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Joelseff

California OTP/SB697 update

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I posted this in the California state specific section but felt it may get more exposure here. Mods please feel free to delete if need be
 
 
Update from CAPA:
 
https://capanet.org/2019/08/sb-697-update/
 
First off, We did not and will not get OTP in California this year.... There are definitely changes to SB697 which I was told was necessary because the legislature was going to kill it outright. They presented it at the CAPA conference in San Diego 2 weeks ago as "parity with NPs but not OTP." I assume because NPs don't have independence yet in California. I spoke with a few of the officials at CAPA who were tight lipped but I got the impression that if NPs gain independence here, they will push for that for us as well and this current bill will get our foot in the door.
 
I do think it's still better than nothing (which we have now) and would relieve restrictions at the practice level though I see most corporate health systems and larger physician group practices not changing much. Currently I work for a 10 provider practice (7 docs, 1 NP and 2 PAs) and the NPs and PAs have the same restrictions for cosignature etc. We have the same scope as well. Last place I worked (corporate 2 hospital system) had hundreds of providers and again, NPs and PAs had the same restrictions in outpatient while we PAs enjoyed the ability to work in ED and OR and FNPs were not allowed to round on inpatients but PAs were (this was defined by the practice/system). What I see this modified OTP as is just making this the law in California in all settings (make the practice define the role) so this part of OTP is preserved. I would have liked the direct billing part etc but I think we have to take one bite at a time. NPs have yet to win independence despite a yearly attempt for the past decade. Don't get me wrong, I'm all for it if they do so we can follow suit and use them as precedence).
 
Still a step forward is a step forward...
 
 
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^^^

I would be utterly stunned if NP's did not win this next year, 2020.  They got very close this year, and there was a long article in the LA times about this and how independent NP's are the answer to California's provider shortage.  PA's were not even mentioned in the article.  The Gov had also indicated he was willing to sign it.  

They are one year away guys, two max.

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^^^ I would utterly stunned if NP's did not win this next year, 2020.  They got very close this year, and there was a long article in the LA times about this and how independent NP's are the answer to California's provider shortage.  PA's were not even mentioned in the article.  The Gov had also indicated he was willing to sign it.  

They are one year away guys, two max.

 

I would be as well. I have read the LA times article and posted on here about it. I actually called CAPA and complained to them about it. I am not against them getting independence in fact would welcome it so we can use it to push our agenda further. From speaking with CAPA leadership... There is a sense (won't go into detail) that they want what we (on this site who complain lol) want but there really is more to it than just nailing a 95 theses to the door of the medical association or capitol Hill.  

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19 hours ago, Joelseff said:

I would be as well. I have read the LA times article and posted on here about it. I actually called CAPA and complained to them about it. I am not against them getting independence in fact would welcome it so we can use it to push our agenda further. From speaking with CAPA leadership... There is a sense (won't go into detail) that they want what we (on this site who complain lol) want but there really is more to it than just nailing a 95 theses to the door of the medical association or capitol Hill.  

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CAPA might be much more motivated and progressive than most orgs, but I just haven’t seen anywhere where it’s the case that PAs have managed to piggyback NP success. I feel like you guys will get OTP (because that’s what you are investing in), and NPs will get independence, and that’s going to be the rewards doled out. If someone goes back and presses for independence later on, authorities will roll their eyes and say “we just gave you OTP, why are you bugging us now?!”. NPs there are arguing for independence... that’s the train PAs have got to be on, because there won’t be another train later. They have to fight their way in there and demand “us too!” Physicians WILL NOT give an inch later on for you guys and lose the one remaining profession they have direct authority over, and nurses sure as can be will not be opening their arms for PAs. While this topic about NPs is moving forward, PAs need to exploit the fact that this conversation is going on. 

I keep harping on this because that’s Armageddon. California is for all the chips. If you get a state like that to be NP independent,  then every other state that isn’t a deep old order state follows suit. Then the NP compact comes into play next. That doesn’t help matters for dependent providers either. I’m more interested in California allowing NP practice freedom than I am in them being held back in the interest of PAs, so I’ll be thrilled to see California NP independence, regardless of what it does to PAs. But if PAs could get in on this too, I wouldn’t have a problem with it. But Jeeze, the consequences of not are so big. 

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It is almost always baby steps. I bet in Cali they can hear my eyes roll in Texas every time someone says "you just need to pass a law" like its writing a postcard. people who complain about "someone should do something" or "change the law" are often the ones who have no idea the work it takes.

