I have been following your discussions here on the recent media coverage of the primary gap, and NPs place in it. I posted this on another forum that I moderate, and felt it was only fair to give you all a chance to chime in. I hope it doesn't come across as an attack, but rather a clinician of a different stripe with some real questions about how we market ourselves. The text below is addressed to PAs, so read in that context:
I have been reading the coverage of the recent articles from CNN and Time that we discuss here, in particular the responses on allnurses.
Of course I have to provide my PA disclaimer.....I work with NPs.....about a dozen of them at my institution. I have never had a negative experience with any of them, and have no need to write a "hit piece". We confer, they give medical feedback, I give surgical, etc....collegial and pleasant.
That being said, I have read over and over again about the presumed advantage NPs provide over docs (this is in their words) becuase they offer a "nursing perspective", "treat the patient, not the disease", "look at the patient as a whole", "offer prevention as well as treatment", etc.....
I really don't see this as NP bashing, but I see these comments as somewhat elitist....or at least "leading the argument". The NPs I work with practice the same medicine (!) as the rest of us, PAs, MDs, etc. Their preop cardiac workups look just like any other. And they're good. A clinic NP treating OM...are they really offering that much of an edge over a non-NP due to their nursing background? What does the nursing backgroud teach about listening, empathy, and thinking about interdependent body systems that our medical model education does not?
This all seems like a phoney selling point that is SO subjective that there is no way to argue it, putting NPs in a position which is easy to defend and impossible to refute.
Thoughts?
Do you feel like you treat your patients any less holistically b/c you were trained in the medical model?
Education does make a superior provider, that is what the nursing establishment is saying. Why else would there be advocating for a DNP to receive the same practice rights as an MD/DO when currently NPs do not ? Unfortunately, while experience does impart a great deal to practicing medicine or nursing, there is a great amount of variety in NP programs as far as education and experience requirements go (that includes direct entry NP programs where the participants have NO prior experience). I agree that often is a relative term, that's why I used it. I don't have any studies to back that statement up - however, if someone is exposed to a broader range of illnesses (i.e. education) then it would be logical that their list of differential diagnoses would be broader as well. I don't know the exact number of times this would be advantageous to a patient, but it is prudent to believe it is of some importance. It may take more than one PCP visit or referral, but it's the recognition of a more involved problem that is the important part.
Physicians are not afraid to open themselves up to competition to independently practicing nurse practitioners because they think the money flow will decrease. There is an overwhelming concern that the inconsistency among programs (in terms of classes, educational requirements, experience required, clinical hours) leads to inconsistency with practice and may lead to worse outcomes than medical education which is standardized (MD/DO/PA). In addition, while patient should be given the choice of a lower cost provider, but I think that if/when nurse practitioners get independent practice rights they will inevitably have a cost similar to that of physicians (with the lobbying for the same reimbursement and the again inevitable increase in malpractice to match that of physicians).
Yet again, I don't care what you tell us your reasoning is for fearing the competition of independently practicing nurse practitioners. If you think your education is superior and creates better value for the customer, then open yourself up to the competition. It also doesn't matter if they have a similar cost, as long as that cost is lower than the current cost. They should receive the same reimbursement, that reimbursement should simply be lowered for everyone providing the same services.
Yet again, I don't care what you tell us your reasoning is for fearing the competition of independently practicing nurse practitioners. If you think your education is superior and creates better value for the customer, then open yourself up to the competition. It also doesn't matter if they have a similar cost, as long as that cost is lower than the current cost. They should receive the same reimbursement, that reimbursement should simply be lowered for everyone providing the same services.
Following that logic then the simple fact is that less providers overall will enter primary care since if that were to occur the reimbursement would be lower for everyone. Then all we would end up with is specialist NPs, PAs, and MD/DOs.
In addition, "competition" already exists, but in terms of cost the copay is the same whether you see a midlevel provider or MD/DO (but the insurance billing would be the difference - so maybe the difference would be felt more with someone who is uninsured).
Following that logic then the simple fact is that less providers overall will enter primary care since if that were to occur the reimbursement would be lower for everyone. Then all we would end up with is specialist NPs, PAs, and MD/DOs.
In addition, "competition" already exists, but in terms of cost the copay is the same whether you see a midlevel provider or MD/DO (but the insurance billing would be the difference - so maybe the difference would be felt more with someone who is uninsured).
