Will there be a PA and NP turf war?

[tmac12]

Great input everyone. There is a lot of uncertainty right now. 

[GetMeOuttaThisMess]

I wish my daughter would do this.  She always wanted neonatology and has been running a peds practice (which is hurting financially BTW) in Austin.  Moving to Houston this weekend.  She even has ~19 Texas Tomorrow Fund credit hours left to use.

[delco714]

Peds is struggling because the peds subspecialists in many cases make LESS than the peds primary care doctors do.

Take cardiology or heme/onc for example.  75% of those patients are on Medicaid.  That means you get a massive paycut compared to adult specialties.

What MD would want to go thru 3 years of fellowship to make the same or less than primary care?  

You want an example of how bad Medicaid is?

In California a 99213 standard E&M code for Medicaid reimburses $10.12, for a comprehensive specialty care visit with an ENT, the reimbursement is $27.19.  What a joke!

 

 

 

Here's an inherent problem. A specialist TECHNICALLY can do anything a PCP can... But a Pcp can't do what a specialist can. I know that's a radical, polarizing statement, but it's true. A floor RN can act as a CNA ..but not vice versa. A icu RN can be a floor RN buy a not certified/privileged floor RN can't be icu RN... Specialists get paid for having the ability to do what others can't. I do think it's weird that soon I will be paid more than some pediatricians and mddo pcp/psych.

 

Yes I know this is a slight tangent from your post. Macintosh to red delicious, maybe.

 

[LT_Oneal_PAC]

2 hours ago, delco714 said:

Here's an inherent problem. A specialist TECHNICALLY can do anything a PCP can... But a Pcp can't do what a specialist can. I know that's a radical, polarizing statement, but it's true. A floor RN can act as a CNA ..but not vice versa. A icu RN can be a floor RN buy a not certified/privileged floor RN can't be icu RN... Specialists get paid for having the ability to do what others can't. I do think it's weird that soon I will be paid more than some pediatricians and mddo pcp/psych.

 

Yes I know this is a slight tangent from your post. Macintosh to red delicious, maybe.

 

I’m not sure I understand. A specialist can legally do anything a PCP can, and vice versa, just neither would do the job well. If you mean by skill, then I diasagree because of every skill you name a specialist can do, I can name one that I did in PC that the specialist can’t, plus I’ll name some conditions I managed that typically are referred to specialist. I feel more limited in scope in EM now than I did in family medicine.

[lkth487]

5 hours ago, LT_Oneal_PAC said:

I’m not sure I understand. A specialist can legally do anything a PCP can, and vice versa, just neither would do the job well. If you mean by skill, then I diasagree because of every skill you name a specialist can do, I can name one that I did in PC that the specialist can’t, plus I’ll name some conditions I managed that typically are referred to specialist. I feel more limited in scope in EM now than I did in family medicine.

It depends on the type of specialty - for all the IM and Peds specialties that's true but only technically - given that if you're a BC pediatric cardiologist, youve completed a residency in pediatrics (and in IM for adult cardiology).   But that's only technically true - if you haven't done it in 15 years, you're not gonna be very good at it. 

[delco714]

I’m not sure I understand. A specialist can legally do anything a PCP can, and vice versa, just neither would do the job well. If you mean by skill, then I diasagree because of every skill you name a specialist can do, I can name one that I did in PC that the specialist can’t, plus I’ll name some conditions I managed that typically are referred to specialist. I feel more limited in scope in EM now than I did in family medicine.

That's superficial. Do you actually recommend pcp doing colonoscopy?
Pcp can't do cysto, toe amp, DBS.. Etc

[camoman1234]

18 hours ago, delco714 said:

That's superficial. Do you actually recommend pcp doing colonoscopy?
Pcp can't do cysto, toe amp, DBS.. Etc

My collaborating physician did sigmoidoscopy for 20+ years in office... Not exactly the same as a colonoscopy, but very similar. Should primary care providers do vasectomies or only general surgery/urology? I work PRN at a FM/UC and the doctor there (my CP) does no scalp vasectomies. Where is that line? Do we not do punch biopsies cause derm can do them? 

[LT_Oneal_PAC]

38 minutes ago, delco714 said:

That's superficial. Do you actually recommend pcp doing colonoscopy?
Pcp can't do cysto, toe amp, DBS.. Etc

I would say only looking at procedures is superficial. If they have been trained colonoscopy, which many of my FM MD colleagues have in the Navy along with endoscopy. I've known others who even do appendectomies. A urologist cannot do a nexplanon implant and a intervential cardiologist can't do a endometrial biopsy. A PCP can do all these. Further a PCP may not have all the procedural training that surgeon has, but there is not a condition they manage medically that a PCP cannot.  Yes, if you take all specialties in aggregate, then they all do something better than the PCP. However care is then fragmented and patient still has a worse outcome overall and you would need something like 20 specialists to cover all the services a good PCP (not your typical FM clinic referral machine) provides in clinic.

 

[sas5814]

The times they are a changing. Many moons ago when FP did pretty much everything I did Flex Sigs (me not my SP...well he did them too as did the other PA in the office). My SP did vasectomies, uterine stripe biopsies, all manner of things that now are only the purview of the specialist.

A few things have driven these changes. First physicians shifted away from primary care to specialty care and began increasing requirements for performing these procedures. Some of it was driven by increased standards of care and proof of competency to perform procedures. Then insurance companies stopped paying anyone but a physician to perform these services.

In medicine form follows money

[Boatswain2PA]

41 minutes ago, delco714 said:

Do you actually recommend pcp doing colonoscopy?
Pcp can't do cysto, toe amp, DBS.. Etc

I know several rural PCPs who do colonoscopies, vasectomies, deliver babies, LEEP, D&Cs, and lots of other minor procedures.

[lkth487]

42 minutes ago, delco714 said:

That's superficial. Do you actually recommend pcp doing colonoscopy?
Pcp can't do cysto, toe amp, DBS.. Etc

Some FM docs at my training institutions still do c-sections.  A couple of rural ones still do appendectomies.  If you have experience and are comfortable with it - go for it (as long as you're also willing to take on the legal responsibilities). 

[LT_Oneal_PAC]

2 minutes ago, sas5814 said:

The times they are a changing. Many moons ago when FP did pretty much everything I did Flex Sigs (me not my SP...well he did them too as did the other PA in the office). My SP did vasectomies, uterine stripe biopsies, all manner of things that now are only the purview of the specialist.

A few things have driven these changes. First physicians shifted away from primary care to specialty care and began increasing requirements for performing these procedures. Some of it was driven by increased standards of care and proof of competency to perform procedures. Then insurance companies stopped paying anyone but a physician to perform these services.

In medicine form follows money

I still did all those things, except flexsig. Not for lack of trying to convince people though. That was the Navy though. No worries about payments.

[sas5814]

Yeah... I did a lot of things in the Army that came to a big old halt when I got out. It was a steep learning curve on the ways of the civilian worls