Update: The Texas Senate version of the bill discussed below, SB 1700, did not make the hearing schedule for the Senate committee, and it is likely too late for any movement, making the bill unlikely to pass.
The battle between physicians and nurse practitioners is alive and well during Texas’ 88th legislative session. In 26 states, nurse practitioners have unrestricted access to running an independent medical clinic, and 14 additional states provide a pathway for NPs to do so after practicing under supervision for a limited period. Despite Texas’ reputation as a state where government stays out of business, it is one of just a few states that require NPs to practice under the supervision of a physician, called delegation.
A group called the Coalition for Healthcare Access is supporting a pair of bills in the Texas Legislature that would remove the mandate for NPs to be supervised by physicians and place regulatory authority for NPs under the Texas Board of Nursing. Amazon, the Texas Association of Health Plans, Texas 2036, the Texas State Chamber of Commerce, AARP, the Texas Organization of Rural and Community Hospitals, and many others have all signed on as supporters of the legislation that would end the practice that costs NPs thousands of dollars a month for oversight from an MD.
Two bills have been introduced toward removing the delegation requirement. Senate Bill 1700’s author is Sen. Cesar Blanco of El Paso, and House Bill 4071 is from Fort Worth’s own Stephanie Klick, a nurse who has been responsible for Texas medical cannabis legislation and is chair of the public health committee in the House. The two bills are nearly identical and allow NPs to diagnose and treat patients, prescribe drugs, including controlled substances and devices, and serve as the primary care clinician of record.
The Texas Medical Association, which represents physicians and medical students in Texas with 57,000 members, has defeated similar bills in past legislative sessions and aims to do so again this year.
TMA President Gary Floyd, who spoke with D CEO Healthcare last year, thinks NPs don’t have enough education. “There’s a significant exaggeration about what they could do if they’re independent,” he told Texas Medicine Today. “They don’t have the training to back that up.”
In an op-ed in the Dallas Morning News, SMU professor Dean Stansel argued that changing NP regulation would allow more providers to provide care in rural areas and address physician shortages, but TMA cites research that says opening up the scope of practice for NPs won’t impact the areas where Texas has provider shortages, and that NPs usually practice in the same areas as physicians.
Other data from the advocacy group Texas Nurse Practitioners found that ending restrictions on NPs resulted in an increase in providers for 25 percent of counties in Nebraska, 33 percent of counties in Nebraska, and the change in Arizona caused rural NPs to increase by 70 percent.
There are also disagreements about potential costs. NP advocates say that they can provide quality care at a lower cost, but there is also evidence that NPs are more likely to overuse diagnostic imaging, overprescribe, or refer more cases to specialists that physicians might handle themselves, which can drive up costs.
NP advocates say the impact would be focused on primary care, where there is a significant need. Nearly three in four NPs are licensed in primary care, while only 36 percent of physicians are licensed in primary care. Talent drain is another issue. If NPs can make work independently without the cost of oversight in another state, they may be more likely to leave.
Other states serve as a model for how Texas could make this work, but Texas was one of the states that suspended the oversight requirement during the pandemic. Neighbors Louisiana, Arkansas, and New Mexico all have either pathways to or outright independence. Delegation was already suspended during the public health emergency, and the change has been the standard in dozens of states nationwide for years.
The physician oversight that currently exists isn’t comprehensive. In 2013, Texas discontinued on-sight supervision for NPs. Today, NPs must pay for a physician review that requires one phone call and a monthly patient note review.
Both versions of the bill have been sent to committees in the House and Senate, where similar efforts in the past have died. Plano NP Peggy Ostrander, the legislative ambassador chair for TPN and a former board member, is frustrated with the process. “If the full chamber would hear the bill and it could get out of committee, we have the votes,” she says.
As is often the case, healthcare legislation creates coalitions that don’t fall on partisan lines, with supporters and opponents for NP practice expansion on both sides of the aisle. The two bill sponsors, Blanco and Klick, are a Democrat and a Republican, respectively.
Opponents of the bill, who have successfully blocked past efforts in Texas despite the changes in the vast majority of states throughout the country, cite patient safety and increased training for maintaining the status quo.
“Until you’ve been through medical training, you don’t know what you don’t know,” Corpus Christi ophthalmologist Dr. Jerry Hunsaker told Texas Medicine Today. “That’s dangerous for patients and expensive for anyone paying for health care.”
But opponents say there are less than noble motivations behind the resistance. “It’s about power, control, and money,” Ostrander says. “As long as it goes on, most NPs have to work for physicians, and if they bill $500,000 each year, why would they let them be free?”