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CAPA might be much more motivated and progressive than most orgs, but I just haven’t seen anywhere where it’s the case that PAs have managed to piggyback NP success. I feel like you guys will get OTP (because that’s what you are investing in), and NPs will get independence, and that’s going to be the rewards doled out. If someone goes back and presses for independence later on, authorities will roll their eyes and say “we just gave you OTP, why are you bugging us now?!”. NPs there are arguing for independence... that’s the train PAs have got to be on, because there won’t be another train later. They have to fight their way in there and demand “us too!” Physicians WILL NOT give an inch later on for you guys and lose the one remaining profession they have direct authority over, and nurses sure as can be will not be opening their arms for PAs. While this topic about NPs is moving forward, PAs need to exploit the fact that this conversation is going on.  I keep harping on this because that’s Armageddon. California is for all the chips. If you get a state like that to be NP independent,  then every other state that isn’t a deep old order state follows suit. Then the NP compact comes into play next. That doesn’t help matters for dependent providers either. I’m more interested in California allowing NP practice freedom than I am in them being held back in the interest of PAs, so I’ll be thrilled to see California NP independence, regardless of what it does to PAs. But if PAs could get in on this too, I wouldn’t have a problem with it. But Jeeze, the consequences of not are so big.   

 

You really think that we should just demand independence up front? Really. It hasn't (yet) worked for NPs in the past decade here. Did you not read where they were going to kill our bill outright? We had to make a compromise. OTP was also a compromise because we had no leg to stand on. Is OTP the best, no but it's what we have to work with. And it does give us a foot in the door where it would have been slammed in our face.  I'm curious lightspeed... How much experience do you have with legislation? How involved are you in NP lobbying, lawmaking etc. You seem to have strong opinions and sound like you have some experience. Maybe you can tell us how to do what you say we should do. I'll tell the CAPA leaders. Hell I'll PM Dave Mittman who is the AAPA president so we can do better at it.

 

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I've been nervously watching this bill (California has a really cool bill tracker that shows you the progress of each bill as it moves through all of the committees and votes- here's SB 697 https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB697) and sending emails to everyone along the way. I'm excited at the progress that it's made, but I'll believe this bill exists when it's got Gavin Newsom's signature on it. As for NP independence, I can't tell how close their bill is to being a reality (https://leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=201920200AB890). The LA times article was an absolute fluff piece, but I can't say I'm shocked that nurses/NPs got good PR. They always get good PR. I believe that the California Medical Association pushed back on the bill, according to this article (https://www.usnews.com/news/health-news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-practitioner-authorities). However, I would love to see CAPA get involved in the "negotiations" that are ongoing between CMA and the California Nurses Association. 

Overall, I would love to see a law that basically gives NPs and PAs the same legal requirements and practice standards. In most larger groups we fill the same role, so it would be a common sense law to give us the same practice rights. However,  I think we can all agree that politics rarely follows any sort of common sense. 

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3 hours ago, Joelseff said:

You really think that we should just demand independence up front? Really. It hasn't (yet) worked for NPs in the past decade here. Did you not read where they were going to kill our bill outright? We had to make a compromise. OTP was also a compromise because we had no leg to stand on. Is OTP the best, no but it's what we have to work with. And it does give us a foot in the door where it would have been slammed in our face.  I'm curious lightspeed... How much experience do you have with legislation? How involved are you in NP lobbying, lawmaking etc. You seem to have strong opinions and sound like you have some experience. Maybe you can tell us how to do what you say we should do. I'll tell the CAPA leaders. Hell I'll PM Dave Mittman who is the AAPA president so we can do better at it.

 

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I’ve worked on getting several pieces of health care legislation passed in my state, and they each did make it through into law. Haven’t worked on practice legislation because I haven’t had to...my state has been independent for some time, and nothing to do there. I don’t doubt the scale of the task ahead of you there, it’s more of a generalized critique. I dealt with the disparity between practice rights by voting with my feet and becoming an NP, but obviously that was convenient and acceptable to me, and doesn’t do a thing for your field. You mentioned the total collapse of the bill if concessions weren’t made, and I understand the need for collaborative gestures in the face of that. But I think where we differ is in where we place the stakes. In the case of California, it makes more sense to push OTP in the face of total collapse, so that you get at least something for members in the largest state. But maybe what Dave Mittman needs get onboard with is the small state strategy to get independence on the books somewhere. The problem he faces even with that is that the concept is easy, but putting the profession in a small state on the firing line like that has real repercussions for real PAs there. I get that too. But I think the stairs are high, and the consequences of not having independence anywhere reinforces the status quo so much, that at this point there is a risk of being locked out of some fundamental shifts on the edge of occurring in healthcare. Of anyone, Mr. Mittman is the best champion you could hope for, and I have no doubt he sees this. His statement have been true to his almost revolutionary vision compared to anyone at the top that has been there in the past. He sounds like...a nurse! But NPs are being cranked out at greater numbers per year than doctors. PAs are coming out at a good rate, but not near NPs.  There will always be money made available to get more doctors out the door into practice, and nurses will always have a role. But the pie will only be divided so many ways, especially under all the healthcare realities I see on the horizon, and the spoils will be split between the big dogs. You don’t want to have the kind of toehold AAs have. Being under the wings of the docs just means they keep you there to help themselves. Is there a solution in what I’m saying?... yes there is: get riled up. Here’s your motivation:

https://www.aanp.org/advocacy/state/state-practice-environment

See all that green out west? With California independent, that means NPs will OWN the entire West with the exception of Utah (which has a “good old boys” character with regard to healthcare environment that makes it more akin to the south than the rest of the region). I would even argue that the map is too stingy in the case of Illinois and Virginia, where NPs gain independence after a few years of collaboration (and might be the future for independence in many of the remaining states that have been hesitant to pull the trigger on independence so far). 

