04 January 2009

Pulling a Lazarus

It's been a solid two weeks since I posted for real on the blog. It took a little restraint at first; every stray thought I had seemed like the perfect topic for a blog post. Eventually I was able to free my mind from the thrall of my cybernetic overlords. Also, I skied. It was a nice time -- family, presents, fine wine, and the enduring joy of repeatedly digging four-wheel-drive vehicles out of snowbanks. I hope you also had nice holidays.

Now I'm back in the harness and will get back to you with some real medical posts soon enough. For the moment, I will throw in my $0.02 on a debate regarding the role of Mid-level providers (MLPs) in the ED, specifically NP's and PA's. Scalpel has made his point in spades, here, here, here, and here, while Ten out of Ten has provided a counter-point here, and Happy the Hospitalist chimed in over here.

Disclaimer -- I am not an expert in licensing requirements, liability, or reimbursement other than in my particular state. Also, there is variability in both the MD and MLP populations -- I've known PAs who were exceptional clinicians, and MDs who were, we joked, "licensed to kill." And vice versa. Your mileage may vary. I'm not interested in a "PA's suck!" "No, doctors suck!" argument. Having said that, I will dive in:

What is a PA or NP? First of all, it's important to understand that in most states, they are "Licensed Independent Providers," which means that they are qualified to examine and treat patients and bill for their services without direct physician oversight. PAs generally need a nominal supervising physician, and state laws vary as to how close the supervision need be. In our state, the doc must be physically on the premises except in critical access locations. NPs have less restrictive requirements. Both NP and PA training programs are highly competitive, and in most cases will only accept applicants with significant healthcare experience (the consequence is that the MLP ranks are full of former nurses, paramedics, and corpsmen). The training can be as little as 2 to 4 years (not counting prerequisites), and yields a masters-level degree. In my experience, the intensity, depth and breadth of the training is substantially less than that in medical school and residency, and the lack of standardized post-graduate training for MLPs requires significant on-the-job learning for new graduates.

The consequence of the more superficial education of MLPs is that they are usually required to function within a narrowly defined scope of practice. In an ER, that may be limited to minor traumatic injuries and other simple complaints. I have known PAs who were highly specialized as vascular or neurosurgery assistants; their understanding of their field far exceeded my own, but they functioned as extenders of their supervising docs and bore limited independent responsibility. For an MLP, knowing your scope of practice and staying within it is essential. (The same principle applies to physicians, I might add, though our scope is comparatively expansive.)

How are MLPs utilized in ERs? This is highly dependent on local and institutional issues and on the experience and comfort level that a department may have with MLPs. The most restrictive environments require the PA to present all cases to a doc and require the doc to see the patient as well -- in essence, this has the PA function like a resident physician. In other cases, the PA just has to present the patient, with the doc electing to see or not see them as they feel is indicated. Some EDs just have the docs review and co-sign all the PA charts, and others have a QA process by which a random sample of the PA charts are reviewed retrospectively. The more autonomously the MLPs operate, the more efficient it is, but that must be balanced by how well the scope of practice is adhered to and how much risk there is that a MLP might get in over his or her head with an unexpectedly complex patient. In a well- run ER, there is ample opportunity (and no disincentive) for MLPs to consult with or transfer care to a physician, as needed. My opinion is that with experienced MLPs and a carefully selected patient population, it is possible to safely run a fast track with completely independent MLPs.

Why are MLPs staffing ERs at all? The primary reason is economic, though as Scalpel noted, there is a shortage of qualified EM physicians which also is an incentive for ERs to hire MLPs if their patient demographics make sense. But the main reason is economic. Consider a PA working a site where the volume is not terribly high -- 2.5 patients per hour. Fast Track acuity typically translates to an average value of about 2.5 RVU per patient. So the PA is bringing in 6.25 RVU/hour, which at a conservative $40/RVU collection rate is $250/hour. Subtract $50 for expenses and pay the PA $60/hour, and the remaining $140/hour is profit for the employer. Incentivize your MLPs so they are a little faster, and your profit margin only goes up. This is an effective subsidy to the physician income base, one of the few refuges available in an era of shrinking reimbursement.

Speaking of reimbursement, how does that work for MLPs? That depends entirely on the internal policies of each individual patient's payer. When a PA sees a patient, it is coded with the ICD-9 and CPT codes based on their documentation, just like when a doctor sees a patient. However, some payers do and some do not issue provider ID numbers to PAs. Medicare and most governmental payers do issue provider IDs to PAs, and if the PA is the sole provider listed on the billing form, will reduce the allowable fee by 15%. Most commercial payers, in my experience, also do credential PAs, and pay at the same rate that they do for physician services, though some may apply a random reduction in the allowable (read your contracts!) between 5-20%. Medicare will pay an E/M code at the physician rate if it is a shared service, meaning that there must be documentation that the physician had (at a minimum) a face-to-face interaction with the patient. However, procedure codes, from lacerations up to and including Critical Care, may not be shared services and will be paid at the rate of the provider who actually performed the procedure. Thus if you think you can improve reimbursement by documenting that you supervised a PA's laceration repair, think again!

If the payer does not allow a charge to be billed in the PA's name, then the charge will be issued in the name of the supervising physician with the PA listed in the second position on the billing form (this will be ignored by the payer, but is necessary for internal record-keeping). Usually these get paid at 100% of the allowable.

Scalpel made a strange argument that MLP services should be at a steep discount from physician rates. While this would be a great way to eradicate MLPs from the health care landscape, I don't see much validity to this. A service provided is a service provided, and the worth of the service, performed competently, does not vary according to the credentials of the individual who provides it. A laceration repair is not worth more to the patient if the doc does it. A chest tube pays the same whether the surgeon or I put it in. Scalpel and I get paid the same though I am AEBM ABEM certified and he, apparently, is not. As far as I can tell, the only rationale behind the 15% holdback from CMS for MLP services is, "Because we can."

What about the vicarious liability implications of using MLPs in the ED? Obviously, there is always liability, but it is generally low. MLPs are under-represented in ED med-mal cases, and given the lower acuity of the patients they see, that makes sense, as does the fact that in most cases the dollar amount at stake is low. If you as the supervising physician never saw the patient, then you can seek to have your name dropped from the case due to absence of doctor-patient relationship. You may be on the hook for negligent supervision, but that is more commonly directed at your mutual employer. There are occasional cases in which a doctor who never saw the patient is found to have some responsibility, but that is more typically in cases where something else happened (an unlicensed PA, or falsification of the chart). In my experience (fortunately quite limited) it is fairly uncommon for the doc to even be named, if they never laid eyes on the patient.

What's the big picture? Scalpel thinks we should "Just Say No to Fast Tracks," and he's partly right. There is a significant added expense when minor ailments are treated in the ER (which is to say that Fast Tracks are profit centers for physicians and hospitals). Given that cognitive services are undercompensated relative to the real work and risk that go into them, it is essential for ER groups to retain the simple cases to cross-subsidize the work on the complex, sick patients. Also, given the ongoing collapse of primary care, it is becoming progressively more difficult for patients to receive care for acute illnesses and injuries at their doctors' offices, and the ER is an attractive one-stop-shop for patients. You can be in and out in a well-run Fast Track in ninety minutes. The macro-economic climate ensures that the customer demand is there, and we do nobody any favors by refusing to meet that demand.
In an ideal world, when primary care physicians are well-paid and plentiful, perhaps that demand will cease to exist and the patients will all go back to outpatient centers. Or, more likely, CMS will cut reimbursement for Type B ED services (aka Fast Track) and hospitals will no longer have an incentive to grow that service line. From a queuing theory perspective, Fast Tracks (and the MLPs that run them) are essential at clearing out the lower rungs of the acuity ladder. It's short-sighted and vindictive to insist that less-urgent patients must wait until the truly sick have been seen. Run a good fast track, and everybody gets seen faster.

My personal opinion is that while I have nothing against PAs, in an ideal world, I would not employ them. It makes the management of a group more difficult to have two different classes of providers at different wage scales, and there is an inevitable tension between the two groups which I find is not conductive to good morale. The economic argument, however, is very compelling, and the decrease in income were we to change to an all-physician model would be painful indeed. Besides, we are not building an organization from a clean sheet of paper; we have had PAs for a couple of decades, they are good friends and colleagues who deliver good care, and their place in our organization is quite secure.


  1. As a current PA student, I really appreciate your balance between Scalpel & Ten. Even as an aspiring PA, I do see the concern about employing MLP's. I also recognize that the economic benefits will always win out and MLP's are here to stay. Rather than debate the their validity, I'd like to start a conversation on how to improve the MLP's ability to aid both the physician and the patient.

  2. Yep, as I stated on scalpels blog, I have been a practicing EM PA for a quite awhile. I tend to perhaps have a different set of duties, as I work in an academic institution and am involved in academic medicine as much as I am clinically. I am also involved to, a seemingly increasing degree in health policy circles..although that was a personal choice. I have stated, and will continue to state that you simply cannot compartmentalize all PA's and NP's into one lump. PA's and NP's need to be evaluated independently, and supervision adjusted accordingly.

    I function with a HIGH level of autonomy, sometimes, perhaps a bit much, but I will always consult a physician, even if only by phone, when I am out of my comfort zone.

