PAs and NPs in OB/GYN?

[saltbreeze55]

There's a lot of discussion around PAs/ NPs expanding scope of practice in emergency medicine, anesthesia, family med and some other fields. I have not seen this about OB/GYN and was just wondering firstly, is it true that ob/gyn is not one of the fields impacted as much? If so, so why this may be? Do you see it becoming an increasing problem in the future for this field? It seems like midwives have been common for a while as well, but it doesn't seem like they are "stealing" jobs from OB.

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[Lawpy]

Yay another midlevel thread!

@efle @Lem0nz @Steve_Zissou lets continue where we left off

 

[Steve_Zissou]

Yay another midlevel thread!

@efle @Lem0nz @Steve_Zissou lets continue where we left off

Every specialty is susceptible. This isn’t about competency or ability, it’s about money and lobbying. If they can take an inch, they will. If they can take a mile, they will. I’ve seen NPs in OB. The only thing I haven’t seen midlevels do in OB is surgery, but I doubt that’s safe either. If, as some surgeons say, you can “teach a monkey” surgery then NPs and PAs will likely be pushing to do surgery in the nearish future.

 

[Lawpy]

Every specialty is susceptible. This isn’t about competency or ability, it’s about money and lobbying. If they can take an inch, they will. If they can take a mile, they will. I’ve seen NPs in OB. The only thing I haven’t seen midlevels do in OB is surgery, but I doubt that’s safe either. If, as some surgeons say, you can “teach a monkey” surgery then NPs and PAs will likely be pushing to do surgery in the nearish future.

Why is physician lobbying terrible but midlevel lobbying so effective?

 

[Lem0nz]

Doubt there is any significant threat at all. The liability and the cost from bad outcomes from surgery (and OB) are not worth the 'value' of the salary differential. Very similar to the post on the IM area about why they won't get replaced like EM did. There is a break even point for value and cost of physician vs. midlevel. Some understanding of how billing and reimbursement works in surgery (and I believe also OB) in regards to 30 day globals and CPT billing greatly helps in understanding how and why this is the case.

Don't let these naysayers scare you.

 

[Dr G Oogle]

There are nurse midwives in OB who do a lot of low risk deliveries and there are women’s health NPs in gyn and OB who do routine care. In residency the midwives did do some crazy 💩 but often owned up to it and they did take care of the relatively more needy pateints, they cannot and do not really waNt to take care of people who actually need a gynecologist or obstetrician, nor are they willing to shoulder the liability for this type of care.

Everywhere I trained and did moonlighting the midwives were not allowed to care for anything that even smelled like an actual problem, and in FPMRS they only see our follow ups like pessary changes and med checks and annual postop visits, if they do see a new patient it has to be run through me or a partner before committing to a treatment plan.

 

[saltbreeze55]

Doubt there is any significant threat at all. The liability and the cost from bad outcomes from surgery (and OB) are not worth the 'value' of the salary differential. Very similar to the post on the IM area about why they won't get replaced like EM did. There is a break even point for value and cost of physician vs. midlevel. Some understanding of how billing and reimbursement works in surgery (and I believe also OB) in regards to 30 day globals and CPT billing greatly helps in understanding how and why this is the case.

Don't let these naysayers scare you.

would you mind sharing a little information on 30 day globals and CPT billing or some resources to learn more?

 

[Splenda88]

Why is physician lobbying terrible but midlevel lobbying so effective?

We are fragmented and they are not. Each speciality is looking out for itself. Hello surgeons!

 

[Lem0nz]

would you mind sharing a little information on 30 day globals and CPT billing or some resources to learn more?

Sure. The really short version is that medical billing is billed 'per visit'. So if you have a patient who comes into the hospital (or the clinic), you bill them for a consult based on level of complexity (1-5) and then you bill them each time you see them afterwards with a different code for some version of follow up. So if you have a patient admitted to the hospital, you get to give them a somewhat larger bill on the first day for the consult, and then bill them every single day they're in the hospital as you manage their problems.

