Category: Advanced Practice

The Case for Removing Barriers to APRN Practice

Despite notable progress toward full practice authority for APRNs, much work remains.

from Charting Nursing’s Future

The 2010 Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health took a bold stand. It called for the removal of practice barriers—laws, regulations, and policies that prevent advanced practice registered nurses from providing the full scope of health care services they are educated and certified to provide.

In the six years since, the Federal Trade Commission, National Governors Association, AARP, Robert Wood Johnson Foundation, American Enterprise Institute, American Hospital Association, The Heritage Foundation, and others have added their voices to the call, and several states have removed or eased restrictions based on the report’s recommendation.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Dave’s Blog: How Do We Measure Our Worth?

How do NPs and PAs measure their worth, when they can only bill at 85%?

by Dave Mittman, PA, DFAAPA

In all societies, consumers are generally able to judge what to pay for each service they request. And the market sets the fees. Shoe shining. Car repairs. Tires. A haircut. All are judged by their relative worth. Having someone clean your house is worth what it is worth to you because you have the money to pay someone for a service you can measure. A clean house is worth something to you. So are shined shoes or a good haircut.

We in medicine do not have that luxury.

How much each patient pays for a service has no natural relationship to the value of the product the health professional “provides”. How does the consumer ever get to judge whether the product they are buying is worth the price they are paying any healthcare provider? Treating hypertension successfully? Cholesterol? A spinal manipulation? Is it worth what the insurance company is billed and the patient’s co-pay? New glasses that are a bit better than your old glasses? Worth it? Psychotherapy you went to for six months at $180.00 an hour and your not even sure what you got out of it? Worth it? How about therapy that saved your child from cutting themselves or worse? Successful cancer treatment? Strep throat, seeing an NP or PA and getting Augmentin? What is really worth the price paid and the asking price of the practitioner? What is naturopathy worth when it does not work, or allopathic medicine for that matter?

How do you measure our worth? Is it what we charge? Clearly, we PAs and NPs, over the last 50 years, have kept health costs down. We would not have been hired had we not saved the system or our practice money. I know we doing that now but who ultimately benefits? Do we even know our own worth?

Does the consumer have any way to measure that worth at all? And is what NPs and PAs charge worth 85% for the same service charged at 100% by a physician? And if it is billed at 100% because of laws put into effect decades ago, is it really worth our professions being kept invisible?

So that is the crux of my question. Yes, we charge less for the same treatment if we give it “alone” in many cases. And, in theory that saves the system money. But it also robs us of our soul. Why, because most health systems don’t want us to charge less for the same service, so they have “the doctor” pop in for what amounts to less than one minute and “consult” thereby presumably guaranteeing the 100% reimbursement to the system. It also guarantees us two things. One is that we look like we are being checked up on. I see NPs and PAs for my care. Invariably, at least now in Florida, a physician will say hello and ask me one question. The PA or NP will determine my treatment and diagnosis and write the prescription, invariably before the physician pops her head in. But it seems like they consent. And that is not really the case. WE also become invisible to the government, to Medicare or Medicaid, to the private insurers who think (seemingly so) that the patient in question was seen by a physician. The biller knows no less. This has to end.

I can’t think of any other professions where that happens in the same way. It’s time we PAs and NPs worked together to change it. It keeps all of us invisible. It was never the intent of the 85% rule. It confuses patients and it robs us of our soul. And that my colleagues, is never a good thing.