But in any event, that map for PAs would be all red under the standards the AANP set for it, even with OTP in place. If that doesn’t call for frantic measures, I don’t know what does. So sure...get OTP if that’s all there is to be gained. But you need to be independent somewhere... anywhere (The VA doesn’t count for much... gotta be a state). If Mittman can do that, he’s found his role as a miracle worker. Even without that, it sounds like you all are very well served with him at the helm, but desperate times are on the horizon. 

I care about this because I know a lot of PAs, and I think the system could support them better than what I’ve been seeing lately. I think they deserve better.

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19 minutes ago, Lightspeed said:

I’ve worked on getting several pieces of health care legislation passed in my state, and they each did make it through into law. Haven’t worked on practice legislation because I haven’t had to...my state has been independent for some time, and nothing to do there. I don’t doubt the scale of the task ahead of you there, it’s more of a generalized critique. I dealt with the disparity between practice rights by voting with my feet and becoming an NP, but obviously that was convenient and acceptable to me, and doesn’t do a thing for your field. You mentioned the total collapse of the bill if concessions weren’t made, and I understand the need for collaborative gestures in the face of that. But I think where we differ is in where we place the stakes. In the case of California, it makes more sense to push OTP in the face of total collapse, so that you get at least something for members in the largest state. But maybe what Dave Mittman needs get onboard with is the small state strategy to get independence on the books somewhere. The problem he faces even with that is that the concept is easy, but putting the profession in a small state on the firing line like that has real repercussions for real PAs there. I get that too. But I think the stairs are high, and the consequences of not having independence anywhere reinforces the status quo so much, that at this point there is a risk of being locked out of some fundamental shifts on the edge of occurring in healthcare. Of anyone, Mr. Mittman is the best champion you could hope for, and I have no doubt he sees this. His statement have been true to his almost revolutionary vision compared to anyone at the top that has been there in the past. He sounds like...a nurse! But NPs are being cranked out at greater numbers per year than doctors. PAs are coming out at a good rate, but not near NPs.  There will always be money made available to get more doctors out the door into practice, and nurses will always have a role. But the pie will only be divided so many ways, especially under all the healthcare realities I see on the horizon, and the spoils will be split between the big dogs. You don’t want to have the kind of toehold AAs have. Being under the wings of the docs just means they keep you there to help themselves. Is there a solution in what I’m saying?... yes there is: get riled up. Here’s your motivation:

https://www.aanp.org/advocacy/state/state-practice-environment

See all that green out west? With California independent, that means NPs will OWN the entire West with the exception of Utah (which has a “good old boys” character with regard to healthcare environment that makes it more akin to the south than the rest of the region). I would even argue that the map is too stingy in the case of Illinois and Virginia, where NPs gain independence after a few years of collaboration (and might be the future for independence in many of the remaining states that have been hesitant to pull the trigger on independence so far). 

But in any event, that map for PAs would be all red under the standards the AANP set for it, even with OTP in place. If that doesn’t call for frantic measures, I don’t know what does. So sure...get OTP if that’s all there is to be gained. But you need to be independent somewhere... anywhere (The VA doesn’t count for much... gotta be a state). If Mittman can do that, he’s found his role as a miracle worker. Even without that, it sounds like you all are very well served with him at the helm, but desperate times are on the horizon. 

I care about this because I know a lot of PAs, and I think the system could support them better than what I’ve been seeing lately. I think they deserve better.

 

I for one really appreciate the insight and posts of Lightspeed on these boards.  What he posts in not "the sky is falling.." rhetoric, it is TRUTH.  We are in an existential fight for our professional lives with basically no allies.  Like I said on another thread, this is a dam, and  when the legislative victories of NP's reach critical mass, the dam will break and PA's will be permanently removed from job postings simply because requiring a doc will be too much hassle for admins when they can just hire an independent NP to do the same thing, probably for less.  MANY of us believe that California is the key to reaching critical mass.  If/when it goes full NP independent, well as the late Bill Paxton use to say, it will be...."Game over man..."

 

I appreciate your insight Lightspeed and advice to our profession.  We need all the help we can get.

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there is some good news out there folks:

https://www.aapa.org/news-central/2019/08/indian-health-service-updates-pa-practice-giving-pas-autonomy-in-medical-decision-making/

 In the revised IHS manual, references to supervisory language have been removed along with the physician co-signature requirement on prescription or medication orders written by PAs within their privileges. The manual now states that the PA’s clinical privileges shall be commensurate with their education, experiences, competencies, and operational needs for the service to which they are assigned.

