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Nurse practitioners fire first shots in latest battle to achieve independent practice

Nurse practitioners say they know how to solve Texas’ shortage of primary care physicians: give advanced practice nurses the authority to diagnose and prescribe without physician supervision. And they’re telling anyone who’ll listen.

A May 21 story in the Texas Tribune, “Nurse Practitioners Want Less Doctor Oversight,” is just one of several recent articles describing the coming battle over scope of practice that is certain to occupy much of TAFP’s advocacy efforts during next year’s 82nd Texas Legislature. The Tribune article pits several claims by nurse practitioner organizations against the position of TAFP and the Texas Medical Association that in the interest of patient safety and the delivery of high-quality medical care, state regulations should continue to foster the collaborative model of care in which physicians delegate authority to mid-level providers.

In the story, Lynda Woolbert, executive director of the Coalition for Nurses in Advanced Practice, argues that lawmakers should grant independent practice to nurse practitioners to help address the shortage of primary care physicians, particularly in rural areas.

“Patients need help managing chronic illnesses; they need well-child exams—all things that aren’t physicians’ strongest suits,” Woolbert said.

The CBS TV news affiliate in Austin ran a similar story on the evening news the following week, and an Associated Press story in April listed Texas as one of 28 states considering the expansion of nurse practitioners’ scope of practice.

“This is the first in what will be a long, sustained effort by the nurse practitioners to achieve the independent practice of medicine,” said TAFP CEO Tom Banning.

Marie-Elizabeth Ramas, M.D., a third-year resident at Lone Star Family Medicine Residency Program in Conroe, Texas, was awarded one of two James Martin, M.D. Scholarships from the TAFP Foundation. Ramas traveled to Austin in June to research scope of practice, meet with numerous lawmakers at the Capitol, and gather materials that will help our legislative team craft a policy brief on this issue to prepare for the upcoming legislative session.

As the Academy prepares for what is sure to be a challenging session, your support and your input is needed to help explain the differences between family physicians and nurse practitioners in their medical knowledge, their qualifications to treat patients, their educational requirements, and the quality of care they deliver.

Since this story’s original publication in TAFP’s QuickInfo e-newsletter on May 27, TAFP has received many anecdotes from family physicians around the state that will help build our case for the value of family medicine. But we could always use more. TAFP encourages physicians to continue sending TAFP your thoughts and any examples from your practice that could help illustrate the differences between a family physician and a nurse practitioner. Send e-mails to Jonathan Nelson at jnelson@tafp.org.

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Patient-centered medical home resources

TransforMED rolls out new product to support solo, small practices

TransforMED, a wholly owned subsidiary of the AAFP, has launched a new service that offers small primary care practices the help they need to implement the patient-centered medical home, or PCMH, model of care.

According to a May 25 news release, TransforMED’s Small Practice Package program “bundles together the necessary tools and components and streamlines the process to enable practices with four or fewer physicians to implement the components of the TransforMED PCMH model in two years.”

Elements of the new program that are available to each participating practice include:

• a medical home assessment to help identify practice expectations, define processes, and understand objectives;
• a gap analysis to a evaluate a practice’s current situation and PCMH opportunities;
• a comprehensive transformation plan that will prioritize goals and set timelines; and
• a dedicated TransforMED facilitator.

The package is available to practices for $1,250 per quarter for virtual online support or $2,500 per quarter for practices that choose TransforMED’s on-site option. Practices must commit to a two-year program enrollment.

Both the virtual and on-site options include unlimited access to Delta-Exchange, TransforMED’s online learning community, and enrollment in the TransforMED Institute, a soon-to-be launched educational forum.

For information, go to: www.transformed.com/small-practice-pkg.cfm

Source: AAFP News Now, May 26, 2010. © 2010 American Academy of Family Physicians.

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Study: Many top-ranked medical schools fail to meet “social mission”

A study released in late June takes medical schools back to the basics, judging them on a set of criteria that has placed many of the typical top dogs at the bottom of the heap. “The Social Mission of Medical Education: Ranking the Schools,” published in the Annals of Internal Medicine, ranks schools not on academic performance, but on their ability to carry out their responsibility to society.

The authors say that for medical schools to fulfill their basic purpose—to educate physicians to care for the population—they must produce an adequate number of primary care physicians, ensure adequate distribution of physicians to underserved areas, and add a sufficient number of minority physicians to the workforce. Overall performance in these three areas gave the schools their “social mission score.”

The researchers analyzed records from more than 60,000 physicians in active practice who graduated from medical school between 1999 and 2001 and completed residency training. They defined primary care as family medicine, general internal medicine, general pediatrics, and internal medicine pediatrics, and used data from the American Medical Association, the Association of American Medical Colleges, and the Association of American Colleges of Osteopathic Medicine.

With scores compiled, the authors ranked the 141 medical schools. No Texas schools made the top 20 and two fell in the lowest 20. The University of Texas Southwestern Medical Center in Dallas was the second-worst following Vanderbilt University in Nashville, Tenn., and Texas A&M Health Science Center in College Station was the 17th worst.

