Over 25 states require advanced practice nurses – nurse practitioners, nurse midwives, nurse anesthetists or clinical nurse specialists – to have some form of collaboration with physicians. States have embedded these requirements into state licensure laws. Initially, the expectation was that physicians would collaborate willingly, without fees with nurses as such had been the professional practice for years. With the expansion and evolution of APN practice, physicians began charging for these services, and without regulation of such, the fees have been used as an impede the growth of independent practice.
NCSBN conducted a survey of advanced practice registered nurses (APRNs) to determine the economic burden and practice restrictions placed on them by state laws. This study was the first comprehensive national review of collaboration price costs. The study determined that APRNs working in rural areas and APRN-managed private clinics were one and a half to six times more likely to be assessed CPA fees, often exceeding $6,000 and up to $50,000 annually. Similarly, APRNs subject to minimum distance requirements, fees to establish a CPA, and supervisor turnover reported a 30 percent to 59 percent uptick in restricted care. iIn 2015, an informal survey of members represented by the Pennsylvania Coalition of Nurse Practitioners (PCNP) reveals these mandated contracts cost CRNPs an average of $500 to $1,000 a month. And online, others have reported charging upward of 4,500 per month.1
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Building on this body of work, the LTNN study addressed four issues:
· Fairness of fees assessed
· Hospitals paying for collaboration
· Collaboration fee savings after full practice authority enacted
Not surprisingly, most advanced practice nurses taking our survey reported that they were still being charged for collaboration. And, overwhelmingly, Advance Practice Nurses felt those fees were unfair. While nurses are not aware of costs paid by hospitals for collaborative care. Previously, depending on how compensation arrangement was structured, employed physicians’ salaries and bonuses were based solely on personal productivity – how many patients they see or how many wRVUs they personally generate – and initially physicians were credited for, or a percentage of, their nurse practitioners’ or assistants’ encounters or wRVUs (re “incident to” reimbursement).
Market data show that current collaborating physician stipends range between $5,000 and $15,000 per year.ii The information, however, is very limited and provides no insight into the state-by-state requirements for supervising arrangements or the different requirements for NPs versus PAs. Moreover, it doesn’t touch on the specific obligations insurers and organizational by-laws may place on supervising physicians. It does not reflect bonus’ structure which has been used as a method to reimbursement physicians for collaboration.
However, all discussions and reports from nurses reflect hospital and health system structuring physician payment to incorporate payment for collaboration. Notably nurses don’t know nor have been made aware of how much physician compensation is premised on APN supervision. If they had this information, one would think such would be value added to APN compensation negotiation as the cost of care is reduced using advanced practice providers. Over 85% of the nurses surveyed indicated that they did not know whether or the amount physicians were being paid to collaborate with them.
And of those practicing in recently enacted full practice states, APNs responded that did not notice or did not receive any additional salary or benefits based on their full practice status. And the overwhelming majority did not think the change in status was applicable to increased compensation. While I do not wish to surmise on the responses, under other circumstances, employees when given more responsibility/accountability expect salary increases.
LTNN continues to survey you to get a better sense of your practice and your perceptions. Please take the opportunity to respond to this or one of our other surveys.
LTNN is a full-service platform providing news for and about nurses, with an emphasis on APN practice. LTNN can be found on FB, Twitter, Instagram with podcasts and videos on YouTube, BlogTalkRadio and Apple Podcasts. Founding in 2019, LTNN is dedicated to providing choice, curated news, educational options and online sources to nurses.
i NCSBN Publishes Findings from Survey of Advanced Practice Registered Nurses with Collaborative Practice Agreements, posted 2/6/2019, HTTPS://WWW.NCSBN.ORG/13374.HTM
ii Darcy Devine, Valuing Physician-Performed NP & PA Supervisory Services (March 19, 2017) as found at https://www.buckheadfmv.com/single-post/2017/03/19/valuing-physician-performed-np-pa-supervisory-services