North Dakota Closer to OTP

[sas5814]

What is independent practice? Not having supervision mandated at the state level? Piffle. If supervision went away today I still have an organization full of physicians, committees, rules and regs I have to deal with. There are also a mountain of rules from other agencies from CMS to the DEA to insurance companies and on and on and on. My life wouldn't change a bit beyond I would now be able to compete in the marketplace against my NP colleagues. That is no small thing and if we don't gain parity we are going to become irrelevant. It won't affect me. It will all the younger PAs when they can't find jobs because they aren't the preferred hire. Note I said hire not provider. If we sit around with our heads in the sand until after things reach critical mass it will be too late.

 

Should we make rules for everyone based on the worst of the bad actors? Of course not. Why dumb down the whole profession for a few dumb people. Create a system where people with skills can use them and the bad actors get treated like they are bad actors.

I understand you don't support it for NPs either. I get it. But you can't un-ring that bell and this is our current reality. We have to deal with it.

[Boatswain2PA]

I'm fine with OTP, if it is defined as the doc and the PA setting the supervisory requirements.  Get rid of government imposed chart review or other supervisory requirements.  No need for co-signing, no need for maximum doc:pa ratios, or anything like that.  These are just needless requirements put forth by bureaucrats.

But leave the requirement for a supervisory physician.  We are, after, all, physician ASSISTANTS.  Pretty sure everyone knew that when they applied to PA school.  That way it is up to the SP and the PA to determine what the PA is competent in, and appropriate level of supervision.

[sas5814]

That is a big part of my point. Organizations and insurers and CMS etc aren't going to just throw their hands up and tell us to run wild.

[Hope2PA]

3 hours ago, Kaepora said:

But again, I don't support this for NPs or PAs.  Only physicians should have independent practice.  This is just keeping up with the Jones' and it's a mistake.

You, we all, may think it is a mistake for both NP and PA, however, are there any efforts from NP's fighting against their own independence? How many NP's are actually writing to leaders and legislators saying they are not qualified to practice independence?  Legislation is continuing to be promoted/pushed by Nursing Lobbyists to increase  independence in states that do not currently grant them the right.  How can you possibly say it is wrong for PA's to try and keep up. If Nursing can say their independence is for betterment of health care, then PA, with generally better education and training, should pursue OTP to give patients a choice of better health care in rural areas especially. I do hope that PA's try to maintain some semblance of control regarding education and experience.  Definitely hope they do not try and keep up by allowing so many 100% acceptance online programs.  That would be the biggest mistake!! 

[ventana]

3 hours ago, Boatswain2PA said:

But leave the requirement for a supervisory physician.  We are, after, all, physician ASSISTANTS.  Pretty sure everyone knew that when they applied to PA school.  That way it is up to the SP and the PA to determine what the PA is competent in, and appropriate level of supervision.

WHAT???

 

HAve you been paying attention to OTP and the whole 10 year push??

 

That has got be one of the the most backwards statements I have heard.

 

I just spent over 2 months chasing signatures to renew my state controlled license - almost had to stop working.  What di this provide for protections or higher functioning to the providers?  NONE - NADA ZIP ZILCH - but my state did milk another $150 bucks out of me and Fed Ex got $50 and my CP at two jobs got to have me hassle them.....

 

Dependent providers are a thing of the past - none, and I mean none of us in the primary care world are any more dependent on one another then the next provider.  (medicine is a team sport after all!)

[sas5814]

"We are, after, all, physician ASSISTANTS"

 

Oh yea...I forgot...we are changing that as well.

[Boatswain2PA]

So, you are in agreement that the whole OTP thing is just a step toward the goal of full independent practice rights?  We get to practice just like physicians?

[sas5814]

I don't think anyone said that or anything close to it but let us imagine it were true...independent practice. What would change? Scope of practice would still be determined by a vast array of rules and regulations from federal, to state, to local. My work day wouldn't change a bit except I wouldn't be having mandatory monthly meetings with a SP I don't see otherwise to sign a chart review that contributes nothing and is generally a waste of time. The physician also wouldn't have any legal responsibility for my work.

All OTP does is eliminate state level mandated supervision and chart review. The one-size-fits-all approach that is outdated and doesn't do anything to improve the quality of patient care. That relationship will now be determined at the practice level.

[Boatswain2PA]

16 minutes ago, sas5814 said:

I don't think anyone said that or anything close to it

Pretty sure Ventana just inferred that with his "WHAT....where you been for the past 10 years!" comment.

