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.