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As the use of mid-levels increases in emergency medicine, EPs must step up and prove their value to society.

Hannibal ad portas “The barbarians are at the gate.”

Inductive reasoning begins with observation and moves with variable speed to generalized theory. Deductive reasoning moves the other way: theory, hypothesis, observation and finally confirmation. But when you are dealing with risk management issues you need to do both simultaneously or you can be caught by the tsunami of thought and blown out with the tide of history.

I’ve spent time recently talking to others in emergency medicine who follow the medico-legal scene, and I am using this column to bring your attention and serious consideration to a problem which is growing exponentially. If your group has not had this discussion, it should. If your malpractice carrier has not spoken with you about it, they will. The professional societies cannot go much longer without debating these policies as they must answer difficult questions when the government comes calling.

What I’m speaking about is the role, supervision and payment for the rising number of mid-level providers in emergency medicine. Let me reflect on three recent malpractice cases I have reviewed and the logic behind the injured parties’ allegations. The first had to do with a simple laceration of the hand and follow-up visits. On these visits, the patient was complaining of some numbness in the distribution of a peripheral nerve. Multiple visits were involved until the patient was referred to hand surgery. The deposition phase was bloody and frightening. It was clear from the billing slips that a full 100 percent had been charged under the doctor’s provider number for the care given, all the way from the closure of the wound to its multiple revisits. The plaintiff attorney summarily brought forth the issue: what was the patient paying for if it was not physician expertise? Why was the patient charged the full freight for non-physician care? Good question.

I remember long before there was a board in emergency medicine, we argued that people deserve care by board certified emergency physicians. The residencies were established on the premise that high-level care would improve outcomes in emergency situations. But the new direction is clear – every paper recently published shows a huge increase in mid-level utilization even at the academic centers. I have been an early and strong supporter of mid-levels. I have been an advisor to the Society of Emergency Medicine Physician Assistants (SEMPA) and have taught at most of their national conferences. But you either think physician input is needed on certain cases or you don’t. If you want to try to defend billing 100 percent when the physician does not actually see the patient, go ahead and do that. I want to hear you testify before the Congress of the United States, a country that is going broke, and tell about how they do not really need physician care but they have to pay physician charges.

A second case I dealt with had to do with low back pain in a somewhat overweight gentleman. This was a “he said, she said” case. The physician who had her name on the chart felt it was not her problem, even though disk compression had pressed on the spinal cord some two days after the visit. The physician testified, “We let the PAs see the ‘minor cases’ in the fast track.” Who should be seen by the PAs with direct supervision – with the physician actually seeing the patient – has never been clearly defined. During my discussion with my colleagues, the argument was brought forth that “If a doctor had to get involved, you would have lost the reason for using mid-levels and you might as well see the patient yourself.” I disagree completely. Just two minutes input from a competent emergency physician can often add valuable information and thoroughness to the evaluation of the patient. The treatment discussion alone can help all parties in coming up with the right solution for a particular patient. Please don’t tell me I have nothing to offer in these situations. If that is the case, why do we need doctors at all?

The real question is, “How much supervision is needed?” The variability in the way mid-level providers are utilized in emergency departments speaks to the lack of consensus on how they should be used. What’s safe and reasonable? Some emergency departments allow autonomous mid-level practice, while others require 100% supervision, making certain all patients are eventually seen by the physician. In other EDs – perhaps most – they allow the mid-level to see some of the cases and decide when they need assistance. The problem is that you don’t know what you don’t know. So in cases where physician involvement may be helpful, the mid-level provider may not recognize the need for input or support. This is evident in the review of medical malpractice cases in which no physician involvement was sought.

Although the requirements for billing at the physician level, as opposed to reduced levels for those cases without direct physician involvement, vary among third party payors, we must decide what is appropriate and cost-effective. Just because we can, doesn’t mean we should. Billing at the physician level for services not provided by the physician may drive costs up when no additional service has been provided.

Believe me, if you don’t think this is being discussed in the halls at CMS, you are wrong. The professional societies need to spend less time on mediocre CPR research and more time justifying why paying for doctor services really does bring a level of care that the patient deserves. If you can’t add something to the care of that patient, don’t charge like you did. The government is looking for ways to reduce costs, they still believe that emergency care is too expensive and we, through our actions, are sending the message that “expensive” physician level care may be overkill. Our approach should be unified and focused on the quality of patient care, how mid level providers should be safely and appropriately incorporated into emergency care, while showing value for the services we provide. Left solely in the hands of the government, without our input, U.S. EDs could end up being staffed by mid-level providers, as opposed to emergency physicians.

