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Everything posted by NeoTrion

  1. CAdams, I just discussed this on a post with our legislative committee. This person kept saying we need our physician "partners" to gain traction with our agenda. I did state that's why this is important it is also important that there is mutual respect between the two parties to be "partners." If there were respect I think they would allow an independent PA board, but they keep thumbing their nose at our board in different ways.
  2. SAS I am on the committee and can attest we didn't have anyone drop out like they usually do. You can always attend the meetings as a TAPA member. I think I am looked at the same as you are, and I have been on the committee for 3 years now. There are usually openings on the off years. The on years that we push legislation always have many that want to serve. Either way I would look forward to working with you in the future. Any idea when the voting results will be announced for office?
  3. Cideous might be time to put up. You cant complain if you don't participate. Consider running for office or getting involved. There are more people in TAPA that would embrace change than you think. But remember majority rules.
  4. TAPA has put these bill forward for consideration. HB 2250 (Lucio III)- Schedule II bill (Senate companion- SB 1308 by Buckingham)HB 3970 (Sheffield)- Mental Health recognitionHB 3128 (Price)- Concussion forms (Senate companion is forthcoming from Perry)HB 4066 (Beckley)- PA Practice ManagementHB 2907 (Darby)- Delegation of radiology interpretation and diagnosis (PAs will be included in committee substitute) TAPA is also supporting SB919 and companion bill HB1592. Feel free to take a look at these bills on the Texas web site. I know SAS has run for office, but it is easy to complain about things when your not part of the solution. Run for office or ask for placement on a committee and make your voice heard. I think why there isn't much support for HB80 is because a large amount of PAs do not want to support what they see as degree creep. We have our share just on this board.
  5. When this issue has not been tabled by the TMB. The can was merely kicked down the road, at least this was the latest information on the legislation committee. TAPA sent the call to action for Texas PAs and SPs to email, snail male, etc... the TMB concerning this rule change. Believe it or not Scott Freshour (TMB cousel) admitted on a government relations call that "it was poorly written rule targeting independent clinic practices with no physician or radiologist over read at any point, but was not intended to change normal workflow in hospital or clinic practices." I have heard in the back channels that he and the president of TMA were responsible for writing this "poorly written rule," but honestly that is just back channel communication. He went on to say he had been overwhelmed with negative responses. So now they are actually willing to talk and have a stakeholder meeting to try and develop consensus before moving forward. This matches with what some of us that are connected to back channel in the TMB are hearing. We had requested a stale holders meeting before the wave of opposition hit, and at that time they weren't responsive. Now they want to talk about this and have been open to a stake holders meeting. Some members that should be invited to the stakeholders meeting have yet to be invited, and were politely told there is not plans to invite them. They were told they could attend as a member of the general public. Next meeting with TMB is March 1st, but I doubt they can get a re-write done and approved by that time. It will probably end up being in the summer. This update was sent out to members over email. TMB is still concerned that this radiology interpretation is not something that can be delegated to us by a physician. As I see this it is just to let the fire cool down a bit, and hope we get distracted by other pursuits on the legislative agenda. I am still encouraging members and non members alike to at least still send their opposition points to the TMB to keep the pressure on. We are also asking Texas PAs to send a copy of what they send to TAPA. We all know government has a habit of misrepresenting the numbers, and this serves as a possible point of contention for TAPA to challenge the number of dissenting emails TMB received. I have heard that TMB will take this up anytime between March - July. Mind you TAPA proposed a rule change for this (rule 185) before the TMB and TMA proposed their restrictive rule (193). TAPA's states this is decided at the clinic site with the SP. Ours was approved and recommended by the PA board and sent to TMB for review. At that point that is when TMA countered with their rule. We pushed our rule through the proper channels due to hearing rumors that TMA was going to introduce restrictive legislation on this. It is also hasn't helped that the push for straight independence by Texas Nurse Practitioners has finally awaken TMA and TMB. They have sent out multiple position statements basically calling out NPs. In this link we are not mentioned at all, but they are definitely going after Texas Nurse Practitioners. https://www.texmed.org/Template.aspx?id=49527. It looks like TMA finally said enough is enough. We are essentially getting hit by the splash damage used to go after them, even though we are not named in the above article. I have also been told that Texas Nurse Practitioners have also tried to go for a Nurse Practitioner Compact like the RNs have. It is looked upon as a backdoor method for independence. If