Well said

[ventana]

https://www.forbes.com/sites/sallypipes/2022/04/11/its-time-to-take-aim-at-scope-of-practice-laws/?sh=62bde93d556e&fbclid=IwAR093y7CD-tNBU6BTFqOtecDuFZwyRjHMor4eQUuTGraIILHyZWGsbuNzDc

 

 

 

 

POLICY

It's Time To Take Aim At Scope-Of-Practice Laws

Sally Pipes

Contributor

I cover health policy as President of the Pacific Research Institute

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Apr 11, 2022,08:00am EDT

 

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"Many state lawmakers understood the benefits of temporarily relaxing these restrictions as COVID-19 ... [+]

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In the last three months, state legislators have introduced more than 70 bills that would modify "scope-of-practice" laws—regulations that set limits on the care physician assistants, nurse practitioners, and other qualified professionals can provide to patients.

 

 

It's no wonder why. Many state lawmakers understood the benefits of temporarily relaxing these restrictions as COVID-19 strained the healthcare system. Freeing up physician assistants and nurse practitioners to provide more services made it easier for patients to access care during the pandemic. And it gave physicians more time to treat patients with more serious medical issues.

 

The same will be true after the public health crisis ends. Permanently rolling back restrictive scope-of-practice laws—and letting experienced healthcare workers do their jobs—is a common-sense reform that could benefit patients and the healthcare system alike.

 

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Physician assistants and nurse practitioners hold graduate-level degrees and have hundreds of hours of clinical experience. Yet some states' scope-of-practice laws bar these professionals from prescribing certain medications or practicing without doctor supervision.

 

That's nonsensical. Physician assistants and nurse practitioners deliver high-quality care.

Consider a recent review of more than 30 studies, which found that physician assistants provide the same or better level of treatment than doctors. Under a physician assistant's care, patients experience fewer complications, reductions in hospitalizations and readmissions, and boosts in quality of life.

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A new University of Pennsylvania study came to a similar conclusion about nurse practitioners. Researchers found that hospitals employing more nurse practitioners report 20% fewer deaths after common surgeries than hospitals with smaller numbers of NPs.

 

Allowing more of them to provide a wider array of primary care could also alleviate the U.S. doctor shortage. The Association of American Medical Colleges predicts the country could face a shortfall of up to 48,000 primary care physicians by 2034.

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Physician assistants and nurse practitioners are well-suited to plug this gap—and enable the 83 million Americans living in areas with an inadequate supply of primary care to access the services they need. In fact, allowing nurse practitioners alone to practice primary care to the full extent of their training could reduce the number of U.S. residents living in areas with shortages by 70%.

Nevertheless, efforts to maintain the status quo on scope-of-practice regulations abound. One of the latest examples is an analysis of data from the Hattiesburg Clinic, an accountable care organization in the southern part of Mississippi.

Researchers found that patients receiving primary care from nurse practitioners, physician assistants, and other "advanced practice providers" spent $43 more monthly than those treated by a doctor. As a result, they concluded, "Nurse practitioners and physician assistants should not function independently."

Other studies have found just the opposite. Research in Health Affairs, for instance, concluded that patients with medically complex conditions spent up to $2,300 less annually when treated by a physician assistant or nurse practitioner instead of a doctor.

Utilizing these healthcare workers could yield significant savings for individual states as well. Researchers at Duke University found that Pennsylvania could improve primary care quality and save $6.4 billion over 10 years by allowing nurse practitioners to treat patients to the full extent of their training.

Unsurprisingly, the authors of the Mississippi study also admitted that if it weren't for the "addition of over 100 nurse practitioners and physician assistants to the Hattiesburg Clinic over the past 15 years, our organization could not have provided services to thousands of patients who might have otherwise gone without care."

Thousands might be a low estimate. More than 1.7 million residents live in primary care shortage areas in Mississippi.

Many of those patients would be glad to hear there's a simple way to ease that shortage—and provide them with high-quality care at a lower cost. Relaxing scope-of-practice laws could do just that.

