Malpractice Costs Will Soar if NPs are Deemed On Par With Physicians

Dear Administrator Verma,

Deeming non-physicians to be essentially equal in training and experience to physicians amounts to a dangerous experiment on American patients. It is improper and unethical for the federal government to be making such decisions regarding the scope of practice of medical professionals.

I have spent over 40 years as a complex litigation specialist. Handling over 35,000 malpractice claims. It seems the law of unintended consequences is at play. Currently the “Captain of the Ship” doctrine limits liability to allied health personnel. It also limits professional and legal liability costs. Placing nurse practitioners and Physician assistants on par will indeed lead to greater claim frequency and increased legal costs. Rates for all providers will increase. In fact underwriters will increase offices with PA’s and NP’s. We could see malpractice costs for internal medicine practices rise from $1-3,000 to $9-12,000 per allied health professional .

We saw the law of unintended consequences occur with EHR and once down that “rabbit hole” there is no return. There is both a patient and physician expense that has not been calculated.

Likewise it is irrational and counterproductive to pay a minimally trained person the same as a highly trained, experienced person. If the reimbursement is the same for poor quality as for good quality, but the poor quality costs less to provide, the entities that degrade quality have a competitive economic advantage. Medicare’s existing price controls are already impeding patient access to high quality care and should not be exacerbated by additional flawed policies that further disregard important differences between practitioners. 

The bottom line is that patients’ lives are at risk. The federal government should follow a policy of “first do no harm.” It violates this principle to impose top-down edicts declaring that non-physicians are qualified to practice medicine. I urge the federal government to reject such policies.

Peter Leone

President, Edge Professional Liability Services https://edgepro.net/

ACTION ALERT: STOP Legislators from Delaying Patient Access to Physicians and Facilities of Their Choice

NO To New Jersey Assembly Bill A5369 & S3816!

Following the example of Congress, the NJ Legislature has introduced a “Patient Protection Act” (A5369 / S3816) that is anything but protective of patient rights.

According to NJ Spotlight, “the proposal has drawn criticism from patient advocates and other healthcare experts who suggest that, in an effort to protect the business interests of Garden State hospitals, it could put patients in danger.”

What does this bill do? It erects a number of bureaucratic requirements that physicians would be required to fulfill before referring a patient to an out-of-state colleague or facility for needed medical care.

Here’s how Joe Nessa, Esq. explains it:

If passed, this legislation could have a devastating effect on patient care. Currently, physicians in New Jersey are free to refer their patients to world-renowned hospitals in Philadelphia, New York City, and across the nation for treatment. New rules imposed by the bill would require physicians to inform patients of the availability of in-state facilities even if they think their patient can receive better care elsewhere, notify the patient’s insurance company of the out-of-state transfer, and report the transfer or referral to the Department of Health. This addition of paperwork and red-tape will force physicians to make the easier, time-friendly decision of keeping their patients in-state, regardless of their thoughts on quality of care. Additionally, as if the above requirements aren’t enough, physicians would also be required to send quarterly reports of each out-of-state referral to their licensing board, accompanied by an explanation of the clinical necessity.

Earlier this summer, this bad legislation was being fast-tracked through the legislative process, and was quickly passed by the Assembly and a Senate Committee. It “has yet to be approved by the [full] Senate,” reports the Fall 2019 Edition of MDAdvisor. However, “[t]he sponsors are continuing to work on this legislation….”

Your help is needed to help STOP A5369 & S3816!  Here’s what you can do:

Call your NJ State Senator and Assembly Members. Tell them you are depending on them to stand up for patient rights and vote NO on A5369 and S3816. Patient care should not be put at risk to benefit the bottom line of special interests.

You can find their phone contact information here:
https://www.njleg.state.nj.us/members/abcroster.asp

If you don’t know who represents you, the legislature has tools to help you find out here:
https://www.njleg.state.nj.us/members/legsearch.asp

Medical facilities in NY and PA have put together a tool for sending e-mail messages to legislators which you might also consider using:
https://actnow.io/Y1rtnGO

Thank you for speaking out! Your voice makes a difference.

Do Not Gloss Over the Devastating Impacts of Policies that Declare Mid-Levels are Equivalent to Physicians

Friend of IP4PI Amy Townsend, MD writes in:

Please do not gloss over the potentially devastating impacts that Section 5 of President Trump’s Executive Order on Medicare will have on our healthcare system.  

I am a board member for Physicians for Patient Protection, a grassroots physician group that promotes physician led care.  We have been actively fighting scope of practice invasion in nearly every state for the last 3 years.  NPs and PAs can be a valuable part of a physician led team but they are not equivalent to physicians in education, training, or ability.  The government permitting them to independently practice medicine through legislation and not education will devastate healthcare.  Here are a few of my concerns:

1.  Patient safety, patient safety, patient safety!!!!

As NPs try to increase their numbers, they have sacrificed the quality of NP education.  They have created degree mills that are churning out 27,000 NPs per year.  Many schools have 100% acceptance and didactics that are 100% online and can be completed in as little as 18 months.  This is followed by a mere 500 hours of shadowing as their “clinical experience”.  Compare this to 16,000 clinical hours for a family medicine physician.  We are seeing and hearing devastating stories of misdiagnosis and mismanagement of these poorly trained practitioners daily.

