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."
Specializes in Cardiology, Research, Family Practice.
On 10/7/2019 at 10:03 PM, 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.
Specializes in Telemetry, Medical Surgical, Dialysis.
On 10/7/2019 at 2:01 PM, 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
Hello, I do not know if you are aware that the NPs at Kaiser are represented by CNA and their contract does not expire until August 2022. No NPs in primary care are being replaced by physicians. Please state facts.
Specializes in Cardiology, Research, Family Practice.
It seems to me like a win-win considering most NP/PAs are employed by physicians or physician groups anyway. Whether a privately owned practice or a large corporation such as HCA, the revenue generated by NPs and PAs directly affects physicians' incomes. If some providers are bringing in 15% less than others, why wouldn't all shareholders be in favor of leveling that disparity? And incident to billing is actually quite tricky in family or internal medicine because established patients are constantly coming in with a variety of new issues.
Regarding kudzui's comment above:
it has been my observation that family physicians are so overwhelmed with patients they quickly refer out any patient that takes a little bit of extra work. One or two visits for a given issue, if not resolved then refer out.
there are also health care conglomerates that encourage their providers to consider early referral to specialists within that "network". In these cases it's not only approved of, it is encouraged, because of the higher reimbursement rate afforded to specialists.
finally, with quality measures such as MIPPS, many primary care providers including physicians will continue to refer out patients who would otherwise be managed in primary care but adversely affect their numbers, such as diabetics with a1c >9.0. Passing the buck so to speak.
as to your point about patients wanting to see physicians - I think you are right. While all of us have plenty of patients who prefer to see us over the physician, I think the majority of patients would probably still prefer to see the physician particularly for complicated issues. It is understandable, and we shouldn't take issue with that.
I understand the bias against NP's at studentdoctor.net, but I would expect that nurses would advocate strongly for nurses. I believe that it is in part because of our unique nursing background and educational approach that NP's obtain equal or better outcomes in many scenarios. Although, this may seem counter-intuitive there are several reasons for this including:
a. ARNP's (perhaps because they have less formal education) tend to adhere with greater fidelity to evidence based guidelines. On average these guidelines will tend to give more optimal outcomes than might be the case where "expert" opinion is substituted.
b. NP's perhaps tend to place greater emphasis on a holistic approach where exercise, nutrition, and social interventions are center stage. This is something indoctrinated from the start of nursing school and which is built upon in NP programs (at least most of them).
c. There is a point of "diminishing returns" with additional MD education and it tends to select for a specific approach (scientific determinism) and personality which may not be as conducive to optimal outcomes and therapeutic alliance.
Of course there is always room for improvement and we should continue to strive for the best NP education possible. However, reimbursement should be based upon services performed and outcomes not degree.
I can't believe that a few people here are actually asking for the same paycheck as the physicians. Common guys, if we want the same pay as the Physician, the management wouldn't hire us in the first place. We were brought in to increase the profit for the management.
Instead of complaining about our salary, we should actually pay more attention to the overflow of the NPs in the market. I'm seriously worried about that.
Great conversation, we don't have to agree. Where I work the're having a difficult time finding physicians, even with trying to get them several years before they graduate and targeting the ones retiring from the military. The only options are NP's. The docs where I work are getting at least double pay and benefits. I'm not asking for equal pay, but half is ridiculous.
Great conversation, we don't have to agree. Where I work the're having a difficult time finding physicians, even with trying to get them several years before they graduate and targeting the ones retiring from the military. The only options are NP's. The docs where I work are getting at least double pay and benefits. I'm not asking for equal pay, but half is ridiculous.
Half is debatable in most places though. In flint Michigan, there is a shortage in every specialty including primary care. But the average pay for most in a practice that’s not solo owned (note groups of 3+ clinics ) is about 180k With experience. WeHad an amazing pediatrician leave our group because they were heavily encouraging a pay per patient model while failing to recognize peds are the most likely to no show and Simply having a pediatrician on board was a benefit unto itself. The fact is clinics know they aren’t reimbursed enough for a physician much less an np. Yes we were loaded with fnps, but having that higher level of knowledge is a significant asset.
I tend to acknowledge the same about most of our physicians regardless of the similarities of cases we see. At the least they should qualify for extra pay for being a significant resource. Maybe you all are hot proverbial excrement NPs and are beyond a physicians training. But I still acknowledge my deficits and recognize the importance those with more education or experience deserve.
Specializes in Psychiatric and Mental Health NP (PMHNP).
14 hours ago, djmatte said:
I tend to acknowledge the same about most of our physicians regardless of the similarities of cases we see. At the least they should qualify for extra pay for being a significant resource. Maybe you all are hot proverbial excrement NPs and are beyond a physicians training. But I still acknowledge my deficits and recognize the importance those with more education or experience deserve.
The argument is equal pay for equal work. I have mixed feelings about this, but favor equal pay for equal work. Doctors definitely have more education and training. However, I don't see the logic in paying them a lot more to see someone with the sniffles. Doctors aren't adding any more value in simple cases that can be handled by a mid-level. I do see doctors having an important role in primary care if they focus on complicated cases and support them being paid appropriately to do so.
