What is the deal with PA's?

[dradams]

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I haven't started med school yet and I am not real knowledgable about certain things at this point. What is the point of hiring PA's? Does it allow the doc to expand the practice and make more money? I would assume this is the case, but I really have no idea if this is true.

Thanks.

 

[raptor5]

PACtoDOC should really chime in in this.
The point is, from a business standpoint for a PA to bill X amount of dollars a year. X will vary based on their efficiency, billing, and patient load. Subtract the PA's overhead and salary from X and the physician could see 150K profit from one PA. Don't quote me on #'s b/c PA salary and overhead can be quite variably depending on geographic location and business accumen of the physician.
From the standpoint of effective and quality healthcare well that question I believe is much harder to answer b/c it depends on who you ask and their vision of a excellent healthcare. I think PA's are a versatile quality addition as long as they are not underutilized and keep within their scope of practice. This opinion comes from a business standpoint not clinical one.

 

[dradams]

That's pretty much what I figured. Having multiple PA's must increase the workload of the doc as well, correct? Otherwise, a doc could have several PA's and make huge $$.

 

[deleted6669]

That's pretty much what I figured. Having multiple PA's must increase the workload of the doc as well, correct? Otherwise, a doc could have several PA's and make huge $$.

most states limit how many pa's a single md can supervise. this # is usually <4 and many practices max out this option.multiple md's in a practice allow for multiple pa's. there are many practices with 2-3 md's and 6-10 pa's.new grad pa's require quite a bit of supervision but experienced pa's can take call by themselves and work with remote(phone) supervison to extend the utility of the practice. for more info on the pa profession see www.aapa.org
we have a few docs on the board who were former pa's, hopefully they wil add their comments here as well.

 

[dradams]

Thanks for the info. Can any primary care doc hire PA's (like a general internist)?

 

[deleted6669]

any md/do in good standing with their state medical board can hire a pa. there are pa's working in every medical specialty

 

[dradams]

I didn't realize that. Thanks.

 

[dr_almondjoy_do]

finally, a productive conversation on how PAs can enhance a practice...

thank you sooo much...

moderator, please close this before macgyver sees this! lol

 

[dradams]

So how much more money can a primary care doc earn employing PA's and does the doctors workload increase significantly by employing PA's?

 

[deleted6669]

depends on what you pay the pa and how much they bring into the practice. also consider that seasoned pa's can take call for you and make your life a little easier that way in addition to doing many basic procedures in the office(some even do sigs). new pa's require frequent supervision(think md intern) but older/seasoned pa's will only have occassional questions and require minimal supervision aside from signing whatever the minimum required # of charts/month is as required by the state.seasoned pa's can also cover the practice when you are away as long as they have a phone # for consults as needed. my state requires skilled pa's to have 10% chart review within 1 month and new pa's to have 50% chart review for the 1st year.
if you pay a new pa 65k/yr and they bill 150 k you make a nice chunk of change even after paying their benefits/retirement /malpractice/etc.
a skilled pa can demand(and get )a higher salary but will earn more for the practice and be able to take on more independent responsibilities. many docs will hire a new grad and train them" their way" with advances in salary and responsibility as they see fit.

 

[dradams]

Great information. Thanks again.

 

[MacGyver]

finally, a productive conversation on how PAs can enhance a practice...

thank you sooo much...

moderator, please close this before macgyver sees this! lol

too late! i've been lurking here all along

Seriously I'm willing to call a truce with PAs, at least for the moment. The NPs and the other non-doctors are the major threat at this time. The number of encroachers into the medical field grows daily. We have to strategize and neutralize the most powerful enemy first. Right now, thats NPs in general especially with the future DNP programs in the pipeline.

 

[dradams]

Ok, so I am going to show my ignorance again. What exactly is an NP and why are you worried about them encroaching on our jobs?

 

[iatrosB]

Ok, so I am going to show my ignorance again. What exactly is an NP and why are you worried about them encroaching on our jobs?

1. Nurse Practioner.

2. Don't ask.

 

[8744]

The real encroachers are the quacks like the chiropractors, acupuncturists, faith healers, homeopathic practioners, aromatherapists, and the like.

 

[dr_almondjoy_do]

I believe that there is a place for everyone, and if any of the "chiropractors, acupuncturists, faith healers, homeopathic practioners, aromatherapists, and the like" want to work for me, I'm fine with it as long as they bring in the revenue.

