Hello. I am considering NP and PA school. I have a few years of experience as an ED Tech in a Level 3 Trauma Center in California (busy, but not too intense). Our ED is staffed with PA's no NP's.
I have a few questions about clinical differences between NP's and PA's. I know that PA's seem to have a great ability to work in surgery specialties like ortho, neuro, peds, and cardio surgery. They do pre and post surgery exams, order interprets tests, and prescribe meds (at least in 47-49 states). Are there any NP's on this forum who do this? Are there any in California who can comment?
Second. I know that most PA schools have a much longer clinical component than do NP schools. I have been told it is because NP's already have so much clinical experience as nurses. But can you really compare the two? In our ED, the nurses are not making differential diagnoses, determining etiology of disease, etc. etc., they are monitoring the pt's overall state and response to the treatment ordered by the Physician (or sometimes PA). Therefore, does this experience compare to the rigorous training PA's get in diagnosing?
Part of my interest in medicine is the actual procedures themselves. I want to do chest tubes, central lines, suturing, first assistant surgery, etc. etc. Are there any NP's out there who are doing this?
Finally, I know some people (including some nurses) who deride the "nursing diagnosis" concept. Can anyone offer up a brief rationale for how nursing diagnoses are of value to an NP in clinical practice?
Ok, after some more research, something that should be added to the above article is that the "respondeat superior" way of determining "vicarious liability" can be used against the physician if the physician employs the NP. Most importantly, though, anyone can be sued and each case is handled individually. However, a self employed NP will cause much less liability on their collaborating physisician than an employed PA/NP.
While this quote looks nice, this depends on how you define independent practice. The number bandied about is different depeding on the quote, but if you look here from the ACNP:
This lists 23 states that require no physician involvement. If you look at one of those states, Colorado, in their nurse practice act you would find this in the prescriptive authority section:
"(d) (I) Execution of a written collaborative agreement with a physician licensed in Colorado whose medical education, training, experience, and active practice correspond with that of the advanced practice nurse.
(II) The written collaborative agreement shall include the duties and responsibilities of each party, provisions regarding consultation and referral, a mechanism designed by the advanced practice nurse to assure appropriate prescriptive practice, and other provisions as established by the board."
Hmm sure looks like physician involvement to me. Similary if you look through the other practice acts there is only one state that does not require some level of physician interaction. That being said, I will repeat what I stated originally, that there are plenty of NP's (and PA's) with defacto independent practice. What I dislike is the idea being promoted that NP's can charge out and open a practice withouth any physician involvement. It is naive to say the least. Yes in at least 15 states you can open a practice without any physician collaboration, as long as you don't prescribe, don't bill medicare or most insurance companies. Failure to have these elements is not associated with successful practice.
The internet is a tremendous source of information, but you have to look at any source critically. There is some tremendously poor information out there, some even in peer reviewed journals.
David Carpenter, PA-C
Clarification:
Independent practice for nurse practitioners is highly dependent on their state board of nursing.
I am getting most of my information from the classes I took while attending NP school.
Billing: It all depends on your state, but you can bill independently as an NP.
See above....In general if you can bill medicare independently then you can bill most insurances independently. Here is the coding guidelines for nonphysician billing. Kinda long.... See #2.
Medicare Coverage of Evaluation and Management Services
Along with other Medicare regulations regarding E/M services, CMS imposed specific documentation requirements for E/M services billed to Medicare. Here are other important general rules regarding Medicare coverage of E/M services.
1. Though Medicare requires physicians to report services using CPT codes, Medicare does not cover every service included in the CPT. For instance, preventative medicine services are CPT E/M services that are not covered by Medicare. Though codified in CPT, preventative E/M services are excluded from Medicare coverage. Likewise, any E/M service performed for noncovered services (e.g. "screening" other than those screening examinations for which a screening benefit exists) would not be payable by Medicare.
2. To be paid by Medicare, E/M services must have been performed personally by the physician or other specified practitioner. Non- physician practitioners who may be paid by Medicare for E/M services without supervision of a physician include podiatrists (D.P.M.), nurse practitioners, clinical nurse specialists, and certified nurse midwife (when E/M services fall within the scope of practice defined by state licensing authorities for these limited license practitioners).
3. Every billed instance of E/M service requires a face-to-face patient visit with the physician or other qualified billing practitioner. A code 99211 service may be performed by a licensed or non-licensed employee of the physician (or employee of the same medical group that employs the billing practitioner) when it is performed "incident to" the physician's care. For "incident to" services, the physician or other qualified billing practitioner is not required to personally see the patient, but must be present in the office suite at the time the service is rendered. The following links will take you to more information regarding "incident to", physician supervision, and non-physician practitioners.