For surgeons (and I think this is all proceduralists), you do medical billing until you decide to operate on them. Once the decision to operate or do an invasive procedure is done, you then bill them once for that procedure and for the next thirty days you don't bill them again. So if they had appendicitis, you bill them once for appendectomy and they give you a lump sum payment that covers whatever happens afterwards. If you send them home that afternoon from observation and they do great, fantastic! You made the system a ton of money! But if they stay in the hospital with a post-op abscess and wound complications for 7-14 days, you just lost the hospital a ton of money. As a surgeon you'll still get your proceduralist piece (this is assuming a hospital employed type model, but it is similar for PP) but you're not billing them for the time you spend rounding on them or managing their post-op complications. The money you get from doing an operation is >>>>> how much you get for a typical medical follow up visit, but you have two or three of those every other day (on average) vs seeing 20 medical patients every single day.

Because of this, where money is made in a surgical type field is in the actual operations/procedures, not the follow up care and, for the most part, not the pre-op and consultations either. While you do make money from those, it pales in comparison to the money/RVU generated from actually doing an operation.

There are barriers keeping NPs and PAs from doing the operations which are and probably will eventually be eroded, but if they can't do them with the same level of quality that a surgeon or gyn doc can, those patients will be sitting in the hospital with multiple complications that are not generating money compared to an efficient, high quality surgeon. So even if the day comes where they try to operate truly and completely independently, it is very unlikely a hospital would hire them to do that over a physician unless said NP or PA can demonstrate the same level of quality and reliable outcomes of a surgeon or gyn.

From personal experience, at PGY7 I am *just now* starting to feel comfortable and confident to do big operations reliably and safely and I have ~5 years more of learning and tinkering before I will be up to speed after a surgery residency and fellowship. Any other surgeon on this forum will tell you the same thing, that it really does take a decade of intense training and practice before you are safe, confident, reliable, and reproducible. NPs and PAs won't do that and won't even attempt to do that. If they take short cuts (and they will) they'll find out why we spend so much time training in a very short order. Hospitals are not stupid. They want to make money. This is not the way to make money and not the spot where cutting cost on an upfront salary will somehow produce more revenue.

Instead, what you see is that the pieces of surgery that can be managed by a non-surgeon (pre-op and some pieces of the work-up and initial consultation, the immediate post-op, the surgical follow up, floor management inpatient, etc.) are being given to NPs and PAs to keep the surgeons in the operating room and build teams that can physically do more operations by allocating more of a surgeons time to actually being in the OR suite. I suspect this will continue to expand over the next decade. When done well, it is quite safe and does increase productivity and gives very reliable quality and reproducibility of outcomes. It also makes a lot of surgeons and OB folk quite happy because they get to spend more time doing what they love (surgery and babies) and less time doing paperwork, documentation, and orders.

 

[Smurfette]

Sure. The really short version is that medical billing is billed 'per visit'. So if you have a patient who comes into the hospital (or the clinic), you bill them for a consult based on level of complexity (1-5) and then you bill them each time you see them afterwards with a different code for some version of follow up. So if you have a patient admitted to the hospital, you get to give them a somewhat larger bill on the first day for the consult, and then bill them every single day they're in the hospital as you manage their problems.

For surgeons (and I think this is all proceduralists), you do medical billing until you decide to operate on them. Once the decision to operate or do an invasive procedure is done, you then bill them once for that procedure and for the next thirty days you don't bill them again. So if they had appendicitis, you bill them once for appendectomy and they give you a lump sum payment that covers whatever happens afterwards. If you send them home that afternoon from observation and they do great, fantastic! You made the system a ton of money! But if they stay in the hospital with a post-op abscess and wound complications for 7-14 days, you just lost the hospital a ton of money. As a surgeon you'll still get your proceduralist piece (this is assuming a hospital employed type model, but it is similar for PP) but you're not billing them for the time you spend rounding on them or managing their post-op complications. The money you get from doing an operation is >>>>> how much you get for a typical medical follow up visit, but you have two or three of those every other day (on average) vs seeing 20 medical patients every single day.

