Paramedic Practitioners

[firecoins]

Any doctor who sees their patients less than their lackey is not worthy to be called a doctor and certainly shouldn't be paid for that nonsense.

No PA or NP should operate where there is a doctor. I was once told the purpose of them was to act where there was none. Like out in the sticks not in a medical center.

agree with this....alot.

 

[wildmed]

agree with this....alot.

I also agree with this statement. There are a lot of services/specialities that PAs could bring to rural areas if there was a push in that direction. Unfortunately, just like for physicians, the money and comfort is in urban areas.

My main goal in perusing PA school is to provide high quality rural emergency/ trauma care. Most rural EDs, at least where im from, are staffed with Family Practice docs. However from my prospective, it would probably be to the benefit of the patient to have at least one medic/PA with a year of EM/trauma residency in each ED. From what I have seen a lot of FP docs, even if they are seasoned in their ED, tend to struggle with the really sick/ high acuity trauma PTs. I personally would rather have a PA with alot of EM( training ( residency, ATLS,ACLS,PALS, difficult airway ect.) take care of me in a critical situation than an FP doc. This seems to be the thinking with the development of the ECP in england and hopefully the US will follow suite.

On another note... correct me if im wrong, but it seems to be the opinion of some people on this thread that EMS is a dying profession? First, thats really disappointing. Secondly, I don't agree. As long as people are getting hurt, or sick in places outside of the hospital, there will be a need for EMS. It is too ingrained into the system that it could just go away. I do think its evolving both for better and for worse, but all professions do.

 

[Arovetli]

However from my prospective, it would probably be to the benefit of the patient to have at least one medic/PA with a year of EM/trauma residency in each ED. From what I have seen a lot of FP docs, even if they are seasoned in their ED, tend to struggle with the really sick/ high acuity trauma PTs. I personally would rather have a PA with alot of EM( training ( residency, ATLS,ACLS,PALS, difficult airway ect.) take care of me in a critical situation than an FP doc.

For high acuity trauma, I'll take the surgical intensivist. There is a reason why the training is 10+ years. PA's with 3 years don't belong here. Preop/Postop rounding, clinic and buffering the night call...maybe...from what I've seen (anecdote alert) of surgical PA's they do alot of scut. It is also highly dependent on how far the attending lets them off the leash.

Also no amount of watered down alphabet courses supplant a proper medical education. The "residency" of a PA does not compare to a true medical residency. I will take the physician who dedicated many many years to their field over the assistant who did not.

There are some very intelligent midlevels, and midlevels have a place in medicine. A trained physician, however, they do not make.

On another note... correct me if im wrong, but it seems to be the opinion of some people on this thread that EMS is a dying profession? First, thats really disappointing. Secondly, I don't agree. As long as people are getting hurt, or sick in places outside of the hospital, there will be a need for EMS. It is too ingrained into the system that it could just go away. I do think its evolving both for better and for worse, but all professions do.

Not a dying profession, but as Vene says, it exists for a world that no longer does. Medicine as a whole is facing some very huge challenges in the coming years. Things will change.

 

[EpiEMS]

agree with this....alot.

Where's the data to back up the argument that a PA shouldn't be attending patients when an MD/DO is present? All the research I've seen demonstrates equivalency in outcomes. Then again, I haven't seen anything about, say, multiple trauma victims.

 

[Arovetli]

Where's the data to back up the argument that a PA shouldn't be attending patients when an MD/DO is present? All the research I've seen demonstrates equivalency in outcomes. Then again, I haven't seen anything about, say, multiple trauma victims.

Studies have compared midlevel care to resident/house staff care of lower acuity patients and found equivalency. Or the literature will compare midlevel care to physician care and find equivalency in outcomes yet the patients will still be low acuity. I am unaware of any studies showing full equivalency in outcomes of midlevels in treating any and all who present.

I feel there is a paucity of evidence in general on the utilization of midlevels.

If you have data to the contrary please present it. It may very well exist, yet I am unaware of it.