 

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Sally Pipes

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Sally C. Pipes is president, CEO, and the Thomas W. Smith fellow in healthcare policy at the Pacific Research Institute. Her latest book is False Premise, False Promise: The Disastrous Reality of Medicare for All, (Encounter 2020). Follow her on Twitter @sallypipes.

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[Reality Check 2]

Common Sense - it might not be dead.

This is an amazing straight up approach to health care analysis.

Refreshing!

[Apollo1]

I'm all for increasing scope-of-practice so that our profession can maintain parity.

At the same time, it's well known that a vast majority of NP's and PA's are not providing PCP care to rural (or even urban) communities (contrary to what multiple advocacy groups tout). Obviously this issue is multifactorial, but is seems disingenuous to argue that scope-of-practice will magically cure the issue.

[rev ronin]

25 minutes ago, Apollo1 said:

I'm all for increasing scope-of-practice so that our profession can maintain parity.

At the same time, it's well known that a vast majority of NP's and PA's are not providing PCP care to rural (or even urban) communities (contrary to what multiple advocacy groups tout). Obviously this issue is multifactorial, but is seems disingenuous to argue that scope-of-practice will magically cure the issue.

Why go rural when you can get a job that meets with your lifestyle expectations?  As long as there are urban/suburban jobs, most PAs who went to urban or suburban PA schools (which is just about all of them, I think...) are more likely to want to work there.

That is, the issue isn't a lack of jobs or support, but that NO ONE wants to work rural, and making more NPs or PAs won't magically overflow care into those areas until people are forced to take those jobs due to inability to get jobs in larger markets.

[mgriffiths]

5 hours ago, rev ronin said:

Why go rural when you can get a job that meets with your lifestyle expectations?  As long as there are urban/suburban jobs, most PAs who went to urban or suburban PA schools (which is just about all of them, I think...) are more likely to want to work there.

That is, the issue isn't a lack of jobs or support, but that NO ONE wants to work rural, and making more NPs or PAs won't magically overflow care into those areas until people are forced to take those jobs due to inability to get jobs in larger markets.

Couple this with the fact that every truly rural job I've looked at has paid significantly less than what I've been able to find in a "less desirable" city.  I worked a truly rural job for just over 2 years in FM and was paid $85k with bonus.  There were reasons beyond finances I accepted the job, and with working like a dog I was able to make approximately $110k with the RVU bonus.  But, when I began looking again a non-rural FM job was paying $110k base with a better RVU bonus structure.

I've continued to look at rural opportunities and the pay is awful...unless you literally go middle of nowhere Alaska or similar.

Examples:

1. Ortho (current job): $111k base with a very doable bonus structure that should bring me to around $140k (the compensation model changed, so I'm basing this off 2021 productivity).  This is working for a hospital in a small town in the midwest that most would consider rural, but really it's a pretty affluent small town approximately 10 minutes from a decent sized city (population 50k+) and then two larger cities (75k+) approximately 30 minutes away.

2. Truly rural ortho (private practice) and base was $75k with bonus system based on an algorithm that was very confusing.  This was an offer I received 10/2021.

3. Rural FM: base $90k with staggering RVU bonus system that would have required over 4000 RVUs/year to make it to $100k.  Offer received 02/2022.

 

The issue is that billing/reimbursement from insurance companies favors hospitals, and even more hospital systems, with "facility fees" and similar add-ons.  I'm not expert enough in billing/reimbursement to suggest a solution...but this isn't it.

To go back to the old FM job I had...I'll add another problem.  It's complicated to explain how I know this, but it was a private practice and the owning physicians were earning over $400k annually EACH from the practice when I was there.  Since 2019 they have been earning over $600k each, with COVID pushing it even further north.  I'm still connected with some of the APPs that work there...their income has remained stagnant while the owning physicians' income has skyrocketed.  Is this any different that what hospital CEOs and similar have been doing?

[ohiovolffemtp]

I have seen primary care and specialties pay less in rural locations.  However, I've found that compensation for EM in rural critical access hospitals to pay better and have a better scope of practice.  In many cases, both the docs and the PA's travel in, work a stretch, and then go back home.  This model probably only applies to other hospital based specialties like hospital medicine and anesthesia though.