Dave Mittman has been a PA and later NP leader for thirty years. He co-founded the LIU PA Program student society, was President of the New York State Society of PAs from 1978-1979 and served on the American Academy of Physician Assistants (AAPA) Board of Directors from 1981-1983. Dave was also the first USAF Reserves PA permitted to practice. Dave spent 9 years in primary care in Brooklyn, N.Y. and left to begin a career in medical publishing with Physician Assistant Journal. Dave has also won the AAPA Public Education award for leading the march in Trenton NJ to establish PA practice. Dave left PA Journal to co-found Clinicians Publishing Group (1990) and Clinician Reviews Journal in 1991. Dave has authored papers in publications as diverse as “Chicken Soup for the Expectant Mothers Soul”, “U.S. Pharmacist”, “The British Medical Journal” and others. Dave¹s paper in the BMJ was the first internationally written paper written on PA practice. Dave and a few very close PA colleagues co-founded the PAs For Tomorrow”” in 2012 which is a new national professional organization representing and advocating for PAs in an different way. Dave as spoken at hundreds of NP and PA meetings and always has some interesting thoughts on the future of both professions. Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs. Dave is married to his sweetheart Bonnie for 32 years and has two wonderful children.

What’s Working in Rural Care Like? One PA Tells All.

When I was in school, being a rural PA was my dream. Now that I’m living it, I wanted to tell you a little about my experience.

from Clinician Today

I am apparently in the minority. According to the 2015 AAPA salary report, 51.7 percent of PAs work in an urban setting of more than 1 million people. Further, 12.4 percent work in an area where the closest town has a population of 20,000 people or less. I am in the remaining 2.5 percent. I serve about 2,000–3,000 people who do not live near a metropolitan area.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Psoriasis Update for the Seekers for Knowledge

Jason M. Cheyney, MPAS, PA-C shares his insight of what seem to be the latest discoveries in the disease and the current treatments.

by Jason M. Cheyney, MPAS, PA-C

I was doing some recent reading on Psoriasis, and wanted to share some of my own insight of what seems to be the latest discoveries in the disease and the current treatments. Psoriasis is considered by many, including myself, to be a form of autoimmune disease. Psoriasis has a primary trigger, which to date seems to be somewhat elusive. We are beginning to understand the cascade of immune responses after psoriasis develops, but have yet to isolate a specific initiator. It seems to be a multi-factorial process to me. I suspect it is a composition of genetic factors that lead to a sensitivity to some environmental factors. Our understanding of psoriasis being an immune mediated disease began in the 1970’s when it was discovered that cyclosporine a potent modifier of immune cells called T-cells was seen to decrease psoriasis activity. Since this discovery, we have been full bore researching how modification of the immune response at more and more specific locations is the answer to psoriasis control. To date, a cure has been elusive, but it seems we are getting closer to finding the immune cells most associated with psoriasis and leaving the rest of the immune system intact.

Psoriasis therapy currently is directed at modification of the over amplification of the cutaneous immune system. Most treatments work on this immune response and cause an immune suppression; there are a few therapies that are considered non-immunosuppressive. I find in my current practice there is a genuine and well placed concern about using these immunosuppressive therapies for a disease that is non-lethal. I am excited about the therapies we have and the new ones that are in the pipeline. Psoriasis therapy is getting so specific that the bulk of the immune system is left intact enabling great control of the disease without cause harm to the patient. It is quite intimidating to most individuals and providers when you read the laundry list of side effects in the drugs product information. If you just went off the list of side effects of the current therapies and didn’t look at the real risk of developing these side effects none of these drugs would be utilized. The biologic therapies in particular are the medications I am referring to. When the side effects are broken down into the real risk, it is much more comforting and reassuring. Most of these medications have a relatively low risk compared to natural illness and malignancy rates seen in the general population. When a drug is being analyzed it does so under extreme scrutiny and any negative or even positive side effects have to be attributed to the drug during study evaluation. Unfortunately, most drugs are compared to a short period of placebo use and not what happens in the general population over time. A few companies have engaged in long term safety studies and have led to a greater understanding and confidence in safety of these drugs in a general practice setting versus a controlled study setting. So how do you find reassurance in the utilization of these drugs? I encourage you to engage in a candid and open discussion with your healthcare provider as to the real risk and side effect percentages and comparison with the general population. If your provider is not sure what those rates are, ask them too kindly point you in the direction of someone or somewhere you can get those. I am always pleased when I find individuals who are open to learning more about their disease state and treatment options. That is the target audience for my blogs. The seekers of knowledge.

