Co-signature law

[ssiegelpa]

Is anyone else as excited as I am that soon the old and outdated law requiring your SP to sign off on all of your charts may soon be gone as long as the Senate passes it? It is such a pain in the butt to put my huge stack of charts on my SP's desk every night to sign off on so that we are in compliance with the laws. Now, it will only be for things that we feel he needs to look over or sign!

 

Next, we have to work on getting controlled substance privileges!

[LIPPER]

This rule should never have been allowed to be terminated. Signing off on charts is a fundemental way of direct MD-PA supervision. It's what sets us apart from NP's and is what the public wants. If we are classifed as midlevel providers, then we shouldn't act as independents. The SP should be forced to (if not already wanting to) review our work.

[ssiegelpa]

http://www.aapa.org/gandp/chart_cosignature.html

[LIPPER]

Siegel;

That's all very nice. Just my opinion. Personally I feel supervision is enhanced by chart review. Where in Fla are you... PM me if your prefer

[coloradopa]

This rule should never have been allowed to be terminated. Signing off on charts is a fundemental way of direct MD-PA supervision. It's what sets us apart from NP's and is what the public wants. If we are classifed as midlevel providers, then we shouldn't act as independents. The SP should be forced to (if not already wanting to) review our work.

What is a "midlevel provider"? Would you care to give a definition? Physician Assistants on the other hand are providers trained broadly in medicine who deliver healthcare along with their physician partners in a cost effective manner. They do not require direct supervision (except part time in Missouri) unlike these so called midlevel providers. Instead they practice under the mantle of general supervision.

 

Or I'll put it another way. Can you demonstrate that the "fundamenta way of direct MD-PA supervision" ie chart co signature helps protect the public or deliver better healthcare? Can you cite any study that shows the public is clamoring for chart co-signature? I'll give you a hint the national practitioner data bank does not show any correlation between requirements for chart co-signature and bad outcomes or bad acts by PAs.

 

David Carpenter, PA-C

[LIPPER]

PA's and NP's are midlevel providers. Florida PA's have it pretty good. I'm quite independent as it is...I'm in heaven.

 

Fundamental supervision (one aspect...sorry) via chart review = MD must review.. thus supervise...I guess a 2nd set of eyes isn't a good thing.

 

The public, or rather the patient population I encounter knows what a PA is, and that we're not supposed to practice independently. Many times I hear "are you going to mention this the the doctor"?... I say absolutely...Gives the patient piece of mind. Doesn't bother me at all. Not a bit.

 

direct studies? I've got no idea. You're right.

 

Can't imagine they're would be any studies like you mention...one way or another ...I'm uninformed; dare there any states that don't require supervision? Those would be the states to survey then...medical error via PA's pre signiture rule and after....

[coloradopa]

PA's and NP's are midlevel providers. Florida PA's have it pretty good. I'm quite independent as it is...I'm in heaven.

 

Fundamental supervision (one aspect...sorry) via chart review = MD must review.. thus supervise...I guess a 2nd set of eyes isn't a good thing.

 

The public, or rather the patient population I encounter knows what a PA is, and that we're not supposed to practice independently. Many times I hear "are you going to mention this the the doctor"?... I say absolutely...Gives the patient piece of mind. Doesn't bother me at all. Not a bit.

 

direct studies? I've got no idea. You're right.

 

Can't imagine they're would be any studies like you mention...one way or another ...I'm uninformed; dare there any states that don't require supervision? Those would be the states to survey then...medical error via PA's pre signiture rule and after....

You have no idea. Florida in my opinion has the worst practice act in the US (although Missouri is right up there). No schedule drugs, Must have prescriptive practice course, must have three months in a specialty before prescribing. Its like the took the worst part of Southern practice acts and then added their own unique Florida weirdness. Don't get me started about FMGs masquerading as PAs or the whole Derm thing. If you want a decent practice act look at Western States CO, UT, OR, WA.

