MD & DO Article on how VA went too far on NP independence.

[46Long]

Opinion | VA Goes Too Far on NP Independence

Doctors' morale suffers, and patient care may follow suit

www.medpagetoday.com

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[Goro]

I'd like to see some real data on patient safety, and not a single anecdote as was in the article. The bulk of the article is about how much the MDs at the VA hated the idea.

 

[throwaway1000000]

I'd like to see some real data on patient safety, and not a single anecdote as was in the article. The bulk of the article is about how much the MDs at the VA hated the idea.

How do you propose that we get this data?
Through a RCT assigning patients to physician care vs NP/PA care? Not sure if that's ethical or if any patient would agree to that.
If NP/PAs can provide equivalent care as a primary care physician (based on current studies), do we really need medical schools or 3 year residencies training primary care physicians? If outcomes are truly equivalent, we need to take a hard look at the medical school and residency model.
I agree the article didn't provide any data and is the same opinion that many physicians have. But I don't think there's anything wrong with an opinion like that. Simply because it's not feasible to do a study to support that opinion.

 

[Goro]

How do you propose that we get this data?
Through a RCT assigning patients to physician care vs NP/PA care? Not sure if that's ethical or if any patient would agree to that.
If NP/PAs can provide equivalent care as a primary care physician (based on current studies), do we really need medical schools or 3 year residencies training primary care physicians? If outcomes are truly equivalent, we need to take a hard look at the medical school and residency model.
I agree the article didn't provide any data and is the same opinion that many physicians have. But I don't think there's anything wrong with an opinion like that. Simply because it's not feasible to do a study to support that opinion.

Retrospective data. How many adverse events for pts with NPs vs those with doctors?

 

[deleted393595]

I'd like to see some real data on patient safety, and not a single anecdote as was in the article. The bulk of the article is about how much the MDs at the VA hated the idea.

Good news, Goro! The VA logs patient data quite well and has a fairly uniform population. We can now assess morbidity and mortality data by looking at VAs in the area providing NP autonomy vs those requiring physician supervision. Should make a solid NEJM or JAMA paper

Retrospective data. How many adverse events for pts with NPs vs those with doctors?

Look at adverse outcomes, rehospitalization rates, cost of care per episode, etc.

 

[Goro]

Good news, Goro! The VA logs patient data quite well and has a fairly uniform population. We can now assess morbidity and mortality data by looking at VAs in the area providing NP autonomy vs those requiring physician supervision. Should make a solid NEJM or JAMA paper



Look at adverse outcomes, rehospitalization rates, cost of care per episode, etc.

Also amount of scripts filled?

 

[Angus Avagadro]

I believe we use mid level practitioners incorrectly. Patients should see the physician first, evaluated, and then make a determination as to whether the patient should follow up with the physician or midlevel. Seeing the midlevel first to make these decisions doesnt make sense to me.
We see the CRNAs make the same claims. Just because a patient survives a mediocre anesthetic by an independently practicing CRNA, doesnt mean they did the right thing, it just means they got away with it.

 

[Matthew9Thirtyfive]

Retrospective data. How many adverse events for pts with NPs vs those with doctors?

Issue you run into with that potentially is that they consult a lot. So they will just grab a doc or other NPs and ask questions and then go treat. So their care may not be totally independent.

 

[zero0]

I believe we use mid level practitioners incorrectly. Patients should see the physician first, evaluated, and then make a determination as to whether the patient should follow up with the physician or midlevel. Seeing the midlevel first to make these decisions doesnt make sense to me.
We see the CRNAs make the same claims. Just because a patient survives a mediocre anesthetic by an independently practicing CRNA, doesnt mean they did the right thing, it just means they got away with it.

I agree that the current model makes 0 sense, but if you're having the doctor see the patient first, is the midlevel's role even justified then (not to say that it's justified now)? Couldn't the doctor just spend another minute with them and the rest be handled by a good scribe and competent nurse at that point?

