Nonphysician practitioners (NPPs) are redoubling their efforts on behalf of scope-of-practice expansion this session, including a pair of bills that seek full independent practice authority for advanced practice registered nurses (APRNs). But the Texas Medical Association is pushing back with equal force, armed with a growing body of research that shows removing physician oversight of the health care team undermines patient safety and health care cost containment.
TMA’s top priority this session is defending against scope encroachments while advocating for boosting the physician workforce to help alleviate the state’s shortage without compromising the high standard of physician-led care.
“We are ready,” TMA lobbyist Michelle Romero said of this onslaught of bills, which as of this writing totaled more than 130.
Topping that list, TMA continues to advocate against House Bill 4071 by Rep. Stephanie Klick (R-Fort Worth) and Senate Bill 1700 by Sen. Cesar Blanco (D-El Paso). Although not identical, the pair would allow APRNs to diagnose and treat patients, prescribe drugs and devices, and serve as the primary care clinician of record, among other provisions.
Senator Blanco recently cited a poll showing 90% of Texans believe it should be easier to access care from APRNs. The poll, commissioned by the APRN-driven Texans for Healthcare Access Coalition, surveyed 800 likely Texas voters in February.
El Paso infectious disease specialist Ogechika Alozie, MD, says these findings are a red herring.
“Changing [independent practice] authority doesn’t change access,” he told Texas Medicine Today. “A newly authorized clinician isn’t going to see three times the number of patients they were seeing; the raw numbers are the raw numbers. We need more people, not more authority.”
Moreover, Ms. Romero points out the poll does nothing to address the stark discrepancies in education, training, and clinical exposure to a diverse array of patients between physicians and other health care professionals.
TMA has balked at nurses’ claims that they are adequately trained to practice independently as well as their argument that doing so would help alleviate the state’s physician workforce shortage.
When primary voters from both parties were asked if they would favor or oppose allowing nurses or other NPPs to treat patients and prescribe medicine without the oversight of a licensed physician, even if it saved money, more than two-thirds said they were opposed, according to a TMA poll conducted in January and February.
TMA points to studies that have found NPPs are more likely to overuse diagnostic imaging and other services, overprescribe opioids and antibiotics, and over-engage specialists, all of which drive up health care spending.
The recent experience of the Hattiesburg Clinic in Mississippi – studied after 15 years of growing its care teams by adding NPPs because of a shortage of primary care physicians – showed the model had “failed to meet [its] goals in the primary care setting of providing patients with an equivalent value-based experience," clinic physicians wrote in the January 2022 issue of the Journal of the Mississippi State Medical Association.
A 2022 study of Veterans Health Administration data by the National Bureau of Economic Research similarly found nurse practitioners who treat patients in the emergency department “significantly increase resource utilization but achieve worse patient outcomes.”
And a January 2022 study, published in the Journal of Nursing Regulation, found “extensive variability” in the education, licensure, and certification requirements of nurse practitioners (NPs) working in emergency departments. Without standardization, the study concluded, “NPs should not perform independent, unsupervised care in the [emergency department] regardless of state law or hospital regulations in order to protect patient safety.”
Other research shows physicians and NPPs tend to practice in the same areas, regardless of state scope laws.
Sustainable solutions
TMA has testified against other problematic scope bills, proposing more sustainable solutions to the problems these bills purport to address.
The House Public Health Committee on Monday is scheduled to consider House Bill 1930 by Rep. Travis Clardy (R-Nacogdoches), which would allow dentists to delegate authority to registered nurse anesthetists to administer anesthesia, even if the dentist isn’t permitted to perform that service him- or herself. TMA opposes this bill, as well as the following, which have been referred to House and Senate committees for consideration:
- Senate Bill 584 by Senator Hughes and its companion, House Bill 4291 by Rep. Valoree Swanson (R-Spring), which would allow physical therapists to treat patients without a physician referral for up to 30 business days; and
- House Bill 235 by Rep. Donna Howard (D-Austin), which would allow pharmacists to “test-and-treat" certain conditions – including influenza, and strep throat – by prescribing drugs.
The aforementioned TMA poll also found strong bipartisan opposition to pharmacist “test-and-treat" authority, with 79% of Republican primary voters and 80% of Democratic primary voters opposed to the proposed scope expansion.
Rather than take away physician oversight, Dr. Alozie echoes TMA’s call for lawmakers to invest in:
- Graduate medical education residency positions, which bolster the state’s physician workforce pipeline;
- Loan repayment programs, which incentivize residents to train in rural and underserved areas;
- Expansion of broadband and telemedicine access;
- The Texas Medical Board (TMB), which licenses new and new-to-Texas physicians; and
- Medicaid payment rates, which allow physicians to care for vulnerable patients without risking their practice’s viability.
Draft bills in both the House and the Senate include funding to sustain GME residency positions created in recent years and to create new ones, which TMA advocates is critical to protecting the state’s significant investment in medical education and to growing Texas’ physician workforce in lockstep with its ballooning population.
The House appropriations bill also includes a rider that would increase funding for TMB, which plays a critical role in supporting a growing physician workforce through licensing.