"Incident to" Services
Non-Physician Practitioner
Prescribing Authority (always a hot topic and has greatly increased for NPs/PAs over the last few years)
Just because PAs can't practice totally independent, yet, does not mean NPs can't. For most NP schools there is a class called NP roles that goes into exactly what your limits/roles in the state where your school is.
That all being said....Being an NP or a PA is great thing, but these back and forth debates get old... I will just leave this debate alone. I will just agree to disagree, and since my wife has been a certified coder for years and a billing supervisor I think I will stick to her advice about billing.
you have been doing a great deal of research on the np and pa roles in practice. have you found the same depth of information on who is responsible for the performance of the pa or np? historically the physician has been responsible for the performance of the pa. while nps have been perceived as responsible for their own performance. has this changed?
i am not sure we are speaking on the same subject, but in general physicians are responsible for the medical acts preformed by a pa under their supervision. this is different from being responsible for the preformance of the pa (this may be a subtle, but important difference).
there are two answers to this question. one is the defacto supervision that is required in practice and the other is the concept of physician liability.
from the supervision aspect there are a number of states that require physician supervision. in these cases the responsibility is the same. i would use florida as an example of this where both np/pa must have practice prerogatives and prescription authority listed with the sp. in states with no supervision required there is generally less physician responsibility attributed to np's. however, in the case where the np is an employee there is generally some responsibility for a physician to ensure safe practice of the employees. it depends on if the practice is structured as a partnership or not. physicians generally operate under a captain of the ship principle where they have some responsibility for what happens on their watch. this is evolving and bears watching. from a physician standpoint there is probably not much of a problem since np's are usually under the bon and the md's are under the bom. it is unlikely that a bon would approach a bom to discipline a physician for supervisory issues.
the second part of this which will eventually drive any limits is liability. i have some data from malpractice claims that i hope to publish one day. there is an interesting concept happening. first of all you have to understand that the majority of np's are employed by either private practices or hospital/university programs. in medical malpractice the practice is relatively insulated from malpractice by the physicians.
the liability for a pa goes pa>>>sp (supervising physician)
the liability for an np in some cases goes np>>>>sp (in states that require an sp.
in states that don't require an sp there have been some attempts to drag in collaborating physicians, but those have generally been rejected unless there is a problem in priviliges or description of privleges. in the case where the np is an employee there have been attempts to define liability as such:
np>>>clinic. this has met with limited success. the problem from a liability view is it allows the plaintiff to bypass malpractice limits for pain and suffering.
this has the potential to make np's more of a liablility than any other provider. as a non-lawyer this does not make much sense to me since employee physicians are not being held to this standard. the difference as far as i can tell seem to lies in the nature of an unrestricted medical license and the nature of a nursing license in some states.
the second problem seems to be part lies in the nature of np practice. np's are certified in their various specialties. however, many np's are working in areas for which they have no training as an np. for example a fnp working as a hosptalist. there is no requirement for an fnp to have any inpatient experience or training in np school and many have no inpatient experience as an np student. there are a number of np theorists and instructors who will state that since np's are independently licensed as np's there scope of practice extends only for those acts that an np has received formal didactic and clinical training as an np. this has two consequences. it has the potential to increase liability if an oraganization hire an np for a job which is outside their scope of practice. this would be similar to the liability that a hospital assumes if it credentials a internal medicine physician to do major surgery. this is a well established area of tort and is the reason that you are seeing major changes in the credentialling process in many hosptitals. the second issue here is that the physician that the np works for will assume more liablity because they have employed someone who is outside of their scope of practice.
for some states such as florida the way their practice act works with delegated practice for both np's and pa's there is no difference. other states such as texas have moved to curtail np practice somewhat based on this theory. other states have not addressed this or addressed np scope of practice at all.
this is the theory going on. what the practical effect remains to be seen. for example despite the fact that there is no nephrology np i see plenty of ads for np's to work in dialysis centers in texas. i don't think there is much effect on insurance either, but the malpractice carriers are watching this closely will probably move quickly if they see a problem.
the other issue will be hospital credentialling. in my area the hospitals are already requesting extensive documentation of training and practice. in both the np and pa you are required to have a supervising physician that is responsible for your medical acts. i have heard of at least two cases locally where np's where denied inpatient privleges. in both cases the cause seemed to be that they had no inpatient experience as np's and that there was a type of np (the acnp) for which this was within the scope of practice.
this is a very long answer to a very complicated question and these are only my opinions and observations. there will be tremendous variation by locality. ultimately liability will drive this discussion.