an NP is independent and licensed in a state within the compact, then they want to be able to work in Texas, but be governed by the restrictions in the state were they are actually licensed. This would effectively give them backdoor independence in Texas, even though they have gone for independence in Texas for multiple years. There bill has never made it out of committee. I don't know how true that it is, but I have heard some of the doctors talk about and are concerned. This could be simply fear mongering. At any rate the American Academy of Emergency Medicine has also voiced their opposition to PA's in medicine in the following link. https://www.aaem.org/current-news/aaem-takes-a-stand-on-the-use-of-apps-in-ed . There was a PA that was invited to speak at the Texas College of Emergency Physicians conference this year. His invitation was withdrawn after the AAEM published their opinion. The topic was "of PA utilization in the emergency department. They stated they wanted a "Physician Perspective." SAS if you haven't seen Eva's response to TMB, I think you would be proud of how it was written. As a member of both PAFT and TAPA I was happy to see the language. Has PAFT sent anything to TMB concerning this rule? As a member of PAFT I would like to know if they are planning anything on their end to support TAPAs efforts or if they plan to attend the TMB meeting as well.
  6. SAS it is good to see that you decided to take the bull by the horns and give some new leadership to our state org. I would like to echo to every Texas PA on this board to send in your opinion ASAP. Legislatively TAPA is working on this, but we need stated opinions behind us. Some feel that this may have been a swipe at OTP or NP OTP in the future.
  7. It would definitely be helpful if PAFT would get involved with this. The more pressure the TMB feels than the better. Since this would also affect NPs it would be helpful to get them in the loop as well. I think TAPA is also reaching out to AAPA for help. We really need to get Texas PA's and our special interest groups on this one.
  8. I have since left this position due to other issues as well. He saw things as a team approach and could not understand why I had an issue with this. Of course this is the same SP that dumped his schedule on another PA and myself, because his wife decided he had to go get a haircut...... Again he stated we are all a team, but if we were sick he would not take our patient's. After both of us left he stated he would no longer higher any more PAs or male providers. Awesome stuff there.
  9. I was looking at Lynchburg personally. Do they also require a fellowship as well, or do they use your current practice as a fellowship?
  10. NeoTrion

    TAPA Elections

    Just wanted to say good luck to those running for office. I took a look at the position statements and have my favorites. It is nice to see some of the more outspoken people run for office. I have been fortunate enough to have worked with enough people on the list, or have been heavily influenced by them in lieu of lively discussions on this and other venues. I think we are in good hands with the choices we have this year.
  11. Of interest, a few vaccines induce a better immune response than natural infection: Human papillomavirus (HPV) vaccine — The high purity of the specific protein in the vaccine leads to a better immune response than natural infection. Tetanus vaccine — The toxin made by tetanus is so potent that the amount that causes disease is actually lower than the amount that induces a long-lasting immune response. This is why people with tetanus disease are still recommended to get the vaccine. Haemophilus influenzae type b (Hib) vaccine — children less than 2 years old do not typically make a good response to the complex sugar coating (polysaccharide) on the surface of Hib that causes disease; however, the vaccine links this polysaccharide to a helper protein that creates a better immune response than would occur naturally. Therefore, children less than 2 years old who get Hib are still recommended to get the vaccine. Pneumococcal vaccine — This vaccine works the same way as the Hib vaccine to create a better immune response than natural infection. So, in summary, vaccines afford us protection with lesser quantities of virus or bacteria and the control of scheduling the exposure. https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-safety/immune-system-and-health It seems you are advocating for infection of healthy individuals when the disease is far worse than the vaccine. Risk vs Benefit of natural infection vs. Vaccine seems pretty clear cut. Your original assertion was somewhat invalidated by the above. As you said, immunology 101. Please post your peer reviewed source as originally requested. At this time the science is on the side of Vaccination and not natural infection due to risk vs benefit of Vaccine vs Natural Infection. https://www.cdc.gov/vaccines/hcp/conversations/downloads/vacsafe-understand-color-office.pdf
  12. To be honest they did not talk about taking levels. They were all about just giving a low level supplement indefinitely. The advise starting every patient on low level vitamin ADEK2. It was mainly recommended to have this replacement to decrease the risk of Osteoporosis and Heart disease. This is recommended in Japan due to the findings of several trials that dealt particularly in postmenopausal women. It is basically the same information that is coming out about Vitamin D and how some studies feel that a more optimal level is above 65 now. Not saying I am a believer, but it I do keep it in the back of the brain pan.