See Jason M Cheyney, MPAS, PA-C speak this April in Orlando, FL at the Skin, Bones, Hearts & Private Parts CME Conference

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Quality of Care by Physicians, Nurse Practitioners, Physician Assistants Equal in Health Centers

In community health centers, PAs and NPs deliver care equivalent to that of primary care physicians, according to a new first-of-its-kind study.

from Contemporary Clinic

Under the Affordable Care Act, there’s a growing dependence on community health centers in the United States—particularly among medically underserved areas that typically serve low-income, uninsured, minority, and immigrant populations. As a result, the health care system is increasingly relying on non-physician clinicians to provide primary care.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

10 States with Highest and Lowest Physician Assistant Salary

Physician assistants earn an average of $92,460 per year, according to the Bureau of Labor Statistics.

from Becker’s Hospital Review

PA salary varies by state from a high of $112,250 in Rhode Island to a low of $50,200 in Mississippi. Here are the 10 states with the highest and 10 with the lowest average PA salaries based on BLS data gathered in May 2012, the most recent data available.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Dave’s Blog: The PA Doctorate—Needed or Not?

Where does the doctorate for PAs fit in? Dave Mittman analyzes just that.

by Dave Mittman, PA, DFAAPA

It is ten years from now.

You are a patient. Or better yet, your two-year-old daughter is a patient. And you know just a little about medical people. You do know that the pharmacist you see, the physical therapist you see and the NP you see all practice at the “doctorate” level. You appreciate that, and in some ways, you expect people who are going to make decisions that could affect your children’s health to practice at that level. Do you want to see “Ms. Assistant” or “Dr. Practitioner”? Not knowing anything more, I know who I would want. I know who I would pick to guide my healthcare decisions, and my daughter’s. If I am a PA, I have to realize sooner or later (and no, not yet) all “advanced” health professionals will have a doctorate. Do I want myself to be in the above situation? PAs spend more hours in their clinical training than almost any other profession and at least deserve what the PTs, OTs, DATs, AudDs, PharmDs, DNPs and others achieve for their many hours spent learning. Especially when most PA doctorates will be earned for even many more hours with on the job clinical training with a leadership and/or educational emphasis.

You are an insurance company. For decades, you have let all other professions know that people who practice on a doctoral level will have a much easier job being credentialed for reimbursement than those with Master’s degrees. I am the company and in some cases, unfortunately, I get to choose. Why not do what again has been the customary and usual way to measure a professional’s competence? Ask if they have a doctorate. PTs, OTs, audiologists, dentists and others have found this out. So will we.

You are a legislator and PAs are coming in asking for full practice. Or let’s bring it down a notch. The legislators realize you can write orders for other professions. PT, OT, speech therapy, order different therapies. You can over-ride a pharmacist in some ways as the prescription you write needs to be filled by them. At the hospital, you write “orders” (poor team based word) for nurses, nutritionists and others. Sooner or later the logical question will be; “How can you expect as a Master’s prepared professional to tell four doctorates what to do?” One profession or another will balk.

In many states, the podiatrist is now the podiatric physician, the optometrist is the optometric physician, the chiropractor, the chiropractic physician. Yes, they changed it to help elevate their status. This is not going away. The problem is the law says you are a physician(’s) assistant. To any patient who has not analyzed the situation, PAs have a problem as our scope of practice is and will continue to be more comprehensive than the above professionals. Yet to insurance companies, legislators, Medicare and patients it would be logical that you would be “assisting” them. A doctorate would help even the playing field and aid in understanding we do much more than what our title says. So would a title change, but that’s another conversation not for today.