I see the utility in midlevels in certain circumstances but I share Veneficus' frustration with the situation.

As a consumer I would not want to pay the same for seeing a midlevel as I would a physician and as a clinician it is a matter of professional pride to take ownership of your patients rather than pawn them off on a lesser provider for the sake of making money.

 

[Veneficus]

For high acuity trauma, I'll take the surgical intensivist. There is a reason why the training is 10+ years. PA's with 3 years don't belong here. Preop/Postop rounding, clinic and buffering the night call...maybe...from what I've seen (anecdote alert) of surgical PA's they do alot of scut. It is also highly dependent on how far the attending lets them off the leash.

10+ is a nice understatement, mine will be closer to 20, from undergrad through residency.

Also no amount of watered down alphabet courses supplant a proper medical education. The "residency" of a PA does not compare to a true medical residency. I will take the physician who dedicated many many years to their field over the assistant who did not.

There are some very intelligent midlevels, and midlevels have a place in medicine. A trained physician, however, they do not make.

Finally, somebody gets it...

I like you.

I also like the idea of taking ownership of patients. A mid level operating where there is a physician is just an extra middleman that needs paying. From the consumer point of view, it is waste.

 

[Veneficus]

On another note... correct me if im wrong, but it seems to be the opinion of some people on this thread that EMS is a dying profession? First, thats really disappointing. Secondly, I don't agree. As long as people are getting hurt, or sick in places outside of the hospital, there will be a need for EMS. It is too ingrained into the system that it could just go away. I do think its evolving both for better and for worse, but all professions do.

It is important to understand EMS in the US is not a profession, it is a vocation.

The question is not about the elimination of EMS, it is a question of becomming a profession or remaining a vocation.

That is the fundamental principle underlying to everything from curriculum, to increased educational standards, autonomy, and ultimately pay.

 

[EpiEMS]

I am unaware of any studies showing full equivalency in outcomes of midlevels in treating any and all who present.

Agreed, I haven't found anything about anything beyond moderate acuity patients. Though I'd wager that even with severe acuity patients, no matter whether you've got an ED PA or an ED MD/DO, they're gonna do the same thing –:censored:whether it is move them to surgery ASAP or get them to a ICU ASAP, right?

I feel there is a paucity of evidence in general on the utilization of midlevels.

I disagree: there's been good research coming out on PAs and NPs since the 1970s.

As a consumer I would not want to pay the same for seeing a midlevel as I would a physician and as a clinician it is a matter of professional pride to take ownership of your patients rather than pawn them off on a lesser provider for the sake of making money.

That's certainly your choice – but they're, as I've presented above, not inferior providers by any means. The midlevels are designed to speed treatment, treat lower-acuity patients, and, when an MD/DO is not available on site, to serve as a physician extender, as far as I can tell. Midlevels also bill at lower rates, so if cost is a factor, as a hospital administrator, I might very well choose to hire 1 MD at $160k and 2 PAs at $80k each rather than 2 MDs at $160k each. That is quite possibly a better thing for patients, both higher acuity and lower acuity. Think about it this way:

Say your ED has 8 low/moderate acuity rooms and 2 beds for high acuity patients. You've got 8 filled regular beds, which the PAs can attend to, and 2 high acuity patients can be dealt with by the MD. You've got some RNs to do other tasks and a couple techs too. A 1:5 ratio is not nearly as good as a 3:10 ratio, right? And I might even go as far as to say that the high acuity beds, if filled, should be attended to by 1 MD, giving 1:2 and giving the 8 moderate acuity beds to either 2 PAs or 1 MD. I'd rather have 2 PAs covering, 'cause 1:4 is WAY better than 1:8.

 

[EpiEMS]

. A mid level operating where there is a physician is just an extra middleman that needs paying. From the consumer point of view, it is waste.

