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Collaboration concerns

The acceptance of NPs in the workplace has not been wholehearted, however. There has been some resistance to increasing the responsibilities of NPs in regard to prescription and reimbursement privileges. According to the Robert Graham Center: Policy Studies in Family Practice and Primary Care in Washington, 50 physician organizations recently submitted a petition to the Centers for Medicare and Medicaid Services asking for stricter compliance in the billing numbers and payments assigned to NPs and an audit.

The American Medical Association guidelines specific to an integrated physician-NP practice state that the responsibilities of NPs must stay within the scope of his or her professional license, and that the physician is responsible for overseeing all patient care. It endorses "the appropriate input of the nurse practitioner" to ensure the quality of care.

The guidelines also state that the NP's participation is contingent upon the acuity of the patient's condition, and that a physician should be available at all times. Also, the NP's role "should be defined through mutually agreed-upon written practice protocols, job descriptions, and written contracts," and that the patient should be informed if they are being treated by an NP.

The AMA addresses the need for "a professional and courteous relationship" between the physician and the NP, with "respect for each other's contribution to patient care."

An increased interest

The interest in such a collaborative relationship between doctors and nurses has fluctuated in recent years. A renewed interest in collaboration was sparked by a study conducted by the Congressional Office of Technology Assessment in 1986, according to Health Care Business Digest. The study showed that 60 percent to 80 percent of all basic care provided by doctors could be performed by nurses, thus lowering the cost of health care coverage.

This study caught the eye of insurance companies, not to mention President Clinton, who included increased roles for nonphysician providers (NPs and PAs) in his proposal for national health care coverage. Although his proposal failed, the topic of doctor-nurse collaboration programs did not fall by the
wayside.

The 1998 budget bill signed by Clinton allowed APNs to receive direct Medicare reimbursements in all areas of the country, not only rural areas, according to Health Care Business Digest, further encouraging the use of nurses in physician practices.

Studies determining the effectiveness of doctor-nurse collaboration programs have come about in the past 10 years.

Several studies conducted throughout the 1990s showed that using nurse practitioners and other nonphysician health care professionals resulted in an increase in income in private practices, fewer hospitalizations among the elderly at a senior center and a lower number of cesarean sections, according to Health Care Business Digest.

In its position statement on cost-effectiveness, the American Academy of Nurse Practitioners conducted a review of studies determining the benefits of doctor-nurse collaborations.

It refers to a study published in HMO Practice in 1994, in which adding a nurse practitioner to a practice doubled the number of patients typically seen by the physician, which translated to an increase in revenue of $1.65 million for every 100,000 HMO members per year.

Another study published that year in HMO Practice showed that the use of an MD-NP team in a long-term care facility lowered not only costs, but also the number of emergency room transfers, length of hospital stays and specialty visits for patients covered by the MD-NP teams.

"The long-standing cost benefits of nursing-specific interventions in a managed care environment are substantial," the AANP wrote in its position statement. "It has been argued that employing nurse practitioners fully could save 20 percent of the cost of primary care."

Latest findings

More recently, two studies published last year assessing the results of doctor-nurse collaboration programs made suggestions for an increase in the number of programs throughout the world.