5 minutes ago, sas5814 said:

....but let us imagine it were true...independent practice. What would change? Scope of practice would still be determined by a vast array of rules and regulations from federal, to state, to local. My work day wouldn't change a bit except I wouldn't be having mandatory monthly meetings with a SP I don't see otherwise to sign a chart review that contributes nothing and is generally a waste of time. The physician also wouldn't have any legal responsibility for my work.

 

Sounds like you already have independent practice, and so do I (other than having to have a physician on the hook and some stupid state regulations).

This proves that independent practice is already in place for some PAs.  Yes, paperwork sucks.  Just had to spend half a day on the phone with malpractice company, and another half-day doing credentialing.  It's the price of doing business in this business. 

Non-independence OTP would get rid of the mandatory monthly meetings (and other stupid regulations)...yet the physician would still be in a supervisory role.

Meanwhile, how about that new grad?  Who makes the decision on what they can/can't do?  With independence-OTP there won't be a physician ensuring they are competent.  Instead it will be a new grad...and someone with an MBA.  That ain't right.

15 minutes ago, sas5814 said:

All OTP does is eliminate state level mandated supervision and chart review. The one-size-fits-all approach that is outdated and doesn't do anything to improve the quality of patient care.

Which OTP are we talking about?  This nebulous term was promised a few years ago to NOT mean independent practice, but rather just getting rid of the silly regulations like chart review, etc.  "No, no, no....we don't want INDEPENDENCE, we want OPTIMIZATION of the team practice!"  

But yet here it is in ND, and it's full independent practice rights, even for the 25 year old new grad.

 

15 minutes ago, sas5814 said:

That relationship will now be determined at the practice level

Who will determine that at the practice level? It won't be the doc's, as they have already lost most of control of healthcare.  It will be the administrators, who couldn't care less about physician/PA/patients.

[sas5814]

Boats we are having a circular conversation. There are just 2 points and I have made them already:

 

You can't make rules for the lowest common denominator. They will always screw things up. The rest of us need to be unencumbered.

The NP aren't going to go backwards in their desire for independence. If we don't get parity we will become extinct.

[ProSpectre]

3 hours ago, Boatswain2PA said:

I'm fine with OTP, if it is defined as the doc and the PA setting the supervisory requirements.  Get rid of government imposed chart review or other supervisory requirements.  No need for co-signing, no need for maximum doc:pa ratios, or anything like that.  These are just needless requirements put forth by bureaucrats.

But leave the requirement for a supervisory physician.  We are, after, all, physician ASSISTANTS.  Pretty sure everyone knew that when they applied to PA school.  That way it is up to the SP and the PA to determine what the PA is competent in, and appropriate level of supervision.

Boatswain, I'm a bit confused about your statements in support of OTP. There are four tenets of OTP, and one of the four is the removal of a legally-mandated supervisory agreement with a specific physician. This is so that practice level decisions about the level of supervision can occur, rather than being state mandated; if the practice wants 100% chart review and every patient presented to an attending, then they can still do so.

See the second bullet point from AAPA's OTP webpage: 

The new policy calls for laws and regulations that:

• Emphasize PAs’ commitment to team practice;
• Authorize PAs to practice without an agreement with a specific physician—enabling practice-level decisions about collaboration;
• Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and
• Authorize PAs to be directly reimbursed by all public and private insurers.

PAs will remain employees subject to all of the practice-level rules put in place by their given employer. I think it is also important to note that this change in ND wouldn't allow PAs to just open their own clinics and practice independently of a physician; it was specifically mandated by the medical board that their support hinges on PAs working within established practices, meaning the team model would still be preserved. They just wouldn't be tied to one specific physician, but rather could collaborate with any physicians in their practice (eliminating any issues created when their legally mandated supervising physician moves, retires, dies or loses his license). 

 

[Boatswain2PA]

I disagree with the move to remove physician level responsibility and oversight from patient care.  

If my grandkids go to the clinic, I want to make sure there is a board-certified specialist responsible for their care.  Don't necessarily need them to be seen by that specialist, but knowing that the specialist is in the chain matters.  

Without this, there is little guarantee that the MLP who sees them knows WTF they are doing.  We see it all the time in the ED, with CMGs hiring NPs out of school and throwing them into the ED where the docs are too busy to appropriately supervise them.  It will only get worse as PA independence further removes physicians from leadership/management of our healthcare system and placing it more and more into the hands of bureaucrats.

Want independent practice?  Earn it by going to medical school.  Or you could earn it by earning your SPs confidence so they let you practice full scope medicine.

[ventana]

9 minutes ago, Boatswain2PA said:

I disagree with the move to remove physician level responsibility and oversight from patient care.  