You are wrong again. Lower reimbursement doesn't necessarily mean lower bring home pay. You show your ignorance of the profit and loss statement. There is never only one part to the equation. An income statement is made up of REVENUES (reimbursement) and EXPENSES. If you work on whittling dow the EXPENSE side of the equation, you can come out with more profit. Doctors and medical personnel don't ever seem to think about this one. They always assume that they need nine support staff for every provider and that you run the practice cheaper and more efficiently on a 20 year old DOS based scheduling system because an EMR is too expensive. They are very reluctant to making their practices run more efficiently because they simply don't understand business. The nurse practitioner model seems to lend itself less to ego and more to practicality, which leads me to believe that nurse practitioners are better able to see that with fewer support staff and a more technologically advanced practice, primary care can be far more efficient than most physicians care to make it. This equals more profits on lower reimbursements.
You are wrong again. Lower reimbursement doesn't necessarily mean lower bring home pay. You show your ignorance of the profit and loss statement. There is never only one part to the equation. An income statement is made up of REVENUES (reimbursement) and EXPENSES. If you work on whittling dow the EXPENSE side of the equation, you can come out with more profit. Doctors and medical personnel don't ever seem to think about this one. They always assume that they need nine support staff for every provider and that you run the practice cheaper and more efficiently on a 20 year old DOS based scheduling system because an EMR is too expensive. They are very reluctant to making their practices run more efficiently because they simply don't understand business. The nurse practitioner model seems to lend itself less to ego and more to practicality, which leads me to believe that nurse practitioners are better able to see that with fewer support staff and a more technologically advanced practice, primary care can be far more efficient than most physicians care to make it. This equals more profits on lower reimbursements.
Regardless of the revenues and expenses balance, lower reimbursement means lower bring home pay. They are directly proportional. You see more patients, you make more money. I am not sure how that relates to having less ego and more practicality...or how the medical model does not promote that. I know many single physician practices that have one secretary and one nurse and still are struggling with their overhead. A lot of this is the increased cost of malpractice as an independent provider, something which no doubt would affect a NP as well if they were an independent practitioner.
Regardless of the revenues and expenses balance, lower reimbursement means lower bring home pay. They are directly proportional. You see more patients, you make more money. I am not sure how that relates to having less ego and more practicality...or how the medical model does not promote that. I know many single physician practices that have one secretary and one nurse and still are struggling with their overhead. A lot of this is the increased cost of malpractice as an independent provider, something which no doubt would affect a NP as well if they were an independent practitioner.
I get sick and tired of hearing physicians complain about malpractice. This does little or nothing to drive costs. In my home state and many other states, we have capped punitive damages on malpractice claims. Guess what? Costs are still rising at astronomical rates. Furthermore physicians don't police their profession and kick out the bad apples. They deserve to bare the burden they have created for themselves.
Lower reimbursement doesn't mean lower bring home pay, it means that you have to find creative ways to bring your service to the customer more efficiently. This is something that physicians simply don't understand. Go study the manufacturing industry for a while and you will understand what I am saying. What this really means is that nurse practitioners who practice independently will bring home more and physicians will bring home less. The physician may make a little more than the nurse practitioner, but not much. That is fair, because the physician doesn't offer that much more than the nurse practitioner does in primary care.
I don't doubt your personal experience but I can't say that the use of the term doctor by a nonphysician cannnot lead to misinterpetation, and at worst, misrepresentation.
Okay, now I'm confused. You said earlier that you had no problems or issues with a psychologist introducing her/himself as "I'm Dr. XXX, the psychologist," but you have concerns with "I'm Dr. YYY, the nurse practitioner"?? Is there some rational reason for this, or is it just personal bias against NPs?
Okay, now I'm confused. You said earlier that you had no problems or issues with a psychologist introducing her/himself as "I'm Dr. XXX, the psychologist," but you have concerns with "I'm Dr. YYY, the nurse practitioner"?? Is there some rational reason for this, or is it just personal bias against NPs?
I guess I never have understood why the medical profession clings to their titles so closely. It sounds to me like "Senator Boxer" being offended by being called Ms. Boxer. Physicians need to get over this business of being called "Doctor". Why isn't it sufficient to be called by your first name and have your credentials follow after the name on a business card or stationary? Do you have some insecure need to inflate your ego by calling yourself "doctor XXX"? That's what this sounds like to me. Most other professsions have evolved. Lawyers and accountants no longer go by Mr. or Ms. XXX. They have clients call them by their first name. This is more conducive to building a relationship with your client or patient. People don't generally like the formal nature of calling someone by their last name. Most people also like to be called by their first name.