The final case – again not seen by the physician but charged at the full amount for a physician – involved the classic young man with chest pain after extensive heavy lifting. After a diagnosis of muscular skeletal chest pain – which, by the way, included a work up with an EKG and chest X-ray but no documentation of movement dependent muscular pain – the patient was sent home. He was found dead eight hours later by his nine-year-old son. Would physician input have made a difference? We will never know, but the jury thought it might. We need to have some consistency and some brutal honesty as to what we do as a profession and what our beliefs really are. What constitutes the chain of care? Who should be doing what? What are the moral, ethical and economic implications of charging for care that we did not actually give? Not to ask the question is to abdicate to people and governments who will be less charitable to us than we are to ourselves. Concord is superior to discord. I believe in our value and our societal worth. Lets prove it, and step up and make these changes for better patient care.

altAnchises the crippled father of Aeneas was carried from the flaming ramparts of Troy, inspired by a new and ethical beginning. We need to do the same. Lets look at patient care again to decide who will do what and at what cost. Having done such an analysis, we then need to use such data to defend ourselves from forces both foreign (the payers) and domestic (the house of medicine) in deciding what constitutes true physician care.

 

 

Greg Henry, MD Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP. 

 

Comments   

# EM Resident 2011-05-06 11:50
A lot of things concerning PA/NP involvement in EDs are not standardized, including the education the midlevels receive, the real life training they undergo, and their responsibilitie s in the ED. I agree that the EM societies need to put forward a consensus on proper midlevel use in the ED (ie: the types of cases they should and shouldn't handle without physician consultation). Personally, I feel that having midlevels working autonomously or even handling chest pain cases in the ED is a recipe for disaster.
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# Salary HeightsEDL 2011-05-06 14:17
Trauma surgeons at 350-400K/annum :-) Anything higher? Worth it or no?
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# Mid-level providersED_Doc 2011-05-09 07:27
I believe billing via mid-levels at the same cost as being seen by the physician is a practice we will be unable to justify. When the medicaid/medica re "bloodhounds" come looking for fraudulent billing and unnecessary expenses, this will be one of the first places they look. Take a look at any other medical disciplines in which extenders are employed, IM, surgical, etc. They are not nearly as free to autonomously see patients in my experience. We as ED physicians need to have strict policies in place concerning how we utilize our extenders.
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# EM Mid-LevelsEMPA-C 2011-05-11 07:23
I agree that there are many issues that need to be addressed regarding proper utilization of the midlevel provider in the ED. I also agree that there are issues with lack of consistency in the training of an EM midlevel. PA's and NP's are trained differently, PA's may differ in backgrounds and in postgraduate training. When I completed PA school, I elected to do an EM Fellowship at the University of Texas, a 1 year PA residency program at a level 1 trauma center taught by MDs. That 1 year of post-grad focused training has helped me exponentially in patient care in the ED.
The MD's must understand that a midlevel is ONLY as good as you care to make them. We are essentially career residents. I see it in my ED, the MD's will spend 15 minutes discussing a case with the Resident but less than 1 minute with a midlevel. Never stop teaching us and we will only be able help you more.
The writer of this article states that midlevels "don't know what they don't know". A very true statement and one that applies to us all. As a PA the thing I hold in greatest value is the trust relationship I have worked very hard to develop with my attending MD's. The way to develop that is to always know your limits as a PA. If something doesn't fit, ask questions, consult your MD. It is always better to ask for guidance than to explain your mistake. I have found that as a midlevel in the ED, MD's can be very harsh in their criticism. An MD will forgive another MD for a mistake where they will berate a midlevel for making the same mistake.
I disagree with the post by EMResident that PA's should not be involved in acute cases. They should absolutely be involved and learning, the MD should never not be involved though. I have had many instances in this ED where both of the attendings are busy with acute cases and STEMI comes in or a full arrest and I will begin care for this pt until the MD can come to the room.
I want the MDs to remember that PAs were created by MDs FOR MDs. We are here to help you. We do not think we are as good or know as much as you, but we strive to be a valued member of the team and an asset the MDs would not do without.
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# EM Docjim 2011-05-11 15:22
Excellent points are raised, especially about PA/NP training. Perhaps we should be more selective and demand more qualification for our mid-level providers. It's hypocritical to beat our chests about EM residency training and close the grandfather track for certification, yet allow MLPs whose only exposure to EM was during their training walk in and practice under our "supervision" which admittedly is cursory at best.