2.  Medical expertise will be gradually diluted down.  

Why will our best and brightest students even try to conquer to academic rigors and expense of medical school when you can take a cheaper, less time consuming course to practicing medicine independently and have the same reimbursement (due to pay parity proposed here).  As a Family Medicine physician that has been practicing almost 15 years, I value every second of my training.  It is needed for me to be an expert at my craft.  

3.  NPs and to a lesser extent PAs, in general are corporate YES men.  

They have not been taught in their training to take ownership of patients as physicians do.  They do not take the same oath to protect patients at all costs.  If they are declared physician equals and can replace physicians, we will lose all negotiating power with corporate entities, government, and insurance companies.  If physicians stand up for patients, they will simply be replaced by a more agreeable, complacent NP.  
There are probably a million additional reasons.  But it is late and I’m sure you all are tired of reading my rant.  But I am begging you all to please give this issue it’s due respect.  The president has it WRONG on this issue.  We can not continue to have this conversations in the dark corners because we are afraid of liking like we are being mean to nurses.  Our profession, our fellow physicians, and our patients need us to speak up.  

Thank you all for your wonderful advocacy.  I believe it is people like us that can and will fix our broken system. 


Amy Townsend, MD, Family Medicine/Hospital Medicine

AOA commits DO member money to lobby for MOL requirements, but why?

A friend of IP4PI writes in:

The AOA just passed a resolution committing our membership dollars to lobby for Maintenance of Licensure requirements [overseen by the AOA].  I was not able to be in the committee hearing, but in our state meeting we voted against it.  On the floor of the house, when I expected our leadership to speak the will of the caucus, they did not speak at all. All states were silent as to the issue and it passed quickly without any objection.  In fact, it appeared that most delegates were not yet awake.  The only comment I got when I asked why we did not defend ourselves was that MOL is inevitable, and we have to vote for it if we want a place at the table. When will doctors learn that if they are told to advocate for their own destruction in order to make it less painful, it means they were never at the table.  We just helped by marinating ourselves for our place ON the table?

[Note from editor: Further demonstrating the AOA’s disregard for members, a provision in the resolutions directing the AOA to “make OCC more manageable and economically feasible was struck.]


H-627 MAINTENANCE OF LICENSURE (H638-A/14) Resolution No. H-627

Be it resolved: The American Osteopathic Association (AOA)

(1) supports the development of state level maintenance of licensure (MOL) programs to demonstrate that ALL physicians are competent TO provide quality care THAT INCORPORATES RELEVANT TECHNOLOGICAL AND SCIENTIFIC ADVANCEMENTS over the course of their career. Flexible pathways for achieving MOL should be maintained. The requirements for MOL should balance transparency with privacy protection and not be overly burdensome or costly to physicians or state licensing boards; 

(2) Continues to address and promote physician competency through the teaching of core competencies at the predoctoral and postdoctoral levels as well as ongoing physician assessment through Osteopathic Continuous Certification (OCC) and the AOA Clinical Assessment Program (CAP) or its equivalent;

(3) Continues to work with State Osteopathic Affiliates, the American Association of Osteopathic Examiners and other stakeholders to establish, AND implement MOL policies that promote patient safety and the delivery of high quality of care;

(4)WILL THROUGH ITS BUREAUS, COUNCILS AND COMMITTEES, CONTINUE TO ENSURE THAT OCC IS RECOGNIZED BY THE FEDERAL GOVERNMENT, STATE GOVERNMENTS AND OTHER REGULATORY AGENCIES AND CREDENTIALING BODIES AS EQUIVALENT TO OTHER NATIONAL CERTIFYING BODIES’ “MAINTENANCE” OR “CONTINUOUS” CERTIFICATION PROGRAMS.;

(5) WHILE SUPPORTING THE USE OF BOARD CERTIFICATION AS A  RECOGNITION OF QUALITY AND EXCELLENCE, SIGNIFYING THE HIGHEST PHYSICIAN ACHIEVEMENT IN A PARTICULAR SPECIALTY; OPPOSES ANY EFFORTS TO REQUIRE OCC AS A CONDITION OF MEDICAL LICENSURE.;

(6) THE AOA COLLABORATES WITH ENTITIES PROPERLY QUALIFIED FOR AND TASKED WITH DECISION-MAKING REGARDING INSURANCE PAYMENT, HOSPITAL PRIVILEGES, NETWORK PARTICIPATION, PAYMENT MALPRACTICE INSURANCE COVERAGE, PHYSICIAN EMPLOYMENT, TO DETERMINE THE ROLE OF PHYSICIAN BOARD CERTIFICATION AND OCC OR OTHER “MAINTENANCE” OF CERTIFICATION” PROGRAMS IN SUCH DECISIONS.;

(7) CONTINUES TO INNOVATE AND IMPROVE THE OCC PROCESS.

APPROVED

https://osteopathic.org/wp-content/uploads/2019-Ad-Hoc-Committee-Report-WITHACTION.pdf

AMA looks for gold in mining patient and physician data.