You have to please the customer, and in our profession, it's the patient and the HMO....

 

[dradams]

So it sounds as though a primary care doc could have an income similar to some specialists if he/she expands his/her practice by utilizing PA's. Would I be correct in assuming this?

 

[windsurfr]

Emedpa, what are your thoughts on this.
I am rotating at an independent IM clinic which has 3 docs and one PA. They actually feel that while the PA can bring in more dollars to their clinic, the actual OVERALL COST of healthcare (to insurance companies, etc) is increased. This is because of increased testing/referrals/etc. Do you have any thoughts?

 

[deleted6669]

windsurfr:
a new grad pa will probably order more expensive tests than a new residency grad md. many places deal with this by saying for the first x amount of time whenever you order xyz expensive test( ct, mri, esoteric serum profile, etc) or send a specialty referal you have to run it by one of the docs first. what I have seen is that over time pa practice patterns, tests ordered, referals sent, etc closely mirror the patterns of their physician supervisors as the pa's learn the practice style of the docs they work with.hiring an experienced pa can avoid many of these problems as they already have a good idea of what is indicated and what isn't or you can hire a new grad, pay them less to start and "train them my way".

dradams: an md practice utilizing pa services can make a significant amount of income> than a solo practice. an md who adds a pa instead of an md partner, while having to do a bit more supervision initially, can pocket a lot of the income generated by the pa.
for instance I work in an em practice with > 40 md/do folks and around a dozen pa's. the pa's make about half what the md's do and generate the same amount of income/provider for the group. the docs see many of the more complex pts and earn greater $/pt but the pa's see more pts overall because for the most part the pts are of lower acuity and require less time/pt. so an md spends 30 min with a big mi while the pa sees 2 abd pains and sutures a lac. both had 30 min of pt contact and generated the same income. the extra money that the pa's make above and beyond their salary and benefits package goes to the docs.don't get me wrong, we are well compensated and get production bonuses but if I see 25 patients a day/100 pts week at an average fee of $500/pt(*)=$50,000/wk =200,000/month= 2.4 million/yr generated by me you can be sure I am not getting anything near that amount back.sure, a lot goes to the facility and paying the nurses, lab techs, etc but the em docs make a lot of money for each pa they hire......

*you may think $500/pt is a little high but if you average in all the appendicitis workups/dka pts/trauma pts/facial lac repairs/fx reductions etc seen by the pa's along with the minor stuff this is a good estimate. to see the triage nurse and get in the door at our facility costs $150 before you even talk to a provider or have any workup. I'm sure they don't collect everything they bill but it's still a big # even at 70-80% collections.....

 

[threepeas]

I haven't started med school yet and I am not real knowledgable about certain things at this point. What is the point of hiring PA's? Does it allow the doc to expand the practice and make more money? I would assume this is the case, but I really have no idea if this is true.

Thanks.

I am a PA in his 1st yr of med school so I can speak on the subject.
As far as medicare billing (private insurance is different but usually follows medicare guidelines eventually) a physician can bill 85% of an MD bill for medical type encounters and 65% of an MD bill to assist in surgery. PAs typically make 50% of the MDs salary. Therefore if the PA can see as many patients as an MD safely then there is an easy 15-35% profit margin for the MD. The NP market is more saturated than the PA market and I have found they are cheaper than PAs. This movement to use mid-level practitiors is hear to stay because it makes economic sense for the greater good.
My predicition for the future:
Look at psychiatry where MDs right the prescriptions and the therapist and psychologist actually practice psychiatry. Look at family practice and urgent care where the PA sees patients and the doc cosigns charts and prescription. This is a trend that will grow for sure where MDs are figured heads, interpret complex labs and mostly right prescriptions while others meet the patients. Also look at how many white men are entering medicine. It used to be 100% now it is about 35% (based on AAMC stats). There is no more "wealth" to made in medicine and the white male is going into business. And just to sound sexist-more women in the field means shorter work hours and less pay on average. It has only been sense WW2 that physicians have made money and held social prominence at the same time. Docs will soon be like PhDs (respected, well trained and educated) but get paid peanuts. Mid-level practioners are just part of this equation. Are things MDs can do about this but that is for another thread.

 

[dradams]

Thanks, emedpa, for the informative post.

 

[OnMyWayThere]

Is there currently anything that a PA can do in the practice that a NP cannot or vice versa?

emedpa, your posts are VERY helpful here. Thanks.

