The Heartland Institute recently published an article outlining the “fight” of California Nurse Practitioners who don’t appreciate being required to have supervised practice experience before being allowed to provide patient care independently of any physician involvement.
A PPP Board Member, Phil Shaffer, MD, penned a response:
Dear Dr. Cohen:
I read your article about Nurse Practitioners (NPs) suing the Board of Nursing to loosen regulations that allow unsupervised care by NPs. As a physician on the board of directors of Physicians for Patient Protection, I am very familiar with the issues your article addresses, and I want to share my perspectives with you.
Your article presents the plaintiffs’ arguments without balancing perspectives. Including substantial counterarguments is essential for readers to fully understand the issue.
You mention that NPs must pay supervision fees to supervising physicians, with a quoted attorney characterizing it as a “handout to physicians,” a characterization you do not dispute. There is important missing context here. While the $6,000 amount is accurate, claims that many physicians charge more than twice this are unsupported. The portrayal of physicians using this as an easy way to profit from NPs’ labor is inaccurate. Supervision fees compensate physicians for both their professional labor in supervision, and in absorbing the substantial malpractice risk they assume when supervising NPs. In many jurisdictions, supervising physicians can be held vicariously liable for the negligence of NPs, even if the physician never saw or treated the patient. See: Rainey Kizer Revier & Bell PLC
This malpractice risk consideration is so significant that many hospitals in states with fully independent NP practice still require their physicians to sign supervision agreements to shield the employer from legal exposure. The $6,000 could therefore be viewed as a form of malpractice insurance for the NP, still far less than what physicians typically pay.
It is entirely valid to reimburse the professional time a physician may expend in supervision. Proper supervision functions as both a safety net for patients and an educational experience for the NP, requiring the physician’s time. This supervision fee is not “money for nothing” but a charge for services rendered and risk assumed. While some physicians may not closely supervise, this is a practice I would never endorse, and those physicians will appropriately be more exposed to malpractice risk.
Another crucial point not considered in the article is how many NPs actually pay the supervision fee. Generally, NPs employed by hospitals or clinics are assigned a supervising physician without incurring a fee. Typically, the supervising physician, also an employee, receives no additional compensation or time for supervision. According to a survey by the American Association of Nurse Practitioners, only 2% of NPs are self-employed, meaning the vast majority are employed and do not pay out-of-pocket supervision fees.
Regarding the three-year supervision period required by law before independent practice, there is an analogous situation in medical education. After four years of medical school, newly graduated physicians enter a 3-8 year period of additional training, supervised by attending physicians. During this time, physicians are paid far less than NPs, approximately $60,000 less per year. This could be viewed as a fee for them to be supervised, obviously far more than the $6,000 charged to NPs. The attending physicians supervising the resident physicians are compensated for their oversight through their salary and time allocated for supervision.
However, this analogy is not exact, as physician training programs are structured with a planned curriculum monitored by an oversight organization: the Accreditation Council for Graduate Medical Education (ACGME). Programs that fail to educate their trainees appropriately lose their accreditation. This structured oversight is not present in the NP training period as envisioned by California. There is no plan for an organized educational experience, no independent supervising agency to monitor quality, and thus one could expect large gaps in knowledge.
Furthermore, at the end of their training, physician trainees must prove their competence through multiple board examinations. In contrast, in the California process, NPs are not required to demonstrate that they have learned anything.
The article characterizes licensing as a “barrier to entry”. Yes, it is. And it is entirely appropriate to erect barriers to prevent unqualified people from treating patients. These barriers should be examined in a historical context. Such barriers were established to ensure safety and competence. In the early 1900s, the Flexner Report exposed the proliferation of diploma mills producing unqualified physicians*, leading to the closure of these institutions and the establishment of rigorous scientific training for physicians. These “barriers” have therefore been designed to protect patients from unqualified practitioners, just as barriers along highways protect inattentive drivers from hitting other drivers.
Portraying these barriers as unfair to NPs is simply misguided. It puts the NPs’ professional aspirations ahead of patient interests. Licensing functions as a mechanism to ensure patients receive quality care. NPs seeking full practice authority should pursue the comprehensive training that physicians undergo. There are NPs who do take this path, and become far better practitioners as a result, obviously serving their patients by doing so. Attempting to achieve greater authority through legislation or litigation does not enhance knowledge or competence, ultimately disadvantaging patients.
I would welcome the opportunity to present this contrasting view to readers. And I would also welcome the opportunity to maintain a dialogue on these issues with you.
Sincerely,
Phillip Shaffer, MD
Board Member, Physicians for Patient Protection
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