If my grandkids go to the clinic, I want to make sure there is a board-certified specialist responsible for their care.  Don't necessarily need them to be seen by that specialist, but knowing that the specialist is in the chain matters.  

Without this, there is little guarantee that the MLP who sees them knows WTF they are doing.  We see it all the time in the ED, with CMGs hiring NPs out of school and throwing them into the ED where the docs are too busy to appropriately supervise them.  It will only get worse as PA independence further removes physicians from leadership/management of our healthcare system and placing it more and more into the hands of bureaucrats.

Want independent practice?  Earn it by going to medical school.  Or you could earn it by earning your SPs confidence so they let you practice full scope medicine.

this is not a supervision issue, but instead a training issue

 

it is 100% true that some places just see NP PA as a cheaper doc.... well that might be true for the highly experienced, but not the new grad

 

I believe there should be mandatory one year residency for PA and especially NP - period - no if's and's or but's about it.

[Boatswain2PA]

One year before what?  Orthopedic surgery?  Neurosurgery?  Or "just" family practice?

Would these fully independent family practice PAs still be called PAs since they no longer assist physicians? Would the surgery, ortho, or cardiologist PAs who DO still "assist" their docs get to keep their title?

 

[EMEDPA]

we will probably be "medical providers" in the near future. In May we will find out the new name recommended by the AAPAs search group, then every state will pursue changes to make it happen.

[Hope2PA]

1 hour ago, Boatswain2PA said:

If my grandkids go to the clinic, I want to make sure there is a board-certified specialist responsible for their care.  Don't necessarily need them to be seen by that specialist, but knowing that the specialist is in the chain matters.  

 In my small township, there are approximately 65 Family Medicine/Primary care physicians. A total of 9, yes, 9 are board certified. Good luck if you are in an area like this.  I very much respect the BC physicians.  However, there are several PA's and at least 1 NP I'd take my grandkids to before many of the non-BC physicians.  New PA, New NP and Medical residents should never think they do not need excellent providers to collaborate with on a regular basis.  Just because someone has a medical degree does not automatically mean they are the best provider.  Physicians, NP and PA can continue to learn and grow, taking more than basic required CEU, the kind you actually have to go to, not the beach vacations that you sign in and leave.  They collaborate with other professionals and investigate if they are uncertain, are open and honest if unsure, but will followup with your care. That is the provider I want for my grandkids. With that, I do believe PA in primary care should 100% be required to maintain Certification by testing just like BC physicians and NP should increase their requirements.

[ventana]

1 hour ago, Boatswain2PA said:

One year before what?  Orthopedic surgery?  Neurosurgery?  Or "just" family practice?

Would these fully independent family practice PAs still be called PAs since they no longer assist physicians? Would the surgery, ortho, or cardiologist PAs who DO still "assist" their docs get to keep their title?

 

same as intern year for doc's

hospital based

rotate through ICU/SICU/Floors/Ortho/GenearlSurgery/Psych (yup this one is important)

 

then some electives

 

would not be hard, just about any non-critical access hospital has this

 

PA<NP needs this as we are now no longer attached to a doc but instead just a revenue stream

 

Not to hijack the thread - but has anyone figured out home much $$$ we make for a hospital system?  If we are generating 80% of revenue of a Doc(common in the IM world) and only making 50% we are a big source of funds.....

[EMEDPA]

my EM group a few years ago figured we bought each doc a BMW every year and paid for their house if they stayed for 20 years. They got 50% of each chart they signed in bonus, 75% if they saw the pt briefly.

[ndpa09]

On 11/22/2018 at 10:43 AM, Boatswain2PA said:

A 25 year old who has never done anything in life beyond school (ie: typical new PA grad) with maturity and self-awareness?

Doesn't exist.

Speak for yourself please.

[Boatswain2PA]

4 hours ago, ndpa09 said:

Speak for yourself please.

When I was 25 I had been in the military for 6 years, and was the Operations Officer at a 24 man rescue unit.  I wasn't on internet discussion boards pressing "dislike".

[ProSpectre]

Just throwing this out there Boats, but according to the newest PAEA program report, the average age of a first year PA student is about 26, which means the average age of a newly practicing PA can't be any less than about 28. The average PCE hours is still around 2,900 (with a median of 2,300). There are of course younger students in some programs, but they are in the minority, so the "typical new PA grad" is in no way a 25 year old with no life experience. 