 

[windsurfr]

windsurfr:
a new grad pa will probably order more expensive tests than a new residency grad md. many places deal with this by saying for the first x amount of time whenever you order xyz expensive test( ct, mri, esoteric serum profile, etc) or send a specialty referal you have to run it by one of the docs first. what I have seen is that over time pa practice patterns, tests ordered, referals sent, etc closely mirror the patterns of their physician supervisors as the pa's learn the practice style of the docs they work with.hiring an experienced pa can avoid many of these problems as they already have a good idea of what is indicated and what isn't or you can hire a new grad, pay them less to start and "train them my way".

dradams: an md practice utilizing pa services can make a significant amount of income> than a solo practice. an md who adds a pa instead of an md partner, while having to do a bit more supervision initially, can pocket a lot of the income generated by the pa.
for instance I work in an em practice with > 40 md/do folks and around a dozen pa's. the pa's make about half what the md's do and generate the same amount of income/provider for the group. the docs see many of the more complex pts and earn greater $/pt but the pa's see more pts overall because for the most part the pts are of lower acuity and require less time/pt. so an md spends 30 min with a big mi while the pa sees 2 abd pains and sutures a lac. both had 30 min of pt contact and generated the same income. the extra money that the pa's make above and beyond their salary and benefits package goes to the docs.don't get me wrong, we are well compensated and get production bonuses but if I see 25 patients a day/100 pts week at an average fee of $500/pt(*)=$50,000/wk =200,000/month= 2.4 million/yr generated by me you can be sure I am not getting anything near that amount back.sure, a lot goes to the facility and paying the nurses, lab techs, etc but the em docs make a lot of money for each pa they hire......

*you may think $500/pt is a little high but if you average in all the appendicitis workups/dka pts/trauma pts/facial lac repairs/fx reductions etc seen by the pa's along with the minor stuff this is a good estimate. to see the triage nurse and get in the door at our facility costs $150 before you even talk to a provider or have any workup. I'm sure they don't collect everything they bill but it's still a big # even at 70-80% collections.....

Emedpa,
I have no idea where you work but physicians (especially employed by a hospital) make no where near 70-80% of their production. Second, the great majority of EM physicians are paid on salary or per hour, not on production. Therefore the providers are not making money off of your service... the hospital is.

 

[threepeas]

Is there currently anything that a PA can do in the practice that a NP cannot or vice versa?

emedpa, your posts are VERY helpful here. Thanks.

I dont claim to know the laws on this subject, but here are some generalities. PAs can do whatever is with in the scope of practice of the supervising physician that A) the physician allows, and B) the state board approves (special procedures for example). Prescription writing is pretty much a non-issue these days in most states between PAs and NPs which was a big legal battle at one time. (The nursing board was always fighting PA's rights to write prescriptions.) You will see more NPs than PAs in pediatrics and ob/gyn. You will see more PAs than NPs in ER, and surgery. This is based mainly on training focus and not because of any law. In maryland NPs have to have a sponsoring MD but I dont know how that effects what the NP can due. Many NPs work with physicians and follow the MDs treatment guidelines. Getting an NP to answer this question might be helpful. Hope this helps some.

 

[PACtoDOC]

Emedpa,
I have no idea where you work but physicians (especially employed by a hospital) make no where near 70-80% of their production. Second, the great majority of EM physicians are paid on salary or per hour, not on production. Therefore the providers are not making money off of your service... the hospital is.

You are misinterpreting what EMED said. He was saying that to collect 70-80% of gross billing is average. This holds true in FP as well, as most docs collect about 70-80% what they bill. Then you take about half that and that is what most docs take home before taxes.

 

[deleted6669]

Emedpa,
I have no idea where you work but physicians (especially employed by a hospital) make no where near 70-80% of their production. Second, the great majority of EM physicians are paid on salary or per hour, not on production. Therefore the providers are not making money off of your service... the hospital is.

you misunderstod my post. the docs do not make 70-80% of what they bill, the hospital collects that. out of that chunk they pay all the expenses to run the er including salaries for all staff. I work for an independent er group that is contracted to the hospital. they get x% of each pt they see so if I see the pt instead of a doc the group makes a net profit that they can divide among thyemselves. so if I see an appy and they get $750 as the provider share and the doc does the same in the next room my overhead is less than his because I make half his hourly wage so the excess becomes "profit sharing" for the physician partners.