Coming out of residency I was looking for a place that didn’t employ MLP’s. Since I’m the guy on the hook, I wanted to see the patient myself from beginning to end as opposed to relying on someone else’s evaluation. If there’s a perfect job out there though I didn’t interview for it. I took the job that had the most pluses/fewest minuses and that included a place with a fast track run by MLP’s.
Our fast track is a four bed area in the ER that the triage nurse sends the least sick patients to. The MLP’s run the show, working up and dispositioning the patients without direct supervision.
Economically it’s a no-brainer. We pay the MLP’s roughly $50/hr. They typically see about 3 patients an hour. If you conservatively estimate that we in total bill $600 for those patients, and collect $150, then that’s $100 left over. $100 an hour, 16 hours a day, 365 days a year. Not to mention they see the bulk of the drug seekers and personality disorders: not fighting those battles is adding years to my career.
The risk is increased liability. My name is at the bottom of thousands of charts of patients I never saw, and that still makes me somewhat uncomfortable to be honest.
Is the risk worth the reward? In my opinion the answer lies in the quality of the individual MLP’s. They have to be efficient enough to generate a healthy profit and not allow the ER to get backed up. They have to be confident enough to dispo the straightforward stuff on their own, but humble enough to be aware of their limitations and ask for advice from the docs when needed.
Fortunately that describes all of our MLP’s. They’ve all been there longer than me; after working with them for the last two and a half years I have come to know and trust them. Our group has never (knock on wood) had a lawsuit originate from the fast track. And while our MLP’s would readily agree that they are not qualified to run an ER, they are more than capable of delivering appropriate care to a selected subpopulation.
That’s how midlevel providers can help.
December 26, 2008 at 2:56 pm
You pretty much described our ER to a T.
December 26, 2008 at 10:22 pm
Right on man, right on.
December 28, 2008 at 12:16 am
I used to like you :>) I do enjoy your blog and wish you posted more often.
I work FT in an ER with a doc for 12 hours, 3-4 days per week. Prior to becoming an NP I was an ICU/CCU/ER RN with 19 years experience before graduating; I worked for 3 years in primary care before moving to my current ER practice. I practice safe, evidence-based medicine and I know which patients are above my skill level. I frequently discuss my dispo’s with my physician colleague before the patient leaves the ER. They frequently ask me about patients as well, especially the diabetics, as this is an area of expertise for me. It irritates me when NP’s and PA’s practices are limited by arbitrary lines; I don’t want to be sued any more than you do.
December 28, 2008 at 9:39 am
Exactly the case with our PA’s – we often also have them help in the main ED but then we superise them more.
December 28, 2008 at 3:15 pm
i turned this into a whole post…hope you don’t mind. perhaps i’m a bit egocentric but this practice seems like a roll of the dice to me. why not just see the patients? don’t you owe them that? not a blast to you directly, I’m just questioning the practice because I actually have heard of this before. Thanks.
http://www.callacode.blogspot.com
December 28, 2008 at 3:51 pm
As a current PA student, I enjoyed reading both yours and scalpels take on the value of MLP’s. Whether you question their value or ability, there is no doubting that they are needed.
December 28, 2008 at 4:55 pm
Newgradnurse, a patient in the ED does not always have to be seen by a physician. I handle even moderately complex cases with a minimum of supervision, although I have also earned the trust of the docs I work with, THAT, if I am concerned, or uncertain, I will at least talk it over with them. As I said in another post, one of the smaller ER’s I moonlight at, is ONLY staffed by PA’s with an MD on backup call in case we get in over our heads.
Depends on the cases. I mean a straightforward renal calculus is…well, straightforward. Chest pain can be either straightforward, or complicated, but an astute PA or NP will recognize when a patient is presenting with something outside of their knowledge base and/or comfort zone, and will consult their attending.
To have a physician see everyone of our patients, negates the positive impact that we have on ED flow. We get, and help move people through.
For example, on Friday, I worked the evening Fast Track shift, and when I arrived, there were over 20 patients in the waiting room. Within 1.5 hours, we were down to 6 in the waiting room. And that includes a cough that they sent back that was actually a STEMI, I transferred her to the critical care area immediately, and then informed my attending of what was going on. He was quite happy with the recognition, and course of action. I ended up seeing 26 patients in 8 hours.
IF I had to call the consultant over from his hallway all night, I would have a. slowed down BOTH hallways to a crawl, and b. backed up the waiting room even further.