As an older student with a military background myself, I understand the value of life experience, and I can appreciate your desire to hold on to the "traditional" PA school admissions model; I also understand why you view the changes currently being pushed for in our profession with suspicion. But you shouldn't sell your future (and current) colleagues short by assuming that anyone without your specific background will be too immature to understand the gravity of their position, to ask for help when they need it, and to practice within the scope of their training and experience. 

[ArmyVetDude]

6 hours ago, Boatswain2PA said:

So, you are in agreement that the whole OTP thing is just a step toward the goal of full independent practice rights?  We get to practice just like physicians?

Except in surgical settings,  where PA's might first assist, we are not ASSISTANTS. Get that crap out of your head. We don't assist anyone. We take care of patients on our own - at times, in collaboration with other healthcare providers

Many PA's have their own panel of patients in primary care and work side by side but separately with physicians. Medical assistants and nurses assist physicians, not PA's (or NP's). Assisting docs in primary care is so 1980;s. 

By the way, soon or later we will  no longer be called physician assistants.  A name change plan has already been set in motion. Our name will likely be changed to either Physician Associate or Medical provider by next year or so

[Boatswain2PA]

5 hours ago, Hope2PA said:

In my small township, there are approximately 65 Family Medicine/Primary care physicians. A total of 9, yes, 9 are board certified.

I'm curious where that is?  A "small" township with 65 FP docs doesn't sound very "small" to me (I often work in towns where there is ONE doc), and I believe CMS requires board certification for payment.  

 

55 minutes ago, ArmyVetDude said:

Except in surgical settings,  where PA's might first assist, we are not ASSISTANTS.

Except in surgical settings, or non-surgical specialty settings like ortho, gen surg, gastro, endocrin, derm, etc.  There are LOTS of specialty settings, including the FP and EM specialty settings, where the PA indeed DOES act as an assistant.  

 

 

59 minutes ago, ArmyVetDude said:

We take care of patients on our own - at times, in collaboration with other healthcare providers

Some of us do.  I get that, really....because I'm one of them.  I work locums EM where I am almost always much better at EM than the FP doc listed as my SP.  Many of us who post here regularly practice very independently (see SAS post above).

But not all of us.   It's dangerous to implement a system where a new PA, who may only be 25 years old and has never DONE anything except excel academically, can suddenly practice independently.

 

1 hour ago, ArmyVetDude said:

By the way, soon or later we will  no longer be called physician assistants.

I'm very aware of the push for this, thanks.

 

2 hours ago, ProSpectre said:

the average age of a first year PA student is about 26, which means the average age of a newly practicing PA can't be any less than about 28. The average PCE hours is still around 2,900 (with a median of 2,300).

We set rules/regulations/laws to set the minimum standard. A new grad PA can reasonably be as young as 24 (younger with exceptional circumstances).  And many programs have watered down what they accept as PCE hours.

Look at it a different way:  There ARE great NP programs out there.  But the minimum standard is a pulse, money to pay the tuition, ability to write papers, and 500 hours in your friend's clinic.  We all agree that this standard sucks, and they have no business practicing medicine.

There are MANY PAs who have the knoweldge and experience to practice their specialty with total independence because they have dedicated themselves to learning their craft and have practiced it for years.  However that is not the MINIMUM standard for a PA.  The minimum standard for a PA, which is met by every PA program graduate, is to be able to practice medicine with the supervision of a physician.  This means we have PAs, and not just a few of them, who have no business practicing without supervision.

 

2 hours ago, ProSpectre said:

But you shouldn't sell your future (and current) colleagues short by assuming that anyone without your specific background will be too immature to understand the gravity of their position, to ask for help when they need it, and to practice within the scope of their training and experience. 

You're inserting words that I didn't use.  I am constantly in awe of "the younger generation", so certainly don't assume that "anyone without" my experience is immature, incompetent, dangerous, yada yada...   I was just using the prototypical 25 year old brilliant straight-A new grad, who has never done anything except for go to school, as an example of why independent practice rights for all PAs is a terrible idea.

[Boatswain2PA]

5 hours ago, ventana said:

same as intern year for doc's

hospital based

rotate through ICU/SICU/Floors/Ortho/GenearlSurgery/Psych (yup this one is important)

 

then some electives

 

would not be hard, just about any non-critical access hospital has this

I'm not following your meaning here Vent.  Please fill in some more for me...

 

[Kaepora]

Are you people telling me that you haven't precepted students where you were glad they had to be supervised?  I practice in an area with *three* BS to MS programs - I precept these kids all the time.  The last student I had was 23.  It was her final rotation.  She was incredibly immature.  Great grades, but my goodness.  She had so much growing up to do.  I wouldn't want her practicing unsupervised.  She certainly wasn't the first or only in my experience.