Speak by Jan. 17 on Pres. Trump’s Executive Order Regarding NP and PA Unsupervised Practice

Speak by Jan. 17 on Pres. Trump’s Executive Order Regarding NP and PA Unsupervised Practice

It’s time for physicians to answer the call for comment on the effect of Section 5 in President Trump’s Executive Order (EO), “Protecting and Strengthening Medicare,” of October 3, 2019.
Section 5 of this order calls for eliminating supervision by physicians of mid-level providers of medical care—nurse practitioners (NPs) and physician assistants (PAs).
More than that, it calls for pay parity (more accurately, “reimbursement parity”) among the same groups by Medicare.
Eventually all third-party payments for care would be leveled (flattened) across physicians, NPs, and PAs, regardless of their clinical training.
Pay parity and elimination of supervision will raise the cost of Medicare, accelerate the corporate takeover of healthcare, deepen the physician shortage, decrease competition in the healthcare sector, and multiply dangerous instances of patients being treated by someone with a fraction of the training received by a physician.
PPA explains this in detail in comments sent to CMS Administrator Seema Verma. To read those comments, see below.
Send comments in an email to PatientsOverPaperwork@cms.hhs.gov and addressed to Administrator Verma by Friday, January 17, 2020,  using the phrase “Scope of Practice” in the subject line.
Comments need not be lengthy. You may copy, paste, and personalize the italicized text shown above. You may consider including a personal story, if you have one, regarding the issues raised by an expansion of the scope of practice for mid-level providers of medical care.
Physicians, it’s time to speak up for your patients and for the value of the training that has defined you!

Administrator Verma:

This e-mail is in response to the call for comment on the effect of Section 5 in the President’s Executive Order (EO), “Protecting and Strengthening Medicare,” of October 3, 2019, with special reference to the issue of Scope of Practice (SOP) and associated pay parity.

To a very great extent, the President’s order has the support of the Practicing Physicians of America (PPA), an organization representing thousands of physicians, and a part of the Free-to-Care Coalition, now comprised of 37,000 physicians and 3 million citizens.

However, PPA objects to Section 5 of the order.

Section 5, although never explicitly mentioning the Nurse Practitioner (NP), will expand the scope of the NP’s role in the American system of delivering medical care.

In what we say next, we do not wish to be misunderstood. The NP is an important member of a medical team, but the team must be led by someone with far greater clinical training and experience. It is simply impossible to equate the 1,000 clinical hours of an NP’s training with the 20,000 clinical hours of a physician’s training.

Physicians are sometimes criticized for raising this point because it is assumed that their motivation is nothing more than the protection of their turf. In fact, our concerns are far more-securely grounded and serious than that, and require evaluation on the merits.

Actual experience and the accumulating data on the gradually expanding scope of the NP’s role in the American healthcare system paint a troublesome picture.

Impact of Overutilization

As a collective workforce, NPs have been criticized for:

Over-authorization of unnecessary procedures;
Over-prescription of medications, including opioids.

At the very least, those tendencies point ultimately to increases in costs, a fiscal impact that is the very opposite of the presumed intent of Section 5.

Impact Favoring the Corporate Takeover of American Healthcare

The increasing corporatization of American healthcare is an undeniable fact that has no demonstrable benefit whatsoever toward restraining inflation and reducing costs in that sector of the economy—a sector that, to the detriment of the general public, is increasingly dominated by special interests, the lobbying dollar, and the campaign contribution.

The largely consolidated hospital industry. These corporate entities, already home to more than 50% of the nation’s physicians, will be incentivized to replace more and more of those physicians with less-expensive practitioners who have significantly less training.

Pharmacy chains. The large chains are already deploying “health hubs” in their brick-and-mortar stores. In some cases, these chains own Pharmacy Benefit Managers (PBM) and insurance companies and have already become anti-competitive, vertically merged behemoths. What is to stop them from exploiting the alignment of interests that are inherent within a vertically merged, integrated entity, and draining even more money from the public’s pocket, not only from increased sales of prescriptions and over-the-counter goods, but also from increased profits through the PBMs they own?

Increasing consolidation and quasi-monopolization that continue to create a less-competitive marketplace are inconsistent with the restraint of inflation and a reduction in costs.

Impact on the Deepening Shortage of Physicians

Another, presumably unintended, consequence of Section 5 will be to deepen the already-critical physician shortage.

