VA proposal for independent APRN practice

[EniG]

The VA has proposed that all APRNs (NPs, CRNAs etc) practice independent of physician supervision and as we know, the VA will likely be used as a model by other organizations. Personally, this is scary for so many reasons. If a family member (or myself) needed surgery or anesthesia, I would want the most qualified and experienced physician in charge of their care, nothing less. I don't understand why these attempts to offer "cheap" health services don't outrage the public and physicians? Alternatively, if the long physician education/training is deemed unnecessary, then how about shortening it if it doesn't make a difference in patient safety/outcomes?

Why don't physicians join forces and refuse to work in an environment where their education and expertise is constantly being undermined? I just don't get the apathy and lack of reaction from ALL physicians while the rug is pulled out from under them!

"Regulations.gov - Proposed Rule Document

In proposed § 17.415(d)(1)(i), a CNP would have full practice authority to provide the following services: Comprehensive histories, physical examinations and other health assessment and screening activities; diagnose, treat, and manage patients with acute and chronic illnesses and diseases; order, perform, supervise, and interpret laboratory and imaging studies; prescribe medication and durable medical equipment and; make appropriate referrals for patients and families; and aid in health promotion, disease prevention, health education, and counseling as well as the diagnosis and management of acute and chronic diseases. In proposed § 17.415(d)(1)(ii), a CRNA would have full practice authority to provide a patient's anesthesia care and anesthesia related care, to include planning and initiating anesthetic techniques (general, regional, local) and sedation, providing post-anesthesia evaluation and discharge; ordering and evaluating diagnostic tests; requesting consultations; performing point-of-care testing; and responding to emergency situations for airway management. The Department of Veterans Affairs (VA) is proposing to amend its medical regulations to permit full practice authority of all VA advanced practice registered nurses (APRNs) when they are acting within the scope of their VA employment. This rulemaking would increase veterans' access to VA health care by expanding the pool of qualified health care professionals who are authorized to provide primary health care and other related health care services to the full extent of their education, training, and certification, without the clinical supervision of physicians. This rule would permit VA to use its health care resources more effectively and in a manner that is consistent with the role of APRNs in the non-VA health care sector, while maintaining the patient-centered, safe, high-quality health care that veterans receive from VA. The proposed rulemaking would establish additional professional qualifications an individual must possess to be appointed as an APRN within VA. The proposed rulemaking would subdivide APRN's into four separate categories that include certified nurse practitioner, certified registered nurse anesthetist, clinical nurse specialist, and certified nurse-midwife. The proposed rulemaking would also provide the criteria under which VA may grant full practice authority to an APRN, and define the scope of full practice authority for each category of APRN. VA intends that the services to be provided by an APRN in one of the four APRN roles would be consistent with the nursing profession's standards of practice for such roles.

[Hatton]

I am certain this will work ok until something goes wrong!  CRNAs and midwives should really recognize how unsupervised practice will increase their liability risks.

[consultpsych]

I am fine with this. There are a couple major scenarios, and I'm okay with all of them.

a) in some circumstances (probably many circumstances), APRNs and CRNAs and other non-MD/DO's do a great job at certain things, and that should happen. If it keeps costs down that might hurt me as a physician, but it is good for society. I'm all for open competition and not for artificial barriers to entering an industry.

b) in many circumstances, those with less training will not do as good a job, and will make more mistakes, and may raise costs (e.g. by consulting frequently rather than knowing what to do in the first place). As that happens, those with the ability will choose to see a physician for those types of issues. In a free system, patients should know how much more it would cost them to see someone with more rigorous training of a certain type, and determine if it's appropriate for them.

Based on knowledge of  my own field (psychiatry), I think there are things psychiatrists do excellently that I would never want an APRN or PA dealing with alone (eg managing treatment-resistant depression in the context of HIV and HAART regimen). There are other scenarios in which I would be fine with an APRN or PA (depression responding to initial treatment). There are other non-MD/DO "practitioners" who are often excellent at what they do and often better than psychiatrists (masters and doctoral level psychotherapists for instance, can be awful but can also be excellent).

[The White Coat Investor]

It was like this when I was in the military. While I was available to the PAs working by my side in the ED, I didn't have to sign their charts.