Two more items to pitch into “the AMA is utter Garbage” file:

  1. The AMA supports resuscitating the dead-end failure that is the “Affordable Care Act.”  Patients have seen soaring premiums, deductibles, and medical costs, while at the same time often losing access to their doctor and other medical facilities of their choice. Physicians have suffered continued suffocation by ACA red-tape. But the AMA supports propping up this disaster of a law and throwing more good money after bad. 
  2. AMA looks for gold in mining patient and physician data. Why is the AMA advocating against the best interests of doctors and patients? Follow. The. Money. The AMA has discovered it is more lucrative to sell patients and doctors out than to support their interests. Since 1983 the AMA has been making millions of dollars per year from the CPT monopoly it secured in a secret deal with the feds back in 1983. CPT has metastasized into the EHR fisaco that now plagues nearly every office and facility. Now the AMA is hoping to find another pot of gold by mining the data CPT helped to create… patient and physician medical data to be exact. How much can the AMA make of the data? Who knows, but you can read more about the new initiative here: https://healthitanalytics.com/news/ama-launches-integrated-healthcare-big-data-analytics-platform.

Danger, Will Robinson! Danger!

ABA Has Failed to Stand Up to ABMS on MOC

Friend of IP4PI, Jef Fernley, DO shares his correspondence with the American Board of Anesthesiology.

Esteemed colleagues of the ABA,

You should have left well enough alone. For decades it was believed that being “Board Certified” was actually a hallmark of a quality Physician, something to set himself/herself apart from the rest, something to inspire confidence, a feather in one’s cap, and print on one’s business card.  The field of Anesthesiology has a proud history of independence and innovation.  The ABA used to be a reflection of that. But you failed to stand up to the ABMS on MOC. I think everyone understands that staring a novel multi-million dollar stream of revenue in the face is a very hard thing to reject.  You should have rejected it.  With the absence of any unbiased supportive evidence for MOC, and let’s be realistic, anyone who has a job taking care of patients rather than publishing papers knows that physician quality can’t be measured by any single test, therefore there won’t ever be any such real evidence. Continue reading

Final MACRA rule still byzantine and unworkable, patients lose.

The final MACRA rule expands exemptions, flexibility, claims ModernHealthCare.com but it is still byzantine and unworkable. Patients lose.

The 2,398 page rule can be downloaded here: https://qpp.cms.gov/docs/CMS-5517-FC.pdf

We haven’t read the all 2,398 pages yet but here are a few initial notes:

  • The low-volume threshold is now < $30,000 in Part B billings OR < 100 Part B Patients.The proposed rule was < $10,000 AND < 100 Patients.
  • The infamous table from the proposed rule showing 87% of solo docs would face a negative adjustment under MIPS has been “bleached.” The sanitized table no longer lists solo physicians separately, and claims that only 10% of practices from 1 to 9 physicians will will face negative adjustment.  Click here for image combining both new table and old table. Supposedly, overall, 94.7% of eligible clinicians will get a positive or neutral adjustment with 5.3% receiving a negative adjustment.

Another trouble spot to look out for (Page 1513):

“One commenter supported the inclusion of ABMS board certification and participation in Maintenance of Certification (MOC) Programs on Physician Compare. Another commenter recommended MOC participation as a measure in future rulemaking as part of quality performance data publicly reported on Physician Compare … We appreciate the points, concerns, and suggestions raised by commenters and, if feasible and appropriate under the statute, we may possibly consider these issues in future rulemaking. ”

Some other low-lights:

Re Privacy:

“We disagree with commenters who maintained that the disclosure of PHI to ONC or an ONC-ACB (authorized certification body) could be inconsistent with reasonable privacy or other organizational policies or would otherwise be an unjustified invasion of privacy or any other interest. As noted, the disclosure of this information would be authorized by law on the basis that it is a disclosure to a health oversight agency (ONC) for the purpose of determining compliance with a federal program (the ONC Health IT Certification Program). In addition, we note that any further disclosure of PHI by an ONC-ACB or ONC would be limited to disclosures authorized by law, such as under the federal Privacy Act of 1974, or the Freedom of Information Act (FOIA), as applicable.” (page 67)

Data-Collection from all-payers:

“In addition, we are finalizing our approach of including all-payer data for the QCDR, qualified registry, and EHR submission mechanisms because we believe this approach provides a more complete picture of each MIPS eligible clinician’s scope of practice and provides more access to data about specialties and subspecialties not currently captured in PQRS” (page 468)

“We desire all-payer data for all submission mechanisms, to create a more comprehensive picture of the practice performance. Section 1848(q)(5)(H) of the Act authorizes the Secretary to include, for purposes of quality measurement and performance analysis, data submitted by MIPS eligible clinicians with respect to items and services furnished to individuals who are not Medicare beneficiaries. As discussed in section II.E.5.b. of this final rule with comment period, we are finalizing our proposal to require MIPS eligible clinicians to report allpayer data on quality measures where possible.” (pg1396)

CMS will be accepting comments for 60 days, however the online comment portal is not yet open as far as we can determine.  Stay tuned!