The State Board
Issue: September/October 2019
Author: Andy Mayer, MD FAAEM
Editor-in-Chief, Common Sense
The issue of independent practice for nurse practitioners seems to be heating up around the country. Many states have already enacted statutes which give nurse practitioners the right to practice independently of a physician. This has become a heated political issue with the nurse practitioners usually out lobbying physicians who often tend overall to be seemingly complacent or even fatalistic about what is going on in modern medicine. I certainly understand the conclusion that we have lost and to just put your head down and try and make a living while being a MD or DO still carries some significance. However, I think this is the wrong approach and that some of these political battles can be won if we make a concerted effort.
This issue has reared its ugly head in my own home state of Louisiana. Louisiana physicians have up to this point been able to prevent an independent practice statute from being passed. This has not been easy but the edges are crumbling none the less. The penetration of mid-level providers whether it be nurse practitioners or physician assistants has been drastically increasing even in states without the independent practice statute. In the July/August issue of this publication, an interview of an emergency physician from Louisiana was published. This board-certified emergency physician was working part time at a busy department in a larger Louisiana city when she was notified that the shifts which she had been working where in the future going to then be filled by a mid-level provider. This cost saving measure was done by a large corporate management group who may simply see mid-levels as a means to increase profits by cutting their labor costs. Again, why pay a doctor if you can pay a mid-level far less particularly in a double or triple coverage situation? Why not simply force the single doctor to sign all of the charts and bill the same amount for less overhead? Remember that to the corporate mind you are just expensive overhead. Think of the money that can be made by a physician staffing company if there was no longer a need to hire physicians!
Another disturbing incident recently occurred in a rural Louisiana hospital. A board-certified emergency physician was working a shift for a corporate management group at this hospital. This small hospital typically admitted some cases but transferred patients needing specialty care to a larger facility in the city. The emergency physician saw two patients requiring admission on this particular shift. One with a subacute stroke and another with a pulmonary embolus. He typically called an admitting physician and wrote holding orders placing them into a bed and the physician assumed care as the attending physician. He did so in this case but instead spoke to a nurse practitioner who he assumed was working with the hospitalist. He wrote orders admitting the patients to the physician he assumed would be the attending physician.
The situation quickly changed when he was called by administration and was told he had to change the attending of record to the nurse practitioner. The emergency physician who was writing these orders refused thinking that there must have been some sort of mistake as Louisiana is not an independent practice state. He thought that it would be inappropriate and possibly illegal to admit a patient with a serious medical condition or really any medical condition directly to a nurse practitioner. The emergency physician brought his concerns to the CEO and to the medical staff. This quickly led to the emergency physician being summarily fired by the corporate management group without any due process. He wrote to the Louisiana State Board of Medical Examiners about this incident and submitted a narrative of the incident to them.
AAEM became aware of this case and became involved. I attended the Louisiana State Board of Medical Examiners meeting in New Orleans to represent AAEM and express our views. I have been a physician in Louisiana for over thirty years but had never attended one of these state board meetings. The monthly meeting was held in a nice room with the board and several staff members present including a lawyer. These are usually public meetings open to all unless they are in some sort of executive session. The meeting was very professional and went through many small issues while I listened for about two hours before the issue for which I attended was discussed.
The CEO of the hospital was allowed to speak first and he related the cost of hiring physicians at his small rural hospital and the difficulties he faced staffing his emergency department and inpatient beds. He related that the inpatient coverage for patients who were admitted to his hospital had changed. This rural hospital averaged a census of only seven. In the new plan, one hospitalist and one nurse practitioner would provide the inpatient services. The physician would work seven days on alternating with the nurse practitioner who would then work seven days. The NP would have no direct physician involvement in the care he proved unless he called the hospitalist who lived in another city. The CEO explained that the NP could call the hospitalist if needed and could also call local doctors who were in their offices or could also call the emergency physician who was always in the hospital. The attending of record was changed to reflect the nurse practitioner as the attending. Thus, if a patient was admitted during the week when the nurse practitioner was on service it would seem quite likely that they may never see any physician while they were an inpatient in the hospital. The CEO explained that he arranged it this way to help insure that there would be no billing errors when the patient was inadvertently billed for services performed by a physician when in actuality all the services would be performed by the mid-level.
The board next allowed me to speak in regards to the independent practice of nurse practitioners in specific reference to this case. I thanked the board for the opportunity and then commented that I had listened to the board discuss numerous issues including letters and requests for clarification. I noted to them that I found it fascinating that the previous two hours of the board of medical examiners meeting rarely even mentioned physicians. There were discussions related to what nurse practitioners, physician assistants, medical technologists, etc. could do in place of a physician. There were discussions related to Nano-needling whatever that is and who could perform it. Can a physician assistant hire a doctor to work at their clinic? Can a physician living in Florida really be the collaborative physician with multiple mid-levels working in Louisiana? Several board members nodded their heads while I was speaking as I was expressing my shock that the state mandated body who regulates physicians and is empowered to sanction them was not discussing medicine at least as I know it. I expressed my concern that the emergency physician was now required to write admission orders for patients who may never again be seen by a physician during their admission. This brings real liability issues to the involved emergency physician. I was thanked for my testimony and the issue was quickly tabled after comments from board members asking for clarification if this process of admitting patients to a nurse practitioner was in fact legal. They asked for their lawyer to contact the Attorney General. One older member of the board made a statement reflecting that they all knew this day was coming but that they just needed to follow the law. In fairness, they had not received copies of any of the documents prior to the meeting due to a clerical error. At this writing, no decision has been made as to this incident but hopefully the ability of a nurse practitioner to admit patients and the idea that the emergency physician may be required to be the backup physician for the “collaborating” physician will be clarified.
In the end, attending this meeting was eye opening as I realized more and more that many of the decisions affecting our future are made in a room like this. I appreciate the time commitment these physician on the state board are making to represent the physicians in my state and I hope that many are fighting the good fight representing physicians. The obvious concern is that if the only feedback they receive is from various non-physicians trying to expand their scope of practice and that the interests of physicians will not be adequately represented.
I am sure all of you have some sort of newsletter from your state board but most of us try to avoid meeting with or being involved with a state medical board action as this often does not mean good news for the physician. Attending one of these meetings was informative. Certainly, the topics discussed were not always very interesting but overall I recommend you consider attending one of these meeting in your state. Witnessing one of these meetings may be the thing you need to motivate you from your slumber when you realize the erosion of medicine as we know it.