Sad to say but your point about CRNAs couldn't be more on the money. The nurse in the PACU can't see the difference between a bad anesthetic and a good one. All they see is the same vitals they wanna see before they move the meat. The patient may be more delirious and combative than if a good anesthetic plan had been used, but they rarely see the true repercussions of what those butchers do. It's usually he ICU doc that sees that a week later, or something the patient or family notices once they're discharged. Or no one may notice anything. Brain/kidney damage may be subtle but it doesn't mean it's not there.

 

[Angus Avagadro]

I see what you are saying. I was thinking the midlevel could follow up at a later visit, freeing the doc up to see more new cases. My sister in law saw the PA and they missed a navicular fracture and nearly had a non union, was casted for months. I would hope an orthopedist would have a higher index of suspicion and have ordered an MRI with a negative plain film.

 

[Matthew9Thirtyfive]

I see what you are saying. I was thinking the midlevel could follow up at a later visit, freeing the doc up to see more new cases. My sister in law saw the PA and they missed a navicular fracture and nearly had a non union, was casted for months. I would hope an orthopedist would have a higher index of suspicion and have ordered an MRI with a negative plain film.

My wife saw an NP for the same thing. Got a plain film and the NP told her that since it was normal, she definitely only had a sprain. I was like uh, I’m only an MS1, but I am pretty sure that’s not right.

 

[46Long]

We see the CRNAs make the same claims. Just because a patient survives a mediocre anesthetic by an independently practicing CRNA, doesnt mean they did the right thing, it just means they got away with it.

That is exactly right..


WHen the definition of good care is , "IS the patient alive" in the PACU. Thats a pretty crude definition of "CRNAS are just as good.

 

[Goro]

Issue you run into with that potentially is that they consult a lot. So they will just grab a doc or other NPs and ask questions and then go treat. So their care may not be totally independent.

That's true and a very testable hypothesis. We'd still need to look at the data to see what it says. The VA allows for three data sets: clinician, NP with Clinician consult, and independent NP

 

[Matthew9Thirtyfive]

That's true and a very testable hypothesis. We'd still need to look at the data to see what it says. The VA allows for three data sets: clinician, NP with Clinician consult, and independent NP

Yeah. Unless they just curbside it or they ask other people and don’t code it that way. Still better than nothing.

 

[deleted947265]

I'd like to see some real data on patient safety, and not a single anecdote as was in the article. The bulk of the article is about how much the MDs at the VA hated the idea.

This article reviews a pretty fair amount of studies. It was 6 years ago but I really doubt there's been some big study showing that patients are in grave danger because of NPs, they just aren't.


Another thing:

Ryan also says that he felt treated "by a cookie-cutter algorithm or protocol,"

Yeah, that happened.

 

[Matthew9Thirtyfive]

This article reviews a pretty fair amount of studies. It was 6 years ago but I really doubt there's been some big study showing that patients are in grave danger because of NPs, they just aren't.


Another thing:



Yeah, that happened.

Uh lol at those “studies.”

 

[Mass Effect]

Retrospective data. How many adverse events for pts with NPs vs those with doctors?

The issue is that NPs get straight-forward cases and MD/DOs get complex cases.

The NPs I've worked with typically get straight forward depression/anxiety or grief while I get agitated delirium in the ICU with QTc of 530 or neurocognitive dysfunction in setting of GBM or advanced MS. They just don't know their medicine, don't understand their drugs, and aren't able to manage more complex patients. I think the worst thing that happened to NPs is specialization. There programs are so short, they don't actually learn medicine. They just learn barely learn their own specialty by algorithm and if any medical component is added in, they either ignore it or don't understand it.

 

[YeOleBoneWiz]

This article reviews a pretty fair amount of studies. It was 6 years ago but I really doubt there's been some big study showing that patients are in grave danger because of NPs, they just aren't.


Another thing:



Yeah, that happened.