Because of this, where money is made in a surgical type field is in the actual operations/procedures, not the follow up care and, for the most part, not the pre-op and consultations either. While you do make money from those, it pales in comparison to the money/RVU generated from actually doing an operation.

There are barriers keeping NPs and PAs from doing the operations which are and probably will eventually be eroded, but if they can't do them with the same level of quality that a surgeon or gyn doc can, those patients will be sitting in the hospital with multiple complications that are not generating money compared to an efficient, high quality surgeon. So even if the day comes where they try to operate truly and completely independently, it is very unlikely a hospital would hire them to do that over a physician unless said NP or PA can demonstrate the same level of quality and reliable outcomes of a surgeon or gyn.

From personal experience, at PGY7 I am *just now* starting to feel comfortable and confident to do big operations reliably and safely and I have ~5 years more of learning and tinkering before I will be up to speed after a surgery residency and fellowship. Any other surgeon on this forum will tell you the same thing, that it really does take a decade of intense training and practice before you are safe, confident, reliable, and reproducible. NPs and PAs won't do that and won't even attempt to do that. If they take short cuts (and they will) they'll find out why we spend so much time training in a very short order. Hospitals are not stupid. They want to make money. This is not the way to make money and not the spot where cutting cost on an upfront salary will somehow produce more revenue.

Instead, what you see is that the pieces of surgery that can be managed by a non-surgeon (pre-op and some pieces of the work-up and initial consultation, the immediate post-op, the surgical follow up, floor management inpatient, etc.) are being given to NPs and PAs to keep the surgeons in the operating room and build teams that can physically do more operations by allocating more of a surgeons time to actually being in the OR suite. I suspect this will continue to expand over the next decade. When done well, it is quite safe and does increase productivity and gives very reliable quality and reproducibility of outcomes. It also makes a lot of surgeons and OB folk quite happy because they get to spend more time doing what they love (surgery and babies) and less time doing paperwork, documentation, and orders.

FYI...post op global period is 90 days, not 30. So for 3 months after operating on a patient, surgeons can't bill anything on them other than the global code (unless a new unassociated problem or new procedure).

 

[Dr G Oogle]

FYI...post op global period is 90 days, not 30. So for 3 months after operating on a patient, surgeons can't bill anything on them other than the global code (unless a new unassociated problem or new procedure).

Double FYI if a patient comes in after a surgery within the 90 days you can still bill for it as long; like if the develop appendicitis after a cholecystectomy

 

[ohmanwaddup]

1 week of my OBGYN rotation was spent with a NP. She mostly did women's health. She had to be partnered with a doc and she was only able to do births that the doc considered low risk. However we are in the midwest and the doc considered anyone with a BMI over 30 risky enough to warrant physician care, essentially making sure 90+% of OB cases went to the doc.

I did one delivery with the NP after doing 5 with the doc. The differences in teaching was wild. The doc had stayed close by and softly talked me through each step and I felt confident doing a delivery with them over my shoulder. the NP was wayyy more casual and basically and offered no feedback or guidance during the delivery, and was not in a position physically to quickly step in. It was pretty scary and I felt way less comfortable doing the delivery.

There is a decent sized movent that believes that OBGYNs are evil/cash hungry and that its much safer to do a more natural water birth at home with only a doula, midwife or NP. Since women's health is already a topic most people are not widely educated on, the constant assault of "chemicals will hurt you or your baby, eat only oranges instead" that American's are blasted with, and the apparent growing mistrust of physicians I personally consider OBGYN ripe for encroachment by non physicians.

Malpractice insurance may provide some buffer, but if state organizations are not willing to punish people, and if malpractice isn't required for certain providers it may not actually be that big of a barrier to entry.

this is all N=1 though

 

[Lem0nz]

FYI...post op global period is 90 days, not 30. So for 3 months after operating on a patient, surgeons can't bill anything on them other than the global code (unless a new unassociated problem or new procedure).

You can tell I'm still a fellow. XD

Do operative takebacks get billed?

 

[Dr G Oogle]

You can tell I'm still a fellow. XD

Do operative takebacks get billed?