Additionally, PA scope of practice is now determined at the practice level: “PAs collaborate with, consult with, and refer to physicians and other members of the healthcare team as indicated by the patient’s condition and the standards of care in accordance with the PA’s training, experience, and current competencies.”

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I’ve worked on getting several pieces of health care legislation passed in my state, and they each did make it through into law. Haven’t worked on practice legislation because I haven’t had to...my state has been independent for some time, and nothing to do there. I don’t doubt the scale of the task ahead of you there, it’s more of a generalized critique. I dealt with the disparity between practice rights by voting with my feet and becoming an NP, but obviously that was convenient and acceptable to me, and doesn’t do a thing for your field. You mentioned the total collapse of the bill if concessions weren’t made, and I understand the need for collaborative gestures in the face of that. But I think where we differ is in where we place the stakes. In the case of California, it makes more sense to push OTP in the face of total collapse, so that you get at least something for members in the largest state. But maybe what Dave Mittman needs get onboard with is the small state strategy to get independence on the books somewhere. The problem he faces even with that is that the concept is easy, but putting the profession in a small state on the firing line like that has real repercussions for real PAs there. I get that too. But I think the stairs are high, and the consequences of not having independence anywhere reinforces the status quo so much, that at this point there is a risk of being locked out of some fundamental shifts on the edge of occurring in healthcare. Of anyone, Mr. Mittman is the best champion you could hope for, and I have no doubt he sees this. His statement have been true to his almost revolutionary vision compared to anyone at the top that has been there in the past. He sounds like...a nurse! But NPs are being cranked out at greater numbers per year than doctors. PAs are coming out at a good rate, but not near NPs.  There will always be money made available to get more doctors out the door into practice, and nurses will always have a role. But the pie will only be divided so many ways, especially under all the healthcare realities I see on the horizon, and the spoils will be split between the big dogs. You don’t want to have the kind of toehold AAs have. Being under the wings of the docs just means they keep you there to help themselves. Is there a solution in what I’m saying?... yes there is: get riled up. Here’s your motivation:

https://www.aanp.org/advocacy/state/state-practice-environment

See all that green out west? With California independent, that means NPs will OWN the entire West with the exception of Utah (which has a “good old boys” character with regard to healthcare environment that makes it more akin to the south than the rest of the region). I would even argue that the map is too stingy in the case of Illinois and Virginia, where NPs gain independence after a few years of collaboration (and might be the future for independence in many of the remaining states that have been hesitant to pull the trigger on independence so far). 

But in any event, that map for PAs would be all red under the standards the AANP set for it, even with OTP in place. If that doesn’t call for frantic measures, I don’t know what does. So sure...get OTP if that’s all there is to be gained. But you need to be independent somewhere... anywhere (The VA doesn’t count for much... gotta be a state). If Mittman can do that, he’s found his role as a miracle worker. Even without that, it sounds like you all are very well served with him at the helm, but desperate times are on the horizon. 

I care about this because I know a lot of PAs, and I think the system could support them better than what I’ve been seeing lately. I think they deserve better.

Oh don't get me wrong a bunch of us are plenty "riled up" but we are facing a huge hill to climb. Mittman is a the AAPA Prez not CAPA by the way and he spoke at our conference about this. (CAPA prez is Roy Guizado) and a bunch of us here know what we have now in Mittman at the helm at AAPA (he started PAFT also). When OTP first came out I was against it and was in favor of straight up independence but realized how a tough sell that would be and again I go back to our support which is unfortunately low from PAs in Cali and nationwide. I am evangelical in getting people to join CAPA AND give to the Pac fund. It's bananas that a lot of PAs in Cali and nationwide complain when something go wrong but won't back the organization fighting for us but I think that is due to some well known hx of bad management by prior administrations.

 

We'll keep fighting and I still don't think the sky is falling but we need to make moves for a better future for PAs.

 

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Question,

is the fear of NP takeover more-so for the primary care/urgent care/ED settings? I work in critical care and under no circumstance do I think any provider other than a physician should have the ultimate say in some of these incredibly complex patients. In the inpatient and surgical settings I don’t see how their independence would have that great of an effect on us. I work with a lot of great NPs and we both have required chart co-signatures as there is always a physician in house.

Another thought I have had regarding corporate medicine only hiring NPs due to their independence is if an independent NP were to severely mismanage a patient what type of liability the practice/corporation would be open to if a physician with the gold standard medical training was not available for collaboration.

i am all for OTP. Just wanted to see what everyone’s thoughts were regarding these scenarios. I’ve been reading these forums closely and find a of these threads unnerving to say the least so figured I’d chime in.

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I don't work in inpt or surgery but I would assume OTP would still be a benefit in that restrictions are loosened. Just because you are not bound to a certain CP/SP it doesn't mean you can't work for the practice or even that Doc if it's a solo practice (which doesn't really exist anymore amirite?). If you work for a hospital it shouldn't change much at all as they restrict providers at the practice level with their SOPs already anyway. It also should promote the taking down of prejudices in hiring against PAs in favor of NPs since there will be no state level mandated chart review and supervision guidelines.

