HUGE step forward for NP's!!!

Trauma Columnist · Oct 4, 2019

Agree that this is a step in the right direction.

djmatte, ADN, MSN, RN, NP · Oct 4, 2019

While I agree that it is probably going to be good for us, things like this are a gut punch to doctors. I can understand the 85% clinician reduction because my training and experience are significantly less than most MDs. Even with 9 years of RN experience on top of my NP, I can tell the differences compared to the seasoned MDs I work with. Even if we do very similar things with similar outcomes, I do think they have a much broader toolbox to work with than NPs or PAs do. If you asked me the same question while in NP school my answer would have been different. It's funny how a year and a half of practice you really see how MDs *should* command a higher pay schedule.

The only edge many physicians will have is that even in autonomous states, MDs will still be tasked with handling the training of new NPs until they get their prerequisite hours. While we clamor for equal pay for equal work, that money doesn't just appear. Odds are physicians will take a significant pay reduction while NPs will see very little in actual increases. It appears to me as a method to save money more than make things more equal.

adventure_rn, MSN, NP · Oct 7, 2019

So many fantastic points by @djmatte.

I, too, suspect that 'narrowing the pay gap' may actually mean 'decreasing MD salaries while keeping NP salaries the same.' While I believe that NPs and MDs can have similar roles and outcomes, it seems to me that the burden of debt is generally much greater for physicians than it is for nurses. We have fewer total years of education, we have less expensive educational options, and many of us have the opportunity to work part- or full-time during graduate school (which med students obviously can't do). So many physicians graduate with $200,000+ in debt (much higher than the typical NP), and med students have several more years of lost wages than RNs since they can't work part-time. I know plenty of well-paid attendings who are drowning in med school debt. I agree that they should be better compensated, if for not other reason their obscenely high cost for school.

It's a nice principle in theory, but in practice a loss for them doesn't necessarily mean a win for us...

MikeFNPC, MSN · Oct 7, 2019

I agree with comments above. However, you don't need a medical degree to take care of 90% + of what walks in my clinic. If you get paid for what you do, then sure, the docs will lose out on the low hanging fruit, but will benefit from the complex higher acuity through billing and coding correctly.

No doubt, healthcare is complex, but this is definitely a step towards the solution.

FullGlass, BSN, MSN, NP · Oct 7, 2019

On 10/4/2019 at 6:02 AM, djmatte said:
The only edge many physicians will have is that even in autonomous states, MDs will still be tasked with handling the training of new NPs until they get their prerequisite hours. While we clamor for equal pay for equal work, that money doesn't just appear. Odds are physicians will take a significant pay reduction while NPs will see very little in actual increases. It appears to me as a method to save money more than make things more equal.

Why is it assumed that only MDs train new NPs? Experienced NPs and PAs can and do train new grad NPs. Most of my clinical preceptors in school were experienced NPs with over 20 years of experience. I'd say they were more qualified than an MD with little experience.

We also do need to save money in health care. There are many clinics that are financially struggling, so money is a real concern to them.

In states with FPA, NPs can open their own practices and they can pass on savings to their customers, if they choose.

We need to pay based on value delivered, not on education or degree. If an NP and an MD both treat the common cold, I fail to see why the MD should receive more money.

I think we need to radically rethink primary care delivery and how many MDs are really needed in primary care. 80-90% of primary care is very basic and does not require a doctor.

I do not see any "magic" from MDs in primary care. I've had the privilege of working with NPs with 30+ years experience and they are more than competent to work in primary care and teach new grads, both NPs and MDs.

djmatte, ADN, MSN, RN, NP · Oct 7, 2019

1 hour ago, FullGlass said:
Why is it assumed that only MDs train new NPs? Experienced NPs and PAs can and do train new grad NPs. Most of my clinical preceptors in school were experienced NPs with over 20 years of experience. I'd say they were more qualified than an MD with little experience.
We also do need to save money in health care. There are many clinics that are financially struggling, so money is a real concern to them.
In states with FPA, NPs can open their own practices and they can pass on savings to their customers, if they choose.
We need to pay based on value delivered, not on education or degree. If an NP and an MD both treat the common cold, I fail to see why the MD should receive more money.
I think we need to radically rethink primary care delivery and how many MDs are really needed in primary care. 80-90% of primary care is very basic and does not require a doctor.
I do not see any "magic" from MDs in primary care. I've had the privilege of working with NPs with 30+ years experience and they are more than competent to work in primary care and teach new grads, both NPs and MDs.