I just accepted my reality that applying to medical school wasn't going to happen this year today. I rescheduled for July, applied to community college to improve my dog[scizor] GPA, and am just going to apply next year. Sorry for your luck bois, I feel ya. :/

Checks out

 

[Goro]

The issue is that NPs get straight-forward cases and MD/DOs get complex cases.

The NPs I've worked with typically get straight forward depression/anxiety or grief while I get agitated delirium in the ICU with QTc of 530 or neurocognitive dysfunction in setting of GBM or advanced MS. They just don't know their medicine, don't understand their drugs, and aren't able to manage more complex patients. I think the worst thing that happened to NPs is specialization. There programs are so short, they don't actually learn medicine. They just learn barely learn their own specialty by algorithm and if any medical component is added in, they either ignore it or don't understand it.

In all of the cases, there have to be similar ones.

 

[Mass Effect]

In all of the cases, there have to be similar ones.

Few and far between.

 

[Goro]

Few and far between.

C'mon Mass...you're starting to sound like some of my True Believer DO colleagues, who find every excuse possible to not test out their precious techniques and see if they are actually efficacious.

 

[Dr G Oogle]

You could actually fairly easily do an RCT. No different than a surgical RCT where patients get randomized to something perhaps not the standard of care or at the very least an arm that is considered not equivalent to the other arm(s). Might take a while to recruit and would have to allow for crossover and measure an outcome that is both useful and common enough that your N isn’t thousands of dollars. A system like the VA which is more or less closed (not as much attrition to another health system) would be an ideal place for a study. Could even do a prospective study and do propensity score matching to mitigate some of the selection bias. The trick will always be deciding on a meaningful outcome. In your avg run of the mill pcp practice “complications” may not be a good outcome since it’s fairly nebulous (how do you define it) and probably isn’t very common. A well designed study could easily start poking holes in the “equivalent care” argument.

 

[Franzd'Epinay]

In all of the cases, there have to be similar ones.

Few and far between.

C'mon Mass...you're starting to sound like some of my True Believer DO colleagues, who find every excuse possible to not test out their precious techniques and see if they are actually efficacious.

I think you're both right.

The difficulty with conducting this type of study is, I think, one of power. As a poster above mentioned, you can get a way with a lot of sub-standard care in medicine. I think those "clinically-significant misses" may be rarer than most would expect.

 

[Mass Effect]

C'mon Mass...you're starting to sound like some of my True Believer DO colleagues, who find every excuse possible to not test out their precious techniques and see if they are actually efficacious.

I mean, what do you want me to do? Compare my outcomes treating an agitated man with QTc of 530 on multiple QTc prolonging meds with the outcomes of an NP who's prescribing straight-up Zoloft or straight-up Trazodone for depression and sleep?

I'm telling you, I have yet to see any NP I've worked with tackle complex cases. Those just aren't the cases they're assigned. It's not a rule that's broadcast, but it becomes evident pretty quickly when every straight forward case goes to a midlevel and every complex patient goes to an MD/DO.

I'm happy to compare my Zoloft prescribing with the NPs Zoloft prescribing if you like, but I'm pretty sure that won't tell you much beyond NPs are good with simple cases.

 

[WhereMyLiberalsAt]

I'd like to see some real data on patient safety, and not a single anecdote as was in the article. The bulk of the article is about how much the MDs at the VA hated the idea.

Taking a punch biopsy when unnecessary, is that patient safety?

Biopsy Use in Skin Cancer Diagnosis

Histopathologic evaluation is the criterion standard for diagnosis of skin cancer. Underuse of biopsies may promote misdiagnosis, and overuse will increase cost and morbidity. There is no benchmark with which to quantitatively compare health care professionals’ diagnostic accuracy and biopsy use....

jamanetwork.com

Wasting an institution’s resources, is that patient safety?

Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners - PubMed

The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.

pubmed.ncbi.nlm.nih.gov

Not the VA, but I don’t know why it would be different there.

 

[Goro]

Taking a punch biopsy when unnecessary, is that patient safety?