 

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29 minutes ago, JoeM said:

 

Another thought I have had regarding corporate medicine only hiring NPs due to their independence is if an independent NP were to severely mismanage a patient what type of liability the practice/corporation would be open to if a physician with the gold standard medical training was not available for collaboration.

 

The same liability they have when a doc screws up.  No difference.  It's why they carry malpractice ins.  That and they will throw the provider under the bus like they always do.  Whether it's an NP or MO/DO it would be no difference.

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It’s very notable that the California Medical Association SUPPORTS SB 697. Usually you have to negotiate and compromise for months to get other stakeholders to merely drop opposition and become “neutral” so that bills may pass. But CMA has actually testified in support of passing SB697, while simultaneously actively campanginginf against the NP independence bill. 

 

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5 hours ago, spflynn4 said:

I've been nervously watching this bill (California has a really cool bill tracker that shows you the progress of each bill as it moves through all of the committees and votes- here's SB 697 https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201920200SB697) and sending emails to everyone along the way. I'm excited at the progress that it's made, but I'll believe this bill exists when it's got Gavin Newsom's signature on it. As for NP independence, I can't tell how close their bill is to being a reality (https://leginfo.legislature.ca.gov/faces/billStatusClient.xhtml?bill_id=201920200AB890). The LA times article was an absolute fluff piece, but I can't say I'm shocked that nurses/NPs got good PR. They always get good PR. I believe that the California Medical Association pushed back on the bill, according to this article (https://www.usnews.com/news/health-news/articles/2019-07-03/california-doctors-oppose-expanding-nurse-practitioner-authorities). However, I would love to see CAPA get involved in the "negotiations" that are ongoing between CMA and the California Nurses Association. 

Overall, I would love to see a law that basically gives NPs and PAs the same legal requirements and practice standards. In most larger groups we fill the same role, so it would be a common sense law to give us the same practice rights. However,  I think we can all agree that politics rarely follows any sort of common sense. 

It looks like AB-890, the NP Bill, did not make it out of the Appropriations Committee and has been postponed until next year. So, stay tuned for that one.

https://a02.asmdc.org/press-releases/20190516-asm-jim-wood-will-continue-fight-ab-890-full-practice-authority-nurse

 

 

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27 minutes ago, lemurcatta said:

It’s very notable that the California Medical Association SUPPORTS SB 697. Usually you have to negotiate and compromise for months to get other stakeholders to merely drop opposition and become “neutral” so that bills may pass. But CMA has actually testified in support of passing SB697, while simultaneously actively campanginginf against the NP independence bill. 

 

That's a really big vote in support of OTP. However, I don't have a lot of confidence that the NP lobby wouldn't overcome CMA's objections if push comes to shove. Too bad CAPA can't get with Jim Wood (sponsor of AB 890) and CMA to just include NPs and PAs in the same piece of legislation. Ideally, we could see a law with the same set of restrictions imposed on both positions. 

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27 minutes ago, Joelseff said:

Oh don't get me wrong a bunch of us are plenty "riled up" but we are facing a huge hill to climb. Mittman is a the AAPA Prez not CAPA by the way and he spoke at our conference about this. (CAPA prez is Roy Guizado) and a bunch of us here know what we have now in Mittman at the helm at AAPA (he started PAFT also). When OTP first came out I was against it and was in favor of straight up independence but realized how a tough sell that would be and again I go back to our support which is unfortunately low from PAs in Cali and nationwide. I am evangelical in getting people to join CAPA AND give to the Pac fund. It's bananas that a lot of PAs in Cali and nationwide complain when something go wrong but won't back the organization fighting for us but I think that is due to some well known hx of bad management by prior administrations.

 

We'll keep fighting and I still don't think the sky is falling but we need to make moves for a better future for PAs.

 

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You also have a significant number of your most seasoned PAs who appreciate the warm embrace of the physician establishment. They’ve worked their careers in circumstances that have been collegial, and aren’t bearing the burdens of education debt that the newcomers are. It’s also the twilight of a lot of PA careers due to retirement. The epiphany for me to have the change of heart (besides getting to know more PAs) was that I figured that if you guys are paying $100,000 plus for your tuition, and going into debt for as much or more than that for living expenses, it should be your profession to steer and oversee. That’s not chump change. There are just a handful of reasonably priced programs now. Everything else has given way to the $100,000 state school and the private schools that cost even more. That’s too much to have to then go out and ingratiate yourself to a superior to put food in the table. As an RN, I had to go out and essentially find an employer in order to work, but nobody handed me a prescription pad and told me to do the same job as the physician for far less pay. Additionally, my performance was evaluated by my peers on the BON. PAs pay too much, train too much, and do too much to play not be the voice that leads their ranks. Marching to the pace physicians set worked when PAs went to diploma programs that cost very little and didn’t have 10 students applying for every seat. It’s grown into its own to the point where new grads aren’t seen as apprentices, but should expect to hit the ground running. The physicians aren’t interested in holding anyone’s hand to get them up to speed, so priority one should be taking the hand away. 

