re: Defeat the Nurse Practitioner scope of practice expansion - Louisiana SB 187

I see the conversation has diverged a bit.

Personally as a physician, and one who spends a lot of his time focused on musculoskeletal complaints modalities and treatments including osteopathic manipulation, I find physical therapist a valuable an important part of my daily practice. Physical therapist are very well trained both concerning their skills and their limitations. Over the entirety of my career I have never met a physical therapist that thought he or she should be practicing independently from or competitively against Physicians. Instead they work collaboratively with us to improve patient outcomes. Sadly when it comes to medical school there is a distinct lack of emphasis and training on musculoskeletal medicine. Osteopathic Physicians do receive more in depth training on musculoskeletal disorders and treatments, than allopathic medical students do in general. However there is a much larger volume and focus on other anatomy physiology pharmacology and treatment options. Simply put the musculoskeletal system gets lost in the volume of medicine that students are learning at med school. Sadly many physicians underperform their training once they are practicing as it pertains to the musculoskeletal system. Part of this is due to the fact that there are very limited life threatening and are permanently life-altering pathological processes that occur in the musculoskeletal system of the extremities. And of those pathologies with high morbidity and mortality are often treated surgically.


Multiple Studies have shown that overall health care costs are decreased and individual patient health outcomes are increased when a family physician is involved with a patient's entire medical care. One such study look specifically at Medicare patients that do not require referrals to go to a specialist. Patients who saw their FP and got referred to the appropriate specialist at the appropriate time versus patients who self-referred had much better outcomes with much lower cost. These studies coincide with the current push for increasing number of "medical homes".


Combining the above two paragraphs brings me to the conclusion that patience should have direct access to physical therapists. However, I would love to see a mandate added that the patient must have a PCP and that doc must be notified of the overall over by the PT.

1. The potential for increased morbidity or mortality as the result of failure to diagnose an underlying condition or treating a misdiagnosed condition is fairly minimal.

2. There is no philosophy of equivalance or superiority to physicians by physical therapist outside of their limited scope.

3. Sadly physicians are failing to meet the musculoskeletal needs of our patients due to ignorance, lack of time, and lack of reimbursement.

4. Direct access would eventually increase PT scrutiny both by supervising boards and by tge legal system and thus increase PT proclivity to refer back to PCP for eval when warranted.

5. This would reduce the number of unneeded physician OV when the complaint is a straightforward minor musculoskeletal complaint.


I do see three potential downfalls though...

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An otherwise healthy 40 year old steps in a hole and wakes up with a swollen ankle shouldn't need to see a physician before getting conservative treatment while they wait to get into their primary

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This sentence makes little sense.

They shouldn't need to see anyone to get conservative treatment for an ankle sprain while waiting to see their primary (24 -48 hrs average as discussed above)

elevate, compression, ice, nsaids, and non weightbearing.

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I did not know this

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Again, a majority of the "collaborating physicians" never set foot in the clinics. One NP testified during committee hearings that she had only seen her "collaborating physician" twice in 8 years.

And that is not ok. I am not sure about LA but that would be illegal and cause board action against the physician and NP in TX, along with FBI investigation for insurance fraud.

When I over sighted a NP I reviewed a random selection of 20% of charts seen weekly, was available 24/7 for phone consultation, had computer linked oversight of all imaging, reviewed every prescription written, and physically was in the office for an hour long review and discussion with the NP weekly.

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Both the physician and NP violated the current law and should be stripped of any practice rights.

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Yeah, I don't know if that is something she should be sharing. I understand her argument but it definitely paints her in a bad light. If the bill doesn't pass she may have trouble finding a physician willing to oversee her.


Disclaimer: I know nothing of current law in regards to NP and oversight, but it definitely makes her look bad IMO as well as any physician she may work with.

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along with FBI investigation for insurance fraud. 

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All billing was done under the NP.

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MD opposition to any of this is based on concern for patient safety

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What were your thoughts when psychologists pushed for prescriptive authority in La.? I recall that the Family Physicians were in support of them gaining those privileges and the bill was put up by a family doc in the senate. Seems you're only concerned about losing control over your fiefdom.

If people want to take the risk, let them. My experiences with seeing a nurse practitioner were mediocre at best and I will not see one again.

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I do see three potential downfalls though...

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1. Increased funneling of patients to orthos instead of primary care when things need referral. An backdoor form of patient recruiting which we all know already happens on a small scale. This will increase surgical interventions, and cost of care.

2. A longer wait time at PCP office to be seen for apparent simple MS complaints, as some physicians will be tempted to make it policy that patients must first see PT. This will definitely shift the narcotic seeking patients to PT initially.

3. Potential decrease in reimbursement for PT services from payers. Currently many require authorization for reimbursement. The attempt to make relatively harmless medications (Claritin, Prilosec) available OTC and cheap for patients backfired. Once these meds were OTC, many payers dropped them from their formulary forcing insured patients to purchase the meds at market cost which was much higher than RX copay cost. This also delayed authorization for more advanced diagnostics and treatments as payers wanted prescription records for PPI's prior to approval of GI consults and EGD's also.

I never saw a fiefdom passed out at med school graduation but if you want to say these other fields are usurping a fiefdom then say what you want. I think people should do what they went to school for and not ask the state Capitol for extra responsibilities after graduating. There's a course catalog at every college and everybody has access to it