NPs can perform primary care without hospital privileges as long as they arrange for patients who need hospitalization to be covered by a provider with hospital privileges or a hospitalist. Nevertheless, if a health plan requires that its primary care providers (PCPs) have hospital privileges, then NPs will need hospital privileges to be PCPs.

Physicians, when arguing to health plans that only physicians should be PCPs, have used hospital privileges as a way to distinguish themselves from NPs. NPs, they argue, do not have admitting privileges and therefore should not be PCPs. Two things are left unsaid. First, many NPs have admitting privileges. Second, many primary care physicians are declining to pursue hospital practice and hospital privileges because of the inefficiencies of having to be in two places—office and hospital—at once.

A patient in need of hospitalization, who is being cared for by an NP or a physician PCP, can be accommodated in several ways. One approach is for the PCP who has hospital privileges to admit patients and continue to manage care during hospitalization. The PCP coordinates specialty consultation, writes admission and discharge orders, takes calls from hospital nurses about the patient’s progress, and evaluates the patient on site once or twice a day, or more as needed.

A second possible approach is for a PCP to turn the care of patients in need of hospitalization over to a physician who has admitting privileges and who does hospitalbased care, and to have patients admitted under that physician’s care. The care of the patient returns to the PCP’s direction after discharge. In this case, the PCP might visit the hospitalized patient, but the visit would be a social or courtesy visit rather than a medical visit.

A third approach is for a PCP to admit to a hospital’s staff hospitalists.¹ The third approach makes sense. The arguments in its favor are: (1) patients get round-theclock access to a physically present provider of medical care; (2) the hospitalists devote all of their attention, every day, to hospitalized patients; (3) the communitybased PCP need not feel torn between visiting hospitalized patients and conducting office visits; (4) the expertise of PCPs is not spread thin by the necessity of being an expert on hospital care; (5) admission and discharge are more efficient because hospitalists are on site to do the initial and discharge evaluation and order writing; and (6) nursing care is more efficient because nurses need not deal with off-site attending PCPs. At a time when hospital days are being monitored by health plans, it is the hospitalists who have the most potential for keeping utilization at a safe minimum.

There is one strong argument against hospitalists. A patient may have established a close relationship with his or her PCP and presumably trusts his or her PCP. When hospitalized, the patient may feel more comfortable with the PCP directing the patient’s care. The counterarguments are: (1) there is nothing to prevent the PCP from visiting or calling the patient who is hospitalized, (2) the PCP presumably has chosen a competent hospital with a competent hospitalist, (3) patients are accustomed to being referred to specialists and may likewise feel comfortable with being referred to hospitalists, and (4) many consumers of health care no longer have the close one-onone relationship with one PCP, since they are signed on with a managed care plan that may have teams of PCPs.

There are two arguments supporting the assertion that NPs who wish to be PCPs should seek hospital privileges.

First, it is a credential that carries weight among professionals. It is something professional groups boast about and battle about, and something that individual
professionals strive for. Physicians sometimes use NPs’ lack of hospital privileges as an argument that NPs should not be designated PCPs by managed care organizations. If the majority of NPs had hospital privileges, physicians would not be able to use the hospital privilege argument against NPs.

Second, some health plans and managed care organizations want their PCPs to have admitting privileges. If that is the case, and an NP wants to be a PCP, the NP will need to get hospital privileges.

The NP who does not need hospital privileges to be a PCP may not want them. For an individual NP weighing the pros and cons of hospital privileges, the issues are: