HUGE step forward for NP's!!!

[MikeFNPC]

Massive step forward for NP's.

WASHINGTON — President Donald Trump today ordered federal officials to consider pegging Medicare reimbursement more closely to time spent with patients, seeking to address potential pay disparities between physicians and other healthcare professionals.

President Donald Trump

These directives are among the tasks Trump gave to the Department of Health and Human Services (HHS) in an executive order. The order also demanded HHS develop several proposals related to insurer-run Medicare Advantage, including one regarding payments for new technologies.

Trump signed the executive order after giving a speech at a rally in Florida.

The executive order gives HHS a 1-year deadline to propose a regulation that Trump describes as intended to let healthcare professionals spend more time with patients.

This regulation is meant to ensure that services, whether done by physicians, physician assistants (PAs), or nurse practitioners, "are appropriately reimbursed in accordance with the work performed rather than the clinician's occupation," the order said.

The order also tasks HHS with proposing a regulation to end what Trump called Medicare's "burdensome" requirements that are "more stringent" than federal and state laws require. The president intends to remove barriers that keep some personnel "from practicing at the top of their profession."

https://www.medscape.com/viewarticle/919415

[hunnybaby24, BSN, APRN, NP]

4 hours 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.

Primary care is not easy and anyone who thinks it is is foolhardy to believe so.

[FullGlass, BSN, MSN, NP]

16 hours 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.

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

Kaiser in California is replacing NPs with MDs? I didn't find any news on this. Please provide us with the evidence. Given that we don't have enough primary care MDs, and that is especially true in California, I find this hard to believe.

Yes, FM and IM docs are highly sought - it's simple supply and demand. There aren't enough of them to go around. And as I have previously posted, that is not going to change, for all the reasons I previously explained. It's not because there is a backlash against mid-levels.

Not only are there not enough docs, in many parts of the country, there is a shortage of ALL providers, including NPs and PAs. Many of these areas also have a shortage of specialty docs.

Pretty much every NP on this forum, including me, supports improved NP education and more NP residencies. There is always room for improvement.

The Institute of Medicine supports FPA and so does the Kaiser Family Foundation.

Here is an interesting report from UCSF on FPA. UCSF is one of the best healthcare education institutions in the US.

https://www.chcf.org/wp-content/uploads/2018/09/NursePractitionerScopePracticeLaws.pdf

[FullGlass, BSN, MSN, NP]

6 hours ago, djmatte said:

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.

MDs are paid considerably more than NPs - 2 to 3 times as much. The reason more current med students are not choosing primary care is that the cost of med school is super high and they graduate with a lot of debt - I think the average is around $300K. So, they just can't afford to work in primary care when they can make a lot more money as a specialist, and I don't blame them!

With regard to chronic disease management, again, the evidence indicates that NPs obtain similar outcomes to MDs. See the links at the end of this response.

Your practice may be very different from mine, but 80-90% of what I saw was pretty basic stuff. It fits the old 80/20 rule. For the complex patients, yes, there is definitely room for doctors to manage them, and I support paying those docs well.

I work in an FQHC, and the use of NPs and PAs does make a big difference to the clinic's finances. I live in a region where we don't have enough providers of any type - doctors or mid levels or specialists. The problem in California is most of these people only want to live on the coast, leaving the rest of the state with a shortage. Let's look at a hypothetical example. The clinic has $500K budget for provider pay. Doctors around here, even brand new ones who have just finished internship and residency, can get $225K to $230K their 1st year. So let's say there is a doc with some experience - she gets $250K per year. The clinic could hire 2 mid-levels or one more doctor. Which choice makes more sense? Obviously, hiring 2 mid-levels will allow more patients to be seen and will generate more revenue. Many clinics, especially nonprofits, have tight budgets and clinics in this area have closed down due to financial issues. In this hypothetical example, the doctor should be leveraged as a consulting resource to the 2 midlevels. I'm seeing more of this in inland California, due to the shortage of providers, especially MDs.

