Captain of the Ship doctrine and NPs.

Trauma Columnist · Feb 26, 2009

Independent APN (advanced practice nursing) is not available in every state. For instance, I live in IL and we have just pushed thru to our state legislature to get rid of collaborative agreements. That does indeed mean we can practice more independently. However, our independence is tempered by what the hospitals will allow us to do in regards to admitting pts.

cessnadriver · Feb 26, 2009

So it is possible , in some states at least, to contract with a rural hospital to provide whatever the NP speciality is on a sole provider basis?

You could replace a physician in the ER if you were an ER NP, peds, FP etc? Condidering the static CRNAs get form anesthesiologists who would like to limit solo practice. How did you deal with opposition form the Subspecialty grous ie ER physicians, pediatricians etc.

Were there lawsuits involved, such as restraint of trade or how was this done? Has it affected salaries much. In the CRNA community a rural solo practitioner can expect to make approx 100% more than an urban counterpart.

Do you bill directly to insurance companies? Has Medicare approved payments?

Editorial Team / Admin · Feb 26, 2009

Here is a link (2007) - not sure if there is an update or not - about NPs in the US and their authority:

http://www.futurehealth.ucsf.edu/pdf_files/NP%20Scopes%20discussion%20Fall%202007%20121807.pdf

Prescribing law by state: http://www.medscape.com/viewarticle/440315

just_cause, BSN, RN · Feb 27, 2009

Here is a link to the new 2009 Pearson report (PDF File) (state by state NP breakdown...)

http://www.webnp.net/downloads/pearson_report09/ajnp_pearson09.pdf

core0 · Feb 27, 2009

So it is possible , in some states at least, to contract with a rural hospital to provide whatever the NP speciality is on a sole provider basis?
You could replace a physician in the ER if you were an ER NP, peds, FP etc? Condidering the static CRNAs get form anesthesiologists who would like to limit solo practice. How did you deal with opposition form the Subspecialty grous ie ER physicians, pediatricians etc.
Were there lawsuits involved, such as restraint of trade or how was this done? Has it affected salaries much. In the CRNA community a rural solo practitioner can expect to make approx 100% more than an urban counterpart.
Do you bill directly to insurance companies? Has Medicare approved payments?

First you have to differentiate between independence and autonomy.

There are no independent PA practices. An NP can practice with no collaborative agreement for prescribing, diagnosis or treatment in these states (this may have changed I haven't updated it in about a year):

Alaska

Arizona

District of Columbia

Idaho

Iowa

Maine*

Montana

New Hampshire

New Mexico

Oregon

Washington

Wyoming

However, to bill Medicare or Medicaid you need a collaborating physician. In addition Medicare guidelines require a collaborating physician to see inpatients. So if you want to practice completely independently you cannot see Medicare or Medicaid patients

As far as specialty practice given today's liability I have a hard time seeing a hospital giving you privileges to practice independently in any hospital setting including an ER. There are numerous rural ERs that are staffed by PAs and NP with remote physician supervision on the other hand.

The term you are looking for is autonomy. Basically the ability to direct your own destiny. In most cases this is intertwined with the ability to own a practice. Both PAs and NPs own their own practice. The amount is roughly two percent of each profession. For the most part these tend to be in rural or urban underserved areas. They also tend to be pretty much confined to primary care (although aesthetics seems to be growing). The structure is usually the same although the mechanics are somewhat different.

Both PAs and NPs can bill Medicare. NPs can receive the money directly. For PAs the receipts must either go to the practice or the physician. Most PAs structure their practice as either a PC (if allowed) or LLC where the PA owns 99% (by Medicare rules the other 1% must be owned by someone else). The receipts are paid to the practice then the PA pays themselves out of the profits. Many NPs structure their practice this way for tax reasons. Most state regulations also prohibit the PA from directly employing the supervising physician. Instead they are employed by the LLC or PC which is legal. Once again in a number of states the NPs must structure their practices in the same way.

