Can NPs and Physicians 'Co-manage' Primary Care Patients?

Tom G. Bartol, MN, NP


September 25, 2020

Nurse practitioners (NPs) have been providing primary care to patients in the United States for 55 years. Yet in all that time, the question of the best way to integrate NPs into primary care practice with physicians hasn't been answered, at least not definitively.

NPs and physicians work side by side in many primary care practices — that's nothing new. But they aren't always providing the same services. Models for the utilization of NPs in primary care vary a great deal. Some NPs carry their own panel of patients. Some provide episodic care to the entire practice's patients.

Still others share primary care responsibilities equally in a model known as co-management. In a recent analysis of this model, the authors defined co-management as "two primary care professionals (an NP and a physician) jointly sharing the responsibility of all tasks needed to manage the healthcare of the same patients."

Co-management goes beyond treating acute and chronic conditions, to such tasks as diagnostic testing and interpretation, preventive care, referrals, follow-up care, and administrative tasks. In co-management, physician and NP share all the work related to the care of their patients, from visits and exams to medication refills and filling out disability paperwork. There are no "physician tasks" and "NP tasks" with this approach.

To investigate the potential of the co-management primary care delivery model, Norful and colleagues extracted data from available studies of the model and interviewed physicians and NPs who practiced co-management.

Here's what they found:

  1. NP-physician co-management isn't possible without NP autonomy. In states where laws or regulations prevent NPs from practicing autonomously, true co-management is a nonstarter.

  2. The co-management model requires that NPs and physicians be viewed equally as primary care clinicians and provided equal resources to accomplish day-to-day work.

  3. Physician-NP co-management requires effective communication; mutual respect and trust; and clinical alignment/shared philosophy of care, including a similar work ethic.

  4. Successful co-management can alleviate individual workload, prevent burnout, improve patient care quality, and increase patient access to care. Having two clinicians familiar with the patient's history and care was viewed as a major benefit to patients by improving continuity of care.

The authors caution that "team-based care" and "collaborative practice" are not the same thing as co-management. Teamwork and collaboration often involve a vertical hierarchy for communication and decision-making, whereas co-management requires a horizontal organizational structure. Another key point is that cost-effectiveness studies of the NP-physician co-management model are needed.

Sounds Great, but Would It Work?

Co-management, as described above, offers a potentially effective model of primary care, one that could alleviate some of the pressure on a specialty that has seen fewer new medical practitioners in recent years. Co-management puts the NP and physician on equal footing, sharing care for a group of patients and doing whatever is needed at the moment for the patient, a model that might have the added benefit of improving job satisfaction among NPs.

Debates about...who is a better provider don't help patients.

Whichever model is adopted by a practice that employs both NPs and physicians, it needs to work for patients, too. Debates about who should do what, who knows more, or who is a better provider don't help patients and don't improve care. As demonstrated by Norful and colleagues, what matters is effective communication, mutual respect and trust, and the alignment of a philosophy of care.

Adopting the co-management model of primary care on a broader scale could be challenging, however. First, more than half of the states in this country do not, by law, permit autonomous practice for NPs. For NPs in these states to practice true co-management, new legislation would be needed.

Another challenge could be finding NPs and physicians whose clinical approaches, work ethic, and philosophies of care don't conflict. Co-management would fail if the patient hears one message from the NP and an entirely different one from the physician. But hiring a new clinician to fill a vacancy can be tough enough in some settings without the added requirement of a specific practice style.

It's an interesting model, and we should look forward to the evidence testing its effectiveness.

Tom Bartol is a family NP practicing primary care in rural Maine. He is also a nationally known speaker and author, sharing insights on healthcare and clinical practice.

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