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Malpractice insurance is the subject of much discussion and angst today. Annual premium costs for nurse practitioners appear inflated in a variety of specialties and subspecialties. The general assumption is that professionals who provide higher-risk services and treat higher-risk populations would pay higher premiums. But our analysis reveals a lack of consistency in coverage costs for people within same profession, risk level and specialty.1 Many factors contribute to this disparity, but all health care providers must become part of the multidisciplinary solution.2

Our own search for a policy has caused us to reflect on the difficulties NP practice owners encounter when trying to obtain malpractice coverage. In addition to finding limited options, we had to correct inaccuracy and confusion about nurse practitioners among customer service representatives.

Perhaps most frustrating was that we found disparity when we compared premium costs for NP employees, self-employed nurse practitioners and incorporated businesses versus unincorporated businesses.

Newcomers
Nurse practitioners are relative newcomers to medical malpractice purchasing. Because of this, insurers have an advantage when they claim it is difficult to evaluate our risk potential. Malpractice claims against NPs are not accurately portrayed ? in part because nurse practitioners are usually not individually named in lawsuits and often work for large hospital corporations that prefer to settle out of court. Scope of practice differs from state to state, which results in lawsuits being reported under the physician's name but not the nurse practitioner license and name.

In addition, boards of nursing across the country are not always notified that an NP has been named in a lawsuit, so an accurate number of the NPs named in malpractice claims cannot be tracked. This leads to artificial lowering of the actual number of malpractice cases involving nurse practitioners.3 Some boards are now requiring that a mandatory National Practitioner Data Bank query be run as part of the licensing process. For this reason, it's important to periodically self-query the data banks to verify their accuracy: http://www.npdb-hipdb.hrsa.gov.

Key Factors
A key complicating factor in obtaining malpractice coverage is that insurance companies are unfamiliar with the individual state rules and regulations for NPs. Despite more NPs opening their own practices (at least 2% of NPs according to the 2005 National Salary Survey of Nurse Practitioners conducted by Advance for Nurse Practitioners), insurers are reticent to insure us without a supervising or collaborating physician on record.

Insurers' distress is related to many factors, including that MDs can go "bare" in some states and carry no malpractice insurance.

One example of a state in malpractice distress is Florida. Two companies stopped writing policies completely in 2005, but one says it will return with low limits of $250,000 and $750,000 claims-made coverage. Until the creation of the Sophia Palmer Nurses Risk Retention Group in Florida in March 2007, CM&F was the only company writing policies in that state. CM&F offers a step-graded premium plan: The first-year premium is under $500, but the premium doubles the second year and continues to rise. With Sophia Palmer Nurses Risk Retention Group, NPs in Florida are now working with Physician Insurance Company (ironically named since it is a private insurer not owned by a physician) for policies, according to the Florida Nurse Practitioner Network Web site.

Our Story
Other problems include misunderstandings about scope-of-practice variations, prescribing issues and even the individual nurse practitioner business entity. For example, insurance companies have different premiums and requirements for nurse practitioners who are self-employed but decide to incorporate. We learned this when we formed a limited liability partnership.

Because we wanted to conduct business under our partnership, we needed to obtain "business" or "firm" insurance. We researched the small number of insurance companies that provide malpractice insurance for NPs in the United States. We studied premium prices and liability coverage. We found differences in online applications (some were simple, some were burdensome) as well as questionable security issues related to requiring personal information online. In addition, a disparity and overall lack of knowledge about our profession was evident when we attempted to contact customer service staff. We eventually chose a company because they appeared to be most comfortable with our business entity based on the forms provided and information derived from the customer service department.

We completed the initial application online and sent prepayment at the time of submission. After 2 weeks, we were informed by letter that "documentation about our supervising physician, business brochures and other information was needed to complete the underwriting process." In Oregon, no physician supervision is required, so we communicated this and immediately faxed detailed information about our business. Then we waited again. The application was held for more than a month, forcing us to fall back on our own individual malpractice policies as our new employment contract was starting. This was a less than desirable outcome - we had hoped to begin this particular contract using our new partnership entity, but we were unable to due to lack of corporate coverage. When it became clear that the conclusion of the underwriting process would take even longer, we cancelled the process and received a refund. We continue to operate under our individual policies.

Insurers
Although numerous insurance companies provide coverage to physicians and physician groups, few have ventured into the NP market. Many companies are unwilling to offer coverage and benefits to stand-alone nurse practitioners, especially in more independent states such as Oregon. Although professional organizations for physicians, nurse anesthetists and nurse midwives provide direct insurance programs and discounts for their members, nurse practitioner organizations have not yet done so.

Needed: One Voice
Clearly, further efforts are needed to expand the choices available to NPs for malpractice coverage, to improve insurers' understanding of the NP role and to reduce premium costs. A united voice is required.

Margaret Helgert and Carla Anderson are family nurse practitioners who are the founders of Advanced Practitioners of Oregon in Wilsonville. For more information, visit www.advancedpractitionersoforegon.org.

References
1. Buppert C. Questions on malpractice insurance. Topics in Advanced Practice Nursing eJournal. 2006;6(1). Available at: http://www.medscape.com/viewarticle/520660. Accessed March 12, 2007.

2. Thorpe KE. The medical malpractice 'crisis.' Web exclusive to the journal Health Affairs. 2004. Available at: http://www.content.healthaffairs.org/cgi/reprint/hlthaff.w4.20v1. Accessed March 12, 2007.

3. Carson-Smith W, Klein C. NP errors lead to litigation. The Nurse Practitioner. 2003;28(3):52-55.




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