Should mid-levels be paid at a doctor’s rate?

The use of advance practice nurses (“APNs” or “NPs”) has continued to grow across the country. In several states, nurse practitioners now have independent authority to own and establish their own professional practices and, depending on the amount of experience they have, to practice independently. 

In Illinois, the Governor signed a Bill which amended the Illinois Nurse Practice Act to allow APNs to practice under their license without entering into written collaborative agreements with a doctor as long as the APN meets certain education and training standards. While APNs can still not engage in certain practices that are reserved for physicians, such as operative surgery, many barriers and restrictions on the ability of APNs to provide care to patients have now been completely removed. The goal of the law change in Illinois, as in other states which have passed similar laws, was to improve access to medical care, particularly in rural areas where there is inadequate physician care available. 

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Many physicians I have spoken to have mixed feelings regarding the independence of APNs. While some appreciate the value that APNs bring to patients and the practice of medicine, others have concern regarding whether the training of such individuals supports expansion of their independence. In some medical practice and hospital environments, physicians and APNs are often cast in competitive roles, where they vie for the same patients and RVUs. These types of situations have created competitiveness, rather than comradery, among health care professionals.

This competitive feeling is about to heat up based on President Trump’s Executive Order “Protecting and Strengthening Medicare,” which was issued October 3, 2019. Under this Executive Order, Section 5 calls for eliminating all supervision by physicians of mid-level providers, which includes APNs as well as physician assistants (PAs). It also calls for reimbursement parity among the same groups by Medicare, and an eventual requirement that all third-party payments for care  be leveled across APNs, PAs, and physicians regardless of clinical training. What this means is that services, whether provided by an APN or a physician, would be reimbursed at the same rate by Medicare. Comments on this Executive Order were due Friday, January 17, 2020, and we do not yet know what the future will hold on this issue.

Most physicians I have spoken with strongly oppose pay parity. Arguments I have heard include a belief that APNs and PAs must still be overseen by a clinician with greater clinical training and experience (becoming a physician requires thousands more hours of clinical training compared to a mid-level). There is also a fear that this parity approach will create competitiveness amongst providers for patients as they both would receive the same pay for the same services, regardless of experience and training. Additionally, there is a concern that compensation parity will decrease the quality of care being offered to patients if employers replace physicians with mid-levels who are less experienced and qualified, yet demand lower compensation and bring in the same amount of reimbursement.   

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This is clearly an area of hot debate among healthcare professionals and it remains to be seen exactly what will happen now that the comments by the AMA, hundreds of physician groups and others have been submitted to CMS for consideration. 

_{Ericka L. Adler, JD, LLM has practiced in the area of regulatory and transactional healthcare law for more than 20 years. She represents physicians and other healthcare providers across the country in their day-to-day legal needs, including contract negotiations, sale transactions, and complex joint ventures. She also works with providers on a wide variety of compliance issues such as Stark Law, Anti-Kickback Statute, and HIPAA. Ericka has been writing for Physicians Practice since 2011.}