A Sign of the Future . . . Maybe . . . Maybe Not

[jmj11]

My wife is an administrator at a local hospital. They were trying to develop a pain program centered around a PA (with various anesthesiologists rotating through). I met with them a couple of time to give them ideas. They searched the entire country to find the right pain PA. They found a great one.

 

Then, they tried to figure out which physician would supervise them. They approached 10 staff physicians and all declined (terrified of legal responsibilities and "exposure" of being the SP to a PA). After almost a year of working on this week they are cancelling their plans and are now going to design a pain center based around NPs who don't need any supervision.

 

I can't imagine how this could happen, but a great advance to our cause wouldn't be total independence as the NPs have, but a total waiver of legal responsibility of a SP for the work of the PA. Many physicians (and malpractice insurers) suffer from NPAphobia, the irrational fear of NPs and PAs.

[discogenic]

This is something I don't understand fully. If an MD can hire an NP and have less responsibility from a med-legal standpoint, have less chart review duties, yet get an equally qualified practitioner (assuming some experience) for the same money, why don't MDs hire NPs every time?

[jen0508]

This is something I don't understand fully. If an MD can hire an NP and have less responsibility from a med-legal standpoint, have less chart review duties, yet get an equally qualified practitioner (assuming some experience) for the same money, why don't MDs hire NPs every time?

 

because they aren't trained like physicians

[discogenic]

But most seem to agree that experienced NPs and PAs are equally capable of doing the job.

[rcdavis]

I am not sure I understand the full legal argument. The northwest is like crazy np heaven, but here in the southeast, BOTH np and pa need physician oversight ( np= collaboration, pa= supervision), but in aloof my hospitals, ALL MLPs are " answered for" ( if that is the correct term) by the sponsoring/supervising physician. And in most legal malpractice cases, ALL sponsoring/supervising docs get diposed to assue there has been adequate " oversight". If there has been ( eg, meets the letter of the state legislature), the n the suit centers on the mlp. Let the superior respond applies if the superior has not been involved appropriately.

 

So it seems to me that , at least in the southeast, the md responsibility is equal in both the np and pa cases.. From a lot to a little, depending on the case.

I cannot think of a case wherein the supervising doc was exculpated simply because it was an np involved...

 

Seems like an inappropriate double standard.

 

davis

[Contrarian]

JmJ11...

 

I've talk to those guys in Anacortes a few times also over the last 18months. The last time was back in Apr.

Part of the "Fit" stemmed from the notion that I was/am doing Addiction, Psychiatry and Chronic pain management in my private practice and other employment situations and was already scheduled to attend a few small and large joint injection skills workshops.

 

After having lunch with them then talking to the lead on this a few times via phone, I got the sense (back in Apr) that they were actually looking for a independent provider. So I stopped pursuing it any further.

 

But YEAH...

LOTS of clinics/hospitals are moving to NP only... due to the percieved "limited liability" issue.

[discogenic]

JmJ11...

 

I've talk to those guys in Anacortes a few times also over the last 18months. The last time was back in Apr.

Part of the "Fit" stemmed from the notion that I was/am doing Addiction, Psychiatry and Chronic pain management in my private practice and other employment situations and was already scheduled to attend a few small and large joint injection skills workshops.

 

After having lunch with them then talking to the lead on this a few times via phone, I got the sense (back in Apr) that they were actually looking for a independent provider. So I stopped pursuing it any further.

 

But YEAH...

LOTS of clinics/hospitals are moving to NP only... due to the percieved "limited liability" issue.

 

But is it only perceived, or is it reality? Are these clinics/hospitals simply mistaken, or is this presumably what their legal counsel is telling them?

[Contrarian]

This is something I don't understand fully. If an MD can hire an NP and have less responsibility from a med-legal standpoint, have less chart review duties, yet get an equally qualified practitioner (assuming some experience) for the same money, why don't MDs hire NPs every time?

 

Jen0508 is correct... "because they aren't trained like physicians"... and most/many have never hired ANY NPP before or have never even worked with any NPP before.

 

They are often thinking "employee" who is under our direction and supervision...GREAT. Most have no idea how to even utilize a PA/NP and generally only learn of our capabilities (or incapabilities) after we arrive on site and start practicing. This is why a lot of NPPS get hired only to find that the practice has NO idea what to do with them, and really thought that they hired a glorified MA/RN. Or find that a few Physicians in the practice are actively limiting their scope of practice and really only wants "assistants"... NOT a solid medical provider."

