House committee hears bill to grant APRNs independent practice for medical acts
By Jonathan Nelson
The long-anticipated scope of practice showdown of the 87th Texas Legislature took place Wednesday, March 24, in the House Committee on Public Health. Two TAFP members — Tina Philip, DO, of Austin, and Troy Fiesinger, MD, of Sugar Land — joined a number of physicians who provided in-person testimony against this session’s attempt to grant advanced practice registered nurses the ability to conduct medical acts without a delegation agreement with a physician.
House Bill 2029 by Rep. Stephanie Klick (R-Fort Worth) would allow APRNs to prescribe medications, order and evaluate diagnostic testing, and prescribe durable medical equipment, all without any physician collaboration. These actions are clearly defined as the practice of medicine under Texas law, yet the text of the bill states that should HB 2029 become law, an APRN performing one of these acts “is not considered to be practicing medicine without a license.”
TAFP has many objections to HB 2029, including the following.
- The training APRNs complete is not adequate to prepare them to practice medicine. Physicians undergo rigorous training to provide complex differential diagnoses, order and evaluate diagnostic tests, and develop treatment plans. That training includes seven or more years of postgraduate education and between 10,000 and 16,000 hours of clinical patient care. APRNs complete two to four years of postgraduate education and 500 to 720 hours of clinical patient care.
- While all members of the health care team — especially APRNs — are important to the provision of high-quality care, members of the health care team are not interchangeable. There is no equivalency between a physician and a nurse practitioner, and allowing APRNs to practice independently will only serve to further fragment a health care delivery system sorely in need of more collaboration.
- Allowing APRNs to practice medicine without a delegated authority agreement with a physician will not increase access to care or reduce health care costs in Texas, despite what nurse practitioner organizations claim. There has been no significant increase in access to care in states that have expanded APRN’s scope of practice nor have costs gone down.
Tina Philip, DO, addressed the last point in Wednesday’s hearing, telling committee members that APRNs practice in rural and underserved communities at about the same rate as family physicians do.
“One of the things this bill claims is that it’s going to improve access to care, especially for our patients in rural Texas,” she said. “The thing that we see is that advanced practice nurses tend to go into practice in the same locations physicians do. They concentrate mostly in cities and suburban areas; they tend to practice in employed and hospital groups, physician groups, retail health clinics; they don’t necessarily go out into those rural areas any more frequently than we do.”
She said that while physician organizations in Texas strongly support improving access to care and lowering health care costs, HB 2029 is the wrong prescription for the state.
“When we talk about rural Texas or rural patients, a lot of times their primary care physician is the only person they have access to, so it would make sense that we need physicians out there that are well-trained, full-scope, to either provide the care or to at least help lead a care team to deliver care to those patients.”
Troy Fiesinger, MD, described his experience as a family physician with Village MD in Sugar Land and as a medical director for the organization’s Houston operation. Village MD has consistently shown that its recipe for collaborative, team-based care produces high-quality, cost-efficient care in several urban and suburban areas around the country.
“While I have spent four years in medical school, three years in residency, and 22 years working as a family physician preparing me to care for these complex patients, I know that I cannot do it alone. I work closely with our nurse practitioners, our physician assistants, our clinical pharmacists, nurse care managers, and social workers to keep my patients home, healthy, and happy. We provide this care through the prescriptive authority agreement and the monthly quality assurance meetings that were set forth in statute in 2013.”
He should know. He was part of the team that helped craft the legislation that put the current prescriptive authority in place.
The committee left HB 2029 pending. Stay tuned for more information as the session progresses.
Dr Alejandro Rocha said
Nurse practitioners and physician assistants ARE interchangeable and convey the same competency and level of medical care as well as training, yet how can the texas legislation consider possibly granting independent practice to one group and not the other?