PA’s and NP’s who are astute clinicians, and practice within defined comfort levels (PA’s AND attendings) can make a major impact on patient care, and throughput.
Primary care will eventually be almost solely provided by PA’s and NP’s, especially in light of the recent study of 12000 primary practice docs who, to a tune of 54% are thinking of cutting back on patients, going part time, leaving medicine altogether, or retiring, within the next 3-5 years….and well, you can see the problem.
December 29, 2008 at 9:02 am
No offense to docs, but I’ve found that NPs and PAs often take the time to listen to me rather than talking at me, as MDs often do. As an intelligent patient, that’s invaluable.
December 29, 2008 at 9:20 am
I agree with you that it’s a difficult situation. At my program, we don’t use MLPs, but then again residents are essentially MLPs and everything goes through an attending sooner or later.
At my moonlighting job, they do use MLPs and I think that they utilize them well. Every chart is presented to a doc, and then it’s up to the doc whether or not they actually want to see the patient or just sign off on their treatment. It still saves the patient oodles of time, but is like having a safety net.
Yesterday, the NP presented a hand injury to me that didn’t look very impressive, but when I went in the room, it was clear the guy had a rip-roaring case of flexor tenosynovitis. He got transferred to another hospital to see a hand surgeon. It would have been easy enough though to just sign off on the Keflex and miss the gravity of his injury. I think the run-it-by-a-doc is a good system in that I can pick and choose what to eyeball and can also vary this based on the NP/PA I’m working with.
Next year, I’m going somewhere where they greatly depend on MLPs to run a busy fast-track. It’s going to take me a while to adapt to this, and I suppose there will be a lot of chart reading to do at the end of the day, and possibly callbacks if I don’t like the way something sounds. MLPs provide a great service in that they are very skilled and definitely cut patient wait time down.
Yesterday, there were also tons of lacerations to repair and sore throats to sort through that would have resulted in a lot of impatient unhappy people if it hadn’t of been for our NP.
December 29, 2008 at 12:09 pm
There seems to be a bit of a mystical dichotomy regarding PAs in the ER. They not only spend extra time listening to patients, but they also crank through these same patients at breakneck speed (even faster than some docs!!!). They improve wait times, but primarily among patients who really should be seen last anyway.
December 29, 2008 at 6:11 pm
I’m not terribly convinced that the liability would increase overall…I think keeping docs away from time-consuming but simple procedures would make the mistake/missed diagnosis potential much less for the sickest patients, those most likely to be injured/hurt by a missed diagnosis. There really is no liability issue if an occasional strep throat gets diagnosed as a viral sore throat because neither is an emergency (see EMTALA), for example.
Scalpel will scream “then hire more doctors!” but we’re living in a time where hospitals are losing millions of dollars yearly in unreimbursed care and hiring docs to do what an NP/PA can do just fine in that context is just stoopid.
December 29, 2008 at 8:09 pm
The problem here is that healthcare costs are skyrocketing because you have 2 “providers” billing for services on a single patient. For a typical CHF patient, we used to just pay one doc for that hospitalization. Now when a CHF patient comes in, everybody’s got their hand in the pie: the ER doc who never saw the patient, the ER PA who worked the pt up, the hospitalist PA who manages the inpatient stay, and the hospitalist “supervising” MD who again never sees the patient but has no problem billing for services. Now we’re paying 4 people for the same services that 2 people are capable of delivering. Thats MASSIVELY inefficient.
Why should we pay both a doctor AND a PA/NP to see/treat a patient?
Why are doctors allowed to double dip on these patients that they never lay eyes on?
If you dont see the patient, then you dont get paid for them, PERIOD. There’s a lot of greedy docs making a fortune and driving up heatlhcare costs by billing for visits by the PAs/NPs.
Its BS and it needs to stop.
December 29, 2008 at 9:49 pm
JoeBlow….You cannot bill for BOTH the doctor and the MLP to see the patient, that is fraud. You are obviously not familiar with DRG’s and the payment system for inpatient stays. Even in the ED, if I see a patient on my own, then I bill for the patient. IF I ask the attending to see the patient, and they dictate a note, then I defer billing to them. You cannot bill a patient for 2 ED providers seeing them for the same visit in the ED.
Kate. Sorry about your experience yesterday, sounds like your NP needs to brush up on their hand examinations. Kanavel’s signs are something that EVERY practitioner should be able to recognize quite easily. I know I sent someone to the OR the other day for one, and no, the attending never saw the patient.