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52 minutes ago, lemurcatta said:

It’s very notable that the California Medical Association SUPPORTS SB 697. Usually you have to negotiate and compromise for months to get other stakeholders to merely drop opposition and become “neutral” so that bills may pass. But CMA has actually testified in support of passing SB697, while simultaneously actively campanginginf against the NP independence bill. 

 

What’s not to like from physicians?.... no more having to wait to have PAs be able to jump in and practice interchangeably without needing to designate a specific supervising physician; less risk of getting individually named in a lawsuit due to cosignature of someone else’s work; nobody being specifically designated and obliged to take time to solve a problem they didn’t create.

And then the PA can also be free to go open their own practice free and clear and bill individually for services rendered.... (record scraaaaaaaatch!). Nope, not under OTP. Who is OTP designed to help out more, physician owned practices and employers of PAs, or PAs themselves? At the end of the day, control is transferred from the physician to the practice... which is run by physicians. Or maybe a newly minted Doctor of Nursing Practice, with lots of graduate level practice management coursework. 

Let me say this in a different way... OTP is a favor that you would never see NP groups be willing to accept, even if it were handed to them.  Maybe in terrible restricted places like Michigan, but nowhere else would OTP be considered a significant plus, let alone “optimal”. If it’s part of a specific pathway bridging toward independence, then maybe. But ultimately, NPs would see value in it only as an avenue to a nicer place, not a destination. 

OTP isn’t bad. I’m a true believer in not letting good becoming the enemy of perfect. Like Confucius supposedly said, “better a diamond with a flaw than a pebble without.” But the OTP movement is one that takes resources and effort, and it’s the last you will hear from Pa groups in the vast majority of situations. It’s an acceptable substitute that is presented right when you are on the edge of having the ability to move towards parity with NPs.

PAFT started here in the back of a napkin, essentially. A few years later the founder is at the helm of your national org. That was some rapid disruption in my mind that shook the foundations. Shake them just a little more. Maybe it’s the more timid folks at CAPA and other state organizations that are worried about the nuts and bolts of the issue. That’s how it should be really, because they are on the ground and feel the effects of radical ideas first, especially when they fail and leave them exposed. But the national orgs are where the BSC voices need to come from. Those are the folks that you need to see at the conventions and think “they’re a bit crazy”. They need to be the disrupters that aren’t reaching out, but pissing off the NPs and the doctors, and serving notice that the status quo is being questioned. Drop a million dollars in Montana on independence, and you’ll get it, and that’s a fire that won’t be stopped. Someone has to make it to the moon to show it can be done. You guys have nobody on the moon. That would be THE BEST MONEY THAT COULD BE SPENT ON YOUR BEHALF. Every penny spent on that for the first state would safe a dollar later on with OTP and the like. 

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25 minutes ago, Lightspeed said:

You also have a significant number of your most seasoned PAs who appreciate the warm embrace of the physician establishment. They’ve worked their careers in circumstances that have been collegial, and aren’t bearing the burdens of education debt that the newcomers are. It’s also the twilight of a lot of PA careers due to retirement. The epiphany for me to have the change of heart (besides getting to know more PAs) was that I figured that if you guys are paying $100,000 plus for your tuition, and going into debt for as much or more than that for living expenses, it should be your profession to steer and oversee. That’s not chump change. There are just a handful of reasonably priced programs now. Everything else has given way to the $100,000 state school and the private schools that cost even more. That’s too much to have to then go out and ingratiate yourself to a superior to put food in the table. As an RN, I had to go out and essentially find an employer in order to work, but nobody handed me a prescription pad and told me to do the same job as the physician for far less pay. Additionally, my performance was evaluated by my peers on the BON. PAs pay too much, train too much, and do too much to play not be the voice that leads their ranks. Marching to the pace physicians set worked when PAs went to diploma programs that cost very little and didn’t have 10 students applying for every seat. It’s grown into its own to the point where new grads aren’t seen as apprentices, but should expect to hit the ground running. The physicians aren’t interested in holding anyone’s hand to get them up to speed, so priority one should be taking the hand away. 

...and to add to that, a significant number of new grads are now finding out that without a residency, finding a job is tough.  Just getting into a residency is competitive enough, but it also delays paying back their school loans for yet another year.

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2 hours ago, JoeM said:

Question,

is the fear of NP takeover more-so for the primary care/urgent care/ED settings? I work in critical care and under no circumstance do I think any provider other than a physician should have the ultimate say in some of these incredibly complex patients. In the inpatient and surgical settings I don’t see how their independence would have that great of an effect on us. I work with a lot of great NPs and we both have required chart co-signatures as there is always a physician in house.