This isn't going away and opens up a can of worms unless our specialty societies take a stand and focus more on guidelines for training and supervision. Imagine the headaches created when a hospital administration hires MLPs and the EM physicians - either contracted group or employee - have little or no say in their qualifications or experience. I know because I've lived it.
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# PA-CAnother EMPA-C 2011-05-11 20:41
I couldn't agree more with EMPA-C's response.

I work in a private hospital ED with tight MD oversight. I wouldn't have it any other way. We (PA's/midlevels ) do no service to medicine, if we loose physician oversight. As a PA, it's crucial that I am an MD/DO's eyes and ears for the patient, but not a substitute for an MD/DO. I never forget my role. Also I'm not 100% positive about our billing procedures, but I do believe our (PA) coding is not billed under physician reimbursement codes. Nor should it be. The services are quite different and not equal.

I hope my PA colleagues continue to work hard and excel in their quest for ED knowledge. I also hope we continue to embrace our role with physician oversight. If we become more of a burden than asset to medicine, the fault will only be our own.
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# EM Mid-LevelsJames Piscioneri 2011-05-12 01:23
I Wholeheartedly agree with the statements of EMPA-C, on May 11, 2011.
I recall the statement "Emergency medicine is Team medicine"

Commonly EMPA-C have been utilized as volume suppressors in the ED. And we have been very successful at that, a well-trained competent EMPA-C can work in tandem with EDMD to optimize excellent patient care, and patient throughput. Not to mention reimbursements. Some groups not (all) see EMPAs only as an income stream. (That's unfortunate for all).
The statement regarding the need for MDs to remember that PAs were created by MDs FOR MDs could not be truer. Groups that invest in having set Clear expectations for both EDMDs and EMPA-C and apply good Leadership and teaching along with collegial communication will succeed in ALL ED arena.
Honest input from both factions will strengthen that group. Decreasing the need to continually search star player. Groups with Physician involved teaching will maximize the EMPA-C component.

As an EMPA-C I have assisted in bringing efficient quality care to the chaotic ED's.
EMPA-C have proven their value in many areas that sometimes go unrecognized.
To list a few.

1] Triage / Wal-Mart door greeter professional triage.
2] Patient logistics,
3] Decreasing excessive weight times.
4] Minimizing LWBSs [Left without being seen]
5] Maximizing low acuity patient flow.
6] Assist meeting administrative Dashboards.
7] Increased patient satisfaction scores.
8] Oversee observation units. Coordinate ancillary cardiac testing.
9] Creating patient flow teams.
10] Maximize efficient dispositions.
11] Decreasing gridlock.
12] Overall increasing efficiency and maximizing reimbursements for EDMDs groups.
All this while trying to clone practice patterns of the EDMD Du jour.

We are here to help you.
We do strive to be a valued member of the team.
EDMDs feeling a need step up and prove their value to society, That should never be questioned?
However Please don't under estimate your EMPA-C and EMNP teammate’s contributions we are all in this together.
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# Mid-level providersJames Piscioneri 2011-05-12 02:20
Let's also take a look at and make a comparison of how legal practice that utilizes paralegals.
It is always escaped me, how brilliant emergency physicians who have to make real-time decisions/life and death decisions never make the comparison of MDs to JDs.
Attorneys commonly can cogitate cases for years. While physicians must act real-time. Looking at one's worth of knowledge. I think the greater value should go to the physician. As far as billing issues, attorneys use billable hours. I don't believe they differentiate between the efforts of the paralegal in preparation and their own involvement. Is this a double standard? I'm not an attorney or a physician. I'm a physician assistant and as this question has been brought up I just can't help thinking about one's worth. As a young man my father told me. "The harder you work the luckier you get". Now as an adult I can't buy that. Life shows us too many discrepancies. Ballplayers making millions for playing a game. Granted better players make more. While CEOs sometimes make millions just in bonuses. Physicians get to have insurance companies determine their worth. They also regulate physicians income with the fear of legal repercussions with exorbitant malpractice fees. Just doesn't seem right. My personal opinion (and it is just that.) Is that the "WORTH is in the RESULT." If we all just kept it to this there would be NO reason to COMPLAIN. Good attorneys would be paid well. Emergency physicians saving good attorneys would be paid extremely well. Makes GOOD sense to me!
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# EM Docs Worth It? John Graykoski 2011-05-12 07:29
I am personally grateful to Greg Henry for his ongoing leadership of our profession. I was able to recognize his contribution to the EM PA Profession when I addressed the members of the Society of Emergency Medicine Physician Assistants at our annual CME conference this spring. I continue to be grateful for his support of PAs.

