Another Perspective of OTP/Independence

[SedRate]

This post may be naive but before roasting me, hear me out. This is coming from a surgical PA viewpoint where being independent doesn't much matter since I can't legally perform surgery independently. 

Given the ever-increasing competition between NPs and PAs, the push for OTP/independence for PAs is becoming prominent. To play devil's advocate, would this not, then, reveal that perhaps a different category of provider should exist rather than the independent trio of physician, PA, and NP providers? After all, the PA field came about to fill a need that wasn't being met. Could PAs therefore still exist but in a different way than the battle between physicians and NPs? Or would this completely eliminate the need for PAs altogether and be the end of the PA field? I could see practices wanting to hire those who are "dependent" and cheaper than those who are independent. And the opposite where practices don't want to hire someone who requires legal oversight. If OTP/independence isn't achieved for PAs, will this give PAs an opportunity to fill a gap that will no longer be met once NPs are fully independent? Or is OTP/independence the only way forward?

I have a difficult time understanding the need for independence for those of us working in surgery. So how would that work for someone like me? Independent but I can't do anything independently? Will my increased malpractice insurance make me less desirable as an assist and lead to practices hiring RNFAs for assisting and independent PAs/NPs for rounding/clinic? I do understand the need for independence in the primary care and psych fields as other have discussed in previous posts. 

[SedRate]

Also, in my state, NPs are independent but hospital systems still require an attending physician. So both independent NPs and dependent PAs require oversight in the hospital setting. I've mentioned this a couple times without any response. Are there currently any NP-independent states that allow NPs to manage patients independently? Do you think this will change of PAs if and when achieve independence or as a part of the NP lobbying steamroll? 

[sas5814]

You touch on a few good points. The surgical fields are probably the prime examply of fields where we remain preferred and independence wouldn't make much difference. It would, however, eliminate the need for you to be tied to any one surgeon. You could just be a member of the surgical department and work for whomever you want within your credentials.

Hospital systems are free to make whatever rules they want and neither OTP nor independence is going to make them all just turn us loose without physician supervision/collaboration. The smart ones will see the opportunity to reduce their administrative burden and the smart physicians will see they are no longer responsible for someone else's work but that will be a slow transition with a lot of resistance.

As for filling the gaps.... the independent NPs have already demonstrated their willingness to fill gaps whenever they appear and their independent status where it applies gives them a significant advantage in doing so. It is one of the reasons we have to develop some kind of parity and quickly

[SedRate]

4 hours ago, sas5814 said:

You touch on a few good points. The surgical fields are probably the prime examply of fields where we remain preferred and independence wouldn't make much difference. It would, however, eliminate the need for you to be tied to any one surgeon. You could just be a member of the surgical department and work for whomever you want within your credentials.

Hospital systems are free to make whatever rules they want and neither OTP nor independence is going to make them all just turn us loose without physician supervision/collaboration. The smart ones will see the opportunity to reduce their administrative burden and the smart physicians will see they are no longer responsible for someone else's work but that will be a slow transition with a lot of resistance.

As for filling the gaps.... the independent NPs have already demonstrated their willingness to fill gaps whenever they appear and their independent status where it applies gives them a significant advantage in doing so. It is one of the reasons we have to develop some kind of parity and quickly

Good points. Thank you for your insight. 

As an aside and as it stands currently at least for my state, PAs aren't required to be tied to any one surgeon per se. PAs can assist whoever they want depending on their particular employment situation and delegation agreements, even now as dependent providers. But that curtails our abilities in the OR which are dependent on whichever surgeon we're assisting. And I can see your point about independence relieving some of the administrative burden. 

I'm worried that the boat has already sailed for PA independence and there's no way to catch up. I wonder if there's any other way around it. 

[sas5814]

Let me ask because I don't have a clue... if Dr Jones is your SP and you do a surgical procedure with Dr. Smith and there is a malpractice case does Dr. Jones get sucked into it by virtue of being your SP? Malpractice cases being money hunts and rarely about truth or actual malpractice I suspect so.

Independence may come eventually. Whether it will be too late only time will tell. I think we have to survive the next 5 years first.