[LT_Oneal_PAC]

@mgriffiths

have to agree with Ohio. Perhaps you have tried, but I find negotiations are much more easily done at rural facilities. Big cities I find have a rigid HR, but every rural area has paid me far, fare more after just a little negotiation. 
 

My county hospital CEO has been pretty good with paying people what they are worth, including giving us all big bonuses working through COVID, working out ways to decrease our work load, etc. maybe it doesn’t always come as quickly as I’d like, but it happens.

@rev ronin is right. We just can’t get people to work here. Multiple people have fallen through that start the process of hiring. Never can find a PA willing to move even near here.

[EMEDPA]

55 minutes ago, LT_Oneal_PAC said:

@mgriffiths

 I find negotiations are much more easily done at rural facilities. Big cities I find have a rigid HR, but every rural area has paid me far, fare more after just a little negotiation. 
My county hospital CEO has been pretty good with paying people what they are worth, including giving us all big bonuses working through COVID, working out ways to decrease our work load, etc. maybe it doesn’t always come as quickly as I’d like, but it happens.

@rev ronin is right. We just can’t get people to work here. Multiple people have fallen through that start the process of hiring. Never can find a PA willing to move even near here.

Agree with all of this- The thing that hasn't been discussed here about rural jobs is that they tend to respect PAs more and give us a broader/appropriate scope of practice based on our training and experience. My last shift I ran two codes back to back without a physician present for either. That would NEVER happen at an urban ED. Also agree that rural pays more for experience. My most recent per diem job gave me a ridiculous low ball offer. I showed them my current paystubs from everywhere else and overnight their offer went up by $27/hr to remain competitive with other facilities. 

[sas5814]

True and true. I worked a rural critical access ER for a couple of years and it was just me and the staff. Code? Me. Gunshot? Me. It was challenging work and I was respected by the hospital and the community.

 

I had to call a neurosurgeon in Dallas once for a big intracranial bleed. He was, as is expected with neurosurgeons, a dick. "Why are you calling me? Where is your physician?"

I said "I'm in a 12 bed critical access hospital. My physician is at home asleep. Who should I call? Ortho?" He told me to send them to his ER and slammed the phone down.

I think that demonstrates the differences in responsibility and respect between urban and rural.

[mgriffiths]

2 hours ago, LT_Oneal_PAC said:

@mgriffiths

have to agree with Ohio. Perhaps you have tried, but I find negotiations are much more easily done at rural facilities. Big cities I find have a rigid HR, but every rural area has paid me far, fare more after just a little negotiation. 
 

My county hospital CEO has been pretty good with paying people what they are worth, including giving us all big bonuses working through COVID, working out ways to decrease our work load, etc. maybe it doesn’t always come as quickly as I’d like, but it happens.

@rev ronin is right. We just can’t get people to work here. Multiple people have fallen through that start the process of hiring. Never can find a PA willing to move even near here.

I think the difference here is EM vs. other areas of medicine.  I don't have a background in EM...so for me to start in a rural hospital with that level of scope would be dangerous for all involved.

[EMEDPA]

2 hours ago, mgriffiths said:

I think the difference here is EM vs. other areas of medicine.  I don't have a background in EM...so for me to start in a rural hospital with that level of scope would be dangerous for all involved.

lots of new grads have significant debt, so the loan repayment from rural sites can be a big deal. A friend of mine working at an affiliated family medicine clinic of my primary rural hospital is making 120k/yr and also gets state and federal loan repayment totaling 60k/yr. Not too shabby. 

[ohiovolffemtp]

On 4/19/2022 at 12:51 PM, EMEDPA said:

Also agree that rural pays more for experience. My most recent per diem job gave me a ridiculous low ball offer. I showed them my current paystubs from everywhere else and overnight their offer went up by $27/hr to remain competitive with other facilities. 

Well, mostly.  One of the larger (but not big 3) EM staffing companies took over staffing the ED at my hospital in Indiana.  Their offer was well below what we were currently making and was  not negotiable.  Almost all of us left, except the 1 doc and 1 NP that lived close.