Pushing for equal pay isn't saving the healthcare industry anything. Owning your own clinic isn't saving anyone any money either as you are now charging for your own overhead and your own payments. My point on what you quoted was based on the premise that all states who have FPA require some hours of work under a licensed provider before you can work on your own. These range from a couple thousand hours to 5 years depending on the state. In MOST cases, these will be MDs who fill that role. And while you have had the priveledge of being in a place with NPs (plural) with 30+ years experience, most the PAs and NPs I find myself around are 10 years or less while the MDs have been in the game since the 60s.

If an MD isn't paid for the work they put into school and the knowledge they bring to the table, nobody will go to med school. While much of primary care is simple, patients are getting sicker and much of it isn't becoming as simple. The ranges of comorbidities and exacerbations are only going up and primary care providers are encouraged less and less to refer as it dries up our own revenue. While it is suggested that an MD should handle more complex cases, where is the line drawn? Because I still see the exact same cases as every other provider here and sorting out complex from noncomplex would be a nightmare in scheduling. On top of that, there aren't enough NPs to fill obligations put on new grads to obtain FPA even in those states who have it. So we are now expecting MDs to teach new grads who are essentially making their own educational path obsolete. And we wonder why some MDs have animosity toward our field.

FullGlass, BSN, MSN, NP · Oct 7, 2019

6 minutes ago, djmatte said:
Pushing for equal pay isn't saving the healthcare industry anything. Owning your own clinic isn't saving anyone any money either as you are now charging for your own overhead and your own payments. My point on what you quoted was based on the premise that all states who have FPA require some hours of work under a licensed provider before you can work on your own. These range from a couple thousand hours to 5 years depending on the state. In MOST cases, these will be MDs who fill that role. And while you have had the priveledge of being in a place with NPs (plural) with 30+ years experience, most the PAs and NPs I find myself around are 10 years or less while the MDs have been in the game since the 60s.
If an MD isn't paid for the work they put into school and the knowledge they bring to the table, nobody will go to med school. While much of primary care is simple, patients are getting sicker and much of it isn't becoming as simple. The ranges of comorbidities and exacerbations are only going up and primary care providers are encouraged less and less to refer as it dries up our own revenue. While it is suggested that an MD should handle more complex cases, where is the line drawn? Because I still see the exact same cases as every other provider here and sorting out complex from noncomplex would be a nightmare in scheduling. On top of that, there aren't enough NPs to fill obligations put on new grads to obtain FPA even in those states who have it. So we are now expecting MDs to teach new grads who are essentially making their own educational path obsolete. And we wonder why some MDs have animosity toward our field.

I'm only talking about primary care, not acute care or specialties. We already have a shortage of primary care docs and that shortage is only projected to get worse for a variety of reasons:

1. The high cost of medical education is driving new doctors to specialize, as primary care just isn't worth it for them. Primary care doctors just don't make enough money compared to specialists.

2. The ACA allowed more people to seek treatment, increasing demand for primary care. It is inevitable that we are going to have some sort of universal health insurance in the future and that is only going to increase demand further.

3. The supply of doctors has not increased, but has remained stable.

Pretty much every public policy analysis has concluded that the solution is to expand the supply of mid levels and grant FPA.

You yourself said you are seeing the same type of patients as doctors. Do you feel you are providing inadequate care?

We need a paradigm shift in how we approach primary care. My point is that the education and training doctors receive is best suited to complex problems, not simple issues, which is what 80 to 90% of primary care is. Internal medicine is focused on patients with these complex chronic conditions. I agree we need some docs in primary care to deal with complex patients, and they should be focused on that and compensated fairly for doing so, especially given the short supply of primary care MDs. We still need FPA and FPA is inevitable.

