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core0's Latest Activity

  1. core0

    Earning a PhD in Nursing after a JD and MSN

    I normally tell someone to follow their dreams, but the route you have charted doesn't make any sense. I will put a caveat that if you have a full ride or mostly full ride to a top 10 law school then you should absolutely take it. Otherwise the reason that you get a JD is to practice law. If you want to engage in health policy or services research through the framework of law there are many other ways to do this including nursing, public health and even economics. All of those degrees can be tailored to look at health policy through the law. If you don't want to practice law but want a better understanding of legal issues a Juris Master (JM) or Master of Studies in Law (MSL) will give you understanding of the law and can be tailored to health specifically. There are a number of institutions that offer combined PhD/JM or DPH/JM degrees that would get let you understand the law and also give you the research skills to for academic pursuits. The biggest issue with the JD is cost. Any of the top ten programs are going to be north of $50,000 and with fees and tuition you are looking at around $240,000 for your JD. If you do a PhD afterwards then you are deferring interest and its not like academic health policy jobs are going to pay enough to pay off that loan. A JD is a professional doctorate. You learn research skills in finding and understanding case law. In addition you learn how to write very well. All of these skills come in handy but there are ways to learn them without spending a quarter million dollars. A JD does not prepare you for academics. Generally law school academics will have a second degree in their area of expertise or increasingly a PhD in Law. If you want to practice law go for it. You have been given a golden ticket. An NP from a top 10 law school can pretty much write their ticket in malpractice, healthcare or compliance law (assuming you finish out of the bottom 10%). There are people that end up in healthcare policy or academia with a JD but they usually arrived there after being dissatisfied with law or by going a much cheaper route through law school.
  2. core0

    NP residency and salaries

    They are both in the abstract supplement of Critical Care Medicine. Presented at the last SCCM conference. https://journals.lww.com/ccmjournal/FullText/2020/01001/111__MEASURING_ADVANCED_PRACTICE_PROVIDER_CRITICAL.79.aspx https://journals.lww.com/ccmjournal/Fulltext/2020/01001/57__DIFFERENCES_IN_ADVANCE_PRACTICE_PROVIDER.60.aspx
  3. core0

    NP residency and salaries

    1. Depends on your organization. Our organization gives you 1 year experience - which leads to a raise one year earlier and $20k a year for the first two years (which sort of makes up the difference between the resident salary and the normal starting salary). The bonus also serves as a retention mechanism to help ensure we get our costs back. 2. For Medicare, the reimbursement is 85% of the physician fee. APP residency doesn't change this. 3. Most are a year. Some are six months. We published data this year that knowledge skills were similar between the two groups but confidence was much higher for the 12 month group. The confidence was also higher for residents compared to OJT Abide, A., Carpenter, D., Xu, K., Gregg, S., Byrd, C., Stein, D., & Meissen, H. (2020). 57: DIFFERENCES IN ADVANCE PRACTICE PROVIDER RESIDENCY LENGTH: 12-MONTH VERSUS 6-MONTH TRAINING. Critical Care Medicine, 48(1), 29. Carpenter, D., Abide, A., Meissen, H., Xu, K., Byrd, C., Stein, D., & Gregg, S. (2020). 111: MEASURING ADVANCED PRACTICE PROVIDER CRITICAL CARE KNOWLEDGE AND CONFIDENCE: OJT VERSUS RESIDENCY. Critical Care Medicine, 48(1), 38. 4. I doubt anyone has an answer for this. In our specialty its not necessarily about salary jump. It's about a guaranteed job and opportunities that the residency gives you. For example US instructor, Running the infectious disease ICU, doing research. We pretty much guarantee a job for anyone that comes out of our residency (as long as they are a personality fit).
  4. core0

    NP's how are you these days?

    We are using Remdesivir in trial. Most of our other patients are getting Hydroxychloroquine (dosing 400 mg PO 12h x 2 doses, then 200 mg PO q12h x 5-10 days (tablets can be crushed & dispersed in water; preferred to remove film coat w/ alcohol before crushing) We are usually adding Azithromycin to Hydroxychloroquine. Watch the QTc on these. Kaletra is an option but I haven't seen anyone getting it, especially with the negative trial. ID is seeing all these patients. Everyone understands these are all theoretical. The Chinese recommendations should be released this week which will be interesting.
  5. core0

    Acute Care NP Schedule?

