The practice environment of nurse practitioners (NPs) and physician assistants or associates (PAs) (collectively referred to as advanced practice providers or APPs) varies by state. Additionally, national organizations differ on how NPs and PAs “should” practice. For one, the American Association of Nurse Practitioners defines the practice environment of NPs as follows:
- Full or independent practice, where the NPs can practice independently under state practice and licensure laws.
- Reduced practice, where state practice and licensure laws require NPs to have collaborative practice agreements with another provider, typically a physician.
- Restricted practice, where state law requires career-long supervision by another health provider.
PAs have a different practice structure as compared to NPs, which also varies by state. The American Academy of Physician Associates defines the practice environment by state this way:
- Optimal practice, where PAs can practice to the full extent of their medical education, training, and experience and continue to collaborate, consult, and/or refer to the appropriate member(s) of the healthcare team “as indicated by the patient’s condition, the PA’s competencies, and the standard of care.”
- Advanced practice, where PAs practice to the full extent of their medical education, training, and experience, but “must comply with additional administrative requirements as mandated in state law and/or regulation.”
- Moderate practice, where the “PA and the healthcare team are limited in flexibility” due to mandated and additional administrative burdens.
- Reduced practice, where state law and regulation “restrict the healthcare team and PAs’ ability to practice in at least one element of PA practice.”
Regardless of the discussion around the practice environment, the risks for doctors who supervise or collaborate with APPs remain a real concern. Physicians who supervise or employ APPs have higher exposures than those who have limited supervision or collaboration roles. According to a recent article in MEDPAGE TODAY, doctors who supervise or collaborate with APPs should be aware that they themselves could be sued if their APP is involved in an adverse outcome. The article shares that physicians who may not have ever seen the patient may be pulled into a suit.
In another article published by Medscape and shared by the Medical Professional Liability Association, court cases show that physicians continually underestimate their liability in supervising APPs. Even in states that have abolished requirements that NPs be physician-supervised, physicians may still be liable by virtue of employing the NP, according to William P. Sullivan, DO, an attorney and emergency physician. Employed or contracted physicians assigned to supervise NPs or PAs are also affected, Sullivan said. "The employed physicians' contract with a hospital or staffing company may require them to assist in the selection, supervision, and/or training of NPs or PAs," he said. He added that supervisory duties may also be assigned through hospital bylaws. In addition to medical malpractice suits, Sullivan said state licensure boards often sanction doctors for improperly supervising NPs and PAs. Licensure boards often require extensive protocols for supervision of NPs and PAs.
Physicians who supervise or collaborate with APPs should understand the rules and laws of their state as well as the guidance from their medical boards. For questions related to coverage, please contact the LAMMICO Underwriting Department at 504.831.3756. For other questions, please contact the LAMMICO Risk Management and Patient Safety Department at 504.841.5211.