 

You seem to have confused independence with autonomy. PA-Physician practice is based on trust. Not every PA deserves significant autonomy, but most do. Autonomy should be based on a realistic assessment by the physician of the PAs capabilities. There may or may not be wide variability in the amount of autonomy that the PA deserves based on practice setting and PA ability.

 

If you want a good example of a good practice act. Look at Colorado. II-V, scope defined by the physician, graduated supervision. This was the thing that we discovered when we actually looked at the data (not only the NPMDB but also private malpractice insurance info) the risks of medical accident are greatest at certain times in a PAs career. For new PAs the first six months in practice. For experienced PAs the first 3-6 months in a new practice. If you look at rule 400 it protects the public by mandating more intense review during these times. This puts the physician on notice that the PA practice needs to be scrutinized at these times. Otherwise the supervision is general and needs only a general review of a the PAs practice every six months. Like a good rule the SP may put stricter rules on place if necessary.

 

The goal of a practice act should be to protect the public with the minimum interference in delivery of health care. Florida fails this on multiple levels.

 

David Carpenter, PA-C

[LIPPER]

Yes, I am mixing autonomy with independence.

 

I am quite autonomous. I am not independent. I'm quite unfamiliar with PA scope of practice outside Fla. That said I'm happy with what I have. Obviously I can't speak for that many others... The ones I know do seem happy however.

 

despite practicing now for 10 years, I still haven't formed a firm opinion on PA prescription rights for scheduled meds.

 

As far as malpractice goes....My head is always on a swivel...I feel better that way.

 

I tend to throw around words like "subservient" and "supervised" probably a little too freely. I spoke to one of my SP's recently after another "controversial" thread I contributed to regarding these words. Her brows were raised with my choice of terminology. I work under 4 MD's. They don't question me anymore. But I still feel like my place is under them, not next to them. They don't make me feel that way. Never give me a reason to feel that way. That's just my opinion.

 

My problem might be that I don't really participate in the PA community. Until joining this board a week or two ago I never truely realized how polorizing many of these topics are...Guess I've been so comfortable with what I have that I ahven't looked to rock the boat pushing for change....

 

FMG's are a totally different topic. I've never encountered one. Hope I don't.

[caldje]

despite practicing now for 10 years, I still haven't formed a firm opinion on PA prescription rights for scheduled meds.

 

:eek: what valid reason, could there possibly be, to prevent PAs from prescribing controlled substances????

 

The most dangerous of all medications aren't scheduled at all.

 

If you can trust a PA with pressors, digoxin, lithium, theophyline... why can't you trust them with simple meds like cough syrup with codeine????

 

Chris

[LIPPER]

:eek: what valid reason, could there possibly be, to prevent PAs from prescribing controlled substances????

 

The most dangerous of all medications aren't scheduled at all.

 

If you can trust a PA with pressors, digoxin, lithium, theophyline... why can't you trust them with simple meds like cough syrup with codeine????

 

Chris

 

 

ever have Tussionex?.....yummy !!!:D

[Gordon, PA-C]

What is a "midlevel provider"? Would you care to give a definition? Physician Assistants on the other hand are providers trained broadly in medicine who deliver healthcare along with their physician partners in a cost effective manner. They do not require direct supervision (except part time in Missouri) unlike these so called midlevel providers. Instead they practice under the mantle of general supervision.

 

David Carpenter, PA-C

 

Lets just cut straight to the chase. Many of us PAs are de facto independent providers. The last time an MD signed one of my charts was about 5 years ago. The last time I got an MDs approval to give a drug was about 3 years ago. The ONLY "supervision" I have is when I'm in the OR and its only for the most critical 10% of the case. I run the floor solo with no oversight. I'm an independent provider on the floor.

[LIPPER]

you da man. Obviously you're smart, and have an excellent relationship with your SP.

 

But is this truely what was envisioned with the creation of the profession...Or what has come to be expected by the medical population?

[d2305]

:eek: what valid reason, could there possibly be, to prevent PAs from prescribing controlled substances????