Biopsy Use in Skin Cancer Diagnosis

Histopathologic evaluation is the criterion standard for diagnosis of skin cancer. Underuse of biopsies may promote misdiagnosis, and overuse will increase cost and morbidity. There is no benchmark with which to quantitatively compare health care professionals’ diagnostic accuracy and biopsy use....

jamanetwork.com

Wasting an institution’s resources, is that patient safety?

Comparison of the quality of patient referrals from physicians, physician assistants, and nurse practitioners - PubMed

The quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.

pubmed.ncbi.nlm.nih.gov

Not the VA, but I don’t know why it would be different there.

the whole idea is to compare a vs beat. You guys work out the details, I've given you the solution . I refuse to believe these are not testable hypotheses

 

[46Long]

It is unethical to conduct such studies.

 

[Dr G Oogle]

It is no more unethical to do this type of study than any other study comparing 2 treatments. One might argue that if you believe NPs provide inferior care it might be more unethical to NOT do this type of study. This is what informed consent is for. If a patient agrees to participate while understanding care may be inferior if provided by one of the groups then you are free to proceed.

 

[Mad Jack]

Retrospective data. How many adverse events for pts with NPs vs those with doctors?

The trouble with retrospective data is that NPs frequently end up with less ill patients and have smaller patient loads compared to physicians. The on molly way to get a fair comparison would be to assign patients randomly of equal acuity in equal number to equally experienced (say, fresh out the gate attending vs fresh out the gate NP) providers. A network like Kaiser could probably make something like this happen

 

[Mad Jack]

It is unethical to conduct such studies.

Why? If you have informed consent and you have two treatment arms, the newer of which is claiming equality or superiority, the only way to sort things out is with a RCT. We have done sham surgery for orthopedic procedures, we can certainly do this

 

[efle]

Everyone always clamoring for these studies! But the cynic in me thinks they'd just come out a wash, and be spun as proof that 7+ years of medical education and training is overkill for managing most of the easy primary measures (DM control, HTN control, etc).

Like, it'd be great if they prove an MD/DO is better than an independent midlevel, but seems like a proper study would carry a big risk of showing non-inferiority instead.

 

[Goro]

Everyone always clamoring for these studies! But the cynic in me thinks they'd just come out a wash, and be spun as proof that 7+ years of medical education and training is overkill for managing most of the easy primary measures (DM control, HTN control, etc).

Like, it'd be great if they prove an MD/DO is better than an independent midlevel, but seems like a proper study would carry a big risk of showing non-inferiority instead.

Color me surprised!

 

[Mad Jack]

Everyone always clamoring for these studies! But the cynic in me thinks they'd just come out a wash, and be spun as proof that 7+ years of medical education and training is overkill for managing most of the easy primary measures (DM control, HTN control, etc).

Like, it'd be great if they prove an MD/DO is better than an independent midlevel, but seems like a proper study would carry a big risk of showing non-inferiority instead.

If it showed non-inferiority then I would be satisfied that NPs are safe providers. I believe in evidence, and if that is what comes out after a proper RCT then hey, my education was a waste after all.

 

[46Long]

If it showed non-inferiority then I would be satisfied that NPs are safe providers. I believe in evidence, and if that is what comes out after a proper RCT then hey, my education was a waste after all.

What's going to happen to all those professors and administrators of all those medical schools if the study turns out in the Mid-Levels aka. (advanced Nursing) favor. Huge disruption, all the bureaucrats, and professors will have to actually work for a living.. LOL

 

[Goro]

What's going to happen to all those professors and administrators of all those medical schools if the study turns out in the Mid-Levels aka. (advanced Nursing) favor. Huge disruption, all the bureaucrats, and professors will have to actually work for a living.. LOL

I'll just go and join the faculty of a PA or NP schools.

 

[46Long]

I'll just go and join the faculty of a PA or NP schools.