This just isn't true. The PA or ED NP operates at lower cost to the consumer. He or she also operates at essentially the same level as the MD, at least, as far as outcomes go. And, don't forget, since PAs and NPs are cheaper than MDs, you have a better patient/staff ratio, so patients are seen more and given quicker attention.

 

[Veneficus]

This just isn't true. The PA or ED NP operates at lower cost to the consumer. He or she also operates at essentially the same level as the MD, at least, as far as outcomes go. And, don't forget, since PAs and NPs are cheaper than MDs, you have a better patient/staff ratio, so patients are seen more and given quicker attention.

I am not sure you are understanding how this operates.

These people are rounding in facilities which submit a bill for their services.

The facility also have physicians that "oversee" the same patients who submit a bill as if they saw the patient.

That is 2 bills for the same service. One for the doctor and one playing doctor.

When I saw it in action, I witnessed mid level providers simply following algorithms on each patient, which is quite something the nurse can do.

There is no reason these same patients cannot be seen daily by the doctor who is billing. If the doctor is too busy, then perhaps the doctor shouldn't get to bill?

Fat chance of that happening though. It is just an additional layer. If there was no physician billing, I could support the use of a midlevel.

But that is not the case.

 

[EpiEMS]

These people are rounding in facilities which submit a bill for their services.

The facility also have physicians that "oversee" the same patients who submit a bill as if they saw the patient.

I was under the impression that midlevels bill at 85% of physician billing rates, at least for many times they're providing care for Medicaid patients. And billing rates vary for private insurers, Tricare, etc.
I'm sure billing and payment varies at many places, much like how ER docs are employees of the hospital in some places and independent contractors in others.
I admit that I'm neither a PA/NP nor MD/DO, and certainly not even close to any of those levels of education, but from a purely business and health policy perspective, midlevels make extremely good sense.

 

[Veneficus]

I was under the impression that midlevels bill at 85% of physician billing rates, at least for many times they're providing care for Medicaid patients. And billing rates vary for private insurers, Tricare, etc.
I'm sure billing and payment varies at many places, much like how ER docs are employees of the hospital in some places and independent contractors in others.
I admit that I'm neither a PA/NP nor MD/DO, and certainly not even close to any of those levels of education, but from a purely business and health policy perspective, midlevels make extremely good sense.

If only the midlevel was getting paid.

But on an inpatient ward, if a midevel sees you 4 days a week and the physician sees you once, you pay 85% of what the physician would get for the midlevel, then you pay 100% of what the physician gets to the physician.

It is a business strategy used by hospital not because of the level of care provided or care access, but because now they are getting 185% instead of 85%for just the midlevel or 100% for the physician.

Consider something for just a moment. The US spends the highest amounts of any nation many times over for some of the worst healthcare in the world among its populous.

Salary in any business is a major expense.

Midlevels are almost non existant outside of North America, low level tech positions are almost nonexistant outside of North America.

Explain to me how generating 2 bills for the same service, saves money?

That is like paying to have your lawn mowed by the guy doing it, then paying a higher price to have what that guy did inspected.

 

[EpiEMS]

If only the midlevel was getting paid.

But on an inpatient ward, if a midevel sees you 4 days a week and the physician sees you once, you pay 85% of what the physician would get for the midlevel, then you pay 100% of what the physician gets to the physician.

It is a business strategy used by hospital not because of the level of care provided or care access, but because now they are getting 185% instead of 85%for just the midlevel or 100% for the physician.

So, say the MD bills $100 and the PA bills at $85 (obviously way low, but for convenience). 4 PA visits = $340. 1 MD visit = $100. 5 practitioner visits = $440. That's cheaper than 5 MD visits for the patient, and since you can train 2+ PAs for the price and time of training 1 MD, it makes good business sense to have the PAs, both from the employer perspective and the patient (i.e. customer) perspective

Midlevels are almost non existant outside of North America, low level tech positions are almost nonexistant outside of North America.

Explain to me how generating 2 bills for the same service, saves money?

