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Co-clinics: not necessarily submitted for your approval

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I figured I'd both share some thoughts and poll my peers here. (thoughts are respectfully and humbly submited).

 

I've been a lone-PA for the past ~8 years in an ortho group of multipecialty practice.

We just highered 2 new mid-levels. One of them is not only wiling to do but is

promoting co-clinics. I am not talking about parallel clinic but a co-clinic, where

the PA/NP goes into the room, works up the patient, waits for the doc to become

available, presents to the doc; the doc goes in, does an exam, (likely modifed), and then

makes the "real" diagnosis, and then the PA dictates and does all the work.

So, in this model, the PA does the work, stands around quite a bit and doesn't make

medical decisions.

 

I never heard about the model of a co-clinc until well after PA school.

Frankly, and--once again--I'm just being honest, I do not get it.

Oh, I get it--insofaras--this works great for the Doc. At my office, the docs

are all paid by RVUs so, when they do a co-clinic, they get increased RVUs, which

increases their pay, and they get maybe 2/3 or 1/2 of the day's charts dictated for them.

 

This new mid-level keeps saying that this model "increases numbers and revenue" which

I do not see, when I do the math. If you take a PA away from their indipendent clinic, that

is maybe say 20 to 30 patients a day. The mid-levels in my office add on typically

from 3 to about 10 (at most) a day to the doc's schedule. When I do the math, taking

the mid-level to do this actually decreases numbers.

 

I feel that I was taught to be an actual provider...an actual practitioner. Where is the

medical decision making in the co-clinic? To be a PA and walk in and see patients, who

are are not on my scedule, and for 2 providers to be seeing patients--as a planned day of

patient schedule--does not make sense to me. To me, the co-clinic model is the PA acting

as a glorified MA and as a scribe, which would be a step down and moving backwards in

my profession. I do not feel that I would require the intensive and riggorous training that

I sacrificed both time from family and ~90K to be a glorified MA/scribe. I've known

MAs to get an on-line certificate to be a scribe and be able to essentially do this for

a significant lesser wage.

 

I have talked with many peers about this; many share the same feelings. The only

ones, so far, that do not agree with me were oddly defensive and came back with

negitive tone and seemed somehow maybe even offended.

 

When I look at the big-picture and look at all of what I was trained for, and all of

what was--and is--expected of me, I just really don't get it. If this is the way

things will evolve for PAs, then I will likely move on to an other profession, if at all possible.

 

I do also feel that when PAs agree to do co-clinics, that they're sort of selling out and also

impacting things for our profession--not in a good way.

 

Once again: humbly submitted. The reason I'm putting the post here in ortho is b/c it

seems ortho is where I see the co-clinic occurring mostly.

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I'm glad this was presented here, I shadowed at an Ortho clinic and witnessed both models as mentioned above. It honestly confused me. Needless to say I spent as much time possible with the more independent PA. I thought at the time it was due to the inexperience of the one, but is this truly that common of a model to follow, even for experienced PAs?

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Guest Paula

I've never heard of a co-clinic. Is it unique to orthopedics? Are the new NP/PA that were hired fresh out of school? I would never do it either. If this starts happening in primary care, PAs are sunk. I could not imagine doing that kind of a clinic in FP. I would quit my job. It is ridiculous. It sounds like a money-scam and the docs would benefit, you would lose.

 

Are PA/NPs being trained like this in school now? I'm stunned at the model. It says we can't diagnose and treat. Yuck.

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it's all about the money. you can bill every visit at the doc rate if the doc sticks their head in and says " so I hear you have bronchitis(listens to lungs) yup, I will have my assistant write you an rx for a z-pak" . total time in room 1-2 minutes. extra bill 200 dollars.....

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I have a doc in our clinic who will be bringing in a PA to do something similar - she'll be his extender in that they'll share a patient panel. He'll see them one visit, she'll see them another. If there's something that needs further or more in depth management, they'll co-manage. If there are any concerns on the patient's part, the doc will stick his head in. Quite honestly, though I am but a fledgling in the profession, I could not practice that way. It would make me crazy.

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We do this for new patients only at my job in interventional pain. I don't put up too much of a stink because I get the credit for the visit on my collections because I do the majority of the work. I admit I liked it the first 6 months, but now I does annoy me at times when I know what to do and I say " Dr. x will come in and discuss treatment options. This also helps me bill "incident too" at the follow up visit.

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it's all about the money. you can bill every visit at the doc rate if the doc sticks their head in and says " so I hear you have bronchitis(listens to lungs) yup, I will have my assistant write you an rx for a z-pak" . total time in room 1-2 minutes. extra bill 200 dollars.....

 

 

As usual it's "all about the Benjamins" not quality of care. I'm don't want to be a "medical trunk monkey" for some physician(s).

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Sounds like someone who is truly a "Physician Assistant" and not someone who is practicing medicine.

All the more reason that our title doesn't reflect the work that we (autonomous) providers do.

 

I'm curious about the arguments of PAs who are in favor of this. I agree that it is loss of a clinician who could be seeing extra patients.

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This model is an insult to our profession. Sounds like a glorified scribe to me and a waste of an expensive medical education. It is amazing to me that practices would view the 15% difference in reimbursement to be more valuable than independent provider delivering care to, and billing for a full load of patients. Perhaps this is seen more in practices that don't quite have the patient volume to fill the PA's schedule independently?