PAs and NPs can also contract directly with insurance companies. However, there is case law that shows that insurance companies do not have to contract with non-physicians (or particular physicians) if they do not want to. The only restraint of trade suit that I am aware of is here:

http://www.thefreelibrary.com/APRN+independent+practice+threatened.-a0176690680

There are also some in the CNM literature.

As far as salaries Advance shows NP owned practices are third in salaries but the difference between this and other practices is relatively small.

In short its possible to practice autonomously either within a physician practice or as an owner of a practice. Ownership of a business has substantial barriers that should not be underestimated.

David Carpenter, PA-C

Dr. Tammy, FNP/GNP-C · Feb 27, 2009

However, our independence is tempered by what the hospitals will allow us to do in regards to admitting pts.

Just curious. If a hospital refuses admitting privileges in an independent state, would the APN have a legitimate claim related to restraint of trade lawsuit?

Trauma Columnist · Feb 27, 2009

Well I guess you could try it. The differences in credentialling at different hospitals impacts my practice immensely. For instance, I work at a small (100 bed) hospital in the ER. I am not allowed to see pts w/o a physician also seeing them. However, I am also credentialled at four other hospitals, where I see pts, order and interpret tests all w/o a physician seeing them!

cessnadriver · Feb 27, 2009

My next question is about compensation. On every web site I can find, it appears the annual salary for an NP is between approx, 75K and 85K with 82K being the 75th percentile. Why so low? Are you billing directly ( For those of you in autonomous practice.) Or is the depressed income a result of overproduction of NPs? What mechanisms are in place to prevent over production. Do you comptete with PAs for positions?

With autonomy you would expect you salaries to be on a par with CRNAs. What are the reasons they are not?

core0 · Feb 27, 2009

Well I guess you could try it. The differences in credentialling at different hospitals impacts my practice immensely. For instance, I work at a small (100 bed) hospital in the ER. I am not allowed to see pts w/o a physician also seeing them. However, I am also credentialled at four other hospitals, where I see pts, order and interpret tests all w/o a physician seeing them!

I think that what the OP was asking was could an NP replace a physician specialist. Ie instead of the EM group, the hospital contracts or hires ENPs (whatever they are) to replace the physicians and run the ER independently. I don't know of any hospital that would do this. Same goes for an NP doing specialty work without a physician in a hospital.

David Carpenter, PA-C

core0 · Feb 27, 2009

My next question is about compensation. On every web site I can find, it appears the annual salary for an NP is between approx, 75K and 85K with 82K being the 75th percentile. Why so low? Are you billing directly ( For those of you in autonomous practice.) Or is the depressed income a result of overproduction of NPs? What mechanisms are in place to prevent over production. Do you comptete with PAs for positions?
With autonomy you would expect you salaries to be on a par with CRNAs. What are the reasons they are not?

I'll let the NPs address the rest, but you should realize that CRNA reimbursement is completely different from other APN reimbursement. CRNAs are reimbursed at 100% of the physician rate. In addition they are eligible for Medicare pass through for rural hospitals. Anesthesia is a low overhead procedure rich specialty. The opposite of primary care (where most autonomous NPs practice). Finally a hospital that does surgery or deliveries must have some type of anesthesia to stay open. The procedure rich nature allows CRNAs in non-rural practices to make more on average than NPs. The pass through and regional need for rural PAs is why you see especially big bucks there. None of these factors applies to NPs.

David Carpenter, PA-C

cessnadriver · Feb 27, 2009

I understand reimbursment for CRNAs as I have been a CRNA for many years. My question is now.. WHY are not NPs reimbursed 100% of the physician rate ?.. Are PAs? If not, why not? are not all APNs equal?

I was informed in this forum that NPs could practice autonomously. If they can do this I would expect reimbursment to be done on exactly the same model as that used for CRNAs.