As far as I know they do. This was taught to me 2nd year of attendinghood and seems to be kosher. Since take backs are unexpected” they can billed. But always recommend clarifying this with billing departments

 

[Oligodinero]

Every specialty is susceptible. This isn’t about competency or ability, it’s about money and lobbying. If they can take an inch, they will. If they can take a mile, they will. I’ve seen NPs in OB. The only thing I haven’t seen midlevels do in OB is surgery, but I doubt that’s safe either. If, as some surgeons say, you can “teach a monkey” surgery then NPs and PAs will likely be pushing to do surgery in the nearish future.

By far the most common MLP in OBGYN is the nurse midwife. You'll see some WHNPs....they mostly do WWPEs....some do colposcopies, biopsies, IUDs, Nexplanon, etc. Some WHNPs and PAs will do first trimester OB visits as those are fairly formulaic and grab the doctor if any red flags or abnormal findings are discovered. I've heard of a few very rural places where PAs do vaginal deliveries....there was. a place in super rural Oklahoma about 20 years ago or so this was the case.....I have no idea if it's still this way.

 

[Goro]

Yay another midlevel thread!

@efle @Lem0nz @Steve_Zissou lets continue where we left off

Indeed. Here's all the thread needs:

Can the wise @gyngyn give some sage counsel here?

 

[gyngyn]

There is a vocal organization of Women's Health NP's (NPWH). They are interested in expanding the role of NP's to include procedures such as IUD and implant insertion (and removal) as well as well-woman office care.
Midwives have a role in some counties (mostly prenatal care under supervision).
I have seen a few PA's in state and county funded clinics.

 

[Steve_Zissou]

There is a vocal organization of Women's Health NP's (NPWH). They are interested in expanding the role of NP's to include procedures such as IUD and implant insertion (and removal) as well as well-woman office care.
Midwives have a role in some counties (mostly prenatal care under supervision).
I have seen a few PA's in state and county funded clinics.

What are your thoughts on that expansion of roles?

 

[gyngyn]

What are your thoughts on that expansion of roles?

If you are trained to obtain consent for IUD placement and do lots of procedures, you get really good at it. This is the pinnacle of their practice. Compare that to your average Ob/Gyn in practice who might place one a week (maybe). It's a pain in the neck to get the devices (unless you are at a government clinic) and consent takes as long as a hysterectomy consent!
The Levo IUD (Mirena) is so good at managing pain and bleeding that the number of surgical gyn procedures can be reduced considerably.
In my view, anything that makes effective reversible contraception happen is worth it, even if (especially if?) it reduces the need for surgical intervention. As long as they bear the liability, I have no problem with it.

 

[Medmortise]

There's a lot of discussion around PAs/ NPs expanding scope of practice in emergency medicine, anesthesia, family med and some other fields. I have not seen this about OB/GYN and was just wondering firstly, is it true that ob/gyn is not one of the fields impacted as much? If so, so why this may be? Do you see it becoming an increasing problem in the future for this field? It seems like midwives have been common for a while as well, but it doesn't seem like they are "stealing" jobs from OB.

The rate at which NPs are being produced due to the ease of obtaining the degree is not sustainable for our system. This leads to their organization backed by massive numbers and funds being able to lobby themselves into roles they are not capable or trained for. It seems crazy to think that a NP/PA with fraction of the training would be doing OB procedures or even surgery but the reality is that lobbying is how this country is run at every level. I predict that within the next 5-10 years, they will have lobbied themselves into doing procedures and surgeries in most specialties.

 

[Lem0nz]

The rate at which NPs are being produced due to the ease of obtaining the degree is not sustainable for our system. This leads to their organization backed by massive numbers and funds being able to lobby themselves into roles they are not capable or trained for. It seems crazy to think that a NP/PA with fraction of the training would be doing OB procedures or even surgery but the reality is that lobbying is how this country is run at every level. I predict that within the next 5-10 years, they will have lobbied themselves into doing procedures and surgeries in most specialties.

Legally being able to do them and being both hired and privileged to do them are two wildly different things. Its really not gonna happen in any significant numbers that impact us in our life time.