[PhysicianOnFIRE]

The White Coat Investor wrote:

It was like this when I was in the military. While I was available to the PAs working by my side in the ED, I didn’t have to sign their charts.

Click to expand...

Active military personnel tend to be reasonably healthy.

Veterans, particularly those requiring surgery, tend to be have multiple confounding comorbities. COPD, liver failure, heart disease, etc... One of my longer locum tenens assignments was in a University-based VA hospital. We cared for the sickest patients in the state.

My father and Godfather are veterans in the VA health system. I think you know where I stand on this issue.

 

 

[EniG]

consultpsych wrote:

I am fine with this. There are a couple major scenarios, and I’m okay with all of them.

a) in some circumstances (probably many circumstances), APRNs and CRNAs and other non-MD/DO’s do a great job at certain things, and that should happen. If it keeps costs down that might hurt me as a physician, but it is good for society. I’m all for open competition and not for artificial barriers to entering an industry.

b) in many circumstances, those with less training will not do as good a job, and will make more mistakes, and may raise costs (e.g. by consulting frequently rather than knowing what to do in the first place). As that happens, those with the ability will choose to see a physician for those types of issues. In a free system, patients should know how much more it would cost them to see someone with more rigorous training of a certain type, and determine if it’s appropriate for them.

Click to expand...

Personally, I have a few concerns with this kind of "let's wait and see" stance. I am more of a "prevent a problem before it happens" type of person. I am not picking on your answer, just addressing it because a lot of physicians share this stance, especially older and established ones who have paid off their loans and made their money.

Issue that I have with APRNs and CRNAs doing certain things that doctors are doing, is that they'll take care of the low-acuity cases which means doctors are left with the more complex and time-consuming patients. A day full of those, day in day out is a recipe for burnout.

The term "artificial barriers" is confusing to me. Strict regulations for the practice of medicine are not "artificial barriers", are for the sake of safety. One can't claim that an anesthesia physician needs all this education, residency, board exams while also claiming that someone with far less education, experience, boards can perform mostly the same tasks (or 90%, whatever). That's not an artificial barrier. Nobody is stopping CRNAs from practicing to the level they want if they get the same education, licensing etc to match that of physicians (like DOs did).

"Those with the ability will choose to see a physician for those types of issues". Most of the patients I have seen, do not know the difference between the different providers, if they do, they understand it very superficially. So asking patients to make a choice between a physician and another provider is like asking them to decide between 2 treatment plans without fully discussing appropriate R/B/A. Sure some well-educated patients will do their due diligence, but the rest ...

Being able to tell the different providers apart in the hospital is an entire puzzle. Patients often call the nurse doctor and the doctor nurse (there is not one day that I don't see this).  Being able to tell the difference, is hard even for me sometimes, short of having to squint to get a glimpse of someone's ID to know if they are a PA, NP, MD etc there is no other distinguishing attire (I wish there were, I think it would be less confusing for everyone).

The other problem is that patients of LES will not have appropriate access to physician services because they will be more expensive than other providers. I don't think it'll take long before insurance plans require a referral from an NP or PA before seeing an MD/DO in that same field ie. use them as the gatekeeper to certain specialties.

As a student, trying to decide on my specialty, I am steering clear of specialties that have big NP encroachment. As much as, NPs say "there is enough work for everyone, we are not encroaching just helping", at the end of the day, what I see in the OR is that one physician supervises 5 or 6 CRNAs. These CRNAs have taken over positions that until recently were physician positions. In terms of the future of this profession, what it tells me is that there will be more residents graduating than positions open, and those positions will pay much less. It's the simple law of supply and demand.

By the time, we hope that the mistakes of these providers come up (if they do and are not covered up), will be awhile and I think the damage will be already done. After everything that we have to go through for our training (seriously, most of us have had to work our behinds off since highschool!!!) I have no desire to compete with others who just take a shortcut and claim that we provide equal services but they provide them for cheaper!

For me, it is scary to see that not much resistance is being put up by physicians. On the same document by the VA there were references to allow APRNs to order/read/interpret imaging as well. You get the gist!