Couple of points of clarification:

PAs and NPs are not the same thing - PAs are trained in the medical model, are trained by physicians and are dependent on Physician supervision as a condition of their license. PA's are not independent practitioners and never will be. Trash the slash!!! PAs/NPs are NOT the same thing. We have totally different training and totally different goals.

Secondly, CMS, which sets policy, permits PAs to be billed at 85% of physician costs. If someone is billing at 100 % that is fraud. Please report them to CMS. The only exception is in Federally Qualified Health Care Facilities and Critical Access hospitals where a formula for cost based reimbursement exists. Some insurance companies may pay PAs at 100% physician charges, but I would seriously doubt it.

ACEP and SEMPA continuously address the training and supervision of PAs in the ED setting. That close working relationship is going to continue and EM MDs and EM PAs working as a team will continue to be the model for EM care into the future.

If you want angst, consider the implications of EM Providers trained in the nursing model of care, with widely disparate standards of training who assert that they can practice independently of MD supervision.
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# Medical Director, EIRMC Idaho Falls, IDJeff Stieglitz MD 2011-05-12 17:34
First a point of clarification.
You are fradulently billing if you are billing at the physician rate for any patient seen only by a PA or NP. That chart should be billed at 80% This has been a CMS policy for over a decade. Our policy is that a physician see every patient, document that and charge 100%
I was, like Dr. Henry, an early adopter of mid-levels. I hired my first one in 1986. I have spent a lot of the intervening time puzzling over their optimal role in the ED.
I have most recently been reading "The Innovator's Prescription" and would suggest that anyone interested in Health Care give it a look. One of the basic premises is that the business models of medicine are all confused and that the reimbursement system perpetuates this confusion and adds to it. A prediction is that innovators will sort this out and reorganize medicine into a more coherent and less expensive system. Business models descibed include a 1) "solutions shop" where diagnosis occurs and treatments are tested against the diagnosis, 2)"value-added process" like procedures like endoscopy, and 3)networks. Here they are talking about a website, for example, where patients with MS could blog with other patients with MS and specialists in MS and get up to date information about the disease and how to live with the disease.
Putting a PA in a fast track and defining what was eligible for "fast-tracking" was an early intuitive approach to this. I did it back in the 80's and I suspect many others did also.
The idea was that some problems were straight forward, diagnosis and treatment were straight forward and opportunities for error were more limited than in the general ED population. These Fast Track complaints did not require a physician for the most part. Now, algorithims, best practice guidelines and protocols abound for everything from strep throat to stroke. We remain confused however, about who should be using them and when.
The physicians in our specialty will always be required for the difficult diagnosis, the difficult or atypical management problems, the research to develop and amend meaningful protocols that actually benefit patients.
Our specialty has the opportunity to be a leader in reasearching and developing the "value added" care though that will absolutely incorporate midlevels. This should be available at less cost. Cold and sinus, sore throat, established migraine care, minor ortho etc, etc. is quite amenable to protocol which has to be validated. At this juncture in history I agree with Dr. Henry that finding ways to control the cost while delivering high quality care is much more critical to our society and economic well being than more CPR research.
I think this is where our midlevels should be focused.
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# Which bus with EPM throw mid-levels under next?Joel 2011-05-15 08:46
I recently took my computer to the shop to get fixed. The bench charge is $75/hour for the "Microsoft certified Tech" to work on it, only that tech never touched it, some junior tech did. But they billed me at $75/hour. According to you I should only pay what $30 per hour? My wife had anesthesia during her c-section, but we only saw a CRNA, should I have paid only 1/3 of the bill? My wife's IV was started by a tech but we got a nursing bill for IV administration. This summer my family was exposed to a Rabid Bat and had to go the ED for treatment. We were only treated in the fast track (by a doctor) but got a FULL ED bill???? We never SAW the main ED! Shouldn't we have gotten a discount because we never got to the main? Our congress has fully admitted that they never read the entire health care bill, it was only read by some junior staffers, but they charged us the same amount! Shouldn't they refund some of their pay check? When you have a case reviewed by a lawyer do they discount the time that the junior partner or staffer reviewed the case or is it just lumped into a general bill?