Another thought I have had regarding corporate medicine only hiring NPs due to their independence is if an independent NP were to severely mismanage a patient what type of liability the practice/corporation would be open to if a physician with the gold standard medical training was not available for collaboration.

i am all for OTP. Just wanted to see what everyone’s thoughts were regarding these scenarios. I’ve been reading these forums closely and find a of these threads unnerving to say the least so figured I’d chime in.

So think a little bigger, because the benefit of independence isn’t always easy to see where you are, and that’s a common problem with the folks trying to ascertain how it affects them. An easy way understand it is to simply look at NPs in independent states and how they function. Basically, you wouldn’t notice a huge difference, much like you do now. But because of that, you should be asking the question “if there isn’t much difference, then why can’t I be independent like them... what’s the harm?” But also, ask who wants to keep the status quo and why. 

Look, the American colonists didn’t freak out and dump tea into the Boston harbor because there was an onerous tax upon them, they did it because “F you (Britain) for making us pay a tax!” I would actually argue that there are more pressing reasons to want independence than just indignation. The effects are system wide. So while you might not see the need for independence in your setting, just the fact that you aren’t tethered to physicians as a profession is a ripple in the water because you are more mobile. That mobility is acknowledged even if it’s subconscious. “Keep these guys happy because they can leave” is what it says. When they hire you, you come to them as a professional with your own skill set and own needs that you want met, and gives you more leverage. Gets you guys out of the mindset that they are doing you a favor by picking you up and attaching you to a reluctant organization or physician. 

Think on this too. NPs are pigeon holed into somewhat broad, but defined specialties. PAs ARE NOT! Who is better positioned to take full advantage of independence... NPs or PAs? You guys are generalists with pretty fantastic education that I feel places you guys well to enter just about any realm NPs function in right out of the box. With some prior HCE, maybe even better leveraged (although it’s hard to beat RN background for HCE, even with the rescue guys, I’ll just say that flatly). So a mobile PA with that great generalist background has greater latitude than an FNP that is trying to retool to be an internist, or an adult acute care NP trying to get into urgent care. If you guys broke the independent barrier, you’d be a force to be reckoned with.... provided that you weren’t distracted by the siren song of the pleasures of OTP. Don’t get distracted by that. It only holds you to a slightly different status quo. Even physicians and medical schools would have to deal with the aftermath of independent PAs. What’s not to like for applicants? Less school, decent lifestyle, less debt and sacrifice, the ability to not be locked into specialties, professional satisfaction with a sense of permanency. And NPs? You think they want to go up against independent PAs?

I know nurses who have RN or NP tattoos (stupid, yeah). It’s because it’s our profession. You feel safe tattooing it on you... like you would your kids names. Your kids will always be yours. How many people, smart or not do you know with spouse or significant other tattoos? The ones you do are usually in the process of regretting them or getting them reworked. That’s PA for you. Your abusive spouse is the physician establishment. All you are doing with OTP is getting a little reprieve from the abuse for a few days per week instead of every day. The only tattoo you are getting is the spouses surname instead of their first name, hoping that you still have good relations with the in-laws to want to have pride in the family name after you have courage to break out and leave. How many PAs have “physician assistant” incorporated into their skin art?  

And if all else fails, freedom just tastes better man! 

So what does independence look like for NPs in hospitalization roles? Maybe no different until you leave. Then you want it so you can put food on the table. Maybe you benefit because the administrations all know that they have to compete for you to keep you from starting your own hospitslist service, or even hire your friends to work concierge medicine when they piss you off and you leave. It’s a strategic benefit, not a tactical one. It’s the war, not the battle.  

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So think a little bigger, because the benefit of independence isn’t always easy to see where you are, and that’s a common problem with the folks trying to ascertain how it affects them. An easy way understand it is to simply look at NPs in independent states and how they function. Basically, you wouldn’t notice a huge difference, much like you do now. But because of that, you should be asking the question “if there isn’t much difference, then why can’t I be independent like them... what’s the harm?” But also, ask who wants to keep the status quo and why.  Look, the American colonists didn’t freak out and dump tea into the Boston harbor because there was an onerous tax upon them, they did it because “F you (Britain) for making us pay a tax!” I would actually argue that there are more pressing reasons to want independence than just indignation. The effects are system wide. So while you might not see the need for independence in your setting, just the fact that you aren’t tethered to physicians as a profession is a ripple in the water because you are more mobile. That mobility is acknowledged even if it’s subconscious. “Keep these guys happy because they can leave” is what it says. When they hire you, you come to them as a professional with your own skill set and own needs that you want met, and gives you more leverage. Gets you guys out of the mindset that they are doing you a favor by picking you up and attaching you to a reluctant organization or physician.  Think on this too. NPs are pigeon holed into somewhat broad, but defined specialties. PAs ARE NOT! Who is better positioned to take full advantage of independence... NPs or PAs? You guys are generalists with pretty fantastic education that I feel places you guys well to enter just about any realm NPs function in right out of the box. With some prior HCE, maybe even better leveraged (although it’s hard to beat RN background for HCE, even with the rescue guys, I’ll just say that flatly). So a mobile PA with that great generalist background has greater latitude than an FNP that is trying to retool to be an internist, or an adult acute care NP trying to get into urgent care. If you guys broke the independent barrier, you’d be a force to be reckoned with.... provided that you weren’t distracted by the siren song of the pleasures of OTP. Don’t get distracted by that. It only holds you to a slightly different status quo. 

