Should a Written Collaborative Practice Agreement with a Physician Be Required for Nurse Practitioner Practice?

Article Outline

• Support for Requiring a Written Collaborative Agreement
• Rationale Against Requiring a Written Collaborative Agreement
• Copyright

Barbara Resnick, PhD, FAAN, FAANP, is a professor of nursing and adjunct professor in the Department of Epidemiology and Preventive Medicine at the University of Maryland in Baltimore. She received her PhD from the University of Maryland and her MS in nursing from the University of Pennsylvania. Her research focus has been on motivation of older adults, particularly regarding performance of functional activities and exercise. She has authored over 100 manuscripts, numerous book chapters on both clinical and research topics relevant to the care of older adults, and, recently, a book on restorative care nursing.

Sandra Nettina, MSN, APRN, BC, ANP, is a nurse practitioner in primary care in Maryland and the current president of the Nurse Practitioner Association of Maryland. She combines clinical practice in family medicine, publishing, consulting, and nursing education. She received her MSN from the University of Pennsylvania in Philadelphia and is an editor for the Lippincott Manual of Nursing Practice. She serves as adjunct faculty and clinical preceptor for the Johns Hopkins University School of Nursing and practices as an NP in Columbia Medical Practice in Columbia, MD.

State regulation of nurse practitioner (NP) practice continues to have considerable variation. Requirements for physician oversight of NP practice widely ranges from independence to different levels of physician collaboration/supervision. The latter usually requires some type of written collaborative practice agreement. Some believe that the written agreement is beneficial because it serves to clarify the practice relationship between a physician and NP, reduces role confusion, and may enhance patient safety. It also fulfills federal requirements for NP Medicare reimbursement.

Another view is that the true purpose of the written agreement is to maintain one profession's economic control over another's. A highly respected NP colleague recently told me that, as a result of changes in the ownership of the health system where she had worked for 30 years, she was suddenly forced to find a replacement for her physician collaborator, the physician whose signature was on the written agreement required by her state for NP practice. None of the health system physicians were willing to accept the responsibility of “signing for her” except one—for $15,000 a year!

Will the boundaries between NP and MD/DO continue to blur, or will they become more distinct? What is the better solution? Is the mandated written collaborative agreement a beneficial or effective way to regulate NP practice?

What do you think? Contact Section Editor Janet Selway at janet.selway@gmail.com if you would like to comment on this matter.

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Support for Requiring a Written Collaborative Agreement 

Barbara Resnick

Many of my colleagues express legitimate reasons to eliminate collaborative agreements. Having worked under a collaborative agreement for approximately 30 years, I am compelled to express several reasons why I think that the collaborative agreement should remain a necessary component of practice.

Although not relevant to all APNs, Medicare still requires APNs to work within a collaborative practice relationship. This collaboration does not need to be elaborate, but it does need to be articulated and real. This is best done if written down; this way both providers know what is required of the other.

There is much debate among APNs and physicians about which discipline provides which type of service or which is best suited to the needs of the patient. A collaborative agreement helps to articulate who can do what. Further, it can serve as an educational tool to help our colleagues understand the extensive skill set and knowledge that we as APNs bring to a practice relationship.

Interdisciplinary care is central to optimizing access and ensuring cost-effective care for all Americans. Formal collaborative agreements help to promote and ensure that interdisciplinary relationships exist, at least those between physicians and APNs.

In conclusion, collaborative agreements provide a way to formalize, clarify, and put in writing the roles and responsibilities of APNs and physicians as related to practice situations. The agreements are problematic in that they do not acknowledge the different levels of experience of the providers involved and may be more cumbersome than is necessary. I recommend fixing the underlying process of developing and establishing a collaborative agreement. Let us not, however, eliminate a useful tool that supports the concept of a team approach to patient care in which the skills of APNs and physicians are appreciated and each provides the appropriate level of care for the patient.

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Rationale Against Requiring a Written Collaborative Agreement 

Sandra Nettina

The written collaborative agreement between an NP and a physician as a requirement for NP practice is an antiquated and unnecessary administrative burden. On the surface it sounds collegial and patient focused, but in reality it has become a restrictive barrier to NP practice and patient access to care. The written collaborative agreement imposes undue oversight by another health profession onto the practice of NPs, who are already regulated fully by boards of nursing.

NPs enjoy providing patient care in an interdisciplinary environment with physicians and other healthcare providers. However, NPs do not enjoy having to wait—sometimes for months—for approval of a collaborative agreement from a state board of physicians or medicine. Problems that have arisen with the collaborative agreement in Maryland include lag time of several months before being able to start practice or change job locations, inability to volunteer or take a temporary job because there is not enough lead time or physician association with the service, difficulty finding a physician in a specialty in some shortage areas to sign the agreement, necessity of paying a physician to sign on as collaborator, and treatment as “ghost providers” because there is confusion about who is the primary care provider.

Almost 10 years ago, the Pew Health Professions Workforce Report raised concerns that overregulation by boards decreases access to health care more than it protects the public. The National Council of State Boards of Nursing has expressed concern that mandating control of various aspects of practice by boards of medicine or pharmacy inserts the interest of other professions into the practice arena. Having some oversight by another profession has been correlated with cumbersome and costly regulation, underutilization of NPs, and restriction of patient access to care by NPs.