 

 

[Zaphod]

EniG wrote:

consultpsych wrote:

I am fine with this. There are a couple major scenarios, and I’m okay with all of them.

a) in some circumstances (probably many circumstances), APRNs and CRNAs and other non-MD/DO’s do a great job at certain things, and that should happen. If it keeps costs down that might hurt me as a physician, but it is good for society. I’m all for open competition and not for artificial barriers to entering an industry.

b) in many circumstances, those with less training will not do as good a job, and will make more mistakes, and may raise costs (e.g. by consulting frequently rather than knowing what to do in the first place). As that happens, those with the ability will choose to see a physician for those types of issues. In a free system, patients should know how much more it would cost them to see someone with more rigorous training of a certain type, and determine if it’s appropriate for them.

Click to expand…

Personally, I have a few concerns with this kind of “let’s wait and see” stance. I am more of a “prevent a problem before it happens” type of person. I am not picking on your answer, just addressing it because a lot of physicians share this stance, especially older and established ones who have paid off their loans and made their money.

Issue that I have with APRNs and CRNAs doing certain things that doctors are doing, is that they’ll take care of the low-acuity cases which means doctors are left with the more complex and time-consuming patients. A day full of those, day in day out is a recipe for burnout.

The term “artificial barriers” is confusing to me. Strict regulations for the practice of medicine are not “artificial barriers”, are for the sake of safety. One can’t claim that an anesthesia physician needs all this education, residency, board exams while also claiming that someone with far less education, experience, boards can perform mostly the same tasks (or 90%, whatever). That’s not an artificial barrier. Nobody is stopping CRNAs from practicing to the level they want if they get the same education, licensing etc to match that of physicians (like DOs did).

“Those with the ability will choose to see a physician for those types of issues”. Most of the patients I have seen, do not know the difference between the different providers, if they do, they understand it very superficially. So asking patients to make a choice between a physician and another provider is like asking them to decide between 2 treatment plans without fully discussing appropriate R/B/A. Sure some well-educated patients will do their due diligence, but the rest …

Being able to tell the different providers apart in the hospital is an entire puzzle. Patients often call the nurse doctor and the doctor nurse (there is not one day that I don’t see this).  Being able to tell the difference, is hard even for me sometimes, short of having to squint to get a glimpse of someone’s ID to know if they are a PA, NP, MD etc there is no other distinguishing attire (I wish there were, I think it would be less confusing for everyone).

The other problem is that patients of LES will not have appropriate access to physician services because they will be more expensive than other providers. I don’t think it’ll take long before insurance plans require a referral from an NP or PA before seeing an MD/DO in that same field ie. use them as the gatekeeper to certain specialties.

As a student, trying to decide on my specialty, I am steering clear of specialties that have big NP encroachment. As much as, NPs say “there is enough work for everyone, we are not encroaching just helping”, at the end of the day, what I see in the OR is that one physician supervises 5 or 6 CRNAs. These CRNAs have taken over positions that until recently were physician positions. In terms of the future of this profession, what it tells me is that there will be more residents graduating than positions open, and those positions will pay much less. It’s the simple law of supply and demand.

By the time, we hope that the mistakes of these providers come up (if they do and are not covered up), will be awhile and I think the damage will be already done. After everything that we have to go through for our training (seriously, most of us have had to work our behinds off since highschool!!!) I have no desire to compete with others who just take a shortcut and claim that we provide equal services but they provide them for cheaper!

For me, it is scary to see that not much resistance is being put up by physicians. On the same document by the VA there were references to allow APRNs to order/read/interpret imaging as well. You get the gist!

 

 

Click to expand...

You should avoid those specialties with easy encroachment. Its a foregone conclusion, and any medical school not saying so plainly is not only doing a disservice to their students but much worse imo.

Theres just not enough issues with NP/PAs etc...to not justify the huge cost savings to the system overall (there just wont be people dropping dead because someone missed a knife lodged in someones neck, wont happen often enough to reverse the obvious). Issues that will be missed will be few/far between and due to their nature will likely be rare and not very impactful to the overall aggregate health of the population. Basically, nothing will change but access will increase and costs will go down, to find any negatives you'll have to drill deep into the data and present case studies, which will not sway the overwhelming money aspect.

We're just at a point health wise where its hard to tell the value add proposition of a doctor over a np/pa for primary care specialties, most issues are frankly the patients lifestyle and compliance choices. Students should be moving to better specialties that dont have such an easy competition from mid levels.

