A reader sent me an intriguing scenario in which physician hospitalists (whom I can only assume are employees of a hospital system) are being forced to sign off on the daily rounds of nurse practitioner hospitalists.
Dear Happy,
Recently we are being required to "use" nurse practitioners to round on patients. Then we are "required" to sign their progress note. In your opinion what is the significance of signing?
That's just nuts. The only situation I could ever find myself agreeing to be the physician of record for any provider whom I haven't first given my consent to practice under my guidance is if that hospital gave me 100% financial protection from any and all malpractice actions brought on by any patient which I was being forced to sign off on for care provided by the nurse practitioner.
The only reason a hospital would hire a nurse practitioner to do daily rounds is because it's cheaper than hiring a physician. By having an NP round on patients, they reduce their labor expenses and increase their operating margins.
That's great for the hospital and great for the folks who's bonus structure is tied to the economic benefits of hiring nurse practitioners. But why would the hospital then turn around and require a physician to sign all NP notes? That's easy. The Medicare National Bank requires that all patients have a collaborating physician for all inpatient charges.
That means, even if you had an independently practicing nurse practitioner with no physician over site practicing medicine in the middle of Idaho, Medicare would require a collaborating physician to be the attending of record if that patient ever got admitted to the hospital. That's the rule and that's why your hospital is mandating you to sign every record of care provided by a NP as if it was your own.
Your hospital is trying to have its cake and eat it too. I suppose they figure they can get patients evaluated by a nurse practitioner with 1/10 the training and a fraction of the scope of a fully certified internal medicine physician, and a fraction of the cost, and then use you, the physician to comply with the CMS rules and regulations.
It's about money and your hospital is putting you in the middle of their money making machine. The only question now is are you going to allow yourself to be used for the financial gain of others and are you willing to accept the legal and medical liablity for the actions of someone with just a fraction of your training? What exactly does signing a nurse practitioner's note mean?
- Does it mean you've seen the patient?
- Does it mean you've only read the note?
- Does it mean you agree with everything the nurse practitioner hospitalist wrote?
It doesn't matter what it means. The fact of the matter is, if the dung ever hit the fan, the one the lawyers are coming after is you, the physician of record, not the NP who has everything signed off on by you. You will be held 100% responsible to the letter of the law. Unless your hospital is willing to pay 100% of all legal expenses AND 100% of any and all judgments against you in a patient you signed off on, I would tell your hospital to take their NPs and shove it where the sun don't shine. And even then, you are left with the lawsuit ready to haunt you for years whenever you apply for hospital credentials.
If you aren't willing to force your hospital to make this happen, I would hope you have the self respect to demand compensation for every patient you place your signature on as if it was your own. That means your hospital should pay 100% of your effort. That means, your hospital would also be paying for an additional NP which is not a business model they would consider investigating.
Many private practices employ NPs in order to increase volumes at a reduced cost, then pocket the difference as a profit distribution. In this case, the physicians accept responsibility for the care provided by the NP, but also profit from the increased volume of reimbursement at a reduced cost. In your situation, instead of you earning this profit for using NPs, the hospital is using you to skim this profit from you and depositing it in their accounts. They are using you and there is no way around that fact.
When physicians hire NPs, they are are hopefully mentored and trained by the physician of record. They do it on their terms and the physicians work closely with their non physician providers to ensure a high quality of care at a comfort level acceptable to the medical physician. That's the only way I would ever work closely with an NP on my patients. It would be on my terms. Why? Because NP education is so woefully inadequate to practice an independent scope of hospital internal medicine.
If your hospital is forcing you to sign nurse practitioner hospitalist notes without protection or compensation, they are using you and you have no one to blame but yourself.