You can't! Have to be a PA or a NP to do that. You would be working at the Car Wash. Which wouldn't be a bad thing

 

[throwaway1000000]

I think this is an interesting thread.
I am going to start IM residency and have definitely more experience than a PA (2 yrs of schooling) and NP (not sure what their curriculum is, but based on online threads seems to be a lot of shadowing and online classes)
If I practice independently now without residency, I doubt I am going to make a decision that would lead to a patients' death. But I would be pretty incompetent.
I mean I am not sure what kind of outcomes to measure that will show a MD is superior to me. I keep a patient panel that is simple. If on occasion, I don't know anything because my simple patient becomes complex, I just refer. hard to interpret EKG (in terms of a midlevel's knowledge base)-see a cardiologist.
Is that really the kind of PCP we want to produce? Someone who triages people?

 

[Mass Effect]

Everyone always clamoring for these studies! But the cynic in me thinks they'd just come out a wash, and be spun as proof that 7+ years of medical education and training is overkill for managing most of the easy primary measures (DM control, HTN control, etc).

Like, it'd be great if they prove an MD/DO is better than an independent midlevel, but seems like a proper study would carry a big risk of showing non-inferiority instead.

I disagree. I think if everything was actually equal, it would definitely show huge gaps in knowledge and skill among midlevels. They're likely equal in terms of DM, HTN, HLD, and common derm presentations, but give them a patient a bit more complicated, especially in something other than primary care, and I bet the studies would be very different.

 

[Goro]

You can't! Have to be a PA or a NP to do that. You would be working at the Car Wash. Which wouldn't be a bad thing

Definitely not true:
Two MDs here: Harding - Physician Assistant Program - Faculty

One MD here: Physician Assistant Faculty and Staff | School of Allied Health Professions - Loma Linda University

One MD here: Faculty & Staff

 

[throwaway1000000]

I disagree. I think if everything was actually equal, it would definitely show huge gaps in knowledge and skill among midlevels. They're likely equal in terms of DM, HTN, HLD, and common derm presentations, but give them a patient a bit more complicated, especially in something other than primary care, and I bet the studies would be very different.

I think those are the patients midlevels want to see as well. Not many midlevels really want to see complex patients. If they do have a complex patient, they refer.
I think what this would do is probably harm PCPs in terms of the salary they get paid. I don't believe there is much of a compensation difference between seeing a complex patient for 30 minutes vs seeing 3 patients with sore throats or hypertension med refills in the same 30 minutes. The PA/NP might even be generating more revenue by seeing 3 easy patients vs an MD seeing 1 complex patient.
That's probably something a PCP will care about-their revenue and what they get paid. Would any MDs really want to practice primary care to make as much as an NP/PA even though they are more knowledgeable? In terms of business wise, corporations will likely pay them based on revenue they generate and not the complexity of the patients they are seeing.
If we were still in a private practice, I would be all for competition because patients could choose who they want to see and a MD PCP has a choice on how they want their patient panel to look like. But, in a employment model, do patients have that much of a choice? I call up a hospital as a patient and they assign me to whoever they think I should be assigned to-MD or PA depending on my complexity. I think patients have a choice now but in the employment model we are shifting towards, I wonder when they will stop having that choice.

At the same time-this can extend to every single field. Not all cardiology patients are challenging to see. Neither are all the procedures that complex. PA/NPs can learn the basic bread and butter procedures in every field including general surgery, orthopedic surgery, urology, opthalmology etc as long as someone is training them.
If we let PCPs be segregated in the above manner, are we going to start allowing all fields to start following that?

 

[Mad Jack]

What's going to happen to all those professors and administrators of all those medical schools if the study turns out in the Mid-Levels aka. (advanced Nursing) favor. Huge disruption, all the bureaucrats, and professors will have to actually work for a living.. LOL

I'll just go and join the faculty of a PA or NP schools.