In my previous position, there was one great doc and one crappy one. The good doc would refuse to see simple patients and he focused on the complex patients that needed a doctor. He even made house calls on patients that had great difficulty getting in to the clinic. The crappy doc actually pushed off the complex patients onto NPs! (No one knows what he actually does, since he also sees very few patients compared to the other providers and numerous patients have refused to ever see him again).

https://www.ncbi.nlm.nih.gov/pubmed/29957606

https://www.ncbi.nlm.nih.gov/pubmed/28893514

https://www.ncbi.nlm.nih.gov/pubmed/30458506

[FullGlass, BSN, MSN, NP]

31 minutes ago, hunnybaby24 said:

Primary care is not easy and anyone who thinks it is is foolhardy to believe so.

No one here has said that. What we are saying is that most of the patients in primary care setting have relatively simple problems like URIs, UTIs, etc.

[popopopo]

Debt isn't the only reason why primary care isn't chosen by more medical students. Like picking any career, it is a multifaceted decision- job satisfaction, salary, passion, and board scores.

As more and more medical schools are opening each year and the residency spots aren't keeping up, I anticipate even more medical students will be funneled(unwillingly unfortunately) into primary care due to the competition of The Match.

Just to clarify, when ya'll are saying primary care, does that not include pediatrics and IM? I think everyone is using primary care here to refer to some sort of family practice outpatient clinic.

[guest478081]

10 hours ago, FullGlass said:

Kaiser in California is replacing NPs with MDs? I didn't find any news on this. Please provide us with the evidence. Given that we don't have enough primary care MDs, and that is especially true in California, I find this hard to believe.

Yes, FM and IM docs are highly sought - it's simple supply and demand. There aren't enough of them to go around. And as I have previously posted, that is not going to change, for all the reasons I previously explained. It's not because there is a backlash against mid-levels.

Not only are there not enough docs, in many parts of the country, there is a shortage of ALL providers, including NPs and PAs. Many of these areas also have a shortage of specialty docs.

Pretty much every NP on this forum, including me, supports improved NP education and more NP residencies. There is always room for improvement.

The Institute of Medicine supports FPA and so does the Kaiser Family Foundation.

Here is an interesting report from UCSF on FPA. UCSF is one of the best healthcare education institutions in the US.

https://www.chcf.org/wp-content/uploads/2018/09/NursePractitionerScopePracticeLaws.pdf

Look harder. By referring too much they do not know when to refer. I don’t think any one here is against fpa laws because the current laws are just dumb and don’t really do anything anyway. A lot of docs even want fpa since they are tired of signing midlevel charts and don’t want the liability.

Kaiser has been replacing docs with midlevels look at their clinics.

NP education is by a large a joke and most people here agree with that notion.

[djmatte, ADN, MSN, RN, NP]

7 hours ago, FullGlass said:

No one here has said that. What we are saying is that most of the patients in primary care setting have relatively simple problems like URIs, UTIs, etc.

20% MAX Of my daily load have those problems. Urgent care on the other hand...

[FullGlass, BSN, MSN, NP]

6 hours ago, kudzui said:

Look harder. By referring too much they do not know when to refer. I don’t think any one here is against fpa laws because the current laws are just dumb and don’t really do anything anyway. A lot of docs even want fpa since they are tired of signing midlevel charts and don’t want the liability.

Kaiser has been replacing docs with midlevels look at their clinics.

NP education is by a large a joke and most people here agree with that notion.

Here you go again. You just make unsubstantiated assertions with nothing to back them up. You are becoming tiresome. You add no value to this discussion.

If you really are a CRNA, you are not qualified to discuss primary care NPs' education, training, or practice. You don't work in a primary care setting, either

You are just a little troll.

6 hours ago, djmatte said:

20% MAX Of my daily load have those problems. Urgent care on the other hand...

As I said, your practice may be different from mine. Since I was in a rural clinic, I had to see everything - no urgent care here.