  13. I personally work in a clinic and don't come across this issue much. We do come across non-compliance a lot. My SP has a very low tolerance for non-compliance. If a patient is a danger to society and does not want to follow the treatment plan I do not see why you cant discharge them. We will maintenance for one month from release and that is it. 75% percent come back after researching the treatment plan for themselves (either by getting a second opinion or by doing their own research). If you go to a cardiologist and the do not want a heart cath, then why continue to treat? Are there any viable alternatives Yes/No? No? Then please seek care elsewhere. What a about a surgeon that needs to do an open appendectomy, but the patient doesn't want any scarring. You don't ask a surgeon to go through the anus to make the patient happy. You all can scoff at these examples but I have seen them happen or patient's make these requests. Personally I feel there is nothing unethical about discharging or refusing care for a patient that does not follow the treatment advice (with the exception of EMTALA). Let them search for another provider that will tell them what they want to hear. Health care is not a right and is a privilege in the United States. We can debate if it should be, but it is not a right. I only have so much time to help the patient population I see, and I am not going to waste it on non-compliance. I am also not going to put another patient's life at risk (as in the case with Vaccines) because someone does not want to follow my treatment plan. A child that is actually allergic to vaccines and is on chemo should not be exposed to another child who's parents "did not want them." I would submit that should the patient or child's family that is not able to be vaccinated when exposed to a diseased non vaccinated child that could be vaccinated but wasn't, could be considered involuntary manslaughter by the patient's guardians of the other child. While we in the United States talk about individual rights, what about the safety of society, and those that are the most vulnerable in society? I would say to the non-compliance issue on a patient (say diabetic), if it only effects the patient only then so be it. That is his/her personal choice. But I do not have to watch you self destruct your health as you fail to follow my treatment plan, or even try to follow it. We are wasting each others time, and I have other people who want healthcare that will follow the treatment plan. But once the personal choices impact society, then were is the ethical dilemma there? People with active Ebola have a right to be free as well. Do we let them run around society or do we quarantine them for the public health?
  14. I did Rheum for multiple years. I have never asked primary care to write my scripts or restart my biologic medication. MTX is definitely something that labs need to be monitored on restart, or at least that is how we did it. Make them attend to their own mess. Pretty soon you will be stuck chasing labs, and they will conveniently forget they said restart MTX. Hydroxy is so much of a problem, but I have no issues restarting my own meds. Plus they might want to lay eyes on him/her before restarting a medication that may have contributed to the hospitalization.
  15. I went to conference where this was discussed. Vitamin K2 does not effect blood thinners, but I will admit it was a BioTe conference. Several MDs in different disciplines were presenting, so it wasn't like unproven science or a chiro presenting.
