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What can we do as a profession to obtain full reimbursement?


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Hello all,

I am a FP in KY and have been practicing for 18 years.   In KY, the PA profession has many obstacles to overcome in order to be employable compared to the NP's.   We are a work in progress.   

 

Since we are seeing many of our jobs going to NP's, we are working on our ability to prescribe controlled substances again this year.   This has been an ongoing struggle for many years but I believe that this will be a positive outcome this time due to the fact that we are (once again) the last state for this restriction. 

 

One of the other big issues that I see here in KY - and across other states - is the ability of the NP's to have 100% billing reimbursement - in line with the MD's.   I have a few friends that work for the companies that negotiate contract rates for MD/DO/NP's and here in KY the NP's are getting full 100% reimbursement now.   PA's are obviously still at 85%. 

 

There was a time when MD's were able to decide for themselves whether they wanted to work with a PA or an NP - however, in the age of corporate medicine, MD's are now just another employer for whatever conglomerate they choose to work for.   They now have no say in who they work with.  It is all being determined by a bean counter with an MBA.   When  push comes to shove over those beans coming in to the corporation - those MBA's are seeing PA's as a financial liability vs the NP's that are getting 100% reimbursement.   PA education vs NP education does not come into play - in the end, it always boils down to $$$.  

 

So, correct me if I am wrong -  the NP's - being independent- can get 100% reimbursement.   We, as dependent providers - get 85%.   Does the PA profession HAVE to be "independent" to get 100% reimbursement?   Is there a way to be "collaborators" with MD's to get full reimbursement?   Is it just a word change or is it more?   Is there a way for the PA's to still be considered dependent providers ( in order for us not to have to formally go through the extensive work it will take us to extricate ourselves from the false MD/PA team fantasy) and get full reimbursement?  

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Hello all,

I am a FP in KY and have been practicing for 18 years.   In KY, the PA profession has many obstacles to overcome in order to be employable compared to the NP's.   We are a work in progress.   

 

Since we are seeing many of our jobs going to NP's, we are working on our ability to prescribe controlled substances again this year.   This has been an ongoing struggle for many years but I believe that this will be a positive outcome this time due to the fact that we are (once again) the last state for this restriction. 

 

One of the other big issues that I see here in KY - and across other states - is the ability of the NP's to have 100% billing reimbursement - in line with the MD's.   I have a few friends that work for the companies that negotiate contract rates for MD/DO/NP's and here in KY the NP's are getting full 100% reimbursement now.   PA's are obviously still at 85%. 

 

There was a time when MD's were able to decide for themselves whether they wanted to work with a PA or an NP - however, in the age of corporate medicine, MD's are now just another employer for whatever conglomerate they choose to work for.   They now have no say in who they work with.  It is all being determined by a bean counter with an MBA.   When  push comes to shove over those beans coming in to the corporation - those MBA's are seeing PA's as a financial liability vs the NP's that are getting 100% reimbursement.   PA education vs NP education does not come into play - in the end, it always boils down to $$$.  

 

So, correct me if I am wrong -  the NP's - being independent- can get 100% reimbursement.   We, as dependent providers - get 85%.   Does the PA profession HAVE to be "independent" to get 100% reimbursement?   Is there a way to be "collaborators" with MD's to get full reimbursement?   Is it just a word change or is it more?   Is there a way for the PA's to still be considered dependent providers ( in order for us not to have to formally go through the extensive work it will take us to extricate ourselves from the false MD/PA team fantasy) and get full reimbursement?  

I'll correct you, you're wrong. NPs don't get 100% reimbursement any more than PAs get 100% reimbursement. The more nuanced is that there are three types of insurance. Medicare, medicaid, and commercial payers. Medicare pays PAs and NPs 85% of the fee schedule. That doesn't change if they are "independent providers" since they are classified along with PAs as non physician providers. This is unlikely to change as Medicare is a zero sum game and to pay NPs or PAs 100% the money would have to come from somewhere else such as physician reimbursement. 

 

Medicaid is set by the state and appears to reimburse both NPs and PAs 75% of the physician rate. This is again a zero sum game and unlikely to change. 

 

Commercial payers are done by negotiation between the practice and the payer. Most don't credential NPs or PAs and direct them to bill under the physician at 100%. The few that do credential NPs and PAs have tried to reimburse as low as 65%. 

 

So, no, independent practice does not mean that NPs are reimbursed 100%. For that matter Kentucky is not considered an independent practice state since NPs need a collaborative agreement for prescriptions. You should understand your states practice environment before making bold statements. 