It should definitely be used as a way to break the sort of extortion that boards, etc...have been running for so long. It really makes it dumb to be a physician for these jobs, why do that when you could do the same thing with likely less risk, definitely less time/work and similar pay.

[EniG]

Zaphod wrote:

You should avoid those specialties with easy encroachment. Its a foregone conclusion, and any medical school not saying so plainly is not only doing a disservice to their students but much worse imo.

Students should be moving to better specialties that dont have such an easy competition from mid levels.

Click to expand...

I am having a hard time identifying these fields. I mean, some are really obvious like anesthesia, FP, derm, EM, etc but other than surgery (because nobody wants to be under the knife of someone without maximal training!!), I fail to see any specialties that are immune. Ophthalmology perhaps because they already share the care with optometrists. GI there is already a "GI fellowship" for NPs training them in endoscopy/colonoscopy and GI pathology. Pulm: there will be NP training for bronchs before long (if not already). I recently read an opinion from an MD rebutted by an NP about the fact that NPs should be trained and allowed to do transbronchial biopsies. I mean this is probably one of (if not the most) risky procedure that pulmonary critical care docs perform. I just don't see any field that is safe from ending up like anesthesia.

And you are right, money talks, except for those people whose life will be impacted by the lack of appropriate training/proficiency in their providers!

[SValleyMD]

Hard to know where the encroachment will go..

Personally I think the next big threat will be to hospitalists..

It all starts with docs letting their guard down and taking on midlevels to ease their pain.. That is the first step in letting them in the door. Hospitalist are bringing more midlevels in to help at night. Critical care is doing the same. You need to just suck it up and protect the turf. Definitely an over generalization but that's my take.

Safest bet is procedure or surgery related specialties. They're not going to touch surgeons, cardiologists, electrophysiologists, ect.

With that said as an individual you'll still likely be fine with nearly any specialty. It still will effect the crappy fringe doctors more than the good solid ones

[Zaphod]

EniG wrote:

Zaphod wrote:

You should avoid those specialties with easy encroachment. Its a foregone conclusion, and any medical school not saying so plainly is not only doing a disservice to their students but much worse imo.

Students should be moving to better specialties that dont have such an easy competition from mid levels.

Click to expand…

I am having a hard time identifying these fields. I mean, some are really obvious like anesthesia, FP, derm, EM, etc but other than surgery (because nobody wants to be under the knife of someone without maximal training!!), I fail to see any specialties that are immune. Ophthalmology perhaps because they already share the care with optometrists. GI there is already a “GI fellowship” for NPs training them in endoscopy/colonoscopy and GI pathology. Pulm: there will be NP training for bronchs before long (if not already). I recently read an opinion from an MD rebutted by an NP about the fact that NPs should be trained and allowed to do transbronchial biopsies. I mean this is probably one of (if not the most) risky procedure that pulmonary critical care docs perform. I just don’t see any field that is safe from ending up like anesthesia.

And you are right, money talks, except for those people whose life will be impacted by the lack of appropriate training/proficiency in their providers!

Click to expand...

And yet it is still extremely profitable to be an anesthesiologist. You have to realize that although this feels like a massive and sudden shift, you're talking about a country that probably doesnt have enough primary caretakers, and even for midlevels, it takes considerable time to train and mobilize a force. There will still be decades of very profitable work out there. An enterprising physician might become even more profitable, and hopefully physicians focus on the tougher things and that leads to better overall care as the brightest are doing things that require more skill overall. You will also have a not insignificant proportion of midlevels who stay away from riskier things because thats just not what they want or feel comfortable with. Yes you will have the occasional cowboy overstepping their bounds, but this is no less prevalent among doctors either.

Nothing at scale changes very quickly in an economy of this size. You will have ample time to still have a great career and enough warning to pivot and best make lemonade out of anything. Just dont get bogged down and ignore the world, change your views and practices in business when it changes.

[RJ]

What a load of crap. See the article below. Is this the future?

 

http://www.omic.com/co-defendant-crna-denies-responsibility-for-failed-resuscitation/

[potbellypigger]

RJ it's exactly cases like this why i will not operate with a crna.  This isnt the first case of that happening.  I'm in the eye, a millimeter of movement can cause blindness and you want me to monitor the patient's vitals also?

[Hatton]

CRNAs are fine if an anesthesiologist is immediately available!