 

The most dangerous of all medications aren't scheduled at all.

 

If you can trust a PA with pressors, digoxin, lithium, theophyline... why can't you trust them with simple meds like cough syrup with codeine????

 

Chris

 

We can't legally prescribe lithium either, but they have a blue ribbon panel working on it.

[AlmostDone2011]

I'm a tech in an ER and I wanted to give my two cents seeing what happens between Drs, NPs, and PAs.

 

There is no difference between PA and NP at the clinic and that is determined by the medical chief. NPs get signed off at the end of the day the same way the PAs do. I looked the Job description for Hiring and the hospital specifically has hired PAs Tend to Level 4-5 Acuity Patients (?Flu, DramaQueens, Suturing, Broken bones)... Young PAs will literally only do 4-5 Acuity PTs. With more experience they are moved to Level 3 PTs which require more of a work up.. One of the full time PAs who has been doing it 20 years is well respected and will do everything except a cardiac arrest.

Seems to me the determination of who takes what is based on a couple aspects... Salaries, Experiences, Relationship with who ever the Doc is that day.

 

As for Drugs I talked the PAs.. They can Prescribe anything here that the Doc can.

As for signing off, I have been asking the Doctors... They dont even look at it because they have too much work to do themselves.. They just sign... in every case the PA is liable for proper charting... If they are doing a big work up where some major ordering is being done.. well the doc is standing right there, if he or she doesnt agree with something the PA is doing, the doc can override it with no problem...

While talking to the PAs they like having an extra set of eyes and a second opinion and do this quite often.

[ssiegelpa]

I love having a second set of eyes looking at my charts when I have questions about things, but for them to look over the charts for every cough and cold makes the SP's job that much harder. So, I would like it for my SP and I to sit down and discuss which charts he wants and I want him to sign off on.

[coloradopa]

I love having a second set of eyes looking at my charts when I have questions about things, but for them to look over the charts for every cough and cold makes the SP's job that much harder. So, I would like it for my SP and I to sit down and discuss which charts he wants and I want him to sign off on.

More importantly it promotes a lack of vigilance. If 99% of the charts don't need any input it becomes 100% no input. The better way to do it is have clear expectation about when input is needed and open communication so that if a PA wants additional input its available.

[Gordon, PA-C]

I love having a second set of eyes looking at my charts when I have questions about things, but for them to look over the charts for every cough and cold makes the SP's job that much harder. So, I would like it for my SP and I to sit down and discuss which charts he wants and I want him to sign off on.

 

Thats all fine and good, but the MDs are gaming the system. I bet you he's billing for ALL of those charts, even though on 99% of them the doc A) never saw the patient; B) knows nothing about hte pt because they didnt read the chart; C) didnt get any checkout from the PA because it was an "easy" case that didnt require his supervision.

 

Docs should not be able to bill for PA services if they never see the pt, never talk about it with the PA, and never write a note/sign in a chart.

[EMEDPA]

The better way to do it is have clear expectation about when input is needed and open communication so that if a PA wants additional input its available.

 

agree- where I work we have to present admissions informally to the doc before the pt goes to the floor for a cosignature. if it's involved I do a presentation. if it's straightforward it's" hey bob, can you sign this? this guy has an appy and is going to the o.r."

most sp's who have to sign charts read MAYBE the dx and plan only. many just stamp them all. I agree with david that new grads and folks new to a practice require more supervision and those with more experience and time in their specialty require very little supervision. my state requires the sponsoring physician have an ongoing awareness of pracice trends. the cosignature requirement is from the hospital, not the state.

as for scheduled meds I think all pa's should be able to write for sch 2-5, just like a doc. one indication of a state with a pa friendly practice environment is the ability of it's pa's to do this. both states I currently practice in allow this.

[coloradopa]

Thats all fine and good, but the MDs are gaming the system. I bet you he's billing for ALL of those charts, even though on 99% of them the doc A) never saw the patient; B) knows nothing about hte pt because they didnt read the chart; C) didnt get any checkout from the PA because it was an "easy" case that didnt require his supervision.