    For our ICUs it all 3 x 13.33 usually 630a to 800p or the reverse. Usually get out by 730 but sometimes there until 9. Most of our specialty APPs are Monday through Friday 8 hours although some are going to 4 x 10s with rotating weekends. Most of the floor staff is 3 x12 hours .
  6. core0

    Question re APP billing

    So the only way that a physician can bill for a APP service is split/shared billing. Here'e what Medicare has to say about that (via the hospitalist): "However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded." This is from Palmetto: "Question: Can you bill split/shared services for skilled nursing facility (SNF) and nursing facility (NF)? Answer: No. Split/shared services cannot be performed for nursing facility services, critical care services or procedures." https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM Part B~Browse by Topic~Frequently Asked Questions~Incident to~AK3F6A4053?open
  7. core0

    Question re APP billing

    It depends on how they are credentialed. Generally in our institution they are licensed NPs and PAs. As such you can't have their procedures billed under the collaborating physician. Either you don't bill for the procedures or you credential them like any other APP and bill for them. We choose not to bill for APP resident procedures or notes. For notes we have them mixed with the resident service so they can bill under shared billing for non critical care E/M by the attending.
  8. Three issues: 1. The RVU bonus should be based on RVUs you earn. The deduction comes on the payment per RVU not the RVU so they shouldn't make you earn more. 2. Since you don't work full time the RVU bonus structure should be adjusted. 3. Your math is off. The 0.97 is the wRVU there is practice expense RVU and malpractice RVU so the practice gets 2.09 RVUs of which 0.97 is work RVUs and usually credited to the provider. This varies slightly by practice location. In addition you assume all RVUs are paid the same. Medicare reimburses around $37 per RVU (depending on location) other insurance may pay more (or occasionally less). You need to know what the blended RVU is for your practice (the average reimbursement for all insurances per RVU). In our market for inpatient work blended RVUs range between $16 per RVU and $60 per RVU depending on the amount of Medicare, Medicaid (which pays less), private insurance (which pays more) and uninsured (which don't pay). My guess is that if your practice management knows what they are doing 2275 RVUs is somewhere around 125% of your salary and if you go above that then both sides make money. Finally this ignores other areas such as in house labs and procedures which can add quite a bit to the bottom line.
  9. Apparently you don't work with internal medicine residents. While there are primary care focused IM residencies, most IM residencies are heavily concentrated on inpatient services. What this does point out is that primary care specialties are not generally qualified for inpatient services. You can see this born out in the use of Family Practice Physicians in hospital medicine. At one point there was a significant FP presence in hospital medicine. However as FP residencies emphasized outpatient ambulatory care it became harder and harder to show training and expertise in inpatient medicine. In most healthcare systems FP cannot be credentialed for inpatient services without a hospital medicine fellowship. The same split occurred in emergency medicine which was largely the domain of FP. With the establishment of EM residencies there are fewer and fewer FP physicians in the ER. Does that mean that FP doesn't do ER or inpatient, of course not. On the other hand the more standardized an organization becomes the less likely they are to credential FP for inpatient or EM. It doesn't matter how long they have been doing something or talented they are, from a liability standpoint the system would assume tremendous liability if they credential them. You wouldn't credential a family practice physician for critical care. They don't have the education, training or credentials to perform critical care just like you wouldn't credential a infectious disease physician to do spine surgery. Are there family practice docs rounding in ICUs and performing surgery in the hinterlands. Absolutely. Is it dependable if something goes wrong. Absolutely not. As far as scope I defer to Carolyn Buppert: "What is the level of care required for my patients? If primary care, hire an adult-gerontologic, pediatric, or family NP, or a PA. If practicing psychiatry, hire a mental health NP or a PA who has specialized in mental health. If the practice is gynecology, hire a women's healthcare NP or PA who has specialized. If the practice is hospitalist, hire an NP certified in acute care or a PA." https://www.medscape.com/viewarticle/917260#vp_3
  10. Interesting what the NC board of nursing says about NP scope: "The population-focused Nurse Practitioner scope of practice is defined by the Nurse Practitioners formal academic, graduate educational preparation, national certification, and maintained competence. The scope of practice is operationalized by the Collaborative Practice Agreement (CPA)."
  11. There are actually two or three states that list scope of critical care. The real issue is risk. Our internal insurance was unwilling to cover liability for non-ACNPs working in the ICU.
  12. core0

