Should Discrimination Against PAs be Framed as a Civil Rights Issue?

[jmj11]

Okay, if you don't know me, I like to ask broad, philosophical questions that may be rooted in specific personal situation, but I'm looking for a bigger discussion than my particular situation. So, I'm not really asking what I should do, but more of what should WE do as a profession.

 

Background: I've been in a battle with the local HMO (Group Health) for months now (see also). Their patients made up 45% of my previous practice. Once I started my own clinic, to my surprise, they have boycotted it. The reasons they gave were quickly proved to be a smoke screen. First they wrote me this dumb letter that they do not allow patients to be referred from the PCP level for headache. I simply showed them the 800 + patients that were referred to me this past year at my previous practice.

 

To make a long story short, I have lots of backing from PCPs, neurologists and patients that I 1) offer care second to none in quality, 2) my patient satisfaction is far above the average and 3) I bill at a lower rate than neurologists for a better service.

 

So, inch by inch we have backed Group Health into a corner, where they are now reconsidering us . . . but if they reject us, it will obviously be because I, a PA, now own the practice.

 

There is a Restrain of Commerce Law that forbids the discrimination against a business on non-business (social) grounds. Clearly they will be violating that law, however, it is not so easy to prove in court unless I have a smoking gun (e-mail, letter) proving that was their motive.

 

Now with that said, I want to make this much bigger than my case. Many of you have faced discrimination as a PA in many places. Should we re-frame this as a, for lack of better words, a civil rights situation?

 

Let me give a different illustration:

 

Imagine that you as a PA devoted your entire career to specializing in renal calculi. You work for a large institution's renal/urology department. Before long, you run the renal calculi clinic. Without question, all your MD colleagues agree that you are the tops when it comes to managing patients with chronic, recurrent renal calculi.

 

However, one day BC/BS announces that they will no longer pay a penny for a patient whom you have seen. They site (to the public) that the reason that they will not allow the PA to follow their patients is, "We only want the best care for our patients. Since (assumed) PAs have inferior training, we will not pay for the services of that PA."

 

Quickly the institution backs you (which is not always the case). They produce data that shows your renal calcui program is far superior the one before or to any competing institution. The urologists and nephrologists vouch for you with supporting letters. They make it clear, if they remove you from the position (due to lack of funding) and replace you with an MD, the quality of service will fall.

 

Still the insurance, per the recommendations of their MD advisers, say that they will not do business with a PA because of "The best interest of their patients."

 

Since the assumptions, PA=poor medicine, is clearly proven wrong, doesn't this become an issue of discrimination based on social prejudice? Is it not the same as saying (in the 1950s) that a woman can't be CEO because their MPs make them too emotional (another irrational leap).

 

So, chew on this thought. If so, how do we stand up to this type of discrimination?

[bradtPA]

What about writing a complaint to the state insurance board representative? Launch a complaint against them for impeding fair trade......

[Guest Swennerb]

It is frustrating to hear that an insurance company would choose not to reimburse your care, ....especially when you can't prove it's bc your a PA. As a profession, I think we should have a separate sub committee specifically to handle these issues. As you said, there are many of us who face these issues all the time. Atleast if we had a group of PA's who met once a month or something to come up with solutions, these things wouldn't just fly under the radar. People would know that the committee exists- they would have someone to go to- little by little we'd put out these fires and hold the guilty accountable, or atleast try! Im not a lawyer, but I would join something like this- I'm sure there are alot of PA's who care and would want to help out.

[ventana]

In MASS there is pending legislation to make it state law that services provided by PA must be covered. I am unsure rather this would be be extended to the credentialing level but certainly would not hurt. State level is tough though as it takes 50 times the effort then one national push......

 

does freedom of information apply to non gov't agency?

 

Having seen a little bit of the insurance world from the inside I can say that it is gross the amount of waste and stupid decisions..... not sure you can convince the raving crazy insurance company of anything....

[jmj11]

I wish the AAPA had a legal arm, like the nurses do, which are well trained in our profession, who are motivated and effective. However, that is wishful thinking. As one lawyer friend told me, never sue out of principle . . . always out of money. So, if there isn't big $$$$$ (like slipping on a banana peel at Microsoft and hurting your back) then there is very little motivation.

[dm123]

Do I ever agree with the legal arm thing. Politics too. It would be worth a substantial increase in dues to the AAPA if they would get a little testosterone.

 

I've had two other businesses other than PA work in the past. Never tried the clinic thing. Made money with one, lost big money in the other due to political changes.

 

Biggest problems were changes in tax laws, some retroactive, insurance companies, and thieves.