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Coloradopa

 

I appreciate your response and the education.  My post was in concern for what my contract negotiator contacts are telling me in regards to NP reimbursement.    And what they have relayed to me is that the NP's contract rates for commercial payers is that of the MD's.    So, if they are not correct in this,it does make me feel better.  

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join AAPA

 

join state lobby

 

send them $$

 

politic yourself

 

 

realize that PA and NP get 100% reimbursement "when the physician is immediately available for consult" and in practices where they bill EVERYTHING under the doc.  (happens a LOT more then you think)

 

 

As the data supports MD/DO/PA/NP all have similar outcomes I think we should all be paid the same.......

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Just to stimulate discussion, and not to suggest that I believe this (however I am not yet convinced), but what is the argument that we should be reimbursed at 100% of a physician's reimbursement?  And whatever logic is used to justify that, shouldn't it follow that we should get compensated the same as a physician?  Very few to nobody is suggesting that.

 

I mean if the argument is that we provide the same service as a physician in certain settings, and should be reimbursed accordingly, why would would also not be compensated accordingly?

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argument is that we have data to prove that we proved the exact same quality of care

 

If the end point is the same - and the patients get the same care - should we not be paid the same?

 

Also, I had my own practice - and all the expense are the same - the phone company, or the landlord doesn't give you a discounted rate because you are a PA - then on top of this we have to pay a CP and it is obvious the math doesn't really work

 

 

Same job, same pay....  Where doc's set themselves apart is that they can do the surgery's and the other things that are physician only.  But lets be real, most of medicine is no longer a "physician only playground"

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argument is that we have data to prove that we proved the exact same quality of care

 

If the end point is the same - and the patients get the same care - should we not be paid the same?

 

Also, I had my own practice - and all the expense are the same - the phone company, or the landlord doesn't give you a discounted rate because you are a PA - then on top of this we have to pay a CP and it is obvious the math doesn't really work

 

 

Same job, same pay....  Where doc's set themselves apart is that they can do the surgery's and the other things that are physician only.  But lets be real, most of medicine is no longer a "physician only playground"

 

So, with that logic, do you conclude that we should be COMPENSATED the same (and not just REIMBURSED the same, as this thread had initially aimed to discuss)?

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argument is that we have data to prove that we proved the exact same quality of care

 

If the end point is the same - and the patients get the same care - should we not be paid the same?

 

Also, I had my own practice - and all the expense are the same - the phone company, or the landlord doesn't give you a discounted rate because you are a PA - then on top of this we have to pay a CP and it is obvious the math doesn't really work

 

 

Same job, same pay....  Where doc's set themselves apart is that they can do the surgery's and the other things that are physician only.  But lets be real, most of medicine is no longer a "physician only playground"

 

I have to respectfully disagree.  As a practicing paramedic, I can intubate, administer medications, splint, reduce dislocations, utilize ultrasound POC and assess and create a plan of care for my patients.  Does that mean I should also be paid the same as a physician?

 

While I understand what you are trying to say, I think there is a certain amount of compensation that occurs due to the nature of the education you receive.  As a paramedic, I completed a one year certification program (still get paid less than RNs).  As PAs we complete 2 years of graduate level training.  Most physicians have completed a 4 years medical program and subsequently completed a residency after that.  They get paid more because they can ultimately do more.  Just because we have a piece of the pie, doesn't mean we have access to the whole pie. 

 

Meanwhile, I feel that reimbursement from insurance providers should be equal across the board.  If you have been trained and can perform a skill, you should be reimbursed $xxx for it.  I can intubate/splint/reduce as a paramedic just as well as many of the PAs and MDs I've seen.

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So, with that logic, do you conclude that we should be COMPENSATED the same (and not just REIMBURSED the same, as this thread had initially aimed to discuss)?

 

Yes and no - but honestly if we are DEPENDENT providers we ourselves set up a system where we are placing ourselves lower....  in reality this is simply not the case in PCP fields.  An experienced PA does the exact same job...

The issue for Compensation has more then the day to day job in it - the fact that they "supervise" (hate that word and always use collaborate but in this post need to be accurate) means that they are tiered higher and therefor should be compensated higher.

 

Overall in the PCP world - the insurance reimbursements should be the same as we do the same thing....  with the higher pay justified for doc's in that they can supervise... but PAs do and should own their own practices and be reimbursed the same

 

 

 

 

I have to respectfully disagree.  As a practicing paramedic, I can intubate, administer medications, splint, reduce dislocations, utilize ultrasound POC and assess and create a plan of care for my patients.  Does that mean I should also be paid the same as a physician?