    ICU Nurse Practitioners

    What we have published so far is that residency trained APPs reach full productivity (as measured by billing) 3 month sooner than non residency trained APPs. The issue with financial benefit is a trickier one. The cost of a residency is tremendous (north of $500,000 for us). The benefits are hard to quantify, but when you have 150 APPs (most likely expanding to near 180 in the next few years) having a guaranteed pipeline of well trained providers is invaluable. It also goes to mission. As an academic medical center training providers is part of the mission.
  13. core0

    ICU Nurse Practitioners

    We have 150 APPs across 4 hospitals and around 15 ICUs. We get hires from 2 pathways. 1. APP residency. We have 3-4 slots every six months (6-8 per year). The residency is a year long and includes ICU rotations as well as OR for intubation, ID, and nephrology. There are also optional rotations in interventional pulmonology, CV surgery, transplant medicine and palliative care. The residency requires a contract to work at the institution for one year (penalty if you don't accept a job offer). There is a bonus for first year graduates that about equals the amount of money you miss due to the lower residency salary. 2. Direct hires - orientation is highly variable but generally 3-6 months (trying to standardize). It generally includes only the ICU you are hired for. We have been experimenting with putting new grads from our community ICU in a 6 month mini residency (n=1). We have started to publish our results (hopefully at SCCM next year). Previously published research show residents are quicker to optimal billing compared to OJT. New research addresses both confidence and medical knowledge comparing 6 vs 12 month residencies as well as OJT vs Residency.
  14. 25% of base salary is the standard amount businesses budget for benefits. On smaller businesses its more like 40%. Also if you are going to work 45 to 50 hours either bill them for that or add it into the premium. Going that way I would look at 50% premium.
  15. core0

    Medical billing and coding for NPs

    You could also look at this one: https://store.sccm.org/SearchResults.aspx?searchterm=integrating&searchoption=ALL Although I have an authors bias.
  16. core0

    New NP, embarrassing salary offer!

    I do a little bit more than coding. What I do know is that billablles are largely irrelevant. You can bill whatever you want. What you really want to know is collections. Lets say you bill $500 for a mid level follow up visit. If you submit it to Medicare you will receive around $65. If you submit it to Aetna for example you will be paid whatever they are contractually obligated to pay. If you have negotiated 130% Medicare then you will receive $84. Note none of these are $500. We have five hospitals in our system. We set billing slightly above our average costs. Our urban hospital collects 30% on billings. Our academic medical center collects around 80% on billings. Our suburban hospitals collect around 110% of billing. The smaller even more suburban hospitals collect around 120% of billing. By way of comparison the urban safety net hospital collects around 10% of billing. What that means is in our system the suburban hospitals support the urban hospitals and our academic medical center breaks even with academic income. The safety net hospital exists due to fairly large subsidies from community government When I worked in private practice I brought in more money but the costs were also much more due to the inability to spread it over as much income. In an 8 partner practice, one partners collections went to pay insurance on the practice (health, malpractice, building etc.). To look at another way, for example if you bring in $300k then approximately $150k would go to support your practice (building, consumable, MA, billing etc) using standard Medicare valuation. That leaves $150k for you. Standard business models are employees cost 140% of salaries. This means after deducting benefits it leaves $107k to pay your salary. I have read Carol Bupert's book and its good. I will have to review it but I don't remember the particular model where you see 10 patients a day and bring in $300k. I showed with normal patient population you can bring in $300k but you would have to be much more productive. As an alternative fraud will get you there (10 level 5 follow ups per day). An APP can bring in $300k per year but not seeing 10 patients per day (my original point) and even when they bring in that much, its not pure profit. In fact depending on salaries that might not cover the cost of employment.