Future Standards for PAs and NPs
Bob Blumm, PA, DFAAPA, PA-C Emeritus
Standards: it seems as if everyone is talking about them today. We are either creating standards, improving standards, setting new standards or raising standards. Ultimately, as decades pass, standards grow, and this seems appropriate considering the health care needs in the United States and our world standing in that sphere. Like most Americans, I had always assumed that we were naturally - Number One - but was disheartened to discover that my assumptions were grounded in my patriotism and not in evidence-based studies. Depending upon the source and the year, the US typically ranks in the top 20 or 30% and shockingly behind all other nation members of the G-10 (including many smaller countries). This surprising revelation gave me pause to reflect on our “standard of care.”
What does the word “standard” connote to the average PA, NP, or patient in terms of academic achievement? It might be interpreted as an entry-level bachelor’s or master’s degree - or perhaps even a doctoral degree. Many of these advanced levels could never have been imagined in the past but are now very much a part of the 2021 working world for PAs and NPs. How quickly times change with more and more clinicians earning doctorate degrees – spurring insurance companies and administrators to establish yet even newer benchmarks based on this academic proliferation. If we as a profession do not set our own standards, someone else or another profession will surely try to do it for us. If ever we needed cohesive leadership, it is now! Maybe you are the person who can lead us into the future?
What do I personally think of standards? I believe that standards are a very positive modifier of our practice protocols and approaches to medicine. I see the patient as the ultimate winner when a profession has high standards. Standards lead to increased study and competence. Standards are set and maintained by academia, education secured at conferences, and CME provided by associations. They are enhanced by experience and certified by procedural attestation such as those through residency rotations. There will, in the near future, be a mandated procedural attestation required within all institutions of medical care. When looking at medical specialties, we note that either a residency or a specialized track of education and experience defines what an institution requires for an NP or a PA to be hired.
Most of the specialty areas need highly experienced, highly motivated, and extremely well-educated PAs and NPs and are willing to provide a mini residency. Some of these specialties require additional education, CME, preceptorship, and a specialized curriculum in addition to an advanced degree. I will repeat a sentence that I wrote ten years ago: “The time is quickly coming upon us that will no longer place on a resume ‘PA seeking a hospitalist role, ---- willing to learn, seeking physician willing to teach.’” That time became a reality more than five years ago. Physicians are engaged in their own fight for survival, focused on issues which affect their profession, leaving little time for the altruism of the past when they sought to be the “teacher” to a nonphysician. The economy, new health care laws, insurance mandated reimbursements, malpractice issues, and the huge financial debt incurred while becoming doctors have caused them to protect their own turf and areas of responsibility.
What will possibly be the standard for the PA in the next few decades? PAs will be a graduate of a doctoral program, be highly intelligent, and have the interest to further their education by means of residencies of various lengths to best prepare for the arduous task of caring for an additional 31 million patients in a decade with decreasing numbers of physicians. The PA will be a team member that possesses a team attitude and team spirit as the care of patients will be delivered by highly trained team members. Personally, I see this as a positive move and will be comforted as a patient to realize that all of the medical personnel with whom I have a relationship share a unified approach and attitude that will enhance my treatment, wellness and outcome. I think that the nursing profession will continue to grow in this same direction as they are recognized experts in so many specialties today.
This shared approach to patient care will require many signatures and notes on the EMR which can become tricky for many clinicians. With a team approach, opportunities for medical error will require heightened vigilance. And when errors occur - who is responsible - the institution, or the clinician? It is and has always been the clinician, and these errors are often due to the exhaustion felt by providers: reading every note, reviewing every test, and reconciling every new medication order. Prior to my own retirement, I began to feel the exhaustion of doing the detective work and realized that I was becoming a relic. As malpractice exposures rise, so too the need for a personal malpractice policy. Younger clinicians are much better suited to the demands of this ever-increasing administrative multi-tasking than those of us from an earlier vintage. This new era makes a malpractice instrument essential, now more than ever. Be careful and refrain from choosing based on cost alone, without fully understanding the policy terms and the provider’s history in the healthcare market. “New” companies with new perks come and go and may not exist in a few years, when you might need them. Make your own educated decision to prevent hardships in the future.
I was recently accepted to a program in Florida! The school doesn't provide health insurance for their students so we are required to obtain our own health insurance. I currently have insurance through my employer, which I'll obviously no longer have once I begin school. Also, I can no longer be on my parents insurance.
Since I start school in January, how early should/can I apply for insurance in Florida? I am from Washington state. Also, does anyone have any tips/insight on which insurances are the most affordable for a student? Thanks in advance.
I've been using CM&F for some years. As a part-time PA, occurrence $500,000/ $1, 000, 000 policy they want $3,060 for the year.
Cinch, a Berkshire Hathaway Specialty Insurance, sent me an offer of $500, 000/ $1,000,000, part time worker for $2196 -- $864 (30%) difference! It covers reputation insurance, licensing board and HIPAA claims.
