Capitol Update: Physicians testify against independent practice for nurse practitioners
In the early hours of Thursday morning, April 21, 2011, the House Public Health Committee took up three bills that would grant independent diagnosis and prescriptive authority to advanced practice registered nurses, or APRNs. The marathon committee meeting began after 7 p.m. on Wednesday and didn’t adjourn until 5:10 a.m. the next morning, and TAFP member Tricia Elliott, M.D., of Galveston, and Texas Pediatric Society member Gary Floyd, M.D., of Fort Worth were there to provide testimony on behalf of TAFP.
Elliott, director of the UTMB Family Medicine Residency Program, stood before the committee at about 2:45 a.m., to testify against House Bill 915 by Rep. Wayne Christian, R-Center; H.B. 708 by Rep. Kelly Hancock, R-North Richland Hills; and H.B. 1266 by Rep. Garnet Coleman, D-Houston, and Rep. Rob Orr, R-Burleson. She told the committee that although little data exists comparing the quality and cost of care provided by physicians to that of nurse practitioners in independent practice, the differences in their education and training is starkly evident.
“In our residency program, our residents complete three years and must be supervised for the entire three-year duration,” Elliott said. “They must pass multiple standard rotations, be evaluated along six core competencies, and undergo 100 percent chart review for the duration of their residency in preparation for practice. Only at the end of these three years, when they have met all of their requirements and competencies, and after completing almost 16,000 — that is 16,000 — clinical hours from medical school to residency, do I as their residency director summarize their experiences and declare them in writing fully competent and able to practice independently.”
No such standard exists for the education of nurse practitioners, she said, adding that nurse practitioners experience between 500 and 1,500 hours of clinical training while pursuing their degrees.
A 2004 survey of practicing nurse practitioners published in the Journal of the American Academy of Nurse Practitioners reported that in the area of pharmacology, 46 percent reported they were not “generally or well prepared” by their education. The authors wrote: “In no uncertain terms, respondents indicated that they desired and needed more out of their clinical education, in terms of content, clinical experience, and competency testing.”
Nurse practitioners testifying before the group argued that independent practice for APRNs would reduce health care costs, but a study published in Efficient Clinical Practice comparing utilization rates among physicians, medical residents, and nurse practitioners in the same setting showed that utilization of medical services was higher for patients assigned to nurse practitioners than for patients assigned to the residents and the physicians. Hospital admissions were 41 percent higher among the patients of nurse practitioners, and specialty visits were 25 percent higher in the nurse practitioner group.
“Twelve years ago, I completed my residency program in the Bronx in New York, in the inner-city, underserved area, and I also practiced in that community for several years,” Elliott told the committee, adding that during that time she worked closely with nurse practitioners. “They are a valuable part, a critical part of our health care team, but they must work with us collaboratively.”
Speaking on behalf of the Texas Pediatric Society, the Texas Medical Association, and TAFP, pediatrician Gary Floyd, M.D., of Fort Worth told the committee that medicine today is moving away from the old model of individual providers working independently and toward a team-based model in which physicians and other health care providers work together to treat patients. “It relies on the use of nurse practitioners, physician assistants, and other health care workers in a collaborative practice that’s driven by what the patient needs. It’s designed to deliver continuous, coordinated, effective patient care.”
He said that while APRNs are trained to emphasize health promotion, disease prevention, and patient education, they lack the broader expertise needed to recognize cases in which multiple symptoms suggest more serious conditions.
“It’s important to understand that their scope does not include independent diagnosis or prescribing treatments for disease processes. Those functions are reserved for physicians under Texas law and are considered medical acts,” he said. “We do believe APRNs are vital to our service, but we think it should be done in a physician-led, team-based approach.”
All three bills were left pending before the committee.
The Senate Finance Committee today approved a $176.5-billion budget for 2012-2013 that spends $12 billion more than the House version and uses up to $3.1 billion of the Rainy Day Fund. The budget now heads to the full Senate.
Though floor debate is likely to be lively, to say the least, it will most certainly meet stark resistance by House and state leaders who have repeatedly stated their opposition to using the Rainy Day Fund for the 2012-2013 budget. The House approved a lean $164.5-billion budget on April 3 that makes massive cuts to education and health services, and does not pull additional money from the fund.
Senators have been actively looking for non-tax revenue to lessen some of the House’s proposed cuts to nursing homes, public education, and Medicaid. The Senate Finance Subcommittee on Fiscal Matters, chaired by Sen. Robert Duncan, R-Lubbock, approved Senate Bill 1811 on Wednesday, April 20, which identifies $4.2 billion in deferred payments, accelerated tax collections, increased fees, state property sales, and other accounting maneuvers to help bridge the gap. Additionally, Duncan identified $600 million in funds that did not need committee approval.
Both the House and Senate budgets for 2012-2013 spend less than the current budget for 2010-2011, and “neither takes into account population and inflation in programs like Medicaid and public education,” according to the Texas Tribune.
Acknowledging that this has been an extremely difficult budget-writing process, both have far to go to ensure access to health care for Texans, support a vibrant primary care workforce in Texas, address the underlying structural flaws in health care delivery, and put in place long-term reforms that will make health care more affordable and increase health care quality, says TAFP President Melissa Gerdes, M.D., of Whitehouse.