December 29, 2008 at 10:04 pm
Joe Blow,
Whoever sees the patient bills. You can’t bill a patient twice, although I like the way you think. The ER docs pay the MLP salaries out of the money that is collected, and keep the rest.
Healthcare costs are skyrocketing because no one will let grandma die with a little bit of dignity.
I want you to know I enjoyed your emotionally charged, completely misinformed rant very very much.
December 29, 2008 at 10:20 pm
Ten out of Ten…
Do the docs at your institution bill for the patients in fast track as well?
I agree with your assessment about end of life care as well. People don’t want to know the tough choices we are going to face soon.
I mean, I was just at a meeting in DC, and one of the discussions was regarding end of life issues and cost containment under a universal plan.
I mean, Should an 80 year old GET dialysis. In some other countries with universal health care plans, patients do not always recieve every service available. This would not go over well here. There are still many discussions needed.
If interested, I will be posting a nice discussion series regarding health care reforms and changes on my blog..
http://physasst.blogspot.com
(My previous comment was kind of confusing, I edited it to make it more clear. The MLP’s bill the patients they see, as do the docs. The docs keep what they collect, the MLP’s are paid an hourly wage by the docs.)
December 30, 2008 at 3:28 pm
My Hospital the PA’s see the patients triaged to Fast Track and in their dictation name the “Supervising Physician” who is the on duty doc on the other side of the dept who only sees the patient when requested, which is rare. The PA gets $50 per hour and some sort of productivity bonus if they qualify. The patient is billed for a ED visit under the Supervising Physicians number and pays the same rate as if they were seen by the Physician both for ED and Physician charges. Can someone answer this question, Is there not a Face to Face requirement to bill under the Physicians number when seen by the PA? It sounds fishy to me and the message I get is dont go there.
December 30, 2008 at 7:31 pm
[...] http://trismus1.wordpress.com/2008/12/26/how-pas-and-nps-can-help/ [...]
December 30, 2008 at 7:52 pm
It sounds fishy to me too. If I’m paying the same price I would pay to see an MD, then I would like to see an MD rather than an unsupervised PA. If I could pay less to see a PA, that might be an attractive option too.
January 1, 2009 at 1:32 pm
ERMurse, I don’t know the answer to that. Our midlevels do the billing for the patients they see, not the “supervising” doc. Maybe Shadowfax knows.
January 2, 2009 at 9:01 pm
Scalpel:
PA’s are never unsupervised and it’s illegal to grant them 100% autonomy. At the end of the day, it’s about delivering competent health care. Whether it comes from an MD/DO/PA/NP it shouldn’t matter. If your going to argue the pricing model,then the same argument can be held with residents.
Ultimately the costs of health care come down to lawsuits. If I file a lawsuit against you and lose, I should be responsible for all your bills to defend a frivolous case. Until that happens, the need for MLP’s is going to increase.
January 3, 2009 at 3:00 pm
So your idea of supervision is something like letting your 15 year old daughter have her boyfriend spend the night in her bedroom while you are asleep downstairs.
My idea of supervision is letting them watch TV on the couch together as I wander in and out of the room occasionally.
January 3, 2009 at 9:36 pm
Scalpel:
I fail to see your point. MLP’s aren’t going anywhere, in fact many of them are taking jobs from MD/DO’s. So, rather than make obscure remarks it might be conducive to venture into some intelligent discourse.
January 4, 2009 at 12:14 pm
When PAs get your daughter pregnant, don’t come crying to me.
January 4, 2009 at 2:11 pm
Scalpel:
In the history of the PA profession, not a single PA has lost their license in my state due to negligence. Your bitterness towards MLP’s is clear and your agenda even more apparent. It’s a shame your in this noble profession.
January 4, 2009 at 7:27 pm
ERMurse and Ten,
I wrote about this in more detail, but in short, just because the PAs identify a supervising physician, it does not mean they will be paid at the physician rate. If they document fraudulently that the doc SAW the patient, then they will get the full payment (at quite a risk). But more likely it’s just so the billing company will know which doc to stick in the MD field on the billing form for the other payers.
January 5, 2009 at 12:25 pm
I agree. They have their place and they are very good at what they do.