    Please see my blog


    I posted several days ago on many of the economic realities regarding PA utilization, and even posted a brief summary of a shift yesterday.

    Bottom line is, medicine is not rocket science, and I agree that a new grad PA has a STEEP learning curve ahead of them, a more experienced, competent PA has far more than a simple, basic understanding of human pathophysiology. To bad some can't see that.

  3. That was an interesting and well-written rebuttal. Regarding this statement,

    "As far as I can tell, the only rationale behind the 15% holdback from CMS for MLP services is, "Because we can."

    it seems to me that a similar rationale would allow them to hold back even more, if they so chose. And given the inarguable need to cut Medicare spending, I suggest that MLP reimbursement might be relatively low-hanging fruit for the knife.

    Besides, no third-party payer really wants their enrollees to go to the expensive ER for minor stuff anyway, so if the LWBS rate increases due to Fast Tracks shutting down, that's icing on the cake from their standpoint.

  4. Good post! Always nice to hear from someone who really knows what they're talking about.

    I'd just like to add that, at least around here, you can be accepted into PA school without much, if any, clinical health care experience, although, it may help you get in. A lot of biology majors and whatnot go into PA school. NP school, on the other hand, you need clinical nursing experience (which varies from school to school obviously). As a result, there is an area bias towards NPs vs. PAs in most specialties. I know of only one PA that works in our hospital in its entirety.

  5. Nurse K:

    I know it's a lofty idea, but couldn't our energy be put into making health care more patient centric? I am stunned by these blogs that consistently impugn upon the role of the MLP or compare which MLP is "better" or more "qualified". While your points about NP's having more clinical experience than PA students is completely false, what exactly is the point of your discussion? Here are the numbers for your information:

    1000 - 2000 Hours 9.81%
    2000 - 4000 hours 15.24%
    4001 - 10,000 hours 19.42%
    10,001 - 20,000 hours 14.61%
    More than 20,000 hours 7.31%
    No Paid Experience, Volunteer/Shadowing Only 10.44

    With that being said, can we now progress into a more forward thinking conversation and talk how we all can work together and transform issues rather than create them?

  6. Nurse K,

    I agree with Emerson. I cannot speak for the PA schools in your area, but nationally, MOST require a minimum of 2000 hours of patient care experience prior to application.

    There are also SIGNIFICANT problems with NP education, and I have had numerous discussions in regards to this with the NP leadership.

    I actually am in the middle of posting a summary of the differences on my site.

    The point is, we both have a place in clinical medicine, and we both tend to be better at different things.

  7. NP schools in california are now admitting "entry level nurse practitioners"; these are students with a bachelors degree (not in nursing). They get their RN in the first 12-15 months and their NP in the last 12-15 months. They therefore have only 12-15 months of NP education. The number of clinical hours required in nursing school have been decreased to 600 in many places. The experiential divide is therefore on the side of the PAs in many places. NP schools have part time clinical rotations where NPs frequently are precepted by NPs and not physicians. PA school is full time with a didactic phase that usually requires at least 2000 hours and a clinical phase of 2000 hours.

  8. If you can't see the difference between 2000 hours of CNA/EMT or other generic "patient care experience" and 2000 hours of nursing experience without an explanation, you're just being silly, PAs. Of course, it's hard for someone who doesn't currently have the nursing 6th sense to see its value. Not super important, just refuting a small part of this post that implied that all experience was created equal between the two types of MLPs. However, NP schools could be a little less fluffy and more medical, that's for sure.

  9. Nurse K,

    The NP we just hired NEVER had any patient experience as an RN. She went and obtained a BSN, and then went right into NP school in Oregon. Never worked the floors...she did volunteer as an EMT....as far as PA experience....well, let's see. I was a corpsman in the military, and we had 4 RN's in my class, 3 P.T.'s, several Respiratory Theraists, 8 paramedics....etc.etc.etc.

    As far as NP schooling, well as I said, I posted today about some serious issued with NP education and their continuing education requirements.


  10. Nurse K:

    With more than 5,000 hours of being a Paramedic Specialist, I would hardly call that "generic" experience. Perhaps I should ask the 9 nursing students in my PA class why they didn't choose the NP route. Then again, an online NP degree does seem attractive compared to my first year of medical school.

  11. Just a really nice comprehensive balanced take on the topic. Nicely done.

  12. The very idea of The Peoples' Republic of California allowing CPA's and Art History majors to become NP's in three years is terrifying to me. A buttload of nursing or EMS experience should be the very minimum to even get INTO a MLP program....Pattie, RN, BSN

  13. AEBM certified?

    Why on earth are you certified in Australian Equine Barefoot Movement (AEBM)?


  14. AEBM certified?

    Why on earth are you certified in Australian Equine Barefoot Movement (AEBM)?



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