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.

Three-Part Patient Satisfaction Tool for Hospitalists

A short and simple way to improve your patient satisfaction scores in the hospital.

by Rajil M. Karnani, MD, MSPA

About three years ago, our hospital was abuzz about patient satisfaction. Our HCAHPS scores were lower than expected, and there was a push by the administration to improve them. As a hospitalist, I wondered to myself, what could I possibly do to improve my ratings? I already believed I was doing a very good job communicating effectively with patients.

Many years ago, I developed the habit at the end of each encounter of always asking patients, “What questions do you have for me?” Much to my dismay, their answers were rarely focused on their health or why they were in the hospital. Instead, they frequently seemed to revolve around things such as an upcoming imaging or blood test, their first meal, and most often, when they could finally go home. That got me thinking. If these are the questions and issues patients really care about, why not anticipate these questions and issues by initiating that conversation with patients before they bring it up with the doctor? I began to do just that. As a result, I developed my own three-part tool that I would use to conclude each patient encounter. The entire process would typically take only about 60 seconds, and if one of the steps didn’t apply to the patient, I would simply skip it and proceed to the next step. Here is my three-part tool, utilizing these common patient questions as a trigger to initiate the conversation:

  1. When can I eat? – If the patient was not on a full diet, I would tell the patient why they were not being allowed to eat and then tell them when they could expect to return to a regular diet. Often, it was because the patient was NPO in anticipation of an upcoming test like an endoscopy or cardiac catheterization, which made a nice segue into the next question.
  2. When is my test? – If the patient was waiting for an important test for which the result could alter their hospital stay or treatment plan, such as an MRI or blood culture, I would tell them when the test was tentatively scheduled and approximately how long it would take to get the results. I would then tell them what the likely decision would be based on the potential results. Finally, I would mention that it is entirely possible that a test could be postponed because of another patient’s emergency need for the same test, but that every effort was being made to get the test done on schedule.
  3. When can I go home? – Based on the patient’s admitting diagnosis, I would provide the best updated estimate of their hospital length-of-stay, typically a range such as two-to-three days or at least one more day. I would also mention why it would take that long, as well as the fact that this was an estimate and it could change based on the patient’s condition or availability of resources.

After addressing these three questions, I would end by asking my usual question, “What questions do you have?” After doing this three-step process numerous times over many months, I noticed something surprising. Many patients would respond to my usual ending question with, “Nothing, doctor, you’ve answered all of my questions.” At that point, I realized I was onto something. By addressing some of the most common concerns of patients without having to be prompted, I was demonstrating to them that I might be understanding their most important and immediate concerns. Moreover, I noticed the tone of these patients tended to be relatively pleasant and calm, which made my job easier. A few months later, when I received my next patient satisfaction scorecard from the hospital, I was in the top 25% of my practice group, up from my previous report. My partners noticed my score, and I shared with them what I was doing. After initiating my process, their anecdotes revealed much of the same results that I had discovered.

If you are looking for a way to improve your patient satisfaction scores in the hospital, especially something that is short and simple to implement, don’t feel like you need to reinvent the wheel. I would simply recommend preempting patient questions and concerns by addressing these three common patient issues when staying in the hospital. Who knows, you might be surprised by how many patients say to you in a heartening way, “Nothing, doctor, you’ve answered all of my questions.”


Dr. Karnani is a subject matter expert in predictive analytics in healthcare, as well as a physician with a medical foundation in academic medicine. He provides a strong skill set in Analytical and Statistical Decision Making, Project Development & Management, and Education & Training. His focus is working with healthcare data to gain actionable insights in the areas of population health management, value-based care, and patient experience.

Dr. Karnani can be reached via email at rajilkarnani@yahoo.com or on LinkedIn here.

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.

Best Tips to Help Avoid Negative Physical Reactions in Patients

Here are a few quick reminders on how to make things go as smoothly as possible for your patients and yourself.

by Hannah Whittenly

There’s no doubt that having patients put their trust in you in a very big responsibility. In every step of the medical process, you pretty much have their life in your hands. One of the worst things that could happen is a patient experiencing some type of negative physical reaction, which might undoubtedly lead a patient to blame you. The following are just some tips that may help reduce the chances of this happening.

Preventing Allergic Reactions

One common negative reaction amongst patients is an allergic reaction. This usually happens due to miscommunication and failing to record negative allergic reactions. The best thing to do is to tighten up how you record negative drug reactions. This can be done by having your staff repeatedly check on every patient to make sure records are accurate.

You can download an algorithm software to help you match the patient with an allergy. This should be updated with every visit by your staff. The patient might get annoyed that you consistently asked about this information, but explain that this is done to increase safety.

Keep Patients Calm

We all know that going to a doctor’s office can sometimes be disconcerting for a patient, especially if he or she is receiving bad news. This is one reason why panic attacks amongst patients is common. The key is to break news in a way that is as reassuring as possible.

Some clinicians may need to go over the six step process they learned while training to break news as effectively as possible. First, you must set up a meeting in a private setting—such as an office or by closing the curtains. Be prepared to answer any questions, and it is important to be honest with the patient. Establish eye contact to let the patient feel like he or she is not alone. Of course, this is just one of the six steps.

Take Contamination Precautions

Contamination could lead to infections and further complications, so do your best to ensure that all equipment is properly disinfected. This is something that all assistants and associates must do as well.

Now, this is just one way to prevent contamination, but there are others. During surgery, for example, you should make sure to use a smoke evacuator tool that helps remove smoke that is produced from the other tools that are used. It not only prevents contamination but ensures highest visibility standards.