 

In NC, an entrepreneur pays fed, state and local tax, both ends of social security, franchise tax on inventory to the state, property tax on real estate and equipment, storm water run-off tax based on amount of impervious surface, unemployment insurance on payroll, local license fees and probably some I've forgotten but just paid to keep from getting mad. People can't income average anymore so if a person has a good year he/she could be in the alternative minimum tax bracket one year and qualify (if the government would let you) for food stamps the next. The inventory tax, property tax, storm water tax isn't income based even with a loss you pay anyway. I went thru 2 CPAs who seemed to work more for the government than me. I finally found an accountant who knew tax law and gave me the benefit of gray, but legal areas.

 

Workers comp and liability gets you at audit time. You pay for the audit period, plus pay in advance for the next year based on audit results.

 

Seems if stuff is not red hot or nailed down it was subject to disappearing. I've heard something like 40% of employees have taken something significant from the work place, especially if they think the boss/owner is making more money than they think he should. Customers do too. Break-ins are a given.

 

I really admire you drive and innovative spirit.

 

One of my favorite quotes of Teddy Roosevelt:

 

THE MAN IN THE ARENA

Excerpt from the speech "Citizenship In A Republic", delivered at the Sorbonne, in Paris, France on 23 April, 1910 -

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.

[SilverPA]

I have two other situations that are causing me problems currently: 1) Several free pharma companies are now requiring an MD/DO signature and will not accept the signature of a PA, even though I can legally write for controlled substances: Lyrica and OxyContin. It drives me crazy that every month I have to walk into my supervising physician and ask for his signature. These are MY patients and he has never seen them - why should he sign for their meds? 2) It drives me nuts that states still require the registration of a supervising physician prior to licensure. To me, this is clearly restraint of trade. We all know that we have to have an SP to practice, but to apply for a license? I am going to be doing some locums work and this is making things nearly impossible for me as I can't go get a license for states in which I would like to do locums work prior to actually doing it - so, I go 'round in circles. This is really something we need to take care of, the first on the federal level (I have contacted AAPA on this already) and second on the local level. Here's hoping we can make some in-roads.

 

Terri

[blueridge]

Consider calling the Rutherford Institute.

 

http://www.rutherford.org/

[Rob77]

We can't sign for Lyrica?? I could have sworn I've signed for that in the past. Is this a new policy by Pfizer?

[physasst]

Do I ever agree with the legal arm thing. Politics too. It would be worth a substantial increase in dues to the AAPA if they would get a little testosterone.

 

The AAPA does have a political arm....they are very involved. I actually work with them in this arena.

 

The legal arm is more complicated...and expensive...people need to remember that the AAPA does not have unlimited funds. I would encourage everyone to donate to the AAPA PAC, and if you wish to develop a legal arm, be prepared to pay for it with a dues increase.

 

Personally, I don't think that you could ever show cause under the Civil Rights Act. Restraint of free trade would be a much better pursuit, but as you noted Mike, incredibly difficult to prove.

[SilverPA]

As for signing for Lyrica, yes, I was always able to sign the free pharma request and this is something new. Schedule V drug - are they going this way on every scheduled drug? If so, that is a HUGE problem for PAs just on the face of it, let alone those of us who work in rural practices.

[Houstonian]

I do not believe you have a civil rights case, because the basis of denial is not race, sex, religion, disability, age or other similarly protected status under civil rights law. The basis for denial is education and certification/licensure (PA rather than MD).

 

However, as long as your practice is in compliance with state laws regarding ownership and physician supervisory requirements, you should be able to compete on a fair basis with other providers for their business. It would be helpful if you could determine exactly what they require for providers to meet their qualifications.

[jmj11]

I do not believe you have a civil rights case, because the basis of denial is not race, sex, religion, disability, age or other similarly protected status under civil rights law. The basis for denial is education and certification/licensure (PA rather than MD).

 

However, as long as your practice is in compliance with state laws regarding ownership and physician supervisory requirements, you should be able to compete on a fair basis with other providers for their business. It would be helpful if you could determine exactly what they require for providers to meet their qualifications.

 

If you are speaking of my case, then it is simple. They will not do business with clinics owned by PAs. They do business with a colleague of mine who is an NP and owner of her clinic, but NPs can practice interdependently in Washington state. But they will not do business with a clinic owned by a PA even though the PA is complying with all state laws.

 

I agree literally that the status of being a PA or an MD is not protected under the law like the other entities. However, speaking philosophically, I think you can make the argument that discrimination based on religion is no different from the PA issue. The reason being, both are the product of personal choice. The discrimination is based on irrational person bias and assumptions and not on any common sense.