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In terms of the billing and $$, etc...

As I stated in the OP: the docs in my office get paid by RVUs. (I'm also not in a private practice).

So, this means the docs who get a mid-level for a co-clinic, gets the doc more RVUs, which means more $$.

It's true that "incident to" can also be billed for M/M but needs certain documentation to satisfy it, i.e., the PA

needs to dictate that the patient was also seen and examined and treatment plan by Dr X... from a medical/legal standpoint as well.

 

To counter this going on in my office: I am compiling facts and figures to show the administration (and not my docs).

Again, if this were a private practice, I would appeal to the docs but they frankly don't care b/c all they see in this

practice is they get more $$ (b/c of increased RVUs) and have less dictations. I feel confident that the facts/figs I present

will be able to show actual decrease revenue and numbers, over all, by taking a mid-level out of their independent practice.

 

This particular PA I wrote about, (who's not only willing to do but promoting co-clinics), is a PA of like ~8 yrs of ortho experience

and has only worked ortho as a PA. This PA is sort of meddling and is "selling" the docs with this model and I'm well beyond irritated.

 

I have professionally drawn boundaries, however, that I will not participate with a co-clinic, and despite fearing doing this

a little bit, I have been told that I'm a very good PA and they respect me saying this and will not require me to do a co-clinic.

I do feel a bit of unrelenting mild pressure, however, and fear that I will be asked at some point perhaps.

 

I agree with all of the posts, thus far!! I particularly like the statement of being "wretched."

 

To draw upon an other component, altogether, I feel that the word "assistant" is our title is ambiguous and only

paints a different picture, particularly in the patients' eyes, of who we are and what we do.

 

I'm currently stable in this practice and not required to change to do co-clinics...for now.

However, I really hate the fact that it's going on in this practice. I don't condone such methods and have been

professionally and respectfully clear with my feelings about it, which has been met with some level of

this particular PA being somehow offended in some way...(much like any PA I've ever found to be in favor of this model, which

is a very interesting behavior indeed).

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God how idiotic to pay a PA to do MA work. Bizarre. That Doc sounds like they could use a good didactic year in PA school to help humble and educate themself. 2000 hours in a year to their 2300 in two ... substantial, yes, severe, no.

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Age

Gender

Previous HCE before attending PA school

Years Experience as a PA

Yrs experience as a Ortho PA

 

Female; I'm guessing mid'ish 30s, ~8 yrs of being a PA, always in Ortho

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it's all about the money. you can bill every visit at the doc rate if the doc sticks their head in and says " so I hear you have bronchitis(listens to lungs) yup, I will have my assistant write you an rx for a z-pak" . total time in room 1-2 minutes. extra bill 200 dollars.....

 

I thought we already billed at the doc rate.??

 

87% if doc is not there.

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I thought we already billed at the doc rate.??

 

87% if doc is not there.

depends on the pts coverage.

medicare/medicaid pay pa's/np's 85% of the physician rate. many private insurers are starting to do this as well.

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depends on the pts coverage.

medicare/medicaid pay pa's/np's 85% of the physician rate. many private insurers are starting to do this as well.

 

that's true--if billing direct. Incident to is at 100% but there's a lotta rules.

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...so, an update on the co-clinics:

 

I have challenged the billing and documentation process, as the documentation was pretty sketchy--at best.

The coding / billing dept manager has totally supported my valid concerns.

At first, I was being considered "the enemy" that is, until this billing/coding manager was like, "un, 'Noreaster' is completely right."

It would have been nice to get a thank you or adda-boy or something but, I know that is not expected.

 

So, co-clinics were all cancelled alltogether and then some started up again, only with modifications.

The good news is there are some satellite offices that the OM is going to help process, which I'll be able to be at certain days--autonomously! ...and also an up-coming urgent care clinic, where I can sometimes be as well, and then co-clinics will be hopefully a non-issue--at least for me.

 

Thanks to all for letting me vent as well as poll my peers!! I have appreciated this site for a very long time!! ...and still do!!

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Gosh, I'm not sure where you all live, but, in my Midwestern town, the specific practice where I work is all PA co-clinics. Honestly, this was a bit new/odd for me, as I just switched into ortho from being practically independent in an ER setting. I may have been so burned out from the ED that any job sounded good if it didnt make me work nights and weekends! I changed jobs (my first change since graduating) for the supposedly better schedule....which, I'm finding out is not all its cracked up to be. Granted, I have no weekends, but, it is all based on the surgeon's day and whenever he wants to add a case (even on our scheduled half day), I'm expected to go,stay late, and be there early. Did I mention that he runs Super slow in clinic and we are always behind?. It is a huge change compared to where I came from and I'm not sure I like my complete lack of autonomy. This is a very conservative town, and most people think I'm the MA and want to see the doctor anyway, even on a simple post op. I have to explain to them what a PA is. it drives me nuts and from a PA functioning standpoint, I feel like im regressing. I would like to change the model, but I suspect it will be difficult to try to do so. I never knew that PA's were that independent in ortho practices. We are a busy hand surgery practice, and we do a lot of varied procedures out of the typical norm. I've been here 6months.... The thought of changing jobs sounds like nightmare, plus I feel so bad that he has been training me for this long....but, I do feel way more like an assistant than an actual PA..... How do your independent clinics work? What if the patients want to see the 'doctor'? Do you see new patients or just follow ups and post ops?

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