 

[Splenda88]

Legally being able to do them and being both hired and privileged to do them are two wildly different things. Its really not gonna happen in any significant numbers that impact us in our life time.

You really think employers who are hiring hospitalist NP after their 500-800 hrs shadowing instead of MD/DO believe they can manage these complex hospitalized patients. These people are smarter than us. They introduce the concept slowly and rely on us to train these people and boom! physicians to NP ratio keep changing slowly. They started with 2:1, slowly it is 1:1, and then 1:2.

 

[Smurfette]

You can tell I'm still a fellow. XD

Do operative takebacks get billed?

Yes, but I do know some surgeons (mostly in PP) who won't bill a patient for it if it was secondary to a complication.

 

[Lem0nz]

You really think employers who are hiring hospitalist NP after their 500-800 hrs shadowing instead of MD/DO believe they can manage these complex hospitalized patients. These people are smarter than us. They introduce the concept slowly and rely on us to train these people and boom! physicians to NP ratio keep changing slowly. They started with 2:1, slowly it is 1:1, and then 1:2.

I have pretty plainly and clearly stated that I think employers will not hire them to do that work because the revenue benefit is not there on the salary differential vs. the speed and safety of surgeons and the fact that our complications are not subtle. And given multiple reasons in this post.

Would love for the anti midlevel crowd to give some compelling reasons why I’m wrong to contrast.

 

[YCAGA]

Sure. The really short version is that medical billing is billed 'per visit'. So if you have a patient who comes into the hospital (or the clinic), you bill them for a consult based on level of complexity (1-5) and then you bill them each time you see them afterwards with a different code for some version of follow up. So if you have a patient admitted to the hospital, you get to give them a somewhat larger bill on the first day for the consult, and then bill them every single day they're in the hospital as you manage their problems.

For surgeons (and I think this is all proceduralists), you do medical billing until you decide to operate on them. Once the decision to operate or do an invasive procedure is done, you then bill them once for that procedure and for the next thirty days you don't bill them again. So if they had appendicitis, you bill them once for appendectomy and they give you a lump sum payment that covers whatever happens afterwards. If you send them home that afternoon from observation and they do great, fantastic! You made the system a ton of money! But if they stay in the hospital with a post-op abscess and wound complications for 7-14 days, you just lost the hospital a ton of money. As a surgeon you'll still get your proceduralist piece (this is assuming a hospital employed type model, but it is similar for PP) but you're not billing them for the time you spend rounding on them or managing their post-op complications. The money you get from doing an operation is >>>>> how much you get for a typical medical follow up visit, but you have two or three of those every other day (on average) vs seeing 20 medical patients every single day.

Because of this, where money is made in a surgical type field is in the actual operations/procedures, not the follow up care and, for the most part, not the pre-op and consultations either. While you do make money from those, it pales in comparison to the money/RVU generated from actually doing an operation.

There are barriers keeping NPs and PAs from doing the operations which are and probably will eventually be eroded, but if they can't do them with the same level of quality that a surgeon or gyn doc can, those patients will be sitting in the hospital with multiple complications that are not generating money compared to an efficient, high quality surgeon. So even if the day comes where they try to operate truly and completely independently, it is very unlikely a hospital would hire them to do that over a physician unless said NP or PA can demonstrate the same level of quality and reliable outcomes of a surgeon or gyn.

From personal experience, at PGY7 I am *just now* starting to feel comfortable and confident to do big operations reliably and safely and I have ~5 years more of learning and tinkering before I will be up to speed after a surgery residency and fellowship. Any other surgeon on this forum will tell you the same thing, that it really does take a decade of intense training and practice before you are safe, confident, reliable, and reproducible. NPs and PAs won't do that and won't even attempt to do that. If they take short cuts (and they will) they'll find out why we spend so much time training in a very short order. Hospitals are not stupid. They want to make money. This is not the way to make money and not the spot where cutting cost on an upfront salary will somehow produce more revenue.