Has anyone used the Cinch malpractice? Any comments?
I am leaning towards making the switch to Cinch.
I am a new graduate, and I just received an Ortho PA job offer in coastal California. I will start training (same salary) as soon as I finish my boards, while I am waiting for my licenses to process. The job is M-F from 8-5. OR 1-2 days/week, but not when I initially start. Call time was not mentioned in the contract, but it's about once/month (no additional pay)
- Base Salary: 100k
- At-will contract; If I stay less than a year, then I have to repay the licenses, relocation bonus, CME. etc. back to the employer.
- Health insurance, vision, and dental
- Incentive bonus: available after 3 months (PA's at the company said that I probably wouldn't reach the bonus requirement until 9-12 months)
- PTO: 10 days/year (accrue on a pro-rated semi-monthly basis from the date employment commences)
- 9 paid holidays
- sick days: 5 days/year (accrue after 3 months)
- CME: $2,500 and 5 days off (in addition to the 10 days PTO)
- All licenses covered: reimbursement for Board expenses, initial licenses and license renewals, including D.E.A. and California license
- $4,000 relocation bonus
- Three memberships reimbursed: example AMA or CMA
- Gas reimbursement: I have to drive to the satellite locations a few days/week.
- Malpractice: company covers professional liability insurance with tail coverage
What's not offered:
- retirement (401k)
What do you think of this offer? Any feedback is greatly appreciated!
I am a 3.5-year experienced cardiology PA in a private single-MD practice. A month ago, I noticed that my MD was submitting a CPT code in his name for every single clinic patient I saw. He was sometimes putting the bill in the EMR before I finished my note and assessment and plan. He personally only saw my patients if they were new or complicated, accounting for 10% of my volume.
At the time I saw all of these bills under his name, I was submitting paper superbills (for unrelated reasons). I thought this was just some misunderstanding where he didn't see me entering my own bills electronically, so he was putting in the billing under his name. I told my manager that he was double billing- his electronic CPT entry on top of my paper one. Could she please talk to him and ask him to stop? I did not want him to get himself in trouble and it seems to be a misunderstanding. Yes, oh yes she would... No, no no, he cannot do that. I made sure she had copies of the incident-to billing guidelines for Medicare in case he needed them.
Days passed and I asked for an update. She said she was still discussing it with him. Then a week passed, and I asked again. She had spoken with him and shown him the incident-to guidelines. He said he was not going to stop billing all of my patients in his name. He said his personal lawyer advised him that he could do it. I told her that his personal lawyer is not my lawyer and he is kind of implicating me in fraudulent billing at this point and I don't want to be a part of it. She told him that if he refused to stop doing it, his PA might then quit. He told her, "ok." At this point it had progressed beyond a misunderstanding of billing to having full knowledge that what he is doing is against the rules and refusing to stop. She said she would speak with him again.
We met again. "Well, there's good news and there's bad news. The good news is that he is going to stop billing all of your patients in his name. The bad news is, he wants you to look for a new job." I was totally stunned. This was not the outcome I was expecting. He did not clearly articulate to my manager why I was being asked to move on. I prepared my resignation letter to hand in at the end of my workday.
Before the day ended, my MD spoke with me privately. He said his recommendation for me to find a new job was not based on money or billing or my job performance but on several other unrelated things. He did not want me to storm off the job today in anger. I could take my time finding my next job, he would provide recommendations, he would accommodate job interviews as needed. It was a positive discussion and I did not disclose that I was on the edge of quitting before he spoke with me.
The next week was uneventful. At the end of each of my clinic days, I provided him with a list of the patients I saw that qualified as incident-to that he could bill in his name. On my last day of that week, he had a vacation scheduled so he was gone for the afternoon. When I finished seeing my last patient, my manager pulled me into her office and presented me with a letter from the MD. It said that this was my last working day and to finish all of my documentation by the end of the day. I would get 2 weeks severance, 4 weeks of unused paid vacation time. No explanation for why he was suddenly firing me. The manager did not see it coming. Perfectly timed for when he was going to the airport so he would not have to talk to me. The employee termination form required by my state says "reason for termination: wanted to replace PA with MD." My doctor has not spoken to me, emailed me, or anything else. That was a week and a half ago.
I am currently looking for a job in the same area where this doctor is located. He is well-known and would certainly talk badly about me if he found out I was telling prospective employers the real reason why I got fired. My biggest obligation right now is to ensure I secure my next job. I have a 9 month old baby.
Should I report the insurance fraud? If so, when? Does anyone have experience in reporting this or reporting an employer for firing them under such circumstances?
I appreciate any comments or advice. I've learned to never underestimate a doctor's ego..... If he didn't fire me for finding the fraudulent billing, he definitely fired me for going to the manager about what he can and can't do.