I get sick and tired of hearing physicians complain about malpractice. This does little or nothing to drive costs. In my home state and many other states, we have capped punitive damages on malpractice claims. Guess what? Costs are still rising at astronomical rates. Furthermore physicians don't police their profession and kick out the bad apples. They deserve to bare the burden they have created for themselves.
Lower reimbursement doesn't mean lower bring home pay, it means that you have to find creative ways to bring your service to the customer more efficiently. This is something that physicians simply don't understand. Go study the manufacturing industry for a while and you will understand what I am saying. What this really means is that nurse practitioners who practice independently will bring home more and physicians will bring home less. The physician may make a little more than the nurse practitioner, but not much. That is fair, because the physician doesn't offer that much more than the nurse practitioner does in primary care.
I agree, costs are rising - but most of those costs are related to insurance and the "administrative costs". Malpractice rates are rising not because of all of the "bad apples", but because patients are suing more - be it from legal persuasion (have you seen the number of medical malpractice commercials lately?) or just due to the economy. Regardless, malpractice rates will continue to rise as well.
The problem with the argument that you can provide the same services at a lower rate is not really something that is going to work well in healthcare since again the cost of practice will inevitably be the same for any independent practitioner.
To get back to the idea of this thread - I personally do not understand the concept of having a doctorate in nursing practice. As has been shown previously, there is less clinical education than medical school or PA school and a lot of classes regarding research and nursing theory. If that is going to be the basis of someone practicing independently then how would that prepare someone for advanced medical decision making ? If someone wants to practice medicine (which is what an independent practitioner would practice as stated above) then why not go to medical school or PA school ? Last I knew, someone who wanted to practice nursing would become a nurse.
A DNP degree as described by most of the educational institutions that offer it make it seem like an advanced degree in nursing practice. If there is equivalent scope of practice then why not equivalent training ? With the argument of less training can do the same job the health care industry could easily spiral downward. In fact, that seems to be going in the opposite direction - RNs requiring BSNs, LPNs replaced by RNs, medical assistants replaced by RNs/LPNs. It's not always the case that it's better to have someone who can do ALMOST everything than someone else be a better option than someone who COULD do everything.
I'll say it again. Show me the studies that indicate the NP training is produces outcomes inferior to MD or PA. My earlier post in this thread lists multiple studies that provide the evidence that the NP training produces outcomes similar to that of a MD or PA. Until you cough up a study, your assertions are baseless and biased. If you want to just bash NPs that's different, but then let's call it what it is.
I considered NP and PA schools for years while working as an RN. I have a MD father and a PA brother. We have spent countless hours going over the pros/cons. Here's the breakdown:
Medical school --I'm 41, not realistic to be admitted, length of training is too long at this stage in my life. Wouldn't live long enough to pay back student loans.
PA school- I liked the idea of being a PA, certainly nothing against it once I completed school. The tuition is 2-3x that of NP. Not working for 2+ years means added student loans (my brother's tab is $109,000 by time he was done). Have to pack up the family and try to sell the house to move to whereever I was admitted. Then move again to new job. That's too much to ask of them (in my case. My brother did exactly that).
Being an RN is a good gig. Being an Np is, for me, a natural progression. It's worked well for me and obviously I'm not alone.
I'll say it again. Show me the studies that indicate the NP training is produces outcomes inferior to MD or PA. My earlier post in this thread lists multiple studies that provide the evidence that the NP training produces outcomes similar to that of a MD or PA. Until you cough up a study, your assertions are baseless and biased. If you want to just bash NPs that's different, but then let's call it what it is.
I an not bashing NPs, I am questioning the validity of independent practice. In addition, other threads have rightly questioned the methods of the study and outcomes, but I would point out the fact that these studies were done with NPs who have physician oversight.
The outcomes validate the independent practice. See my post No.27, even if you throw out all the studies published in nursing journals (we all know they're biased), respected MEDICAL journals surely would be looking for poor study design/research methodology and biased results before publishing in their journal. British Journal of Medicine, JAMA, NEJM, Yale Journal on Regulation, Annals of Internal Medicine.
"NPs who have physcian oversight"
Is that supervision similar to a PA whose SP signs charts once a week or avail for phone consultation?
mbreaz1
132 Posts
Yet again, I don't care what you tell us your reasoning is for fearing the competition of independently practicing nurse practitioners. If you think your education is superior and creates better value for the customer, then open yourself up to the competition. It also doesn't matter if they have a similar cost, as long as that cost is lower than the current cost. They should receive the same reimbursement, that reimbursement should simply be lowered for everyone providing the same services.