However, I also provided you with evidence that NPs do just fine caring for patients with chronic diseases. I also stated there is a place for MDs in primary care, but we need to rethink how we use them.

[FullGlass, BSN, MSN, NP]

16 hours ago, popopopo said:

As more and more medical schools are opening each year and the residency spots aren't keeping up, I anticipate even more medical students will be funneled(unwillingly unfortunately) into primary care due to the competition of The Match.

Just to clarify, when ya'll are saying primary care, does that not include pediatrics and IM? I think everyone is using primary care here to refer to some sort of family practice outpatient clinic.

I'm a bit confused by your response. Primary care doctors must also complete an internship and residency and those residencies are not magically increasing in number. While there may be some more medical schools opening, there is still expected to a primary care doctor shortage.

https://www.washingtonpost.com/health/america-to-face-a-shortage-of-primary-care-physicians-within-a-decade-or-so/2019/07/12/0cf144d0-a27d-11e9-bd56-eac6bb02d01d_story.html

Primary care can include outpatient pediatrics, as well as outpatient IM. A "family practice" outpatient clinic may have separate areas for peds, IM, and women's health, depending on the size of the facility.

[popopopo]

3 hours ago, FullGlass said:

I'm a bit confused by your response. Primary care doctors must also complete an internship and residency and those residencies are not magically increasing in number. While there may be some more medical schools opening, there is still expected to a primary care doctor shortage.

https://www.washingtonpost.com/health/america-to-face-a-shortage-of-primary-care-physicians-within-a-decade-or-so/2019/07/12/0cf144d0-a27d-11e9-bd56-eac6bb02d01d_story.html

Primary care can include outpatient pediatrics, as well as outpatient IM. A "family practice" outpatient clinic may have separate areas for peds, IM, and women's health, depending on the size of the facility.

Thanks for the clarification of primary care. I agree there will still be a shortage for now since residency spots aren't keeping up with the med school expansion. Family med has the highest unfilled numbers of spots from what I gathered from the 2019 nrmp data.The students who didn't get their first pick in residency will have to either wait a year to reapply, or make due with what's left through the soap process.

[agiboma, BSN, MSN, NP]

Well its definitely a big step in the right direction for NP's to be recognized for the work we do.

[GoodNP]

Many great points in this thread. I definitely agree that physician education and training is superior to NPs'. It always astounds (read: embarrasses) me when NPs or PAs compare themselves on equal footing as physicians. Then again, I'm not pursuing independent practice. I know my limitations.

However, there is an imbalance in the amount and often, dare I say, quality of actual work performed. I follow guidelines, perhaps a little too cookbook-y at times, but whereas my physician peers are throwing a z-pack at every URI that walks in the door, I'm only giving antibiotics when they are actually indicated, and then I'm preferentially giving amox-clav. Whereas the physicians don't document PMH, PSH, fam hx, etc, I do. It's never fun when you see an established patient and they casually reference their kidney transplantation which has never been documented in the chart of years of being seen at this clinic. My physician peers also aren't diligent about preventive care screenings. They're not ordering enhanced imaging or genetic testing for women at high risk for breast cancer (nor would they even know bc they don't ask about family history), no lung cancer screening CTs, they're not following pap guidelines, not recommending HPV vaccines, no hep C screening, no PPSV for diabetics, no AAA screenings for smoking history. I am so diligent about these low hanging fruits and make sure it is ALL done. When I look at their documentation I can't help but roll my eyes. I refuse to believe they are performing fundoscopic exams on all of their PEs. Last month I found a rather large thyroid mass during a PE, turned out to be cancer, and the patient later told me in all the years she has been seen by Dr. X he had never checked her thyroid. Oh, but he's doing fundoscopic exams? Please. And yet, I get paid 15% less, for doing more.

I concede that they are better qualified to handle more complicated cases, but I would bet a paycheck that NPs actually perform better than physicians on preventive care. Which is supposed to be our wheelhouse right? So, with such a push for preventive care, I think that at a minimum we should be fully reimbursed for those services.