As you set down with the big wigs in Washington did you ask them if they are ready to pay the bill for emergency medical care WITHOUT mid-levels? Let's do simple math, my ED staffs 3 doctors and 2 PAs at the same time. Say the docs only make $150/hour and the PAs $60/hour. Our group's hourly expense for wages is ~$570. If we follow your thoughts and replace the Docs with PAs our hourly wages expense is over $750/hour. Plus the docs get LOTS more in CME, vacation, life insurance, oh yeah and they expect to be made partners in a couple of years. BUT we aren't seeing any more patients per hour. Is your group now making more money or less money? Is your group being reimbursed for more or less? Or is your group now having to INCREASE billing across the board in order to maintain their current income? Do you think your group will be making MORE money or LESS money? Do you bill less for the doctor who was grandfathered into emergency medicine than the one who was residency trained? Isn't that doctor not quite the same as the residency trained? Is a 4 yr residency trained doctor not more qualified than a 3 yr? Should we bill the same? Maybe we should do like the lawyers and the senior doctors with 10+ or 20+ years of experience should bill higher than the 1st year grad? If a patient has sutures done by a medical student is that visit then free? If it is done by a resident is the visit discounted 75%?

Let's take it one step further and say we have a billing level for PA/NP visits. So if the case becomes more complicated and the physician is consulted and sees the patient are we billing for BOTH the mid-level and the doctor? They BOTH saw and managed the patient!

You want to review a few cases where a PA or NP screwed up, fine. I am sure I that I can match you case for case where a MD or DO screwed up. Mistakes are not limited to those who didn't complete 4 years of medical school and 3 years of residency.

Are PAs/NPs the ones responsible for the rising costs in health care? Why can't we work as a TEAM to fight the real problems in medicine? Why aren't we objecting to insurance CEOs making millions/billio ns? Why aren't we questioning a society where football makes enough money yearly to provide health care to all the uninsured Americans? Why aren't we objecting to the MILLIONS and MILLIONS of dollars we are spending ordering CT scans, x-rays, labs on patients for fear of malpractice and poor press gainey scores? Why aren't we working together to set standards of care for the child who bumped his/her head on the corner of the desk and who's parents are now DEMANDING a CT scan or they will write a letter to administration? AND 10 years from now they will be suing us because the child has cancer! Or antibiotics for the patient with the sniffles for 15 minutes or the patients who visits the ED every 5 days for nothing complaints? Pts in the ED for percocet refills or to have their teeth fixed? Or the stable alcoholic who comes to the ED 5-7 nights a week to sleep it off? Or to force Psychiatry to see their patients in the ED within 24 hours rather than allow them to languish tying up beds and staff for DAYS. Why don't we work to solve the in-patient beds problems so we can clear up the boarders problem? Why do we provide expensive emergency care to the non-emergent? Wouldn't it be more cost effective to refer the chronic pain, the toothache, the simple sprain or strain to an urgent care? If you REALLY were concerned with the cost of emergency medicine THESE would be the focus of your rants.

Maybe I am wrong and we aren't a team after all.
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# NPs and PAs/What;'s to do?Iatros 2011-05-15 14:39
Having worked with mostly NPs in most ED's, I have a lot of respect for these concerned and hardworking practitioners. Within the scope of their training and experience (remember most were experienced nurses before the NP training, they are quite useful. Most have an innate 'radar' that warns them of a patient problem that is more serious than initially thought.

It is, however, not right to allow these folks to practice without MD supervision, unless it is within the scope of certain reasonable guidelines of having written, developed protocols, and available rapid physician input. Mention has already been made of the circumstances in which NPs may practice and bill at 100% of physicians. The vast majority of NP employment is NOT under these circumstances. Physician input is necessary (but certainly not always done).

I have worked with certain contract companies that expected the NPs to work independently, with only lip-service to physician supervision (such as sign the NP charts before you leave). and then bill at 100% physician rates even if the physician never stepped into the room. Is the adequate supervision? I am not so sure now, but the dichotomy of CMS rules and regulations encourages this to be done, even if I feel it is unethical.

Dr. Henry's insightful, and deeply well thought-out arguments force me to consider well my own feelings in this. I feel that the problem will only get worse as the demands on the EP and NP increase for more throughput at the expense of thoughtful consideration of patient problems. I hope that conscientious EPs will refuse to participate in unethical use of the NPs/PAs.

What will happen? The future is unknowable, but trends are more easy to spot. This thorny problem will not be sorted out easily. Some physicians and contract companies feel that the presence of the physician in the ED, on hand for consultation as needed, represents assumption of supervision. Most of us think the doc should be involved in at least talking to and laying eyes upon the patient to properly assume the supervisory role.

To quote Cicero under different circumstances: O tempora! O mores!
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