Prevent Outbursts

If your patient is going through something that is life-altering, then he or she has every right to be angry and upset. However, such feelings can lead to more than just tears; they can lead to physical reactions. Make sure that you’re always reading the body language of your patient. If they seem to be getting aggressive, step back and give them their space. Perhaps give them some time to cool down so that they can think things over. It may even be wise to have a psychologist come and help talk them through their feelings.

Whatever you do, it’s important to keep the patient from resorting into physical outbursts. These can be harmful to you, your staff, and your patient.

These are just a few suggestions that may help keep your patients safe. Keep in mind that the key to most of these is open dialogue and communication. In essence, try to put yourself in the patient’s shoes, and do your best to provide the kind of service that you would expect should you be a patient because that is how your patients want to be treated.


Hannah Whittenly is a freelance writer and mother of two from Sacramento, CA. She enjoys kayaking and reading books by the lake. For your smoke evacuator needs, Hannah recommends Megadyne.

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.

Social Networking with Purpose: A Guide for OTs

1.86 billion Facebook users and myself agree: online networking platforms represent one of the best technological advances in recent years.

from WebPT

If you aren’t leveraging the online sphere to grow your occupational therapy network, you may be missing out. However, we all know by now that the online world can be a rabbit hole of dead ends and misadventures. It is, therefore, critical to approach social networking with purpose. Here are three steps to help you do just that.

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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.

Intensive Speech Therapy Helps Months after Stroke

Chronic aphasia, the inability to understand or express speech well due to brain damage from stroke, affects about 30 percent of stroke survivors.

from Reuters

Even months after a stroke, survivors can make major strides in communication and quality of life with intensive speech therapy, a recent study in Germany suggests.

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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.

Opposition Grows to ‘Workplace Wellness’ Bill That Would Scale Back Genetic Privacy

The bill, approved by a House committee last week, would eliminate long-standing genetic privacy protections from workplace wellness programs.

from STAT

Opposition to a congressional bill that would explicitly remove genetic privacy protections from workplace wellness programs grew on Monday, with one of the country’s leading wellness associations calling the proposed changes “punitive.”

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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.

High U.S. Drug Prices Cover Pharma’s Global R&D—and a Whole Lot More, Study Finds

A new study found that Big Pharma makes more from high U.S. drug prices than it spends on research around the world.

from FiercePharma

Sure to add fuel to the fiery U.S. drug pricing debate, new work from several health policy experts showed that pharma makes more from platinum pricing in the U.S. than it spends on research around the world.

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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.

Hospitals Could Bear the Financial Brunt of the American Health Care Act

How the GOP’s replacement of the ACA could impact healthcare providers.

from STAT

The stakes couldn’t be higher for America’s hospitals in the debate over the GOP replacement for Obamacare. Here’s a quick breakdown of the top issues to watch and how they could impact providers across the country.

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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.

How Do You Know You Want to Be a Nurse?

Thinking about becoming a nurse? If so, here are some great points you may want to consider.

by Lisa M. Tufts, RN

So, you have decided to go to nursing school… why? Let’s see if this is the right career path for you. Whether it is your first or second career choice, there are questions you should ask yourself before you spend the time, money, and energy it takes to follow a path that leads you to a career where your job is to care for people who are acutely and chronically ill. So, ask yourself some important questions:

  • Have you ever been in a hospital, as a worker, a patient, a visitor?
  • What is your current career and does it relate?
  • What interests you in nursing? If you are choosing nursing for monetary reasons, then you are you choosing it for the wrong reasons. First of all, nurses, especially new nurses, do not make a lot money. Second, unless you can afford to pay cash for your education, you need to pay back your student loans after your graduate. Last, you need advanced education, which cost even more money to make an advanced salary with years of experience, so forget that idea.
  • Have you ever cared for a sick person?
  • Have you ever worked in a hospital or nursing home?
  • Do you realize that you will be working with bodily fluids? Yes, all the bodily fluids. The job is not glamorous.

Do yourself a favor if you are thinking about going to nursing school, and get a job as a nursing assistant. This is a great place to start to determine if a career in nursing is for you.

Frankly, I believe being a nursing assistant should be a requirement to becoming a nurse.

If you are already in nursing school and not working as a nursing assistant, you should. You need the experience of caring for patients at the basic level. You will be surprised at how much you will learn as a nursing assistant, especially when the nurses that you work with know that you are a nursing assistant—they can and will show you things, like wound care, for example. You will get opportunities to see things as a nursing assistant that you might not see in nursing school. This will be very beneficial toward your education and experience. It also shows that you are serious about your nursing career.

Think about it; who would a Nurse Manager want to hire? The new grad with patient care experience, or the new grad who has been working at a grocery store while they are in school.


Lisa Tufts began her career in healthcare as Certified Nursing Assistant at the age of 17. Since then she has remained in healthcare in various roles from Medical Coding, Executive Assistant, Medical Assistant, and has not been a Registered Nurse for six years.

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.

The Opioid Epidemic and Untreated Pain: Ethical Tensions

Research shows that since 1999, consumption of hydrocodone has more than doubled and consumption of oxycodone increased by nearly 500%.

from Johns Hopkins Nursing

I recently attended a funeral for one of my former classmates from high school who died of a heroin overdose. Tragically, there was more than one funeral that day. There had been two overdoses within my community in one week. With recent headlines such as, “21 heroin overdoses reported in Ohio in a day,” and “Maryland reports 383 overdose deaths in the first three months of 2016,” I am less surprised by such events, but increasingly alarmed.

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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.