 

Docs should not be able to bill for PA services if they never see the pt, never talk about it with the PA, and never write a note/sign in a chart.

Its perfectly legal to bill for PA services without seeing the patient. Thats the definition of general supervision. We are assumed to be capable of handling patients within our scope and experience. It is assumed that we are capable of calling if we have questions.

 

All billing for PAs occurs under either the physician or the clinic. So if they are billing for the PA under the PAs NPI number for Medicare they within the law. Commercial carriers for the most part require that PA services are billed under the physician. There is no requirement by either Medicare or most insurance companies that the physician have any input into the case unless the state law requires chart review.

 

David Carpenter, PA-C

[Guest gimlet72]

The only reason they wanted to pass the Co-Signature bill is because NP do not have their charts co-signed. This bill was not meant to give PA's more independence it was just to level the playing field. The truth is MOST doctors do not read the 20-30 notes that the PA did that day, they will just go through and sign them. In order to have a good PA - MD relationship the doctor must trust the PA's decision making ability. If that is in place then there is no need for the doctor to co-sign every note

 

Even though legally they will not have to be signed many hospitals will still require co-signatures in hospital notes.

[Contrarian]

Lets just cut straight to the chase. Many of us PAs are de facto independent providers. The last time an MD signed one of my charts was about 5 years ago. The last time I got an MDs approval to give a drug was about 3 years ago. The ONLY "supervision" I have is when I'm in the OR and its only for the most critical 10% of the case. I run the floor solo with no oversight. I'm an independent provider on the floor.

 

 

Isn't this fraudulent...???:rolleyes:

[PADad]

More importantly it promotes a lack of vigilance. If 99% of the charts don't need any input it becomes 100% no input. The better way to do it is have clear expectation about when input is needed and open communication so that if a PA wants additional input its available.

 

The signing of charts (all, random 10%, etc. is in know way effective in impoving quality. This is studied and proven.

 

However, some sort of oversight based on risk or probability is helpful in avoiding errors and improving quality. This is essentially a second pair of eyes guided by an evidence base.

 

I helped to implement a clinical managment system with Kaiser Permanente that enabled the SP and PA to decide which types of patients, patient parameters, and diagnoses the SP would review. This was completely customizable. SP/PA teams wanted different levels of review that fit their purposes.

 

We also had physicians reviewing selected physician work and specialists checking on specific types of cases ID'd by diagnoses. Our hospital uses pharmacists and infecetious disease MDs and RNs to check on an array of diagnoses and treatment decisions - making recommendations to the attending provider. Hospitals in our collaborative have experienced a >75% reduction in CABSI and a >60% reduction in SSI.

 

PAs and MDs need to more familiar with truly effective forms of QI.:D

[EMEDPA]

I helped to implement a clinical managment system with Kaiser Permanente that enabled the SP and PA to decide which types of patients, patient parameters, and diagnoses the SP would review. This was completely customizable. SP/PA teams wanted different levels of review that fit their purposes.

 

.:D

 

so that was your fault?:p;):D

I'm there just a few hours/mo now(typically 4 ) as a per diem clinician. in my state the requirement is 10% or 10 charts whichever is more.

I see less than 100pts/mo there now so I just pick 10 charts/mo for review based on interest or acuity(admissions, etc).

[ssiegelpa]

Hate to bring up a dead thread. But, I am at a new job now and since they got rid of the requirement for co-signature in Florida I had a question. They are requiring that the physicians co-sign all of the charts of the patients that I see, no matter what. Are there any legal issues with this? Given that I did not discuss the case or review the case with the doc. Thanks for any help.

[ssiegelpa]

Hate to bring up a dead thread. But, I am at a new job now and since they got rid of the requirement for co-signature in Florida I had a question. They are requiring that the physicians co-sign all of the charts of the patients that I see, no matter what. Are there any legal issues with this? Given that I did not discuss the case or review the case with the doc. Thanks for any help.