TAFP continues to advocate for the restoration of funding or lessening of cuts to the following priorities.
- Primary care residency training through the Texas Higher Education Coordinating Board;
- Family Medicine Residency training through the Texas Higher Education Coordinating Board;
- Physician payments in Medicaid and CHIP;
- The Statewide Primary Care Preceptorship Program;
- The Physician Education Loan Repayment Program;
- GME formula funding;
- Early Childhood Intervention services;
- Children with Special Health Care program funding; and
- Comprehensive obesity prevention programs.
With just 39 days left in the session, time is running out. The Texas Legislature is mandated by state law to pass a balanced budget. If the House and Senate can’t reach an agreement by sine die on May 30, they’ll have to reconvene for a special session this summer.
Russell Thomas, D.O., a family physician in Eagle Lake, told the House Committee on Public Health that while telemedicine offers exciting opportunities for expanding access to care to rural and underserved populations, a measure currently being considered would remove too many restrictions on the practice.
House Bill 2333 by Rep. Rick Hardcastle, R-Vernon, expands use of telemedicine to allow physicians, physician assistants, and advanced practice registered nurses to treat patients over the Internet without first performing an exam in person.
“The problem we see with this particular bill is not the issue of opening up and expanding medical care; we support that,” he told the committee in the April 20 hearing. He testified on behalf of TAFP, TMA, and TPS. “The bill as proposed would allow for a person to establish a relationship with a physician and yet never have to see that physician. That brings up a lot of problems.”
Thomas said the removal of the requirement for a face-to-face examination would inhibit the development of meaningful physician-patient relationships and damage the continuity of patient care.
TAFP Treasurer Troy Fiesinger, M.D., of Sugar Land testified before the Senate Committee on Health and Human Services on Tuesday, April 19, in support of Senate Bill 1022, commonly called the IMG licensure bill. The bill, by Sen. José Rodríguez, D-El Paso, would allow international medical graduates to receive a medical license after two years of graduate medical education instead of three, as is current law.
Fiesinger, who is faculty at Memorial Family Medicine Residency Program, said the residencies see the growing need for primary health care in Texas and want to do their best to meet this need, but licensure hurdles for international medical graduates create a ripple effect that draws qualified physicians from Texas.
As Fiesinger explained, IMGs must complete three years of residency to apply for a Texas license. Until they apply for that license, they cannot sit for their family medicine board exams, which occur first in July and August. If that license application cannot be completed until July, they miss the first board date. Board certification for them is then delayed three to four months until November. They also then cannot apply for credentialing from insurance companies, which is a requirement to be paid as a physician. Nor can they apply for hospital privileges, which are essential to work as a physician. This delays the physician’s ability to work for often five or six months.
When the residents graduate June 30, their medical education loans come due July 1, he said. “In many cases, they have to support families, and there is financial pressure on these young physicians. With Oklahoma and New Mexico having a two-year requirement, many of these graduates will look at another state to get a license there. I can think of [a] graduate who obtained an Oklahoma license, moved to Oklahoma to practice, and never came back. Texas lost a physician in that case, a physician who cared for many of our citizens.”
“Certainly when we’ve invested taxpayer dollars on college education, medical education, and residency education, I want our taxpayers to benefit and our physicians to benefit from that investment. One family doctor can take care of 2,500 patients and see 4,500 patients each year. In the office, that can be over 100,000 visits over a full-time career and it has a major impact on the health of Texans.”
Asking for the support of the committee, he said, “We feel this simple change will help family physicians start their careers sooner, maintain practices in Texas, and benefit our citizens and help the future health care needs of our citizens.”
The bill was left pending. The House version of the bill, H.B. 1380 by Rep. Vicki Truitt, R-Keller, was passed by the House on Tuesday, April 19.
Did you see the second edition of the Capitol Report news webcast? Join TAFP communications staff Jonathan Nelson and Kate Alfano for an insider’s look into the recently-passed House budget, graduate medical education, the IMG licensure bill, and legislative battles to come.
Rep. Richard Peña Raymond of Laredo, chair of the House Human Services Committee, and TAFP past president Doug Curran, M.D., speak about the House budget and its effect on local and rural communities. TAFP Vice President Clare Hawkins, M.D., program director of the San Jacinto Methodist Family Medicine Residency Program in Baytown, reflects on how the cuts will affect their ability to train the next generation of family doctors. TAFP Treasurer Troy Fiesinger, M.D., speaks in support of a proposed bill to ease the licensure burden for international medical graduates, asserting that removing this burden would keep more Texas-trained doctors in the state.
Remaining dates: April 28, May 6, May 30
Thanks to the physicians who volunteered for the Physician of the Day program this week: Monique Cortez, M.D., of Austin; Monte Horne, M.D., of Hamilton; Nejla Shami, M.D., of Austin; and Daniel Voss, M.D., of Jarrell.
The Physician of the Day program brings a family physician to the Capitol each day of the legislative session to provide health care to members of the Capitol community. For more information on how to sign up and to view the calendar of open dates, go to the Physician of the Day page of the TAFP website, www.tafp.org/advocacy/get-involved/physician-of-the-day.