Also what other field has such disregard for professional post graduate training? I dont see paralegals wanting independent practice of law, nor engineering technologist etc etc. I also dont see mid levels performing brain surgery or coronary bypass grafts but once you let the camels head in the tent the whole body will soon follow, so you can be sure you'll one day see midlevels doing independent hip replacement surgeries etc because of the inevitable snowball effect
Dr.Ángel Quesada said
I’m trying to get the Texas license .Im family medicine physician board certified , living in San Antonio Texas and working in federal facilitiy. I have medical licenses from others States . I’m from Puerto Rico. I have more experience and medical credentials that mid levels- nurse practitioners, I cannot get the Texas medical license because I don’t have ECFmG certification ( for foreign graduates. It was not required to get the Puerto Rico medical license ). Florida medical board has more flexible medical board laws , and easier to get the medical license than Texas. I have Florida license and others State license, why I can’t get the Texas license?.
Petra De Leon said
Physicians state that an APR. shouldn’t be granted full practice authority despite of the fact that we are placed in work settings practicing alone. Physicians prosper from our hard work and spend anywhere from from 5-15 minutes per month to sign our supervision delegation forms in which they COLLECT 2500-3500 from each APRN and can supervise up to 6 totaling 21000 per month. Physicians are more concerned about losing this easy revenue that’s why they are trying to block HB 2029. During COVID the majority of physicians didn’t see patients they were seen by APRNs they did t worry about our skills, education etc but yet we were in the front line taking care of their patients. It’s not about competency it’s about GREED.
Marlowe A Driscoll said
Real soon there is going to be a huge surge of patient due to the COVID-19 social suppression. One idea that comes to my mind, nurse practitioners spend 3 solid years focusing only on Family Medicine. They don't rotate to different specialties postgrad as do physicians, however, the training is 100% specialty focused. Think about that when competency is in question. Additionally, the requirement to become a practitioner is to have experience for several years in the field before entering studies. Look at the statistics, most FNP's entered the career after many years of experience. I have a Critical Care and Emergency nurse for 30 years. Would you agree that I have seen it all?
I felt the same way as Petra. I used to live in Texas and now live in CO. We have FPA for our NP and I see BETTER care when I visit an NP vs when I see a DO/MD. They take more time, listen more carefully, and have, in my opinion, better bedside manner. Plus about 16-17% of physicians work in family medicine where the majority of NP work in family medicine. If I thought I would lose my cash cow to their own ability to treat a cold, flu, sprain, or infection, I'd be 100000% against it as well.
And no, surgeries won't happen because there is ZERO training in NP programs for doing surgery and that violates the Nursing approach to medicine. If they want to do that, then they need to go to PA or Med School. There is a reason that they went to NP school, its to offer the best care a NURSE practitioner can, not a PHYSICIAN practitioner can.
If I were an NP who lived here where physician oversight and "collaboration" was required and my supervising physicians supported keeping that status quo, I would send EVERY.SINGLE.CHART. over to my supervising MD for signature, since they deem me not adequately prepared to work without their supervision. If they get upset at this, tell them it's because YOU told us NP that we are not prepared so we MUST turn to you, you wanted this, you got it!
Wisconsin Governor just vetoed the FPA bill. It is really sad. I have been an FNP for 15 years and have wonderful MD/DO collaborators...and have put in over 30,000 hours of FT family practice, preop clinic, and a urology specialty. I am tired of MD's saying they have so much rigorous training in residency--which is awesome and needed but who is to say med school curriculum is the only one that will provide accurate dx and adequate care? I am working Family Practice and have learned the zebras after this long of being in practice.
There has not been any negative studies regarding a lack of care from APRN's. On the other hand, I do agree that new graduate NP's should be required to collaborate for at last 4,000 hours but then given the opportunity for FPA. What is funny is don't we all collaborate anyways? I have never worked in a silo and don't intend to. So, I will continue to pay my collaborating MD 820.00 a month for us to have a once a month.
I do not know any NP's who work beyond their scope of practice. We are very careful.
Another interesting thing is the MD group I work in do not like to take the complex patients, women's health, or mental health patients...they send them to us the NP's.