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Is a nurse practicioner or physician's assistant useful and when do I need one? Print E-mail
Contributed by AlgosDoc   

Nurse Practitioners and PAs as Part of Your Pain Practice

1. Nurse practitioners/physician's assistants are not trained in chronic pain, have limited experience in chronic pain, and should never be placed in the situation where they are totally responsible for the medical direction of the patient's care.  Some practices use NP/PA as an ersatz pain physician to manage the patient until they need an injection.  This model universally fails to meet the needs of the patient and ultimately compromises the integrity of the physician's practice.  Continual integration of the physician into the follow-up care of the patient is absolutely necessary when long term patient care is anticipated.  If the physician's practice is that of a block shop only, then a NP/PA may be useful in performing the initial assessment, but patients are not at all enamored by the idea of being sent to a physician's office, and are seen only by a NP/PA on the initial visit.  If the patient is seen by the NP/PA, then the physician on the same initial visit, there may be billing issues since only one bill may be submitted.  Depending on the data input system into the chart, a NP/PA may expedite the laborious data entry, however remember PA/NP are very expensive.  The data entry aspect of charting is better performed by a MA at much lower cost.  
2. NP/PA given too much autonomy can cause the entire practice to tilt in an unexpected direction.  Prescribing guidelines of the practice need to be given to the NP/PA.  The NP/PA should not direct the medical care of the patient: this is the function of the physician.  Therefore every 3rd office visit should be with the physician.
3. In some states, PA do not have prescriptive authority for opiates making them much less useful in a comprehensive pain practice.  In those states, NP are a better choice.
4. NP/PA should NEVER be delegated the task of performing spinal injections or fluoroscopic injections.  Astonishingly this has occurred in several practices but is absolutely indefensible both medically and legally.  Trigger point injections, peripheral nerve injections, etc should be the extent of injections performed by NP/PA.
5. NP/PA are expensive, and the practice needs to have a sufficient volume of patients to justify having such.  NP/PA typically need to see about 15-20 patients per day to pay for their salaries and benefits.  A practice with less volume than this may not support a full time PA/NP.   
6. Collaborative agreements are often mandated by state laws.  These agreements between yourself and the NP/PA often require a chart review of 5% of the NP/PA charts per month.  Although this may be a cursory evaluation, it should be documented in some fashion that it is occurring.  

My personal experience with NPs over the past 7 years have been excellent, with a good
collaborative relationship.  The rules of the clinic operation are well defined, and I have found backing the NP up in their implementation of these rules has cemented the NP/MD relationship.  It is important to have the same fundamental direction of clinic operations, NP and MD.

Facts about NPs:
There is no pain or chronic pain NP certification or training.  Most have a general NP or NP-family medicine certification.  NP is usually a 1-2 year program after completion of the BSRN with usually some intervening experience in work.  The salaries of NP for chronic pain usually range from $50-75K and benefits need to be the same percentage as other employees. NP malpractice may be independent of the MD costing around $3000 per year, or may be part of the MD medical malpractice policy with no extra charge.  Billing for NP is generally at a full rate except for Medicare patients.  When a physician is not on the premises, the NP billing is set at 85% of the physician rate and must be billed under a separate billing number.

My current NP:
Our current NP spent 2 months training with me during the first year without seeing patient's independently, attended the American Academy of Pain Medicine annual meeting, and has been active since that time in our practice seeing follow-up patients, returning patient telephone calls, performing ligament/tendon/trigger point injections, and fills all of our intrathecal pumps.  I have not had to call a patient in over a year except for the rare night/weekend call.  The first 12 months, the NP not only generated enough collected revenue to pay for her own salary and benefits, but earned enough for a 10% bonus with significant revenue pumped back into our business.  We anticipate hiring a second NP by the end of 2005 when she finishes her training.

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Last Updated ( Sunday, 15 May 2005 )
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