Section 5’s call for parity of compensation for services will mean that a corporation that employs physicians will have no economic inventive to retain them because the corporation will receive the same amount for a patient’s time with an NP as it will for the same patient’s time with a physician. The NP, however, will be available to the corporate employer at far less cost than a physician.

The long-term effects will be inescapable.

The rate of attrition among physicians will accelerate.

Fewer young adults will step up to replace them because it will make no sense to incur the high tuition of medical school and undergo the years of training that follow.

We will experience shortages among the ranks of well-trained physicians that go far beyond the tens of thousands already expected.

Impact in Fostering a Less-Competent Workforce for Delivering Medical Care

As taxpayers, we must speak against the absurdity of the government spending equal Medicare dollars for the services of highly trained physicians on one hand and on the other hand the same services (or what may appear superficially to be the same services) from practitioners who have a mere fraction of the physicians’ training and expertise.

Even among older NPs, there is dismay over the declining standard of training now being received by younger NPs via diploma-mill programs that are eager to churn out “graduates” with less training, sometimes conducted largely online.

A Cameo Illustrating the Problem

Not long ago, I met a four-month-old patient and his frantic father, a veteran, whose wife was deployed overseas. Less than 18 hours before, an NP in a large, pediatric hospital had sent the child home, despite obvious symptoms of a bowel obstruction, a surgical emergency. The child was now extremely ill and in great danger. Fortunately, this child was transferred to an ICU setting in time and was able to recover after being treated properly.

Nearly every physician I know can tell at least one such story—and sometimes more than one—from personal experience.

Section 5 will accelerate the replacement of physicians with NPs. In turn, that will multiply occurrences like the one described above. It is unavoidable that the outcomes will, in some cases, be tragic.

Impact Overall

While we understand that the executive order of October 3, 2019, was meant to push back against proposals of “Medicare for All,” Section 5—with its provisions for an expanded scope of practice for non-physicians and pay parity—will have the particular impact of reinforcing the trend in American healthcare toward corporatization, consolidation, and quasi-monopolization.

The large, special interests will complete the process of turning medicine into big-box operations, with low quality and little discipline from a marketplace in which competition thrives.

Decreased competition is never a prescription for restraining and reducing costs.

Decreased competition means that the choices available to all will shrink; and it will be the choices of the underprivileged that will shrink the most. Factor in the consequences of “pay parity” and it will not be long before ALL AMERICANS are paying more. The foreseeable consequence of higher costs in healthcare will certainly be increased public support for a “Medicare for All” system—the very outcome the executive order was meant to avoid.

A Call to Remove Section 5 from the EO

For the reasons cited above, the Practicing Physicians of America call for Section 5 of the EO to be removed. Its implicit expansion of the scope of practice for a less-qualified workforce and its provision for pay parity among professionals of vastly different levels are threats to America’s health and the ability of a competitive marketplace to discipline the pricing of services.

Our Recommendation of a Better Path

The Practicing Physicians of America ask that all federal measures be aimed at strengthening the eroding foundation that, historically, has been responsible for the high quality of American healthcare.

Foster competition.

Increase choices for the public.

Sections B and C of an annotated white paper I was honored to help write in the spring of 2019 offer innovative models for charity care and for expanding access to health care. As a solution to the deepening shortage of physicians, we offer Section D (“Reverse Our Physician Shortage”)

That paper inspired the growth of the Free-to-Care Coalition mentioned above.

The physicians of the Coalition stand ready to speak for our patients and for our profession.


Marion E. Mass, M.D.
Co-founder, on behalf of Practicing Physicians of America

19 Responses

  1. Azhar says:

    Patient care would be compromised and there would be more law suit if all system driven by NP. They need physician supervision, it would be night mare to health care if we allow NP’s solely to run healthcare.

  2. Muhammad Arif says:

    You get what you pay for!

  3. Carlos Albrecht says:

    All cars, included Ferrari and Kia should cost the same
    CEO of Hospital to make same money as a base office manager
    Attorneys same compensation as Paralegals
    Master jet mechanics same as jet fuel personnel
    STOP this absurdity
    Ill conceived idea trying to pauperize our profession

  4. James Lilja MD says:

    Why bother going to medical school, residency, etc?
    Why stop there— how about not having any credentials at all? ANYONE can perform a medical service!

  5. Susan Schulze says:

    I agree with Dr Mass! Np’s and PA’s must have supervision. Physicians should not be paid the same as mid-levels.