 

Reminds me of a practice down the street that had a few physicians who actually campaigned to have ONLY physicians referred to as "providers."

 

So... if these relative Neophytes to NPP utilization find a PA and if the PA that they do hire is "GREAT"... its all good. They live happily ever after...

 

Now if the PA has some issues with clinical skills and that practice has to hire another provider to replace them... this opens the door for them to consider a NP.

 

The PA could be great and have excellent clinical skills, but the first clinical decision the PA makes that ANY of the Physicians are uncomfortable with for whatever reason will trigger a protectionist posture from them and this again opens the door for a NP due to the perception of limited if any liability.

 

Then when they say yes to the NP, and the NP starts the next day versus their experience with the PA who may have had to wait weeks for a OK (practice plan approval) from the State to begin, and find that they don't have to call the insurance company and pay extra $$$ to obtain a practice rider, etc... then after a while, they see that CLINICALLY NPs and PAs are interchangable without clinical practice distinctions of differentiation... they are sold.

 

Thing is... the NP doesn't have to be "great" because the NP is "Independent."

NO ones name is on the NPs work but the NPs.

No ones name is on the NPs malpractice insurance but the NPs.

The is NO piece of paper sitting in a file cabinet somewhere saying that another professional is legally liable for the NPs work.

The NP can be credentialed as a separate entity and assign payment to the practice.

[LT_Oneal_PAC]

 

I can't imagine how this could happen, but a great advance to our cause wouldn't be total independence as the NPs have, but a total waiver of legal responsibility of a SP for the work of the PA. Many physicians (and malpractice insurers) suffer from NPAphobia, the irrational fear of NPs and PAs.

I've been saying this for a while. Remove the liability, and you'll see a huge explosion in the use of PAs.

[discogenic]

Jen0508 is correct... "because they aren't trained like physicians"... and most/many have never hired ANY NPP before or have never even worked with any NPP before...

 

The PA could be great and have excellent clinical skills, but the first clinical decision the PA makes that ANY of the Physicians are uncomfortable with for whatever reason will trigger a protectionist posture from them and this again opens the door for a NP due to the perception of limited if any liability.

 

Then when they say yes to the NP, and the NP starts the next day versus their experience with the PA who may have had to wait weeks for a OK (practice plan approval) from the State to begin, and find that they don't have to call the insurance company and pay extra $$$ to obtain a practice rider, etc... then after a while, they see that CLINICALLY NPs and PAs are interchangable without clinical practice distinctions of differentiation... they are sold.

 

Thing is... the NP doesn't have to be "great" because the NP is "Independent."

NO ones name is on the NPs work but the NPs.

No ones name is on the NPs malpractice insurance but the NPs.

The is NO piece of paper sitting in a file cabinet somewhere saying that another professional is legally liable for the NPs work.

The NP can be credentialed as a separate entity and assign payment to the practice.

 

With this in mind, some desired legislative changes for PAs would be what? Setting up SP relationship such that a PA could also 'start the next day' so to speak? Reduce SP liability when working with a PA, provided that's even possible in the case of any non-physician provider?

 

Do MDs see NP independence as a good thing? I would think that they would, given the points you've made (easier hiring process, less liability (if true), equal clinical competency, etc.). Will PAs ever see that kind of independence, or will PAs even work toward more independence, or will the fact that PAs are (I hate to use this expression but) under the thumb of MDs make independence impossible?

[discogenic]

I've been saying this for a while. Remove the liability, and you'll see a huge explosion in the use of PAs.

 

But isn't it always going to be assumed that since PAs are employees "supervised" by MDs that the liability will ultimately fall to the MD? If it's true that NPs are independent and therefore don't increase MD liability, perhaps that's why some are seeing facilities that hire exclusively NPs. What does the PA profession do about that?

[Gordon, PA-C]

i dont see a physician group being excited about letting more NPPs make any moves that could contribute to independence. NPs circumvented them, they wont let it happen again.

 

The MDs didnt "let" the NPs get independence, the NPs took it by force without their permission.

 

Right now, any state nursing board in the country could declare that brain surgery is the scope of practice of nursing, and there's not a damn thing the MDs could do about it.