This

You can't! Have to be a PA or a NP to do that. You would be working at the Car Wash. Which wouldn't be a bad thing

Not true at all. Plenty of non-PA or NP faculty on board at these schools. You don't even have to be a NP or PA to be a preceptor.

 

[Dr G Oogle]

What's going to happen to all those professors and administrators of all those medical schools if the study turns out in the Mid-Levels aka. (advanced Nursing) favor. Huge disruption, all the bureaucrats, and professors will have to actually work for a living.. LOL

to use a quote of something I recently said to an NP, I’ll paraphrase ... “nurses, NPs, PAs whatever, follow guidelines. Doctors write the guidelines”. Anyone can do cookbook medicine. Heck I recently taught my 3 year old how to do a physical exam and she pretty much nails it Every time starting with looking into eyes, ears, nose and ending with checking my DTRs. Now all she needs to do is complete a history of nursing paper and she can go be an NP.
A study will only show Equivalency if you choose the wrong outcome I.e death, instead you can make a composite outcome for patient harm = delay in diagnosis, delay in starting effective tx, exposure to unnecessary testing or consult and you will find a difference. Especially if you truly conduct and RCT and let complex patients into the NP group.

NPs are not the enemy, they were allowed to become the enemy, they can be very useful and effective team members they just shouldn’t be autonomous.

 

[Angus Avagadro]

If it showed non-inferiority then I would be satisfied that NPs are safe providers. I believe in evidence, and if that is what comes out after a proper RCT then hey, my education was a waste after all.

I think we need to come to grips on how much we will tolerate mid levels missing, like in the example I used above for my sister in law. Like the old saying, medicine is expensive, but bad medicine is REALLY expensive. AMCs look only at labor costs but not the total costs. I would be in favor of looking at costs of complications, over testing, delayed surgeries, A1C levels, excessive referrals, etc.

 

[46Long]

ANy physician who graduated in the past 20 years, we should file a lawsuit against the federal government. We want out tuition money back plus interest for changing what they sold us..

 

[bonemann]

cant you do the study retrospectively by having comorbidity matched patients? not perfect, but maybe sufficient?

 

[Allosteopath]

@Goro, I saw some reddit post a while back showing that adverse outcome data isn't mandated reporting for non-physician/dentist practitioners. I would think that this would make validity of a retrospective study be called into question.

But certainly it may have been the forum's animosity towards midlevels.

 

[hallowmann]

I disagree. I think if everything was actually equal, it would definitely show huge gaps in knowledge and skill among midlevels. They're likely equal in terms of DM, HTN, HLD, and common derm presentations, but give them a patient a bit more complicated, especially in something other than primary care, and I bet the studies would be very different.

Some of you guys really oversimplify what primary care does. Controlling DM or HTN with 1-2 drugs and limited comorbidities is easy, sure. More complex patients, comorbidities, added limitations to many medications due to coverage or adherence, and you have to get creative and it can get very not easy quickly. The issue with measuring outcomes in primary care is that they're either relatively long-term or by the time outcomes occur, they've already be referred to the appropriate specialty. Much of primary care is about prevention afterall. Eventually, most people get diagnosed and hopefully treated, but actually being able to collect data that shows that they were diagnosed earlier or with less testing/referral is a bit difficult.

I do agree that the poor outcomes would likely be more obvious in other specialties. I usually can tell when I get a patient from an PNP. Benzos, stimulants, an atypical and a mood stabilizer with a patient with a diagnosis list of adult ADHD, anxiety, bipolar disorder, and schizophrenia who screams cluster B and history of substance induced psychosis.

I don't believe there is much of a compensation difference between seeing a complex patient for 30 minutes vs seeing 3 patients with sore throats or hypertension med refills in the same 30 minutes...

There absolutely is a difference. The midlevel is generating way more RVUs with those 3 pts than the physician with the 1 complex patient.

...
At the same time-this can extend to every single field. Not all cardiology patients are challenging to see. Neither are all the procedures that complex. PA/NPs can learn the basic bread and butter procedures in every field including general surgery, orthopedic surgery, urology, opthalmology etc as long as someone is training them.
If we let PCPs be segregated in the above manner, are we going to start allowing all fields to start following that?