 

While I understand what you are trying to say, I think there is a certain amount of compensation that occurs due to the nature of the education you receive.  As a paramedic, I completed a one year certification program (still get paid less than RNs).  As PAs we complete 2 years of graduate level training.  Most physicians have completed a 4 years medical program and subsequently completed a residency after that.  They get paid more because they can ultimately do more.  Just because we have a piece of the pie, doesn't mean we have access to the whole pie. 

 

Meanwhile, I feel that reimbursement from insurance providers should be equal across the board.  If you have been trained and can perform a skill, you should be reimbursed $xxx for it.  I can intubate/splint/reduce as a paramedic just as well as many of the PAs and MDs I've seen.

 

Sorry to disagree - but a medic is in no way a provider - you practice solely on the license of medical control and under very strict guidelines/protocols.  They are simply not the same thing - although on the surface it appears similar.  A more accurate comparison is paying a medic the same as a Doc to treat and manage patients in the  in the ER - and that is not done........

 

your training statements are also inaccurate

in general - PA is 3 years post baccalaureate

MD/DO is 3-4 years post baccalaureate plus residency

 

 

If an Average pay (my opinion) for a PA is in the low 100'2 where as average pay for IM/PCP doc is low 200's and specialists is likely low 300's now - simply not fair on the PCP side to have double the pay for one more year of schooling (maybe) and residency - when we do the same thing!  

 

BTW if we look at years in school - Many PA have their PA degree then return for additional degrees - I have an AS, BA, MS, MBA and will sign up for the new Doctorate of Medical Science when it comes out-----  that is more then the fastest - 7 year program for MD or typical 8 year program...

 

 

MD/DO can leverage their pay by employing PA/NP and medical directorship of facilities...

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I think Ventana's argument is a perfect segue to the concept of PA + X years of primary care experience --> MD/DO primary care residency. It isn't a fast track through med school, it shouldn't really irritate any of the doctors because we skip the "cruddy" part, it isn't financially advantageous, it rewards our knowledge/effort, and it removes the glass ceiling on our profession. It may not be practically necessary with regard to quality measures, but I, for one, would love to see that option. 

 

I really don't understand why there isn't a push for this with our huge "doc" shortage. We constantly throw international graduates in to the residency mix. We apparently have sufficient to even ample residency slots for the primary care world. The idea of such a "classic" profession changing, I think, must just require a tremendous load of momentum to shift mindsets.

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Printer2100, I would likely agree agree with you comparing a 5yr ortho vs. PGY1 resident.  But, in my limited experience ortho PAs generally are not learning surgical techniques.  They assist in surgery, but everything is basically guided by the surgeon.  I think that would be one major area that honestly should limit a PA's ability to become an orthopedist.

 

The other side of this argument about "# of year of practice = resident trained physician" is that you change the entire dynamic of PAs finding jobs out of school. It would essentially become the same as how med students are matched into residencies.

 

Lastly, I disagree with the statement that having the opportunity to work as a PA and become an MD/DO through experience isn't financially advantageous.  While PA students have tremendous debt, it usually does not even compare to the debt newly minted doctors have leaving medical school - and then residents usually don't start paying anything on their loans until they complete their residency.  Working hard, I can definitely pay off my $100k+ loans in 2 years because my income is at least 2-3x the average resident and then if I could have the income of a physician after a few years, that is definitely advantageous.

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You misunderstand. This is not skipping residency, it allows you to apply for residency.

 

A PGY1 has learned less surgical technique than a PA with 5 years of experience, but I think your point here is a confusion of above.

 

MD primary care = (4 yrs med school) + (50k x 3 yrs residency) + (200k x 3 yrs work) - (200k debt) = 550k over 10 yrs

 

PA primary care = (2 yrs PA school) + (90k x 5 yrs experience) + (50k x 3 years residency) - (100k debt) = 500k over 10 years

 

That is assuming several things, but you can see it is not seemingly a financial advantage. If it is, it is minimal. After 10 years it is a no brainer advantage to the physician, which means any PA with more than 5 years of experience loses out big.

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To be honest, I like the idea of medical practice in general shifting towards the above model. It "likely" helps fill a primary care shortage, allows for a bit of testing out certain specialties, places you on more stable footing as a whole through those first 10 years, and absolutely strengthens your abilities in residencies versus straight out of med school. My suspicion is that it could tremendously help with the burnout and stress that so many people feel in medicine. I do see faults in not having enough specialist providers though due to the sheer time constraint of getting to the end goal.