Ok, after some more research, something that should be added to the above article is that the "respondeat superior" way of determining "vicarious liability" can be used against the physician if the physician employs the NP. Most importantly, though, anyone can be sued and each case is handled individually. However, a self employed NP will cause much less liability on their collaborating physisician than an employed PA/NP.
To some extent. There have been attempts to use NP's (and PA's) as independent contractors. This has met with mixed success. It is rare that they are truly independent and generally the courts have rejected this as an attempt to bypass liability. If you are talking about a self employed NP as an independent owner/operator of a practice then yes you are correct. If you are talking about an NP as an independent contractor with an urgent care center then either corporate or personal physician liability may apply.
I am not sure we are speaking on the same subject, but in general physicians are responsible for the medical acts preformed by a PA under their supervision. This is different from being responsible for the preformance of the PA (this may be a subtle, but important difference).
David Carpenter, PA-C
Here is a PA "requirement" from one board of medical examiners.
"Must secure a contract to provide patient services under the supervision of a doctor of medicine or osteopathy who practices medicine and who is responsible for the performance of the physician assistant."
As with NPs, PA statutes vary state by state. Some states have the language you posts prarienp. Is that from ohio's laws?
The plain and simple fact is, both PAs and NPs are sued less than doctors. If a doctor was involved in a case AT ALL they are likely to be named in the law suit. There are multiple legal ways to define "defacto" responsibility for the midlevel's actions. However, if the midlevel fails, ON THEIR OWN, to consult the physician as is required by their protocols or in the case of PAs, standard of care, the physician is safe. The battle over who causes more liability is a strange one to start because all in all, if you do what you are supposed to do and do it well while covering your butt, you wont lose a law suit (in general). Malpractice premiums usually do not go up for a doc when they supervise a PA or NP acording to the articles I have read but they are a little old.
Here is a PA "requirement" from one board of medical examiners.
"Must secure a contract to provide patient services under the supervision of a doctor of medicine or osteopathy who practices medicine and who is responsible for the performance of the physician assistant."
Help me understand the difference, thanks
You would have to look at the rest of the practice act to see what this involves. How I would interpret this is that the board is telling the physicians that they are responsible for the acts of the PA. So if the PA commits a medical error they can be ultimately held responsible. It is also telling the PA that they need to have a written agreement with a physician (avoids claims that the physician did not agree to supervise). There are also cases where a PA may work essentially independent of the particular physician or group (surgical assisting comes to mind). This reinforces that the supervising physician is still responsible. I would read this more aimed at the physician than the PA.
A more common statement is from Colorado:
Liability for Actions of a Physician Assistant. A primary physician supervisor may supervise and delegate responsibilities to a physician assistant in a manner consistent with the requirements of these Rules. Except as provided in Subsections (2)(B)(3) and (2)(D) of these Rules, the primary physician supervisor shall be deemed to have violated these Rules if a supervised physician assistant commits unprofessional conduct as defined in 12-36-117(1)(p), C.R.S., or if such physician assistant otherwise violates these Rules. The primary physician supervisor shall not be responsible for the conduct of a physician assistant where that physician assistant was acting under the supervision of another primary physician supervisor and there is a form in compliance with Section 4 of these Rules signed by that other primary physician supervisor. The primary physician supervisor shall also not be responsible for the conduct of a physician assistant where that physician assistant consulted with a secondary physician supervisor and documented such consultation in the chart note as required under Subsection (2)(A)(5) of these Rules.
The concept here is similar to delegated practice in nursing except that it happens at a higher level. Just as you could be held liable for the actions of a NA under you supervision, so can a physician be held liable for the actions of a PA.
This is probably the main difference between collaboration and supervision. How this is enforced at a state level varies. It would be unusual for an SP to be disciplined by the BOM for a single bad act by a PA. Where you usually see a failure to supervise charge is where there is a pattern or clear evidence of a lack of supervision.
In practice there is really no difference. A physician is just as responsible for the acts of NP's or PA's in their practice. This will differ based on the state, but I have seen board action for the failure to supervise an NP (or an RN) in my state. Mostly the state board holds physicians responsible for any acts that occur within their practice. If the physician has a collaborative agreement with an NP practice (is not an employee of the practice) then they probably have less responsibility to supervise than if they have a supervisory agreement with a PA.
As with NPs, PA statutes vary state by state. Some states have the language you posts prarienp. Is that from ohio's laws?
