Healthy Alliance
NP-Physician teams offer a broader approach to practice, a more efficient division of labor, potential cost savings and improved quality care

By Radha McLean
January 29, 2003

At the Milton S. Hershey Medical Center at the Pennsylvania State University College of Medicine in Hershey, Pa., three nurse practitioners work in collaboration with physician teams in both the inpatient and outpatient settings. The nurses educate patients about health care concerns, from the importance of receiving flu shots to conducting breast exams and, sometimes, see their own patients for acute care issues. Among this group of MDs, NPs and other health care professionals, working together side by side has done nothing but benefit the patient population, according to Tom Weida, MD.

"It works out very well," said Weida, associate professor and medical director of Penn State's University Physician Group, Fishburn Road Family Practice. The help of NPs improves the efficiency of the practice, he said. "They can help us meet patient access demands better. It can allow better patient access for the community."

Weida also has found that hiring the NPs, who are women, helps improve the comfort level of female patients when it comes to gender-related health issues.

"The nurse practitioners are female, so the female patients are more inclined to get Pap smears and breast exams than they are with male physicians," he said.

Not only that, but the NPs at Hershey Medical Center have a strong interest in patient education, which they bring with them when seeing patients, Weida said. "They educate patients on prevention and lifestyle changes," he said. As a result, patients are more likely to consult with physicians after having been educated by the NPs. "It helps improve a lot of patient care. It opens up the discussion for topics in lifestyle changes and prevention with the doctors," he said.

Weida's team is not the only one to place NPs in collaborative roles with doctors. A spate of collaboration efforts is taking place across the United States in which doctors are employing NPs and advanced practice nurses to contribute to the workload at hospitals, outpatient settings and geriatric centers. Many health care professionals believe that such a relationship improves the efficiency and quality of care, as well as lowers the cost of patient services by having nurses conduct incidental services, thereby allowing the doctors to use their time more wisely.

Harborview Medical Center in Seattle employs NPs in a range of settings, including urgent care clinics, short-stay and limited-stay units, as well as in acute and critical care service teams, including neurosurgery. According to Cathy Ivers, recruitment and retention specialist at Harborview, a network of NPs and physician assistants was put into place to improve the quality of care within a large medical team.

"High activity was the driver for the programs here," Ivers said. "[We developed the programs out of] a concern about maintaining quality of life and navigating the system. They are an adjunct to an already stretched system in place."

The NPs improve the workflow and communication among the health care teams, Ivers said. "Nurses are great communicators. They are used to dealing with a multitude of service issues to help a patient get out of the hospital. We recognize those services as making a real contribution."

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.

In "Interventions to Promote Collaboration Between Nurses and Doctors," published last year in The Cochrane Library, Merrick Zwarenstein, MD, reviews the results of two short-term randomized trials of doctor-nurse collaborations in hospital care settings.

In the first trial, doctors, nurses and other health care professionals made decisions together regarding patient care for a period of six months. Among the 1,945 patients studied, the length of hospital stay decreased from six to 5½ days, and hospital charges lowered from $8,000 to $6,700.

The second trial compared length of hospital stays in two female wards for a period of three months.

Length of hospital stays shortened slightly, from 12 to 10½ days, in the ward with nurse intervention.

"While the results of these studies are not sufficiently convincing in and of themselves … the findings are promising," Zwarenstein, senior scientist at the University of Toronto and the Institute for Clinical Evaluative Sciences in Toronto, explained. "A concerted effort should be mounted to develop and test these and other interventions to promote improved health care quality, efficiency and outcomes through doctor-nurse collaborations. They suggest that it is worth doing more rigorous studies of interventions to improve nurse-doctor collaborations."

A more thorough study, "Can Nurse Practitioners and Physicians Beat Parochialism into Plowshares?" explores both the history of the NP role in the U.S. health care system, its evolution and what is being done on a policy level to increase the presence of NPs in the workplace and doctor-nurse collaborative practices.

The study, conducted by the Robert Graham Center and published in the September/October 2002 issue of Health Affairs, claims that doctors and nurses often fight for control over issues such as scope of responsibilities, insurance reimbursement and prescription privileges, rather than work together. Lead researcher Robert Phillips, MD, and colleagues write, "Far too often, nurse practitioner and physicians professional organizations do not work together, but rather expand considerable effort jousting in political arenas."

Removing barriers

Phillips, the center's assistant director and the lead researcher, is quick to propose a solution to this problem. He wrote that "physician-NP relationships could evolve by … removing barriers that prevent [NPs] from being fully functional members of collaborative health care teams."

The study lists the results of limited research on doctor-NP collaboration programs.

"Studies of NP-physician teams have demonstrated cost and quality-of-care improvements in nursing homes, ERs and surgical inpatient settings. Disease prevention and care of chronic conditions also benefit from NP-physician teams. Physicians who work with NPs report improved job satisfaction, reduced workloads and increased ability to offer a higher standard of care."

The researchers highlight several examples of public policy programs to improve the presence of nurses in the workplace being developed at institutions nationwide, including the University of Houston's Greater Houston Partnerships for Quality Education; partnerships in training at the University of California, Davis and University of California, San Francisco; the Area Health Education Centers programs, taking place in four states and funded by the U.S. Department of Health & Services; and Community Partnerships in Health Professions Education, taking place at universities in seven states and funded by the W.K. Kellogg Foundation.

Empirical proof that one method of doctor-NP collaboration works better than another is limited, according to the Robert Graham Center. "Evidence is lacking on how best to distribute patient-care functions within a collaborative team and how to improve providers' willingness or ability to collaborate," the study states.

Yet, researchers make myriad suggestions, such as more education for NPs and changes in regulations and payment policies that would allow NPs to write more prescriptions and receive more insurance reimbursements. These changes would lead to stronger relationships with doctors, more opportunities for treating patients and improved all-around quality of care, researchers say.

Contact Radha McLean at radhaam@hotmail.com