[LT_Oneal_PAC]

But isn't it always going to be assumed that since PAs are employees "supervised" by MDs that the liability will ultimately fall to the MD? If it's true that NPs are independent and therefore don't increase MD liability, perhaps that's why some are seeing facilities that hire exclusively NPs. What does the PA profession do about that?

 

It is a law that a physician's apology (basically a confession) can't be used against him in court, so I think it's pretty easy and reasonable to implement a law stating that a physician has no liability on a medical decision over which he had no input. I would even go so far to say that if a physician was consulted by a PA that he had the choice to follow that medical advice or not. If the physician over ruled the PA, then the PA could document that the physician decided to direct the care of the patient through the PA.

 

Same thing happens in anesthesia with independent CRNAs. CRNA is 100% independent and liable for their actions. The surgeon is not liable for an anesthetic or being consulted by anesthesia. However, if the surgeon says "give 300 mcg of neosynepherine" and the patients strokes, that's on him.

[Contrarian]

With this in mind, some desired legislative changes for PAs would be what? Setting up SP relationship such that a PA could also 'start the next day' so to speak? Reduce SP liability when working with a PA, provided that's even possible in the case of any non-physician provider? [short of independence... its just not possible to limit a "supervisor's liability." By definition... they are responsible for the work of the superviseee. So this is where the semantics play a role and the reason the NPs chose the word "collaborate" instead of "Supervise."]

Do MDs see NP independence as a good thing? [it can be said that just like the average PA couldn't give a care about a lot of the issues we harp on at this site... a lot of Physicians really don't care about NP independence. The reality is that No Physician is at risk of losing their job to a PA or NP. Mind you... I said "job" since MOST of them are "employees" and not solo business owners where NP independence would/could theoretically interfere with their turff. So as a most likely subordinate "Co-Worker," I can see why many physicians who are also employees wouldn't have a problem with the "independence" of NPs. As a thought, they may actually prefer and be cool with the idea that they as "employees" don't have to accept the risk (without any benefit) of another/other "employees."] I would think that they would, given the points you've made (easier hiring process, less liability (if true), equal clinical competency, etc.). Will PAs ever see that kind of independence, or will PAs even work toward more independence, or will the fact that PAs are (I hate to use this expression but) under the thumb of MDs make independence impossible?

 

Naaah... most are comforted in the notion that they (we) 'are trained in the medical model' and think that this somehow endears us to physicians. We think that because academic physicians "blessed" our programs (accredidation) that the non academic physicians in clinical practice actually care about our profession.

 

We continue to parrot nonsense about how superior we are to NPs by virtue of our "medical model" training and what OUR perceptions are of their training when in reality our "masters" (physicians) are the ones handing out the grades. And from what I've seen in hiring practices... physicians seem to think we are equal clinically and the patient outcomes seem to bear this out.

 

Even in the face of this, they still hold on to the fable that WE are by default the "preferred" non-physician provider because we sit at their feet and gaze into their eyes lovingly without ever uttering the word and banishing the thought of independence.

 

So NO... not likely to ever happen or even be pursued. Because a "assistant" by definition has to have someone to assist and therefore can't be independent.

Now why would the profession pursue independence when they won't even investigate a name change...???

[burnpac]

The MDs didnt "let" the NPs get independence, the NPs took it by force without their permission.

 

Right now, any state nursing board in the country could declare that brain surgery is the scope of practice of nursing, and there's not a damn thing the MDs could do about it.

 

Not true. Try to get credentialed at any hospital to perform any procedure without the approval of medical staff. Ain't going to happen anytime in the foreseeable future.

[andersenpa]

The MDs didnt "let" the NPs get independence, the NPs took it by force without their permission.

 

Right now, any state nursing board in the country could declare that brain surgery is the scope of practice of nursing, and there's not a damn thing the MDs could do about it.

 

 

+1 to Steve's comment. Not to mention a payer to reimburse for those services.

 

Gordon as a surgical PA you should know better.

[Contrarian]

I'm sure he does... and his statement was likely one for hyperbolic effect versus a true belief.

 

His point is taken that if the Hebrew Isrealites asked the Pharaohs for freedom and would have only left captivity if granted permission... we wouldn't have such a great fairy tale to watch on AMC every easter. Because there would have been no need for "frog rain," "blood rivers," or "parting of Red Seas."

 

And no current state of Israel.

[burnpac]

Here is my take on this.