January 5, 2009 at 3:44 pm
Now retired, but for years was the most experienced provider in my group when in came to derm. Colleagues came near and far to get my take on many cutaneous dxs (no one else used a dermatoscope) and identified several MMs who were sent immediately to surgeons for wide excisions. Although an an FNP/MSN/RN by ANCC/AANP certification I had ojt’d in derm for many years. I loved it, stayed with it and made my derm/mentor’s practice quite lucrative for him. When I re-entered primary care in a rural setting where there was ONE derm (transient) for the ENTIRE population of a 70 mile strip of East Coast and TONS of cutaneous pathology which was usually all reated with TAC when I got to town. I like to think (nay, I KNOW), that without my expertise and management, lots of folks suffering with a multitude of dermatologic dz processes would have done without. I wouldn’t go back to practice, now, since this vitriol has surfaced in the medical community. When I was active, I was accepted as a colleague by my fellows above and below the food chain. What in heaven’s name has happened? Leads me to think that some bad mojo is being disseminated in Med School Curricula today. Sadly, and as usual, the end result of all this turf warring is that the patient gets the short shrift. Think it’s any different in speciality practice these days? NOT. Behold now and observe the derms near and far now battling one another in the Moh’s arena. Fellowships/payment/reimbursement/who is allowed to charge for what…….most disheartenting. Glad to be retired in VA and recalling the ‘golden’ days of medicine. Nice memories, but gone forever are THOSE days.
January 6, 2009 at 11:58 am
“I like to think (nay, I KNOW), that without my expertise and management, lots of folks suffering with a multitude of dermatologic dz processes would have done without.”
So nobody else in town could prescribe steroid cream? Weird.
January 6, 2009 at 10:40 pm
scalp – who said I just rxd steroid crm? You don’t read very well. But if you must bring up topicals, when did you last treated anyone with Zonalon, topical Dapsone or topical methotrexate? Or even know their indications? Do you write compounded rxs for specific conditions when nothing commercially available will do? No, I didn’t think so. Moreover, YOU are exactly the sort of practitioner likely to have inadequacy issues and feel it is incumbent on you to mock dermatology (but the first to call us when you encounter an odd lesion.) Please grow up – medicine already has a surfeit of immaturity. AND for the record, when we come up against a difficult case we do exactly what you do – consult, send them on and follow up. There is no mystery to it. AMA minions and folks like you notwithstanding, NPs are here to stay (having been here since 1964). This predates your emergence from the primordial ooze. Our dermatologic surgical skills are second to none which is why patients pay upfront $$$ to access them. I remain Elated to be retired and NOT to have to deal with your mind set. ARE you a safe, successful surgeon? This might excuse your hubris (IF you have the goods to back it up, otherwise, just noise).
January 7, 2009 at 11:35 pm
I was going to write a parody post based upon the exploits of the Amazingzucchininurseofmanytitles, but I couldn’t improve upon the self-aggrandizing super-awesomeness of the original.
PLEASE continue sharing YOUR wonderfulness with us. I think (nay I KNOW) that you have much to teach us, just as you have taught many before us.
January 8, 2009 at 3:18 am
Scalp – being retired and weary of YOUR hauteur, I happily decline. But please DO ‘attempt’ to write your parody post? I HAVE the free time for this. But YOU? Where do you get off having time to open fire with your bilious little word gun? How dare you? You -with the nerve to berate a woman old enough to be your MOTHER? YOU, a mere blip on the radar screen of shifting dullness who should be working your sniveling little keister off in the temple which pays your salary and NOT threatening to ‘write a parody’. (I’m enjoying this!) You, who purport to a pastime of ‘pushing buttons’? HA – given your alleged medical duties you ought to be propping your eyelids open with dermabond AT THIS VERY MOMENT (dermabond hat you likely steal from the sample closet ). Rather than attempting to inoculate others with your boorish attempt at jocularity…. try playing LEGOs with your kid as a responsible parent is supposed to. PS = He IS cute – good looks come from mom I suspect. Scalp, You are far too young to know a good parody from a bleeding rectal pruritus but out of pity I will refer you to the ‘Adventures of Bernie X – NYC Cab Driver” By the late, but great Gerald Sussman (National Lampoon circa 1977). That is parody extraordinaire unlike your pitiful scribblings here! NOW, take my advice and stop wasting what seems to be this inordinate amount of time on your hands. Since MY teaching days are happily at an end (and you correctly state that yes, I have taught many before you), I recommend you enjoy this moment. Now, good night, and thank you for validating my high index of suspicion where you are concerned. This truly WAS FUN but at my age I require sleep now! BTW – it’s Zucchini FLOWERS, which are in season only briefly and quite delicious when sauteed in olive oil and garlic.