  6. Julian Sanchez says:

    np and pa needs Md supervision they don’t enough clinical training. Quality of care will decrease this is absolutely insane

  7. Ron Kuffel, MD says:

    If the reimbursement is to be the same for non-physicians as physicians, then the product must be equal with the quality of care the same. Therefore, don’t have anyone attend medical school, internship, residency, or fellowships. Shut them all down. And live, as best you and those you love can, with the new level of medical care that you have engendered.

  8. Geeta Gyamlani says:

    Pay parity and elimination of supervision will raise the cost of Medicare, accelerate the corporate takeover of healthcare, deepen the physician shortage, decrease competition in the healthcare sector, and multiply dangerous instances of patients being treated by someone with a fraction of the training received by a physician.

  9. Dr Rodriguez says:

    This all seems very concerning. There is no way that a nurse practitioner should be unsupervised in a hospital setting particularly in the ICU or CCU I have observed and taught numerois practitioners and PAs – none of which I have seen (even the most brilliant ones )should go unsupervised in complex situations.
    I think it is a very scary thought to imagine having a critical illness in a complex situation and having no one there except the nurse practitioner with only 1000 hours of experience making a life altering decision. I think we should do everything we can to prevent this from happening.

  10. Grace LaTorre says:

    Agree. We need remove section5

  11. Nidhi says:

    I could not agree more

  12. Lavanya says:

    Disagree with the decision of Mid-levels as independent practitioners. The title is self explanatory… “mid-level”, they are not to the level!

  13. Jose J. Aldrich says:

    This will be the end of medicine. Good luck to the people that get sick!

  14. Cen says:

    Mid level NP PA visit shouldn’t allow to bill insurance. Only MD DO can bill insurrance for patient visit

  15. Veronica says:

    Shame on you! I am a Nurse Practitioner. I am not arguing the reimbursement side of this article, but to paint our profession in such poor light is shameful. I understand MDs have much more training and, therefore, their education costs are higher. I do believe they should have a higher reimbursement rate. I do not agree with your disgraceful anecdotes regarding NP practice. EVERY FIELD, including MDs, has stories about incompetent practitioners. I have seen many terrible decisions made by MDs (both in my practice as a bedside RN and as a Nurse Practitioner) and often because they are too arrogant, and in a rush to even listen to their patients. NPs have excellent outcomes, a lot of common sense, and are extremely competent. Lastly, as a Nurse Practitioner, I was trained on when to refer out to a specialist, when a condition becomes complicated. I have noticed the opposite of what state in your article. I notice MDs referring out for management of every condition their patients have. You have lungs? You should probably see a Pulmonologist. You have a heart? Let me send you to my favorite Cardiologist.

  16. […] to the nonprofit Practicing Physicians of America (PPA), section 5 will not only eliminate supervision of NPs and PAs but will also lead to pay […]

  17. Joshua Achilles Dover says:

    1,000 clinical hours for np? That’s amazing the level of ignorancy! My adn program was 1,500 clinical hours, my bsn was 1,000. Then before you can apply to our MSN program you must have 3 years minimum paid clincal training( were already totaling 8,700 clinical hours before our program. Then in my msn they required 2,500. Plus for one year we also do nothing but clinical following internship to subspecialties. I don’t know what state your in but my clinical hours are near tripled compared to a Pa, and I required 6,000 more clinical ours to apply to a MSN program then most medical school. Totalled up. Most NP’s are required to be in the medical field from start to finish. Most doctors go into medical school with undergrads in science but have no healthcare experience.

  18. W.Joseph Laughlin MD says:

    PAs and NPs don’t know when they don’t know.MDs
    realize when something is seriously wrong (doesn’t add up)with the patient.The great majority of well trained PAs and NPs want an MD backup.The present oversight of PAs and NPs by MDs is a part of the health care system that works well for the benefit of the patient.
    PAs and NPs can assume further responsibility for patients as their training (led by MDs) continues.PAs and
    NPs do not do a resident training program of 3 to 7 years.Certainly they don’t complete a fellowship program.Families in the know will not accept PA or NP management and treatment without MD oversight.For sure , MDs will not allow treatment of their children, grand-children , or parents without speciality or sub- speciality MD direct involvement. Will Medicare officials allow treatment of their families without the involvement of a MD?Please tell me what high ranking government official will not want an MD directing treatment for themselves?

  19. […] of Practicing Physicians of America, earlier raised concerns about the changes in NP training in comments to the Centers for Medicare and Medicaid Services (CMS) last […]

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