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1.  There is no primary care shortage except in extreme rural areas. 

 

2.  There will ALWAYS be a PC shortage in rural areas, even if you increase the number of providers by 100 times over.  Nobody wants to live and work in a town of 100 people in rural oklahoma.

 

3.  PAs will never see their pay level rise to match physicians.  The BEST you can hope for is that insurance/medicare reduces physician reimbursement to PA levels.  So while you may congratulate yourselves for being paid the "same" as a doctor it won't result in any significant pay raise.

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You misunderstand. This is not skipping residency, it allows you to apply for residency.

 

A PGY1 has learned less surgical technique than a PA with 5 years of experience, but I think your point here is a confusion of above.

 

MD primary care = (4 yrs med school) + (50k x 3 yrs residency) + (200k x 3 yrs work) - (200k debt) = 550k over 10 yrs

 

PA primary care = (2 yrs PA school) + (90k x 5 yrs experience) + (50k x 3 years residency) - (100k debt) = 500k over 10 years

 

That is assuming several things, but you can see it is not seemingly a financial advantage. If it is, it is minimal. After 10 years it is a no brainer advantage to the physician, which means any PA with more than 5 years of experience loses out big.

 

Ah, that makes a lot more sense and something I could possible get behind.  I love the idea, but definitely need to let it ruminate a bit more before saying I really agree with it.

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1.  There is no primary care shortage except in extreme rural areas. 

 

2.  There will ALWAYS be a PC shortage in rural areas, even if you increase the number of providers by 100 times over.  Nobody wants to live and work in a town of 100 people in rural oklahoma.

 

3.  PAs will never see their pay level rise to match physicians.  The BEST you can hope for is that insurance/medicare reduces physician reimbursement to PA levels.  So while you may congratulate yourselves for being paid the "same" as a doctor it won't result in any significant pay raise.

 

Completely agree with #'s 1 and 2, and during school have been told as much multiple times.

 

I'm not sure I agree with #3.  While I don't ever see us getting the same reimbursement level as long as we continue to be overseen by physicians (something I actually do like), I don't think physician salaries will ever drop to PA salaries - unless they drastically change the cost of medical school and increase resident salaries.  Honestly, I think the ever decreasing physician reimbursement, causing a decreasing physician salary, will break our healthcare system - the docs will revolt.

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There may be no primary care shortage in the traditional sense that we are volume depleted, but I don't think anyone would deny that there is a problem with access. It may be an educational issue, but the utilization of the ER and even urgent care for problems that are more effectively and efficiently managed by primary care is problematic.

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interesting discussion.  these issues all boil down to leadership in the profession.  here are my suggestions.

 

1.  find the "primary source" that states advanced practice clinicians should be reimbursed at the 85% rate.  this is important because it should come with some rationale behind the "rule."  I've actually asked the AAPA legislative representative, but haven't gotten an answer.  i would hope that the decision wasn't made by a bunch of bureaucrats sitting around the table looking for ways to save money and decided apc's were easy targets.

 

2.  we need to make an evidenced based argument that in fact most apc's work very independently with minimal supervision.  i know my md partners think of me more as a junior partner (I'm new at this) asking occasional questions rather than them providing any real hands on supervision.  in fact, they expect me to work independently.  the fallacy that we are supervised needs to be communicated to our governing representatives with articulate arguments.  the time is actually ripe for this as government and the private sector is relying more and more on apc's to deliver healthcare services to our populace.  the reason for this is obvious - because we have ably demonstrated over many years that we are intelligent, capable practitioners of medicine.  they know it, the docs know it and we know it. 

 

3.  a national union of np's and pa's would seem appropriate here, but i have a better idea.  let's get aapa and the np's national governing body to work together to hire lobbyists to make our case.  i was recently in Washington, DC and my wife pointed out a large building named the "American College of Surgeons", and she asked - "why do they have such a big building in D.C.?"  The answer - LOBBYING for their interests!!!!  we need to do the same.

 

4.  call your congressman.  let him know your concerns.  ASK to meet with him.  they do this all the time with constituents.  go to the meeting with 2-3 other colleagues and be prepared with data and to poke holes in any arguments about paying us 85%.  what are those arguments?  i don't put in 85% of the sutures in a laceration when taking care of a patient.  what's Medicare's argument for the 85% rule?  what's the rationale?

 

 

 

 

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