Détente in Scope-of-Practice Issue for Physicians, APRNs?

Scope of practice for advance-practice nurses has been a toxic issue in recent legislative sessions. Nursing organizations have sought independent prescribing and practice authority; the powerful Texas Medical Association (TMA) has swatted away what it sees as a challenge to physicians’ oversight authority.

The TMA and the Coalition for Nurses in Advanced Practice appear to have reached a détente in advance of the 2013 legislative session.

Since 1989, Texas has had a site-based model for advanced practice registered nurses (APRN). More than 20 years created a polyglot of physician oversight regulations—some based on geographical distance, others based on care delivery, and still others based the number of APRNs. The inefficiency of current regulations for both nurses, who have been trained to prescribe independently, and physicians, who sometimes must travel to remote locations, is becoming more intolerable as the state faces increasing shortages of healthcare providers.

The so-called collaborative prescriptive authority model would require an APRN to be credential by the Texas Board of Nursing, which is already the case, and have a collaborative prescriptive authority agreement with a physician or physician group for consultation and referrals. The model exists in 17 of the 32 states that require physician involvement.

Bruce Malone, an Austin orthopedic surgeon and former TMA president, said scope-of-practice is “a big issue for us,” but that TMA would be amendable to a collaborative arrangement.

“We’re going to have no problems with it,” he said. “Things have changed since the agreement in the 1980s with electronic medical records and texting. We want the rules to reflect modern communications technology.”

According to a May report by Ray Perryman, a noted Texas economist, using APRNs under the collaborative would enhance efficiency, boost economic output by $8 billion and create nearly 100,000 more jobs. The report projected impact in 10-year increments through 2040. By that time, the total impact would be nearly 180,000 new jobs and more than $23 billion in additional economic output.

The report estimated Dallas-Fort Worth would gain more 32,000 additional jobs with fewer APRN restrictions and that would grow to more than 40,000 jobs by 2020. The additional DFW economic output would be more than $2.6 billion and grow to more than $4 billion by 2020.

The report emphasized savings by more fully using APRNs, who are less expensive to train and who can reduce the need for more costly treatment because they can provide more preventive care.

James Dickens, senior program management officer for the U.S. Department of Health and Human Services Dallas regional office, chaired a roundtable panel of Texas advanced practice nurse associations, the Texas Nurse Association (TNA) and Texas Team Advancing Health through Nursing address the Institute of Medicine’s recommendations that APRNs be allowed to practice at the full scope of their training.

Dickens said, “We want full autonomous practice but we believe the legislature won’t support that at this time. The consensus was that the timing is just not right. We believe the collaborative model was an opportunity to move the needle, streamline the process, and increase access to care. But that’s not the end goal.”

Alexia Green, a Texas Tech University nursing professor and co-leader of Texas Team, said, “There is plenty of evidence from unbiased groups that APRNs provide similar or higher quality care. The data support this. Professional dogma does not. We have to do what’s best for Texans.”

Jim Willmann, TNA general counsel and director of governmental affairs, said the advantage of the collaborative model is that it can be defined by the physician and nurse rather than overly restrictive external rules.

“If they have worked together for 20 years, the doctor needs to spend less time with them. Details of the relationship would be decided by them based on reality. The current restrictions are very costly and barriers to access to care. We are hopeful and optimistic we can move the ball forward,” he said.

Health reform could insure as many as 4.5 million through Medicaid expansion and insurance exchanges if Gov. Rick Perry’s decision not to participate in Medicaid expansion is overturned. The state has the nation’s fastest growth rate, with 5 million new residents expected to be added this decade.

Meanwhile, the physician population is aging even more swiftly than the general population. Nearly half of Texas physicians are over age 50 and 1 out of 4 are 60 or older.

Texas has 202 physicians per 100,000 residents, compared with the national rate of 257, according to the Centers for Disease Control. Texas has fewer physicians than the national average for 36 out of 40 medical specialty groups. Nearly half of Texas counties are classified as health professional shortage areas, and 29 counties have no PCPs.

APRNs could help stem a potential crisis in care access. A recent RAND Corp. study estimated that the nurse-practitioner (NP) population could nearly double by 2025.

One of the reasons for that explosive growth is that NPs and physician assistants (PAs) often earn more than $100,000 annually. Yale University researchers calculated that, for women, becoming a PA has a better return on investment for schooling than becoming a physician.

Nursing generally is a hot profession. Nursing represented the largest increase–40 percent–in hospital job openings from the first quarter of 2012 to the second quarter, according to the recruiting firm HEALTHeCAREERS Network. For NPs specifically, it was 16 percent. The U.S. Bureau of Labor statistics predicts that 1 out of 5 new jobs created this year will be in nursing.

In Texas, the demand for nurses is especially acute. As of May 2011, the demand for nurses exceeded the supply by 22,000. The Texas Nursing Workforce Shortage Coalition, which is composed of about 100 state medical centers and hospitals, warned in a letter that “without stable, continued funding for nursing education, this gap will widen by 70,000” by 2020.

There were fewer than 10,300 graduates from Texas RN programs in the 2010-2011 academic year, according to a report by the Texas Center for Nursing Workforce Studies. That report estimates the number would need to increase to more than 17,700 by 2015 and need to more than double by 2020.

Steve Jacob is editor of D Healthcare Daily and author of the new book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at [email protected]


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