There are 2 bills for the same service all the time. If you've got a radiology clinic owned by a hospital and serviced by physicians who are in their own practice, you get a bill from the hospital and a bill from the docs. Pretty common setup, happens for ERs too.

But, aside from being common, generating 2 bills with the PA-MD team gets the patient seen more often by a trained provider. The patient is seen more, seen faster, and treated effectively at lower cost per visit and at a lower total cost.

I'm by no means qualified to speak on the medical component of PA vs MD care quality, except insofar as I've never seen large scale studies showing that PA care quality is any less than that provided by physicians. I am only trying to speak to the business and policy side, so I apologize for any errors I've made.

 

[wildmed]

venificus,
first of all, the way your projecting your opinions on midlevels is mildly offensive. I don't know where your interacting with NP/PA, So I am in no place to judge, but they definitely deserve more credit than you give. I know PAs that work solo coverage in EDs, who do multitudes of fully independent, highly invasive procedures in IR, cary their own patient loads in FP offices and even run level 1 trauma alerts in hospitals where all of the 1st responders on the trauma team are midlevels. There are even PAs that very successfully have a there own practice, cary there own patient load and pay a retired doc to look over a certain percent of their charts and sign them.These people sure as heck do not run off of any "algorithm" and are fully competent providers.

I've been around in hospital healthcare for almost my entire career and have worked with countless midlevels.The billing your are talking about does happen however i've been told its not exactly legal and obviously is wholly immoral. What happens more often is that the patient gets billed at 100% instead of the 85% because the doc meets with the pt once and then is attended to by the midlevel for the remainder of their care but is still under the " physicians care". There is a pretty big backlash against even this right now. I do however think that this gets tricky with surgical PAs when the doc and the PA are both "Providers" in the OR. Honestly, this is all just perpetuated by a healthcare system that is driven by profit and unfortunately by greed.
Ill reiterate this, PAs really were not men't to work in urban areas, they where supposed to work in places with dire healthcare need. Those that do, make a HUGE difference in the level of competent healthcare that is available in those communities.

Lets get this thread back on track and talk about the furtherance of EMS why don't we?

I think many agree that making a midlevel EMS provider is not a great idea, How ever expanding the scope of practice and required education of our top level of EMS provider to include treat and street protocols, more advanced field protocols ect would probably alleviate any need for one anyway. I honestly think going back to a system with maybe a higher level EMT as an initial first responder and then a high level ALS backup, similar to what is used in australia is the way to move forward.

Random thought:
Does anyone else find it odd that in this country people leave EMS to go to nursing, and in other countries people leave nursing to go to EMS? In most cases nurses are not ALS providers per-sey ( flight nurses/AP nurses excluded) but paramedics are? Pay for paramedics tends to be much higher than nursing as well in those countries as well. kinda backwards right?

 

[EpiEMS]

Random thought:
Does anyone else find it odd that in this country people leave EMS to go to nursing, and in other countries people leave nursing to go to EMS? In most cases nurses are not ALS providers per-sey ( flight nurses/AP nurses excluded) but paramedics are? Pay for paramedics tends to be much higher than nursing as well in those countries as well. kinda backwards right?

It seems backwards to me, frankly, because I perceive paramedics as having more clinical autonomy than any RN short of an NP. In terms of compensation, EMT-P education is shorter than RN education. But EMT-P working conditions are more dangerous. I'm not sure how many paramedics there are in the US, but I can say with fair certainty that there are about 2.7 million RN jobs and 227,000 EMS jobs at all levels of providers. One would think that EMT-Ps would be making as much or more than RNs, but it could be the union factor. Or the "nursing is a profession, EMS is 'just a technician.'"

 

[Medic Tim]

It seems backwards to me, frankly, because I perceive paramedics as having more clinical autonomy than any RN short of an NP. In terms of compensation, EMT-P education is shorter than RN education. But EMT-P working conditions are more dangerous. I'm not sure how many paramedics there are in the US, but I can say with fair certainty that there are about 2.7 million RN jobs and 227,000 EMS jobs at all levels of providers. One would think that EMT-Ps would be making as much or more than RNs, but it could be the union factor. Or the "nursing is a profession, EMS is 'just a technician.'"