[Kaepora]

I'm in PA, where we have "reduced practice" in the form of a collaboration agreement.  I do not, however, have to have my notes or orders cosigned from the state's perspective.  My hospital system has the NPs see patients in a completely independent manner in their outpatient offices, and in the hospital - it depends.  The hospitalist NPs do not need their notes cosigned - in fact, in the step down units, the NPs are practicing medicine independently, with a physician just available if needed.  When the PAs are there though, the physician needs to see the patient and cosign.  It's becoming a point of contention.  I think all of the other specialties do require cosignature for NPs.  

Edited August 2, 2019 by Kaepora

[SedRate]

16 hours ago, sas5814 said:

Let me ask because I don't have a clue... if Dr Jones is your SP and you do a surgical procedure with Dr. Smith and there is a malpractice case does Dr. Jones get sucked into it by virtue of being your SP? Malpractice cases being money hunts and rarely about truth or actual malpractice I suspect so.

Independence may come eventually. Whether it will be too late only time will tell. I think we have to survive the next 5 years first.

No, I cannot just work with any surgeon. A delegation agreement between each surgeon and appropriate malpractice insurance is needed to assist whoever I want and within the scope of that particular surgeon's specialty. Right now I actually have a handful of surgeons who can serve as my SP at any point in time. According to my state, I am not limited to just one SP. If Dr. Jones is a plastics guy and he's listed as my SP, I can do plastics with him. But if Dr. Smith is also listed as my SP and is an Ortho guy, I can only do Ortho when I'm working with him. I can't do medicine that is outside the scope of practice for whoever is acting as my SP at that point in time. So if I'm seeing a Dr. Jones patient who fell and broke their hip, I can't diagnose or treat their hip since Dr. Jones is a plastics guy and doesn't have hip fracture care within his scope of work. And for that, I do see your point regarding administrative burden of being independent, amongst other reasons to become independent.

I worry that becoming independent will increase our administrative costs as a surgical PA (namely hospital credentialing fees and malpractice insurance) and make us less desirable for surgeons to hire. They may want to hire RNFAs to assist rather than a costly independent surgical PA. Will our reimbursement for assisting also increase? 

[SedRate]

14 hours ago, Kaepora said:

I'm in PA, where we have "reduced practice" in the form of a collaboration agreement.  I do not, however, have to have my notes or orders cosigned from the state's perspective.  My hospital system has the NPs see patients in a completely independent manner in their outpatient offices, and in the hospital - it depends.  The hospitalist NPs do not need their notes cosigned - in fact, in the step down units, the NPs are practicing medicine independently, with a physician just available if needed.  When the PAs are there though, the physician needs to see the patient and cosign.  It's becoming a point of contention.  I think all of the other specialties do require cosignature for NPs.  

"I do not, however, have to have my notes or orders cosigned from the state's perspective."

"When the PAs are there though, the physician needs to see the patient and cosign."

Forgive me for my confusion, but is this in the hospitalist/step-down units only that you need cosignatures as a PA? Interesting to hear that hospitalist NPs don't need cosignatures but other specialty NPs do. 

[SedRate]

4 hours ago, Lightspeed said:

My malpractice insurance as an independent provider feels like almost nothing. 

That's great to hear. Would you mind sharing the general ballpark cost and whether your employer covers it all? I'm not familiar with the going NP malpractice rate, at least for psych. As an independent provider, do they require you to pay overhead and other expenses like a partner would or are you treated as an employee where they cover your costs?

To my understanding, psych doesn't need the highest tier malpractice coverage. As a surgical PA, I'm required to maintain at least $1mil/$3mil, and the cost difference between the lowest tier at $100k/$300k and my coverage at the highest tier in my state is $4600. Ouch. Glad I don't have to pay that on my own. 

[Kaepora]

9 hours ago, Sed said:

"I do not, however, have to have my notes or orders cosigned from the state's perspective."

"When the PAs are there though, the physician needs to see the patient and cosign."

Forgive me for my confusion, but is this in the hospitalist/step-down units only that you need cosignatures as a PA? Interesting to hear that hospitalist NPs don't need cosignatures but other specialty NPs do. 

No, all PAs in all service lines, per Pennsylvania law I believe, but definitely in my system, require cosignature.  In Pennsylvania, NPs do not need cosignature, but each hospital system can set more strict requirements.  