Yeah that ship has already sailed. All of those fields have tons of midlevels right now doing exactly what you described.

 

[Mass Effect]

Some of you guys really oversimplify what primary care does. Controlling DM or HTN with 1-2 drugs and limited comorbidities is easy, sure. More complex patients, comorbidities, added limitations to many medications due to coverage or adherence, and you have to get creative and it can get very not easy quickly. The issue with measuring outcomes in primary care is that they're either relatively long-term or by the time outcomes occur, they've already be referred to the appropriate specialty. Much of primary care is about prevention afterall. Eventually, most people get diagnosed and hopefully treated, but actually being able to collect data that shows that they were diagnosed earlier or with less testing/referral is a bit difficult.

I do agree that the poor outcomes would likely be more obvious in other specialties. I usually can tell when I get a patient from an PNP. Benzos, stimulants, an atypical and a mood stabilizer with a patient with a diagnosis list of adult ADHD, anxiety, bipolar disorder, and schizophrenia who screams cluster B and history of substance induced psychosis.

Wasn't trying to simplify at all. Just making the point that uncomplicated DM and HTN is easily treated by an NP, but more complex cases - even in primary care - and they fall apart. I do agree that prevention is not their skill set or within their expertise. They follow an algorithm, dependent on illness/symptoms.

And don't get me started on the psychiatric ****shows we see. I just got a patient on THREE different benzos - Valium, Xanax, and Ativan along with 90 mg of Adderall. I'm thinking about turning in this provider to the state board.

 

[throwaway1000000]

Some of you guys really oversimplify what primary care does. Controlling DM or HTN with 1-2 drugs and limited comorbidities is easy, sure. More complex patients, comorbidities, added limitations to many medications due to coverage or adherence, and you have to get creative and it can get very not easy quickly. The issue with measuring outcomes in primary care is that they're either relatively long-term or by the time outcomes occur, they've already be referred to the appropriate specialty. Much of primary care is about prevention afterall. Eventually, most people get diagnosed and hopefully treated, but actually being able to collect data that shows that they were diagnosed earlier or with less testing/referral is a bit difficult.

I do agree that the poor outcomes would likely be more obvious in other specialties. I usually can tell when I get a patient from an PNP. Benzos, stimulants, an atypical and a mood stabilizer with a patient with a diagnosis list of adult ADHD, anxiety, bipolar disorder, and schizophrenia who screams cluster B and history of substance induced psychosis.



There absolutely is a difference. The midlevel is generating way more RVUs with those 3 pts than the physician with the 1 complex patient.



Yeah that ship has already sailed. All of those fields have tons of midlevels right now doing exactly what you described.

agreed on all counts. but problem is what is going to be done

1) in terms of reimbursement, i think it's a pretty big issue that often gets ignored in these forums. corporations will likely transition to employing PCPs only to see these complex patients and you can only bill so much for seeing these types of patients. they will be happy to have the np see the 3 sore throats and keep a greater margin of profit. i mean can't they bill like 80% of what a physician bills.

2) yes. i think they do a lot of stuff but still haven't come for the bread and butter of procedural specialities. once they do, i am sure the proceduralists will start fighting back. for now most proceduralists see PAs/NPs managing clinics and floors and giving them more time in the OR or interventional suites ultimately increasing their $$$. for now it's mainly non-procedural specialities and primary care that are screwed

ultimately, as i read more, i doubt anything will ever be done. the only solution is for MDs to stop training mid-levels but that won't happen.