I know nurses who have RN or NP tattoos (stupid, yeah). It’s because it’s our profession. You feel safe tattooing it on you... like you would your kids names. Your kids will always be yours. How many people, smart or not do you know with spouse or significant other tattoos? The ones you do are usually in the process of regretting them or getting them reworked. That’s PA for you. Your abusive spouse is the physician establishment. All you are doing with OTP is getting a little reprieve from the abuse for a few days per week instead of every day. The only tattoo you are getting is the spouses surname instead of their first name, hoping that you still have good relations with the in-laws to want to have pride in the family name after you have courage to break out and leave. 

And if all else fails, freedom just tastes better man! 

So what does independence look like for NPs in hospitalization roles? Maybe no different until you leave. Then you want it so you can put food on the table. Maybe you benefit because the administrations all know that they have to compete for you to keep you from starting your own hospitslist service, or even hire your friends to work concierge medicine when they piss you off and you leave. It’s a strategic benefit, not a tactical one. It’s the war, not the battle.  

 

 

I think we'll get independence but I agree with you that we have to be purposeful about it. We have full OTP in North Dakota now so that may be a good place to start but we'll see. OTP is what we have right now. I don't think it would be a good idea to change gears now and screw up chances of OTP and I disagree with you about your point about not being able to piggyback off of NPs. If (or likely when) u guys get independence here in Cali, it would be easier to show that we should have that too since they granted us parity with NPs with OTP. (this was "nodded" to during conversations with some CAPA folk) OTP/SB697 in California does put us in PARITY with NPs here. It sets a precedent. We don't need California NPs or their organization to help us with that because we got the parity on our own. If they grant NP independence, what would be their argument against giving PAs independence as well?  Sent from my SAMSUNG-SM-G891A using Tapatalk

 

 

 

 

 

 

 

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Does anyone else feel that indepence among the NPs is eventually going to hurt PAs and NPs independence? I'm not talking about mental health NPs because I dont know enough but most of the medical NPs have horrible clinical judgements, suck at working things up, or utterly sends the most stupid benign crap to the ER. Maybe its just NPs in california that I'm not impressed with. Maybe most go to online schools.

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2 minutes ago, Joelseff said:

I think we'll get independence but 8 agree with you that we have to be purposeful about it. We have full OTP in North Dakota now so that may be a good place to start but we'll see. OTP is what we have right now. I don't thinn it would be a good idea to change gears now and screw up chances of OTP and I disagree with you about your point about not being able to piggyback off of NPs. If (or likely when) u guys get independence here, it would be easier to show that we should have that too since they granted us parity with NPs with OTP. OTP/SB697 in California does put us in PARITY with NPs here. It sets a precedent. We don't need California NPs or their organization to help us with that because we got the parity on our own. If they grant NP independence, what would be their argument against giving PAs independence as well?  

Sent from my SAMSUNG-SM-G891A using Tapatalk

 

I don’t know what the argument would be because, like you, I tend to think logically. To get into the mind of most detractors I have to break out of that mindset. I guess maybe the whole “NPs specialize and you are generalists”, which is not the whole story at all, but could be persuasive. You won’t get any help from physicians because, as I’ve argued, independence is the bridge too far for them. They will give up NPs to that if they have it rammed down their throat, but they will fight to the death to keep you guys in the fold. 

But you’ve turned me with what you said about parity. That’s enough of a benefit in and of itself because despite the conventional wisdom slightly favoring NP independence there, it’s not there and might not be there ever. So maybe the lesson is that pursuing OTP in NP restrictive states is the best use of finite resources. I was arguing with someone on SDN who is in Michigan (no nurse practice act there even), and although he’s a terribly flawed source (and I haven’t researched it much), but OTP there may have provided the one place in the nation where PA latitude exceeds that of NPs. That might not be saying much because Michigan sounds like a cruddy place to be an NP, but if true it destroyed an argument I’ve used in the past that nowhere in the world do PAs have a more favorable practice environment than NPs. That may just the the place where they do now, but only until NPs gain independence there (if they ever do). 

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Does anyone else feel that indepence among the NPs is eventually going to hurt PAs and NPs independence? I'm not talking about mental health NPs because I dont know enough but most of the medical NPs have horrible clinical judgements, suck at working things up, or utterly sends the most stupid benign crap to the ER. Maybe its just NPs in california that I'm not impressed with. Maybe most go to online schools.

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And I'm not saying all. I have met a few decent ones.

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