  16. SAS, you and I have talked/debated a number of times about subjects on the Huddle. You and Melinda convinced me to get more involved in TAPA; mainly in a grassroots effort to have my point of view heard. Rev I know exactly whom you are talking about, and I was on a conference call with him not to long after this issue came up. SAS I think you hit the nail on the head. You have to become involved and make an attempt to become more involved to complain. I think we have way to many keyboard warriors that cry out for change, but do very little to make change happen. Personally I didn't see Facebook postings as a wanted poster, but of course I wasn't on the wanted poster. I tend to agree that when you hold an office, you do open yourself up to ridicule. It comes with the territory, but I wouldn't expect holding a TAPA office would open my family to threats of physical violence. I am a bit concerned about how the Texas delegates voted. I was part of the legislative committee when this came out, and was more than a little surprised that this was only talked about among the upper level of leadership. Most of what we have been working on in the committee has been geared toward a very different strategy in the future. While I wasn't totally upset with what I read, I was surprised by the wording in the resolution. I was also told that letters and communication with the AAPA delegates would not change how they voted. This does puzzle me especially since they are suppose to represent TAPA, and by extension the membership of TAPA. I got the distinct feeling that the decision had already been made to support the resolution, and pressure from the membership was going to do absolutely nothing. I think the delegates were mainly voting with the will of the Board of Directors. Perhaps I just need more education on how TAPA/AAPA delegates vote, but I was told on this conference call that "it didn't matter what was said to the delegates." Maybe there was some fear after it was advertised whom the delegates were, and as a result all communication was closed. I also have to admit that some posts on the Facebook group were pretty out of line. It is ok to disagree and be civil, but calling people names is for junior high school students. It comes to down to one thing - Participation. I did post in the Huddle that if people were so up in arms about this resolution, that they should go to New Orleans and be heard. The floor was to be open to AAPA members as well as delegates. This is where the newer the generation of PAs can take the bull by the horns and lead. I am a firm believer in listening to some of the PAs that have been in the action and know a thing or two. Respect the people that came before you, but think with your own mind. Make your own decisions and lead with them. But make sure you lead and stay behind a keyboard to make a point!
  17. Any chance you can give me a link to this law/rule? So to be clear if I see a patient that is brand new to the clinic and make diagnosis-es, that has to be build under my NPI? What if he personally introduces himself and says he agrees. Then he goes back to his own schedule? Does that satisfy the requirement?
  18. This question came up during a conversation at lunch today. We have a physician that loves to send us labs that he ordered. We were just curious that in a clinic setting, is interpretation of these labs billed under whomever ordered the lab? The physician often orders labs and pushes them toward the NPs and PAs without telling us what he is looking for. I have occasionally have had my SP come behind me and order Rheumatology labs without telling me what he is looking for. The way I was trained is that if you order the lab, then you own the lab. For a while I would send them back saying I didn't order this, and got called out in a staff meeting. I stood my ground saying "If you would communicate to me exactly what you are looking for, I would be able to provide better care." Of course this didn't sit right with the SP. It was agreed at the meeting that communication needs to be improved for this to happen. Unfortunately this didn't happen and my SP continues to do this. My question is interpretation of labs a separate charge, or is it built into the cost. We are a clinic with our own lab. I just want to know what the thoughts of the brain trust are!
  19. I just wanted to write and see if someone with more wisdom can answer some questions. I and a peer work at a duel specialty that also practices allergy testing in Texas. Currently a PA sees all the new and established allergy testing as well as clinical consults. There were some issues with our scheduling software, and it was found out that these patient's were being scheduled and billed by the physician for 100% reimbursement. This was being done when the physician was not on site (sometimes not in the state), and never laid eyes on the patient. He was not co-signing the notes either. After we found out about this, we did use the F word (fraud), which quickly got his attention. We were called into his office and were informed that this was approved by the ABIM (American Board of Internal Medicine), and was completely legit. He also said that since he follows up with the patient after that visit, that it is completely legit. The thing is that he follows up with maybe 25% percent of the patient's that are initially seen by the PA. He was very straightforward in saying that the reason why they do not bill under the NPI of the actual provider is because then they do not get 100% reimbursement. We pointed out that the ABIM will not stand by you if the practice gets audited by the state or federal authorities. He became very defensive and ask what we wanted to do. We all stated we were educated that to bill us to see those patient's and for him to bill 100% under his NPI, he must have face to face contact with the patient or co-sign the visit note. He said he would be willing to just pop in and say hi. Well that lasted for about a week and half, and he decided to go home a couple of times because he was tired. He then started