Instead, what you see is that the pieces of surgery that can be managed by a non-surgeon (pre-op and some pieces of the work-up and initial consultation, the immediate post-op, the surgical follow up, floor management inpatient, etc.) are being given to NPs and PAs to keep the surgeons in the operating room and build teams that can physically do more operations by allocating more of a surgeons time to actually being in the OR suite. I suspect this will continue to expand over the next decade. When done well, it is quite safe and does increase productivity and gives very reliable quality and reproducibility of outcomes. It also makes a lot of surgeons and OB folk quite happy because they get to spend more time doing what they love (surgery and babies) and less time doing paperwork, documentation, and orders.

This is really interesting and I learned a lot. But couldn’t this be changed in the future? It’s not like post-operative billing is banned in the constitution.

In other words, billing policy doesn’t make me feel anymore safe from midlevels than the current laws that require them to be supervised in some states.

 

[calivianya]

We had midlevels on my OB/gyn rotation and they just did office visits and office procedures - IUD insertions, paps, etc. They didn’t even step foot in the hospital at my facility. I don’t think the physicians were bothered by this in the slightest. Just meant more time delivering babies and more time in the OR, with less healthy patient visits.

It sounds nice on the surface, but the thing that bothers me about this a little is that not everyone wants a hard/complicated day every day. I really feel like this is what midlevels are doing to most of the parts of medicine that they are working in - taking all the easier work and only leaving physicians with the harder stuff. It seems like a surefire way to increase physician burnout to me.

 

[Lem0nz]

This is really interesting and I learned a lot. But couldn’t this be changed in the future? It’s not like post-operative billing is banned in the constitution.

In other words, billing policy doesn’t make me feel anymore safe from midlevels than the current laws that require them to be supervised in some states.

Yes absolutely. You can actually take entire classes on this and I did during my masters. The trend however is moving more toward something called capitation. What capitation is is where an insurance company will pay a hospital system for an entire patient population rather than the individual patient. In this case the hospital is in charge of taking care of everything that walks in the door regardless of cost and regardless of what the problem is with the patient.

We certainly aren’t there yet, but in that sort of system quality is king and dictates how many dollars you keep in your pocket rather than the procedural fee for service model we’ve used for the last several decades. Again, that’s probably a couple decades away at least, but there are entire systems that have already moved toward this or are doing it entirely. Look at the NHS in England for a national model, or Kaiser at home in CA for a local model.

The trend will definitely continue in that direction and it’s probably an zero chance we’ll swing back toward fee for service. But no one knows if/when/how long it’s going to take for us to get there. With how American medicine and politics works it will be in incremental change and very slow.

To be clear, those sorts of systems are also using midlevels. But they aren’t doing it as a race to see how many patients can be seen for the cheapest cost. They’re doing it to see what level of acuity is actually safest for them to see vs. a physician that uses the least amount of resources and treats patients. It’s quite fascinating.

 

[Oligodinero]

We had midlevels on my OB/gyn rotation and they just did office visits and office procedures - IUD insertions, paps, etc. They didn’t even step foot in the hospital at my facility. I don’t think the physicians were bothered by this in the slightest. Just meant more time delivering babies and more time in the OR, with less healthy patient visits.

It sounds nice on the surface, but the thing that bothers me about this a little is that not everyone wants a hard/complicated day every day. I really feel like this is what midlevels are doing to most of the parts of medicine that they are working in - taking all the easier work and only leaving physicians with the harder stuff. It seems like a surefire way to increase physician burnout to me.

Yeah....but it's up to the SP to decide how they want to utilize the MLPs. If the docs or their corporate overlords are only concerned with profits then yeah it makes sense to have the MLPs see all the simple cases all day. But in private practices or smaller groups the docs can certainly have the front office schedule some paps, IUDs, etc with them. I know a whole group of OBGYNs employed by UPMC who do this....they have OR and office days. In their office days they're seeing prenatal, paps, colpos, lesions, IUDs, Implanon, endometrial biopsies, etc. And UPMC seems just fine with this. They also have MLPs (NPs and PAs) doing some 1st trimester uncomplicated prenatal visits in addition to paps and gyn issues like bleeding, discharge.