The plain and simple fact is, both PAs and NPs are sued less than doctors. If a doctor was involved in a case AT ALL they are likely to be named in the law suit. There are multiple legal ways to define "defacto" responsibility for the midlevel's actions. However, if the midlevel fails, ON THEIR OWN, to consult the physician as is required by their protocols or in the case of PAs, standard of care, the physician is safe. The battle over who causes more liability is a strange one to start because all in all, if you do what you are supposed to do and do it well while covering your butt, you wont lose a law suit (in general). Malpractice premiums usually do not go up for a doc when they supervise a PA or NP acording to the articles I have read but they are a little old.
I would disagree on this. NP's and PA's are sued just as much as Physicians . I do some expert witness testimony. It used to be that the NP or PA would occasionally be named, but usually dropped. The reason for this was the deeper pockets of the physician. With the advent of pain and suffering limits the usual procedure is to sue anyone that is remotely connected with the patient. While this has long been standard procedure, the difference that we are seeing now is that all parties are being kept in the suit if possible. Previously going after the PA and the physician was the same pot of money. Now each provider is on the hook for the entire amount (your state may vary). From my point of view this is a very good reason for all providers to carry their own malpractice insurance. If you look at my other post the physician is still liable even even if the PA fails to consult them.
This liability is not significantly different for NP's that are in a practice. Overall physicians do pay more for insurance, but unfortunately PA and NP insurance prices are increasing quite quickly. My premiums have tripled in the last 3 years without any claims. Fortunately they are still 10% of my physicians malpractice.
I read somewhere (I honestly cannot remember where) that NPs have difficulty getting insurance reimbursement in comparison to PAs. I am planning on applying to an accelerating nursing program with the end goal of becoming an Neonatal Nurse Practitioner or OBGYN NP, if thats possible, and I was very excited about this possibility. Now I don't know what to do! Is this true? Does anyone have an info regarding this?
I read somewhere (I honestly cannot remember where) that NPs have difficulty getting insurance reimbursement in comparison to PAs. I am planning on applying to an accelerating nursing program with the end goal of becoming an Neonatal Nurse Practitioner or OBGYN NP, if thats possible, and I was very excited about this possibility. Now I don't know what to do! Is this true? Does anyone have an info regarding this?
Thank you,
Lindsay
I feel bad for you having been introduced to all of this stuff via these forums. Please, please, please FORGET about reimbursement.. dont worry about it. Learn how to take care of folks in whatever way you think best fits your current situation in life. If that be NP, PA, MD or whatever.. worry about reimbursement (or better yet, let your employer worry) later. Right now enjoy how much fun it is to learn how to take care of people. Go for it!
I feel bad for you having been introduced to all of this stuff via these forums. Please, please, please FORGET about reimbursement.. dont worry about it. Learn how to take care of folks in whatever way you think best fits your current situation in life. If that be NP, PA, MD or whatever.. worry about reimbursement (or better yet, let your employer worry) later. Right now enjoy how much fun it is to learn how to take care of people. Go for it!
I disagree. Too many PA's (and MD'or NP's) don't understand reimbursement and pay the price. Go to Michael Powe's talk at AAPA or almost any reimbursement talk. Listen to any reimbursement talk. They will tell you horror stories about reimbursement. Face it what we bring in is why we are there. Even if you are in a practice you should know how to code and what you are bringing in. That way you aren't suprised if someone tells you that you aren't pulling you weight. We had a PA here recently that comitted suicide because medicare refused to pay her for 16 months.
We had some coding and billing stuff in school, but I am suprised how many schools don't do this. One of our new MD's undercoded for nine months before he saw me coding a visit and asked some questions. The practice assumed since another physician from that program had classes in this, that he new how to code.
To the OP, the only time you have to worry about this is if you are trying to open an independent practice. Hopefully that is not something you will be doing until you get some experience. As part of that experience you need to understand all the business aspects of a practice as well as the medical aspects.
Of course with NPI coming in May, who knows how things are going to work out.
I am planning on applying to an accelerating nursing program with the end goal of becoming an Neonatal Nurse Practitioner or OBGYN NP, if thats possible, and I was very excited about this possibility. Now I don't know what to do! Is this true? Does anyone have an info regarding this?
caldje
177 Posts
Ok, after some more research, something that should be added to the above article is that the "respondeat superior" way of determining "vicarious liability" can be used against the physician if the physician employs the NP. Most importantly, though, anyone can be sued and each case is handled individually. However, a self employed NP will cause much less liability on their collaborating physisician than an employed PA/NP.