 

All "non physician" practitioners will continue to proliferate in the hospital setting. We can't train them fast enough to fill current and future demand. The problem that jmj described is real in isolated settings, and is a matter of ignorance more than anything. At our facility's ED, the old group had PA/NP phobia, citing "liability" risks. It was impossible to confuse them with the facts. :-) CEP came in and took over the contract, and now there are oodles of PAs, and a few NPs working in the ED. We also have a CEP PA fellowship in our ED, training ED PAs five at a time. The Hospitalist program at our facility is hiring multiple PAs and is centered around the PA model. Our inpatient chest pain unit is run by a PA.

 

If you travel to the SF Bay area, nursing (CNA) dominates the inpatient setting, and it is tough to break into if you are a PA.

 

"Independence" doesn't matter in the hospital if you are not a physician. I know of no NP who can admit and independently manage an inpatient outside of some rural and isolated setting. I know of exactly one NP in independent practice in California, in the OP setting. In our facility, NPs must be associated with a physician with privileges, who is responsible to "supervise" the care that the NP gives per medical staff bylaws.

 

The EHR is rapidly making the "burden" of supervision much less onerous. I haven't touched a paper record in the in and outpatient setting since July 31, when we went live with computerized physician order entry (CPOE). In our system (I have been creating electronic progress notes for 18 months prior), 100% of all orders are electronically routed to the attending physician for cosignature. Orders are valid and actionable immediately upon my signature, so the cosignature is administrative only. I route all progress notes, procedures, H and Ps, and discharge summaries to him too. My physician partner can dispense with hundreds of cosignatures in three clicks of the mouse (achieving the paper trail that documents 100% record review with a minimum of fuss). The medical staff has eliminated all chart audits of PAs and NPs since CPOE. In my opinion, the helps level the playing field where NPs are involved.

 

Liability insurance has never been a problem in California for PAs, and I assume that the same is true in all states. Insurers use the cold hard facts in making insurance decisions, and all the data point to the fact that PAs have a stellar safety record. Any PA with a clean record can get covered rapidly and independently of their physician partners.

[rcdavis]

^^^^ my experience also

 

Again, in my part of the world NP do NOT have independence.. They cannot work without a physician supervisor/collaborator, their notes - in the hospital- need countersignatures. If they get sued, so does the physician. They do not stand alone.

I fear this may change, but right now, that is the way it is in the south.

[Contrarian]

...[brevity edit]... The problem that jmj described is real in isolated settings... [brevity edit]...

 

While I'm NOT disagreeing with anything you or RC wrote... I must point out that using Inpatient/Hospitalist/ED PA-Cs as an example in this discussion is as much "isolated" as the situation JmJ11 relayed.

 

MOST NPPs (PAs and NPs) DO NOT work in the Inpatient Medicine realm where NO one is disputing that the only real "independent" providers are Physicians. MOST work in outpatient medicine, be it Specialty or Primary Care.

 

The OUTPATIENT sector is where "independence" matters and is NOT only relegated to Physicians. Due to our aging population, and the ACA and other issues, It is the OUTPATIENT primary care/preventative medicine sector that will recieve the largest influx of reimbursement and what will be focused on for decades to come.

 

This is why the "stakeholders" in Outpatient medicine/primary care are currently advancing upon each other with drawn swords. The battle for turf and money is heating up with the Physicians trying to hold on to what they got, and the Advanced Practice Nurses trying to cement and expand what they got. With PAs sitting on the sidelines swinging "pom-poms" rooting for the physicians.

 

Also, with the advent and proliferation of the "Hospitalist as Specialist" movement... I'd venture to "guess-timate" that MOST outpatient providers don't even have hospital credentials anymore like they used to... and surely, many outpatient practices see no need to pay for the hospital credentialing of their Primary Care NPPs since the dedicated hospitalist teams will perfom a clean reception and handoff for any of their hospitalized patients without the inherent hassles and schedualing conflicts that accompany running back and forth between the hospital and clinic daily and in the middle of the night to see patients.

 

So the "supervisory" requirements of the Inpatient realm is kind of a moot point for outpatient NPPs since only physicians are truely independent in that setting nationwide.

 

Lets keep it in some kind of perspective gents...

