Physician Assistants

I only see my neph about 3-4 x a year. I see the neph’s PA more than I see her- the other 8-9 months. It seems that the neph and the PA come to different conclusions on how to handle lab results and other issues. What I would like to know is, are PAs fully capable of interpreting lab results, prescribing medication and understanding dialysis problems or do they have to consult with the nephrologist? My PA seems to totally take the place of my neph, but they seem to come to different conclusions which leaves me wondering well which one is giving me correct info?.

This is my opinion only, Jane, but even non-nephrologist DOCTORS have a hard time understanding the complexities of kidney failure, the labs, the meds, etc. I would not trust a PA to take on the sort of role you are describing, and the fact that they are coming to different conclusions is evidence that their clinical judgment is not the same. If I were you, I would talk with my nephrologist about my lack of comfort with that system–or find another nephrologist.

Your nephrologist has to look over your chart and sign off on what the PA does. Why do you think they don’t agree on your treatment?

I see. Sometimes I feel more comfortable with the neph’s decisions and other times her PA seems to make better calls. From what I’ve experienced, unless one has a knowledgeable, up to date neph, even the neph can be off. The same goes with the rest of the team. It doesn’t matter if they’ve been in dialysis for 30 yrs- either they know their stuff or they don’t. And as you’ve stated elsewhere, nephrologists are not necessarily experts on dialysis.

And nowhere I have ever lived has it been possible to find another more competent neph. The availabilty is just not there unless one lives in a big city or just happens to have a top neph in a smaller locale.I feel the only realistic answer for most patients is to educate themselves. If there was a course that could clearly take each aspect of the tx and show patients what they need to know and do, then if a neph/PA gave the wrong direction, patients would know and could speak up. The first chance I get, I will be going through KS to see if it is comprehensive enough to support patients in this way. And as I said before, another school is needed to educate on machine usage.

When a PA fills in for the neph does he get a percentage of the neph’s fee or does the entire fee go to the PA?

For ex., my neph seemed to be concerned about a value on my labs and the PA had a totally different view. The neph would of put me on medication and the PA did not decide the value warranted medication. Other times it is just the opposite. I wondered what educational training does a PA have to be able to fill in for a neph as this arrangement has been set up by Medicare? You say the neph must sign off on what the PA does- would it be the same with the dietitian? Do nephs sign off on everything the team does or is the team given leeway to prescribe meds and make tx choices for patients without the neph’s input/oversight?

Here’s the Medicare transmittal that describes who must see the patient for the physician to get paid under the capitation payment. It states:
Under this methodology, separate codes are billed for providing 1 visit per month, 2-3 visits per month, and 4 or more visits per month. The lowest payment amount applies when a physician provides 1 visit per month; a higher payment is provided for 2 to 3 visits per month. To receive the highest payment amount, a physician would have to provide at least 4 ESRD-related visits per month…In order to bill for ESRD-related services under the MCP as a telehealth service, at least 1 visit per month must be furnished face-to-face (not as telehealth) to examine the vascular access site. The clinical examination of the vascular access site must be furnished face-to-face “hands on” by a physician, clinical nurse specialist, nurse practitioner, or physicians assistant. Additional visits under the MCP may be furnished via an interactive telecommunications system.
http://www.cms.hhs.gov/transmittals/downloads/R517CP.pdf

This transmittal doesn’t say it, but elsewhere there is an instruction to bill home patients under the 2-3 visits per month because a nephrologist is supervising the care of the patient all month but may not have to expend the same effort with home patients (usually more stable) as with potentially less stable in-center patients.

Most dialysis facilities schedule clinic appointments for patients once a month where patients can meet with the physician, nurse, social worker, and dietitian. The reason for this is that the current ESRD regulations require that facilities do a care plan on unstable patients monthly and a care plan on stable patients every 6 months. It’s impossible to tell if a patient is stable or unstable unless you assess him/her monthly.

So far as the qualifications of nurse practitioners, here’s a FAQ on nurse practitioners from the American Academy of Nurse Practitioners:
http://www.aanp.org/default.asp (click on What is a Nurse Practitioner)

Here’s information about NP certification:
http://www.aanp.org/Certification/Program+Description.htm