I have an AAS degree in ems. All the pre rec and general classes are the same as the nursing program. THe only difference is that we do Medic classes and they do nursing. Same degree different concentration.
The program I went through is starting a community paramedics program next semester as Maine is beginning a pilot project. I am thinking I might go for it.

 

[EpiEMS]

I have an AAS degree in ems. All the pre rec and general classes are the same as the nursing program. THe only difference is that we do Medic classes and they do nursing. Same degree different concentration.
The program I went through is starting a community paramedics program next semester as Maine is beginning a pilot project. I am thinking I might go for it.

Understood, and your compensation should most certainly reflect it. If EMS were to become a profession as we recognize professions (e.g. medicine, law, divinity, etc.), it would be most preferable. Ideally, that'd be the standard: Associates degree in EMS as entry level for medics, and bachelors as an upgrade, ending up with graduate degrees. Nursing has done a good job at making itself into a profession:censored:– this is recent change, I feel, considering the history of the field.

 

[Medic Tim]

Understood, and your compensation should most certainly reflect it. If EMS were to become a profession as we recognize professions (e.g. medicine, law, divinity, etc.), it would be most preferable. Ideally, that'd be the standard: Associates degree in EMS as entry level for medics, and bachelors as an upgrade, ending up with graduate degrees. Nursing has done a good job at making itself into a profession:censored:– this is recent change, I feel, considering the history of the field.

Where I went in ME the starting wage for a medic is 10 an hour. Where I work in Canada a Primary Care Paramedic (the equivalent of an EMT-Intermediate) makes more than double that. It is also the minimum level on the trucks. The PCP course here is 9 months didactic m-f 9-5 then 2-3 months in the hospital and on the trucks. For Advanced Care Paramedic it is another 1-2 years with at least a couple years experience as a PCP. There are also a few BS Paramedicine programs out west. With my 2 year EMS Degree there was still an education gap I needed to fill on my own.

I agree that there needs to be a shift in EMS education. A min of 2 years for medic would be a good start. I would also like to see Basic done away with and the EMT level turn into what an Intermediate or AEMT Currently is. I would love to see EMS in the US move from a vocation to a profession.

 

[wildmed]

I fully agree with the above. I think EMS is moving in that direction, abet slowly, but eventually we will get there. I had a good conversation with a long time medic the other day that suggested that EMS try to move in alignment the AMA to advance itself. This idea had never occurred to me but it would make sense due to the fact that EMS professionals are trained within the medical model, even if it is extremely paired down version of it. It would definitely give some weight where it would count politically. I would guess that this could bring EMS to the level of nursing and beyond rather quickly. Ideally this would make the Medic the equivalent of the nurse, but trained within the medical model.
The community paramedic idea seems to be catching on rather quickly, eagle county EMS here in CO was one of the first to establish a community medic program. So far its been pretty effective. I personally think its a great idea, especially if you could mix being a community medic with traditional 911 EMS. I think it would help with burnout and job satisfaction because your A. making an attempt to decrease BS calls. B. making an attempt to help people STAY healthy C. Shifting the majority of real emergent calls to people who really, actually need your assistance. However, then we come back to the idea of a "community paramedic" being advance practice and the argument has come full circle as to if this is a good idea or not.

 

[Veneficus]

I'm by no means qualified to speak on the medical component of PA vs MD care quality, except insofar as I've never seen large scale studies showing that PA care quality is any less than that provided by physicians.

If that were the case, there would be no need for a physician at all.

I have never seen such studies, but the very idea that somebody with considerably lesser education performs care as well as somebody with more, is either terribly flawed research or the research is set up to demonstrate the outcome specifically.

I am really not concerned about offending mid level providers, if they want to play doctor they should go to medical school.