Home Forums Discussions General Discussion NP or PA

Help! I am in need to hire NP or PA but I have absolutely no experience in working with them. I know that I should bill at 85% rate for pts they see. I also know that they are rather hot commodity these days. Doctors in my area tell me that NPs are making 80-90k with the spread depending on benefits. I am hiring not for my primary care office but for local psychiatric hospital where I am providing consult service - H&P, f/u. I am thinking paying per pt. Any ideas? Does 80-90 k sound right? I would appreciate any input.

I see you are in Georgia, as I am. I am a nurse practitioner so am familiar more with our practice. That being said..if you are going to be using them in a remote place where you are not on site, you probably want to go with an NP. I know that we practice under our own license where a PA would practice under yours. There are no restrictions on having a physician on site and in some cases, like mine, we have our own practices. In Georgia, at least, I think a physician has to be on site... I am sorry I do not know the requirements for PAs but the ability to "autonomously" might be more of what you are looking for?

I think paying per patient would be fine.. at least if it were me looking for a job... I think the going rate for NPs is $40-$50 an hour (I am in rural NE Georgia) may be a little higher in more urban areas.

Hope this helps!

Don't know Georgia, but the bottom line is get the best one you can afford. You are hiring a junior "partner" and it will reflect on you.

Try to find one where their previous supervisors say the patients loved them. Try to find one who's ego is small enough that they will stay within their "scope of practice"- something to learn about and set up for malpractice coverage. Try to find one that is used to a significant workload, as in not fresh out of school. You pay more, but their references are more helpful to judge what you will get.

If you are going to try to pay by the patient, you ought to have a really good idea of how much income is likely/possible, and provide a guarantee for most of it with an incentive for higher production. Why should a good "helper" take all the risk?

As a sub-specialist I am only familiar with NP/PAs seeing patients where I have established the diagnoses and treatment plans. In primary care they are much more a replacement for common problems. Hard for me to believe that they would be doing the Consult for you, but I don't know what's normal for your area.

Thank you guys very much. I am more concerned about finding the right person, not in terms of knowledge, but rather attitude. I interviewed few NPs and unfortunately all of them were clearly looking for some 9-5 job with minimal pt contact. They want to discuss labs, etc on the phone with PTs, and "manage" chronic medical conditions. Over the phone, of course. One NP used to consult some destitute pts in community clinics about medicine side effects and availability, sort of almost social worker. I guess Obama pays for stuff like that.

I agree that finding the right person is pivotal, not so much the degree perhaps. We have had midlevels that had totally different health care approaches than ours, and it really didn't work. If you hire a midlevel, he or she is an extention of your practice, unless for some reason you really want to fund an independent practitioner out of your office. That means, he or she needs to be willing to practice medicine your way... use the drugs you are familiar with, refer as you would refer, treat problems the way you would, etc. We have seen nurse practitioners who were not willing to do this, as they felt they had the license to practice independently, but if they accept your employment you need to be able to set the tone. Also, you need to set limits as to what things they see; there are procedures my PA's have done elsewhere that I do not do, so I can't supervise what I can't do myself.

I have seen practices where a physician will take on a midlevel, spend time to nurture and train the individual and then after two or three years the midlevel will go elsewhere and take a large chunk of patients with them. Do you have them sign a noncompete clause or anything of the sort???
I have never had a midlevel, and will likely never so am asking mainly out of curiosity.

We have not experienced that in this area. The PA's that came to us from other local practices brought a few patients with them, but mostly the patients in this area are with a practice because of the physician, of whom the midlevel is but an extention. The loyalty is more typically to the practice itself.
Our experience with a new graduate was also not good. We needed someone productive from day one. A new grad from NP/PA school is nothing like an MD who is just completing a residency, but more like a third year medical student. That piece of paper does not mean much.

Hi everyone,

Interesting topic. Over the past 25 years, I have been in a supervisory relationship with six mid levels. Over the first 18 years, I was at a Community Health Center, with a maximum of three mid-levels at any given time. For the last seven years I've been in private practice, with one physician's assistant.

I am a family physician, so my comments apply only to this specialty. Specialists may have very different perspectives.

All of the comments so far in this thread are very well taken. Patients, generally speaking, view the mid-level as a doctor, I have had very few patients who have objected to seeing the mid-level. Those that did, usually didn't like me either.

I agree that there is not much difference, practically, between a physician's assistant and a nurse practitioner. In my experience, a physician's assistant probably has somewhat better fund of basic knowledge, compared to NPs. The NPs, especially if they have worked as nurses for a while, usually have more clinical experience.

The most important quality for a mid-level is to know what they don't know. I'm not sure exactly how you determine this in an interview, but once they start you will find out pretty quickly. I emphasize to them that I would much rather be bothered too much, than too little, especially for the first six months or year of their practice.

A mid-level should be time and energy consuming, especially in the first six months. During residency, it took me quite a while to develop a basic approach to patients and their problems, and I don't think I really perfected this until several years in practice. A mid-level right out of training will benefit greatly from guidance, a mid-level who has worked elsewhere will take time to learn your approach and preferences. This is an investment. My physician's assistant was actually the first mid-level I worked with, we have worked together for over 25 years, she knows how I think and I know how she thinks.

However, as also mentioned earlier, you don't know how long you'll be working with any given mid-level. To put time and effort into them, and (usually when they've just gotten good) to see them move on is frustrating.



There is also an interesting development in Maryland. I'm not sure if this is the case in many other states. Maryland nurse practitioners no longer require a supervising physician. It is required that they have a collaborating physician. Once this physician indicates that he or she will serve in this capacity, the nurse practitioner is required to have no contact with him/her. No cosigning, no chart review, they may never see each other again.

I believe that one of the reasons for this is to try to remove any legal liability from the physician.

I doubt very much that that would be effective. I'm guessing that if a nurse practitioner were sued, the collaborating physician would be brought in to the legal proceedings, alleging that the collaborating physician provided inadequate oversight. Anyone with any thoughts or experience in this area?

Gene

I partially agree/disagree. Your suspected outcome is probably right on.

I believe the reasoning behind this is just to provide more "primary care providers" without making it more attractive for MDs to actually do it. MDs are being strongly undercompensated by the insurance companies. The mid-levels will be more willing to accept the current reimbursements w/o complaint, and it potentially prevents doctors from doing what they probably should do en masse...stop accepting insurance.

Here in Washington state, NPs can practice independently and several new "Family Medicine" clinics have popped up, completely run and staffed by NPs.
Dave
FP

Dave,

Do you know what, if any, physician involvement is necessary?

Thanks

Gene

One other point I've learned about working with mid-levels over 13 years is that the best thing I ever did was to share my office room with them, it really increases communication.

I know that doesn't apply to EasyRider's situation, but it made a world of difference for me. Probably hard to do if you use Dragon.

I'm obviously a little prejudiced here, but, a thought or two...
I've been precepting for second year PA students for thirty odd years, and my impression is that the specifics of license and title are less important than intelligence and experience. The ability to think logically and manage differential diagnosis can be taught, to a certain degree, but, does require a certain native ability. Our office has hosted several NP students as well as a few 4th year medical students. Although we do preselect our students, requiring from their schools that they be in the top quartile, the same needs for success apply across the board.
If there were a good way to test for critical thinking, as well as interpersonal skills you would have an easier task.
Good luck!

In Alaska, no physician involvement at all is necessary for a NP.

Thank you guys. Most helpful.