Given these trends, yes, experienced docs will be training the next generation of primary care providers. So what? That has always been the case. As the supply of experienced NPs and PAs increases, especially with FPA, they will take on more of that responsibility.

GuestNP · Oct 7, 2019

I am so glad I only own and operate cash pay practices. This type of policy change and debate does not even affect me.

I think NP's should be compensated for equal work. At the end of the day it is about how much your produce for a specific practice. If the NP sees more patients and bills out more, then they should be compensated fairly.

Most MDs will go the way of specializing in the future and us NPs will do primary care, urgent care, a large chunk of ER work, and basic hospitalist duties. Let them have the specialties and make the big bucks. Let us have general practice with fair compensation.

guest478081 · Oct 7, 2019

2 hours ago, FullGlass said:
Why is it assumed that only MDs train new NPs? Experienced NPs and PAs can and do train new grad NPs. Most of my clinical preceptors in school were experienced NPs with over 20 years of experience. I'd say they were more qualified than an MD with little experience.
We also do need to save money in health care. There are many clinics that are financially struggling, so money is a real concern to them.
In states with FPA, NPs can open their own practices and they can pass on savings to their customers, if they choose.
We need to pay based on value delivered, not on education or degree. If an NP and an MD both treat the common cold, I fail to see why the MD should receive more money.
I think we need to radically rethink primary care delivery and how many MDs are really needed in primary care. 80-90% of primary care is very basic and does not require a doctor.
I do not see any "magic" from MDs in primary care. I've had the privilege of working with NPs with 30+ years experience and they are more than competent to work in primary care and teach new grads, both NPs and MDs.

It’s basic to those who do not know what they do not know

kaiser in cali has started to replace NPs with physicians in primary care since they are essentially using the quality of care model. The midlevels referees too much stuff that should have been easy to handle by a primary to specialists thus wasting money and time.

Much of primary care is basic basic but often midlevels don’t even know who to refer patients too much less properly handle things they should be able to in primary care.

Im not against FPA, but the way midlevels are trained leans them to being more useful with working with specialty physicians. The requirement of broad knowledge is not gained in a 1.5 year program that NPs go through. They at least need residencies. Primary care seems easy bc it’s hard to outright kill someone but badness Over time is just as dangerous to a community.

FM and IM docs are some of the most sought out specialties in medicine by recruiters. There is a reason they aren’t just filling all of these spots with MLP. OFTEN places have dozens of openings for primary care physicians but none for midlevels. Patients want doctors often times and recruitment demand reinforces this notion

djmatte, ADN, MSN, RN, NP · Oct 7, 2019

1 hour ago, kudzui said:
It’s basic to those who do not know what they do not know
kaiser in cali has started to replace NPs with physicians in primary care since they are essentially using the quality of care model. The midlevels referees too much stuff that should have been easy to handle by a primary to specialists thus wasting money and time.
Much of primary care is basic basic but often midlevels don’t even know who to refer patients too much less properly handle things they should be able to in primary care.

Exactly. There’s few things I consider basic in primary care. Most of what I see in flint Michigan are complex cases surrounded by socioeconomic instability and generations of poor health outcomes. And dissuading physicians from entering it is a bad idea imo. As I started earlier, I get more insight from their wealth of knowledge. And sadly many nps won’t give them that credit. And at the same time we talk primary care, some NPs advocate for autonomy even in their specialties because of how “easy” it is.

guest478081 · Oct 7, 2019

15 minutes ago, djmatte said:
Exactly. There’s few things I consider basic in primary care. Most of what I see in flint Michigan are complex cases surrounded by socioeconomic instability and generations of poor health outcomes. And dissuading physicians from entering it is a bad idea imo. As I started earlier, I get more insight from their wealth of knowledge. And sadly many nps won’t give them that credit. And at the same time we talk primary care, some NPs advocate for autonomy even in their specialties because of how “easy” it is.

Cooking is easy doesn’t mean I’m good at it right?

its embarrassing for nursing to come in and say XYZ medical profession is easy. Hence why public sometimes doesn’t take us seriously