This is not about “If you wanted to be a doctor, you should have gone to medical school.” This is very much about a profession that either fits into the 21st century and recognizes that it is no longer 1975, or a profession that will stay misunderstood and undervalued for what they bring to the table. It is very much about a train that has left the station. Ask the Pharmacist, or the dentist, or the psychologist, or the chiropractor, or the DPT, or the DNP or the AudD if they want to be physicians? The answer will be “No, why?” Why would PAs not want to be PAs educated to the highest level they could be?

Let me tell you, twenty years ago I thought wanting a doctorate was more ego than anything else. It had no place in MY clinical world. It would not get me a larger paycheck. I became a PA in part to show the world that “non-doctors” could deliver the same care as “doctors” did. I know how good we are and never wanted to take a boat the Caribbean to become a physician. I bleed PA blue. I thought only academic PAs and NPs needed doctorates. But times change. Professions change. People change. We are, like it or not, part of many professions that practice in the same space or close spaces and if we are expected to advance, we had better at least consider change. Especially when we are the only profession ignoring that change. Again, ten years from now, we will be the “odd ones”. Realize, we are not making the rules, only following the rules followed by almost all other professions on this one. Healthcare changes. Professions change and like it or not, we must change also.

I have also never met a PA (or NP) who has obtained a doctorate who has not said that it made them a better all-around clinician. It filled in some holes. It gave them greater understanding and appreciation. I hear these sentiments often. I believe them.

Realize the transition for the PA profession to become a doctorate profession will take decades. It will hardly effect most PAs practicing today unless they are in their first decade or second decade of practice. Some of them may have to eventually do “at work, on the job” bridge programs. The NP profession has tried to push the doctorate as the initial degree earned at graduation from NP school with mixed results. We should learn from them. Keep programs at a Master’s level adding clinical doctorates earned by more clinical experience plus an emphasis on other tracks. NPs are already feeling some positives from their shift. Doctorates are opening doors. Doctorates are giving them seats at the table. Doctorates give more understanding to topics not stressed in NP school. Doctorates open eyes.

Doctorates are not needed because those professions need to compete with, or want to “be” physicians, but because it seems professions eventually need to let the public, legislators, insurance companies and other health professionals know that their postgraduate education offers the level of education and sophistication needed to take on the responsibility they have. Doctorates give that guarantee.

Eventually, PAs will realize the same thing.

Dave Mittman has been a PA and later NP leader for thirty years. He co-founded the LIU PA Program student society, was President of the New York State Society of PAs from 1978-1979 and served on the American Academy of Physician Assistants (AAPA) Board of Directors from 1981-1983. Dave was also the first USAF Reserves PA permitted to practice. Dave spent 9 years in primary care in Brooklyn, N.Y. and left to begin a career in medical publishing with Physician Assistant Journal. Dave has also won the AAPA Public Education award for leading the march in Trenton NJ to establish PA practice. Dave left PA Journal to co-found Clinicians Publishing Group (1990) and Clinician Reviews Journal in 1991. Dave has authored papers in publications as diverse as “Chicken Soup for the Expectant Mothers Soul”, “U.S. Pharmacist”, “The British Medical Journal” and others. Dave¹s paper in the BMJ was the first internationally written paper written on PA practice. Dave and a few very close PA colleagues co-founded the PAs For Tomorrow”” in 2012 which is a new national professional organization representing and advocating for PAs in an different way. Dave as spoken at hundreds of NP and PA meetings and always has some interesting thoughts on the future of both professions. Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs. Dave is married to his sweetheart Bonnie for 32 years and has two wonderful children.

Nurse Practitioners Salute South Dakota for New Health Care Law

AANP applauds South Dakota for aligning with neighboring states to provide patients full and direct access to nurse practitioners.

from AANP

The American Association of Nurse Practitioners commends Governor Daugaard and the South Dakota Legislature for enacting into law Senate Bill 61, which provides patients with full and direct access to nurse practitioners. By adopting the law, South Dakota becomes the 22nd state to authorize nurse practitioners to provide the full scope of services they’re educated and clinically prepared to deliver, and it retires the Board of Medicine oversight of nursing practice. These changes will significantly enhance patient access to high-quality health care.