The Texas schools’ composite social mission scores, from best to worst: the University of North Texas College of Osteopathic Medicine in Fort Worth (55), the University of Texas Medical Branch in Galveston (56), Baylor University College of Medicine in Houston (84), the University of Texas Health Science Center at San Antonio (86), Texas Tech University Health Science Center in Lubbock (114), Texas A&M HSC (125), and UT Southwestern (140).

Three historically black colleges had the highest social mission rankings, and public and community-based medical schools had higher scores than private and non-community-based schools. Also, the schools that received greater amounts of research grants from the National Institutes of Health tended to fare worse, with a few exceptions. Geographically, schools in the northeast and in more urban areas were less likely to produce primary care physicians and physicians who work in underserved areas.

One rationale for the study the authors stress is the rising concern about physician workforce, especially “as citizens and policymakers reconsider the U.S. health care system and seek ‘quality, affordable health care for every American.’” Primary care advocates echo this point. In a June 22 Texas Tribune article on the study, TAFP CEO Tom Banning questioned the responsibility that taxpayer-supported medical schools have to train and recruit the physicians Texas needs. He told the Tribune, “What we need to ask is, should the state be supporting those schools that receive significant outside funding the same as the schools producing doctors who are going to go in and care for Texas patients?”

Detractors were quick to criticize the study’s timeframe, definitions, and societal benefits not included in the criteria. One scathing review came in a statement released by the American Association of Medical Colleges. “Like other attempts at ranking medical schools, this study falls short. By defining ‘societal mission’ and ‘primary care’ so narrowly, it provides a very limited picture of medical education’s many contributions to society in the U.S. and around the world. And that serves no one well.”

The AAMC continued to say that medical schools are producing more primary care physicians, and that other types of physicians like general surgeons, OB-GYNs, and other specialists should have been counted as primary care physicians.

Troy Fiesinger, M.D., faculty member for the Memorial Family Medicine Residency Program in Sugar Land, disagrees. He says that the numbers used in this study are more accurate than other data often cited in the press because they include only actively practicing family physicians, internists, and pediatricians—those “trained to look at all of a patient’s health care needs and ensure they are met,” he says. “To include other specialists in the category of primary care physicians only increases the fragmentation of our health care system that negatively impacts our patients’ health and underestimates the shortage of primary care physicians.”

He continues. “Many of our state’s medical schools clearly value biomedical research—which often generates expensive treatments—and production of specialists over production of primary care physicians and research on more clinically effective and cost-effective treatments for the diseases that impact the majority of Texans.”

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Loan repayment program opens rolling enrollment

The Texas Primary Care Office of the Texas Department of State Health Services has announced a more-frequent application schedule for the state’s Physician Education Loan Repayment Program. The program assists certain qualified physicians with educational loan forgiveness of up to $160,000 over four years.

Previously, applications were accepted annually. Now, applications from primary care physicians will be accepted and processed quarterly. Applications from subspecialist physicians will be accepted and processed as they are received and completed.

The revisions were made by the Texas Higher Education Coordinating Board and TPCO after the latest annual application deadline of June 15, 2010. Applications received, approved, and finalized between June 16 and Aug. 31 will have a service start date of Aug. 31. For applications received, approved, and finalized after Sept. 1, the service start date will be the last day of the state fiscal year quarter.

To be considered for the program, primary care and subspecialty physicians must be practicing in a designated Health Professional Shortage Area. Subspecialty physicians also must provide evidence that there is a need for their subspecialties.

As long as funds are available, the program is able to accept up to 225 new PELRP participants per year as authorized by Texas law.

To be eligible to apply for PELRP assistance, a physician must:

• Have completed residency and/or fellowship training,
• Be employed by, and seeing patients at the location referenced in the application that is currently open and operational,
• Be practicing in a designated Health Professional Shortage Area, and
• Have a full physician license with no restrictions from the Texas Medical Board.

To receive loan repayment assistance a physician must:

• Have eligible outstanding student loans, made from an accredited U.S. lending institution,
• Provide four consecutive years of direct patient care service in a HPSA in Texas,
• Be board eligible in years 1 - 3 and board certified, as recognized by the American Board of Medical Specialties (ABMS) or Bureau of Osteopathic Specialists, as applicable, by year 4.
• Provide care to Medicaid enrollees and/or CHIP enrollees if the physician treats children,
• Not be fulfilling a service obligation to any other program that offers loan repayment or loan forgiveness, and
• Not agree to another service obligation for loan repayment or forgiveness during the four-year PELRP commitment.

DSHS and THECB are partners in administering the PELRP. DSHS is the point of contact for applications, practice opportunities, and program questions. THECB verifies all loan data and disburses the loan repayment funds on behalf of selected applicants.

For more detailed information and a link to the online application, go to www.TXLRP.org. For more information call (512) 458-7518 or e-mail TexasPCO@dshs.state.tx.us.