co-signing some of the charts, but there is no further direction on what his plan is. The primary physician did say that the other physician that is on site will have these visits charged under their NPI. The other physician is unable to help because they do not know what is going on in that area of the clinic. That physician is boarded in another specialty as well as internal medicine, which is well within their license to participate in allergy testing. They were unaware that any of the allergy testing was being billed under their NPI when the lead physician was gone. So here is my question. Is my understanding of the law correct that the patient has to have a brief face to face with the patient ("hi, my name is Dr. E), or cosign the chart in order to bill under their NPI? I do not see how incident to billing could be utilized for new or consult patients without meeting these two criteria. This is also considering that at times the led physician is not even in the state. I am looking for the actual law or literature that states this is legal or not legal. I was told that the clinic employs a part time billing auditor for these kind of situations. Personally I would like to talk to this auditor with information either confirming my thoughts, or educating me on this type of billing they are utilizing. I have already found issues with her insistence concerning the percent of chart audits. That law was changed in Texas at the prior legislative session, so I know some of the information she has given is somewhat inaccurate. It is also within her best interest. If she has missed something, it does benefit her to tell me something to shut me up. I think this goes along with the old adage, "If you can't impress them with brilliance, then baffle them with BS." We also work under the physician practicing another specialty in the clinic, and see our own patient's in our own POD. I am unaware if he is billing this under our NPI or under his. All new patient's do go through him, but follow up visits with these patient's are seen by the PAs or NPs. This physician also does not co-sign the notes or do a face to face with the patient. I have no idea how this is billed, but that would be the next logical question for me to ask should I find information affirming my suspicions noted above. Any advice would be greatly appreciated.
  20. Yes, this was placed in the sunset bill I believe. You still have the option of a temporary if needed. I would say that one to two months is the average now. Hopefully you have it by now.
  21. Well mistakes are made and we learn from them. I was told by an older PA to not carry multiple state licenses because you eventually have to account for them. He also told me never to let one expire. Depending how it is listed on a web site, it may look like it was revoked to a potential employer. I can tell you that it isn't easier for new graduates. It is somewhat easier for you to get a license in Texas from another state. The fact that your license expired complicated the matter. As I recall Texas is one of the harder states to get a medical license issued. I have worked with multiple MDs that run into trying to get a license here and have to wait 2 months usually. Sorry this happened to you, but it is the bureaucracy.
  22. Honestly it depends on how soon your started the process. I know I was in licensing for at least a month or two before my temporary came through. Of course that was before the changes that were just made with the board meeting more. I know that has no bearing on a temporary, but there was more in flux at that time. I think they are better about getting things moving these days. I had to get the name of my licensing agent and check with them weekly. I had multiple instances of TMB saying they didn't get something when I had a signature showing it did. It didn't hurt to stay on them to make sure these things either got resent or "found."
  23. I did get a response from TAPA on this matter via the Huddle. At that time they stated they were waiting on the AAPA to decide and that they would state their position after. Well AAPA has decided and we still have yet to hear from them. We also have a state association that tried to bargain putting anesthesia assistants on our practice act in order to gain support for other en-devours they were working towards. It is true that in Texas things are becoming very pro NP. While PA's are not permitted to own a majority share of a healthcare practice, a NP has no problem with it. According to TAPA it is because they put limits on PAs, but seemed to forget about NPs. As long as an NP has a RN license then she can technically own the company do "monitor the public health." Our state organization has said it is a definite gray area, but said that NPs are breaking the law. I invited them to tour the Texas panhandle, to see these NP owned practices but have heard nothing.
  24. Not to resurrect a to old of a thread but I have found something that might help. Mind you right now they are only publishing 2014 values, but this will give you a ball park estimate of what was going through your NPI. We have had almost the exact situation at the practice I work at as well. If anyone has any other way I would be open to exploring this further. data.cms.gov/utilization-and-payment-explorer
  25. Had a similar problem in Amarillo. I our case they were saying NPs can practice medicine and need no co-signatures but PAs did. The hospital admins (all RNs except for the CMO) based their argument on a position statement posted by the board of nursing that did not recognize PAs. We fought it with the help of TAPA and the involvement of the TMB. It still took us a year to get everything straitened out, and I can't say things are perfect but it was a decisive win for us. Our administration knew very little about PAs. They knew a lot about NPs (some not always true) due to almost all of our administration consisting of RNs. Give TAPA some time help out. We were making little progress until we go them involved. Good luck!
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