[burnpac]

JMJ's original example was a hospital-based pain center (at least that is the way that I understood it.). At our hospital, inpatient or outpatient doesn't make any difference. Practitioners still have to follow medical staff bylaws. The bylaws maybe different at the hospital in question, so that may be why there's a difference. However, if the outpatient pain center is under the jurisdiction of the hospital and medical staff, I doubt very seriously that NPs will be allowed to practice completely unsupervised.

 

I understand the nuance of completely outpatient, private practice based settings and the supposed advantage independence would have in this environment. The reality is is that there are very few people who are practicing as solo practitioners in this day and age of team-based medicine.

 

Technology will continue to level the playing field among various nonphysician providers.

[Contrarian]

JMJ's original example was a hospital-based pain center (at least that is the way that I understood it.). At our hospital, inpatient or outpatient doesn't make any difference. Practitioners still have to follow medical staff bylaws. The bylaws maybe different at the hospital in question, so that may be why there's a difference. However, if the outpatient pain center is under the jurisdiction of the hospital and medical staff, I doubt very seriously that NPs will be allowed to practice completely unsupervised.

 

I understand the nuance of completely outpatient, private practice based settings and the supposed advantage independence would have in this Environment. The reality is is that there are very few people who are practicing as solo practitioners in this day and age of team-based medicine.

 

Technology will continue to level the playing field among various nonphysician providers.

Completely agree... but you may have missed the part about me also having extensive talks and lunch with POC in admin of the hospital about that job and the fact that the pain clinic is hospital owned but a OUTPATIENT clinic. Its two towns away from me and about a 45min drive. Oh and we are back into that q 15yr cycle where the hositals are buying up as many private outpatient practices as they can get

 

Except that since the reality IS "very few people are practicing as solo practitioners in this day and age of team-based medicine"... and the fact that most are someones "employees"...

 

What I'm seeing and hearing is that these physician employees (who are often consulted when recruitment and hiring decisions are made) appreciate the fact that they won't be held liable by default for the actions of other licensed "employees."

 

Here... in the PNW... where the community we are disscussing is located, this comes up often and plays a huge part in how the position is even conceptualized, advertised, funded.

[jmj11]

I will say again, from my perspective, that I don't have a strong drive to be "independent." My drive is to offer needy patients a service they don't have. I was thwarted for years in opening my own clinic to serve patients because of physician NPAphobia (the irrational fear of NPs and PAs). I approached 4 physicians myself about being my SP and all 4 backed out because they (and they had never worked with a PA before) were paralyzed in fear that I would harm a patient in my stupidity and they would be sued.

 

I see the same thing playing out in this local hospital situation. They think that a NP could function as the hub to this pain clinic, and be supervised by the MD rotating through, but not have any legal ties to that physician. At least on a state level, the NP can be credentialed (per Washington state law) without the name of any physician on their paperwork, thus they see no ties of legal responsibility.

 

As I said before, what would have benefited me more than anything was a legal firewall between a supervising physician and myself. That would liberating and create many more PA positions. But I don't know if this is even realistic.

[LT_Oneal_PAC]

I don't see why it's something that would be hard. What physician would lobby against it saying "No, I want more liability." Yes, we are "supervised" by physicians, but we make autonomous decisions. How could it be argued that a physician should be held liable for those decisions?

[Contrarian]

... [brevity edit]... How could it be argued that a physician should be held liable for those decisions?

 

I guess you missed it the first time... so I'll repeat.

 

Plantiff Lawyers would have a field day with this... because LEGALLY as in written in the PA practice laws, the word "SUPERVISE" is used for PAs (and in some states for NPs also). There is NO way to change the definition of "supervise" therefore there is no way to change the responsibilities of and what is required of one who "supervises."

Simply put... a "supervisor" IS responsible for the work that they supervise.

 

That is why there is a growing movement to change the terminology used in the practice acts from "supervise" to "collaborate." Because "collaborate" would mean that we have to work with physicians but does NOT add the burden of liability since one is NOT responsible for the work of those they collaborate with.

 

This would be the first step (with several other to follow) to erecting that "firewall" JmJ11 is talking about.

Example:

 

You can "collaborate" with me to bake a cake by giving me a few eggs and the recipe.

Now if I screw it up and the cake turns up crappy... its all on me.

 

Now if you "supervise" me baking a cake and I screw up the cake.

WE SCREWED UP THE CAKE because as my supervisor, you were ultimately responsible for the outcome of the cake.

 

Just a few thoughts...