't apply to our daily practice? Should we reevaluate our training length? Or else we have to protect our turf from midlevel encroachment. There should be one path to medical education and practice and just one common insurance. Capitalist greed created these midlevels so that we fight amongst ourselves while higher ups reap the rewards.
 
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90dayMD

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I'm not PM&R but don't you think the goal of medschool+residency is not to be replaced by someone with half the training? Midlevels always claim they aren't there to take any doctors job blah blah blah. I don't think 1 yr or 2 yr fellowship should be needed to get a job in any field. It's easier to train midlevels to do simple procedural task than complex thinking. Are we wasting more time learning concepts we don't need or more training which doesn't apply to our daily practice? Should we reevaluate our training length? Or else we have to protect our turf from midlevel encroachment. There should be one path to medical education and practice and just one common insurance. Capitalist greed created these midlevels so that we fight amongst ourselves while higher ups reap the rewards.
Well then a lot of reevaluation needs to be done if we are going to think that midlevels can be physicians. Why do we take pointless boards and USMLEs and take all this non sense type of BS courses?

Let's go from high school to a 3-4 year medical program and then straight into residency, perhaps decreasing the number of residency years. LEt's get rid of boards, licensing nonsense, etc.
Bc if we are saying that nurses with an online degree can do the same job - why are we being forced to do all these onerous requirements?
 
Mar 26, 2020
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Well then a lot of reevaluation needs to be done if we are going to think that midlevels can be physicians. Why do we take pointless boards and USMLEs and take all this non sense type of BS courses?

Let's go from high school to a 3-4 year medical program and then straight into residency, perhaps decreasing the number of residency years. LEt's get rid of boards, licensing nonsense, etc.
Bc if we are saying that nurses with an online degree can do the same job - why are we being forced to do all these onerous requirements?
 

blue.jay

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Feb 5, 2014
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Because doctors are jokers. We do 2-3 year fellowship then later hospital will decide to hire a NP and ask you to train them. Then few months later they call themselves NP dermatologist, NP endocrinologist, NP hospitalist, Nurse anaesthesiologist, whatever bullcrap
 

90dayMD

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Because doctors are jokers. We do 2-3 year fellowship then later hospital will decide to hire a NP and ask you to train them. Then few months later they call themselves NP dermatologist, NP endocrinologist, NP hospitalist, Nurse anaesthesiologist, whatever bullcrap
Yep quite ridiculous.
 
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