[MediMike]

Quick Google shows the requirements for PA cosign in PA (heh) is time dependent initially then based on an agreement between PA/MD/DO

[SedRate]

14 hours ago, Lightspeed said:

Here’s what I’ve noticed that most smart NPs do. Make sure your employer provides malpractice on their dime. Psyche is a hot field right now, and I noticed that most prospective employers didn’t balk at anything asked for, and I was actually impressed at what the initial offers came with. Then carry your own policy on top of that. NP malpractice insurance typically won’t cost you more than $2500 per year for high tier plans.

You never hear us complain about our malpractice insurance costs. I’ve always felt that maybe PA malpractice was high because the real target was the physician in a lawsuit. Only a PA who has been sued could enlighten us as to whether that was on the plaintiff’s menu or not. I’ve also heard that NP insurance is low because it comes from the same companies that offer it to the RNs as well. Not sure about the latter because physicians pay out the nose, even though the pool of doctors might be a bit smaller (and I’m not even sure it is). 

Do you know if independence changed your malpractice rates?

If PA malpractice is already higher than NPs, what's not to say that independence won't increase those costs further (more liability, more cost) thereby causing PAs to continue to look less desirable than NPs due to higher overhead. Yes, PA independence will decrease administrative burden, but if it's more expensive to employ the PA, why wouldn't employers continue to hire NPs despite equal practice capabilities? 

I'm not sure why PA malpractice rates are so high when PAs are also attached to physicians who are "bigger fish" for lawsuits. It doesn't make sense that a dependent provider would have higher malpractice insurance cost than an independent NP. I wonder if it has to do with the medical model of PA-physician practice vs nursing model of RN-NP, like you alluded to. 

[Hope2PA]

1 hour ago, Sed said:

Do you know if independence changed your malpractice rates?

If PA malpractice is already higher than NPs, what's not to say that independence won't increase those costs further (more liability, more cost) thereby causing PAs to continue to look less desirable than NPs due to higher overhead. Yes, PA independence will decrease administrative burden, but if it's more expensive to employ the PA, why wouldn't employers continue to hire NPs despite equal practice capabilities? 

I'm not sure why PA malpractice rates are so high when PAs are also attached to physicians who are "bigger fish" for lawsuits. It doesn't make sense that a dependent provider would have higher malpractice insurance cost than an independent NP. I wonder if it has to do with the medical model of PA-physician practice vs nursing model of RN-NP, like you alluded to. 

I could be wrong, but was once told it has something to do with the fact that NP are  lumped in with LPN and RN since they are all nurses. Rates are different for each but it helps to keep rates lower as a group, power in numbers.

[SedRate]

1 hour ago, Hope2PA said:

I could be wrong, but was once told it has something to do with the fact that NP are  lumped in with LPN and RN since they are all nurses. Rates are different for each but it helps to keep rates lower as a group, power in numbers.

Makes sense. Thanks for your insight. 

[SedRate]

I didn't think of it that way, but I see how that could be possible. Thank you for your thorough and thoughtful response.

[Lexapro]

NP insurance is pretty cheap because RNs/NPs get lumped in together, from what I understand. I pay $900/year for 1/5 mil coverage.

[Cideous]

3 minutes ago, Lexapro said:

NP insurance is pretty cheap because RNs/NPs get lumped in together, from what I understand. I pay $900/year for 1/5 mil coverage.

For malpractice as a provider????  Jesh, I'm in UC and was quoted at $3k.

[SedRate]

No kidding. $900 is unreal. Mine is $7000, albeit for the highest tier occurrence coverage. Glad I don't have to pay for it myself. 

[SedRate]

Nope. I've heard nursing insurance was cheap but figured NP insurance would be commiserate with PA insurance. 

[LT_Oneal_PAC]

I certainly don’t see why rates would go up? You aren’t anymore likely to get sued and the payout in the event when you did get sued wouldn’t be likely to change. Physician rates might go down since they aren’t going to be brought into a suit they weren’t involved in, but it’s such a rare occurrence that I doubt it would be significant. Remember insurance doesn’t operate on what they think will happen. They operate on statistical methods based on the past.

[SedRate]

Good point and makes sense. I didn't think of it that way. Thanks for your insight.