The Pros and Cons of Mandated Collaboration
Article Outline
The following seven states have no legal requirements for physician involvement in nurse practitioner (NP) practice: Alaska, Idaho, Maine, New Hampshire, New Mexico, Oregon, and Washington. (In Maine, an NP must practice under physician supervision for 24 months, but after that may practice without mandated physician involvement. In Utah, NPs need a physician collaborator only to prescribe controlled medications. Sometimes people include the District of Columbia in the list of states without mandatory collaboration. The District's code says, “Generally, advanced practice registered nurses shall carry out acts of advanced registered nursing in collaboration with a licensed physician or osteopath.” Nothing need be filed with the board of nursing.
Similarly, people may include Michigan in the list, but this is misleading. Michigan has no requirement for physician involvement, but neither does it have a scope of practice for NPs. So, in Michigan, in order for an NP to have the legal authority to diagnose and treat, there must be delegated authority from a physician. Michigan law allows physicians to delegate whatever they want to whomever they want.
In each of the other 40 states, there is some legal requirement for physician involvement. That involvement may be called supervision, collaboration, direction, standard care arrangement, consultation/referral plan, collegial relationship, standardized procedures, referral process, or protocols. In many states, an NP must submit a written collaboration agreement to the board of nursing.
In some states, NP organizations are submitting legislation or are considering submitting legislation to do away with mandatory collaboration in NP practice. Some NPs are wholeheartedly in favor of doing away with written agreements; others are half-hearted about it. This column outlines the advantages and disadvantages of mandatory collaboration.
Pros of Mandatory Collaboration
For the NP
Access to professional consultation: With mandated collaboration, the NP with a clinical dilemma and a written agreement with a physician always has someone with whom he or she can consult. The physician collaborator, by signing the written agreement, has agreed to be available. This is more important to some NPs than others. New NPs may need frequent consultations; experienced practitioners may never need a legal connection to a physician collaborator but, like physicians, refer patients to specialists when needed, utilize rounds, and pick up the phone, when necessary, to ask the opinion of a colleague.
For the Public
Quality of care: Organized medicine, when faced with an effort to do away with mandated collaboration, argues that the collaborative requirement is necessary to preserve quality of care. There is no evidence for this argument. However, given that most states have collaborative requirements, neither is there evidence to disprove the argument. While it is currently impossible to determine whether mandatory collaboration ensures quality of care, patients, legislators, and third-party payers may find comfort in knowing that there is a designated physician who promises to be available for consultation with an NP.
Cons of Mandatory Collaboration
For the NP
Cost: An NP who has his or her own practice usually must compensate the physician collaborator. This expense may deter an NP from starting or maintaining a practice.
Difficulty finding a collaborator: Some NPs want to start their own practices but cannot find a physician willing to agree to collaborate.
Potential for loss of a collaborator: Several NPs have signed on with collaborating physicians, opened practices, and are happily conducting business when the physician collaborator decides to leave town or take a job that precludes the collaborative relationship. Some of these NPs have been forced to give up their practices. Others have scrambled to find replacements but found they were not in a good negotiating position because of the mandate for physician involvement.
Down time: Because, in some states, written agreements must be approved by the board of nursing before an NP can begin to practice, and because it can take months for a board to review and approve a written agreement, some NPs find themselves ready and willing but unable to work, pending approval of the written agreement.
For the Public
Decreased access to care: When NPs are free to open their own practices or to independently contract with businesses, schools, or institutions, consumers have more options. When physician collaboration is mandated, NPs sometimes cannot find or afford a collaborator or may not want to risk starting a practice only to have the collaborator leave them. Faced with difficulty finding a collaborator, a rural NP may leave the area, thereby leaving rural consumers in need of affordable healthcare.
Cost: Under the economic model of price determination according to supply and demand, anything that limits the number of medical practices leads to high prices for office visits. Conversely, if more NPs were free to open their own practices, the cost of an office visit could be expected to decrease. And, because taxpayers ultimately pay the cost for boards of nursing to review and approve written agreements, there could be savings if those agencies were no longer required to perform those reviews.
For the Physician Collaborator
Professional liability: If an NP is sued, the physician collaborator is likely to be sued as well. In some cases, a collaborating physician is named in a lawsuit against an NP, but the physician is dropped from the suit if, during the discovery process or during trial, it becomes clear that the NP did not consult with the physician about the case. Nevertheless, a physician who is named in a lawsuit must mount a defense, and this is costly. Physician collaborators may be held liable in a lawsuit against an NP if the physician agreed to be available but did not exercise the degree of supervision or collaboration for which the agreement called.
Cost: Companies that insure physicians may charge an increased premium if the physician is an NP's designated collaborator.
For Businesses
Cost: Businesses that want to contract with NPs for employee healthcare and schools that want to contract with NPs for student health services must pay the physician collaborator and the NP. A release of NP from mandated collaboration would decrease the costs to businesses that want to provide health services.
Changes in the law can lead to the expected results and also can lead to unintended consequences. While the seven states that do not require physician involvement in NP practice are not known to be any more or less healthy places to live than the states where physician involvement is mandated, we really do not know how a change of law would affect the various stakeholders. It does seem healthy to consider change, talk about the pros and cons, take a stand, and let the legislative process do its job.
PII: S1555-4155(10)00029-2
doi:10.1016/j.nurpra.2010.01.008
© 2010 American College of Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