Equal pay for Equal work? If that happens. That is a massive IF, then the Doctors will not choose PC. There is absolutely no reward in that. Not worth their time. Full Stop. they will choose specialties and worst-case scenario, they will start leaving the country. Trust me, there are several countries in the world that would take them and treat them with respect and bathe them with money.
That scenario will actually create a huge demand for the PCPs here in the US after a few years. And the chain will repeat once again. PCPs earning more due to the demand and what will you do then?
Again demand that NPs should get equal pay? That will not work. That's the end of it.
Meanwhile, the corporates will kick us out and started hiring PAs. It's a profit for them. They can employ 3 PAs in place of a single NP. Ultimately, we would be the losers.
I'm not ready to lose my job just cause we got greedy. I'm happy with the pay I'm getting. I'm happy with the work I'm doing and I'm certainly happy that I'm working under great doctors who treat me with respect.
If you want more money, go ahead. Trust me, there are dozens of new grads, (who are willing to work for less than 100k,) are ready to replace you.
Equal pay for Equal work? If that happens. That is a massive IF, then the Doctors will not choose PC. There is absolutely no reward in that. Not worth their time. Full Stop. they will choose specialties and worst-case scenario, they will start leaving the country. Trust me, there are several countries in the world that would take them and treat them with respect and bathe them with money.
That scenario will actually create a huge demand for the PCPs here in the US after a few years. And the chain will repeat once again. PCPs earning more due to the demand and what will you do then?
Again demand that NPs should get equal pay? That will not work. That's the end of it.
Meanwhile, the corporates will kick us out and started hiring PAs. It's a profit for them. They can employ 3 PAs in place of a single NP. Ultimately, we would be the losers.
I'm not ready to lose my job just cause we got greedy. I'm happy with the pay I'm getting. I'm happy with the work I'm doing and I'm certainly happy that I'm working under great doctors who treat me with respect.
If you want more money, go ahead. Trust me, there are dozens of new grads, (who are willing to work for less than 100k,) are ready to replace you.
To piggy back on this, evening out pay won’t be sustainable by most institutions. If you are working for a larger organization, you will and probably should be paid less than someone with a higher degree and especially more overall experience. I welcome autonomy because it improves access by those who want to go on their own and cuts out payment for collaboration “services”. But to suggest a larger organization pays you as much as an MD will be a nonstarter because it would kill their bottom line and they will never keep an MD At the pay reduction “equality” would foster. If you complain about your pay now, go out alone and do it better.
Specializes in Psychiatric and Mental Health NP (PMHNP).
1 hour ago, djmatte said:
To piggy back on this, evening out pay won’t be sustainable by most institutions. If you are working for a larger organization, you will and probably should be paid less than someone with a higher degree and especially more overall experience. I welcome autonomy because it improves access by those who want to go on their own and cuts out payment for collaboration “services”. But to suggest a larger organization pays you as much as an MD will be a nonstarter because it would kill their bottom line and they will never keep an MD At the pay reduction “equality” would foster. If you complain about your pay now, go out alone and do it better.
I agree with a lot of your points. I'm wondering if there is a way to compensate providers based on the complexity of their patients. Is this the RVU system? (I've only been paid a straight salary). That would allow MDs to make more money for treating the difficult cases, which is what they should be doing. Experienced NPs who are capable of doing more complex work would also benefit. Just a thought.
I for one am not talking about "absolute" equity in pay (for NP's) verses MD's, but rather "parity" of billing and compensation. For example here in Florida as a new graduate PMHNP I'm being offered (by most providers) around 115K with benefits and only one place is offering me a 1099 option where they will compensate me $60.00 per medical management visit and $100.00 per assessment (and they expect 15 minute appointments almost everywhere). Now I know they are being paid 85% of MD compensation for my services. Also from my clinical experience where I also took part in the billing process I know my psychiatrist charged $120.00 for a 15 minute medical management appointment and $280.00 for a one hour assessment. Couple this with the multiple offers I've had from states like Washington/Arizona for 150K (with benefits) or 70% (of fees) 1099 and I conclude that Florida (and many other states) seriously lack parity. Also, my wife was offered $85.00 per hour as a telepsych provider while still in school in 2016 by an agency charging other companies upwards of $135.00 hour for her services (a job she has held since 2016). If these companies can pay agencies $135.00 per hour why can't they pay me even $75.00 on a 1099 basis (a job I would be thrilled to have even without benefits since I could work from home with my wife)? I believe that most NP's would be thrilled to be compensated at 75% of MD levels and furthermore I believe they will tend to achieve outcomes at least equivalent if not superior to MD's on many different measurements of quality and outcomes. Here is a Medscape article showing average compensation for a family practice physician at around 230,000 (2018) https://www.medscape.com/slideshow/2019-compensation-family-physician-6011329#2 . 75% of that figure would be around $175,000 and yet I know multiple FNP's in Florida working for 100K. What is worse many of their supervising physicians bill "incident too" (inappropriately) so as to capture fees in excess of the 85% NP compensation rates.
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