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New Health Care Opportunities Continue for Nurse Practitioners, Physicians

“Jobs at the top end, like doctors, surgeons, specialists, highly qualified nurses, physician assistants and others, will continue to be in demand for years.”

from The Chicago Tribune

“While it’s true that there are numerous jobs in health care that will be in demand for years, if not decades, because of an aging community, people often overlook jobs because they focus on the inner workings of hospitals and medical facilities — the technologists, the assistants, the technicians,” says Joan Stanley, analyst for the U.S. Department of Labor. “Jobs at the top end, like doctors, surgeons, specialists, highly qualified nurses, physician assistants and others, will continue to be in demand for years.”

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Fighting Finger Droop – Mallet Finger

Dealing with patients who have a droopy finger can present diagnostic and treatment challenges for providers unfamiliar with this injury.

by Thomas Gocke, MS, ATC, PA-C, DFAAPA

Dealing with patients who have a droopy finger can present diagnostic and treatment challenges for providers unfamiliar with this injury. A drooping finger is more commonly known as a Mallet finger injury. Mallet finger injuries occur when a forceful blow is delivered to the tip of a finger while the finger is flexed. Specifically, the extensor tendon is injured, resulting in the inability to actively extend the finger at the distal interphalangeal joint (DIP). This inability to extend the DIP gives the injured finger a droopy appearance.

Mallet finger injuries involve the Extensor Digitorium Profundus tendon as it inserts into the distal phalanx (DIP joint). This injury is classified as either a soft tissue injury (ruptured tendon) or a bony injury (avulsion fracture). In the soft tissue Mallet finger injury, the extensor tendon is ruptured at or near the tendon insertion into the distal phalanx. This type of injury shows no bony abnormalities on x-ray. In the bony Mallet finger injury, there is a portion on the distal phalanx that has avulsed or fractured off the distal phalanx. This bony abnormality will be readily apparent on x-ray. If the bony injury involves > 30% of the articular surface, then strong consideration should be given to surgically repair this bone fragment back to anatomic position. This will allow for restoration of function at the DIP joint.

Treatment of the soft tissue Mallet finger centers on placing the injured finger in an extended position to better approximate the ruptured tendon edges. In most cases, the tendon will heal and the DIP joint motion will be functional. Normal physiology of healing will allow the two ends to reapproximate. However, cosmetically, the involved DIP joint may have some drooping but will be able to actively extend the distal phalanx. As for the bony Mallet finger, again the objective is to reapproximate the bone fragments in order to allow them to heal. By extending the distal phalanx, the fragments should realign in reasonable anatomic position. If the bone fragment involves >30% of the articular surface of the distal phalanx, the extended position causes blanching of the skin, and/or the bone fragments do not reapproximate within 3mm of each other, these are cases where surgical repair is needed. Regardless of the type of Mallet finger injury, a stack splint or an aluminum finger splint will usually serve to adequately immobilize this injury. Again, in the case of a bony Mallet finger injury that does not reduce with extension maneuvers, neither the stack splint nor the aluminum splint will be effective.

Mallet finger injuries will usually take about 6-8 weeks for either a soft-tissue or bony Mallet finger injury to heal. An important point to reiterate with patients is to not try to flex the DIP joint during the healing process. Any disruption of the healing tissue will negate the healing time and the 6-8 week healing process will have to start all over. In these cases, the amount and quality of tissue healing will most often be less.

To learn more about this and other orthopaedic-related injuries, go to www.orthoedu.com.

See Thomas Gocke, MS, ATC, PA-C, DFAAPA speak at Skin, Bones, Hearts, and Private Parts’ 2017 Orlando (April), Myrtle Beach, San Antonio, and Las Vegas events.