PAs/NPs will both likely get full independent practice in the near future and we have to see what happens when the system reaches a new equilibrium. as much as PAs/NPs outcome data gets spewed on these forums, i don't think mid-levels and physicians will ever have the same outcomes on all patients (not just your sore throats, dm, htn). it is just not possible for a pa or np without residency and less schooling to be the same as a 3yr trained pcp. it is like me practicing without a day of residency. even with 2 more years of schooling than an np/pa, i will still suck in primary care if i don't do a residency. how do i measure this? idk

New study out showing the difference in opoid prescribing rates between mid-levels and physicians. pretty astounding.

what bothers me more is the reimbursement. i didn't train to be a physician just to see the complex patients. no thanks. i will take higher pay any day by seeing simple sore throats, dm, htn management than be stuck seeing complex patients and be reimbursed poorly....seems like from my brief experience this is what happens in academic settings? PAs/NPs see all the easy patients and the MDs see the tougher patients. both have like a 100k-150k difference in pay? 3 yrs of residency and 2 extra yrs of schooling for a 100k-150k pay difference?

i honestly don't understand this independent patient panel for np/pa. when i was working with a primary care MD, i saw a PA/NP having their own primary care patient panel in the same office.
how does this work? why do they get paid less than a physician for seeing the same number of patients per day? How do patients agree to this? do they know they are probably paying the same amount for pa/np that they do to see a physician?

i think they are np's/pa's are greatly helpful as long as they work for a physician. each physician defines the scope of practice and either the np/pa works under that scope or gets fired. but the problem is that their scope of practice is starting to be controlled by corporations. it is anyone's guess how far they will take that scope.

none of this is scientific data. pure anecdotal and hypothetical opinion. if i am wrong and what i said is all BS, someone can correct me

 

[Matthew9Thirtyfive]

agreed on all counts. but problem is what is going to be done

1) in terms of reimbursement, i think it's a pretty big issue that often gets ignored in these forums. corporations will likely transition to employing PCPs only to see these complex patients and you can only bill so much for seeing these types of patients. they will be happy to have the np see the 3 sore throats and keep a greater margin of profit. i mean can't they bill like 80% of what a physician bills.

2) yes. i think they do a lot of stuff but still haven't come for the bread and butter of procedural specialities. once they do, i am sure the proceduralists will start fighting back. for now most proceduralists see PAs/NPs managing clinics and floors and giving them more time in the OR or interventional suites ultimately increasing their $$$. for now it's mainly non-procedural specialities and primary care that are screwed

ultimately, as i read more, i doubt anything will ever be done. the only solution is for MDs to stop training mid-levels but that won't happen.

PAs/NPs will both likely get full independent practice in the near future and we have to see what happens when the system reaches a new equilibrium. as much as PAs/NPs outcome data gets spewed on these forums, i don't think mid-levels and physicians will ever have the same outcomes on all patients (not just your sore throats, dm, htn). it is just not possible for a pa or np without residency and less schooling to be the same as a 3yr trained pcp. it is like me practicing without a day of residency. even with 2 more years of schooling than an np/pa, i will still suck in primary care if i don't do a residency. how do i measure this? idk

New study out showing the difference in opoid prescribing rates between mid-levels and physicians. pretty astounding.

what bothers me more is the reimbursement. i didn't train to be a physician just to see the complex patients. no thanks. i will take higher pay any day by seeing simple sore throats, dm, htn management than be stuck seeing complex patients and be reimbursed poorly....seems like from my brief experience this is what happens in academic settings? PAs/NPs see all the easy patients and the MDs see the tougher patients. both have like a 100k-150k difference in pay? 3 yrs of residency and 2 extra yrs of schooling for a 100k-150k pay difference?

i think they are np's/pa's are greatly helpful as long as they work for a physician. each physician defines the scope of practice and either the np/pa works under that scope or gets fired. but the problem is that their scope of practice is starting to be controlled by corporations. it is anyone's guess how far they will take that scope.

none of this is scientific data. pure anecdotal and hypothetical opinion. if i am wrong and what i said is all BS, someone can correct me

Did you mean this?

Differences in Opioid Prescribing Among Generalist Physicians, Nurse Practitioners, and Physician Assistants - PubMed