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.

Anchises 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.