Texas Nurse Practitioners: The Fight for Full Practice Authority

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NPs are more likely than physicians to work in rural areas and in underserved areas; removing the unnecessary regulations of the collaborative practice agreement will expand access to high quality health care in the areas of highest need.
Dr. Cara Young, Assistant Professor at the University of Texas, Austin

One of the most contentious issues in healthcare today is the fight for full practice authority (FPA) among nurse practitioners. NPs in Texas and beyond are trained to work as independent healthcare professionals; in their mandatory graduate degree programs, NPs are prepared to serve as care providers who prescribe medication, order laboratory tests, sign death certificates, issue handicap placards, refer patients to specialists, and take on other responsibilities. Unfortunately for Texas NPs, their regional practice authority falls short and in effect, it restricts their ability to practice to the full extent of their education, experience, and credentialing. This inadequacy is threatening the future of American healthcare.

In Texas, the restricted practice conditions are especially troubling given the imminent shortage of primary care providers across the country. By illustration, the Association of American Medical Colleges (April 2016) predicted a deficit of between 14,900 and 35,600 primary care doctors in the U.S. by 2025; according to a 2013 AAMC report, Texas fares even worse than most states, ranking 42nd nationwide in its ratio of doctors per 100,000 people. NPs in the Lone Star State and other regions are well-trained to meet the healthcare needs of a growing, aging population, particularly in rural regions with underserved populations. In fact, 89 percent of NPs nationwide are trained to work in primary care. And in spite of the wealth of evidence that NPs provide safe and resource-efficient healthcare services, Texas NPs can’t legally work to the extent of their abilities.

According to the Texas Nursing Practice Act, NPs are required to have written “prescriptive delegation” consent—also referred to as a collaborative agreement— from a supervising physician. In addition to the TX Board of Nursing, NPs are also regulated by the TX Board of Medicine. Notably, it was only recently that TX finally eliminated the requirement that a doctor be on-site to oversee NPs at all times, and the fight continues.

The Texas Tribune (Feb. 2017) reported that State Representative Stephanie Klick, R-Fort Worth, proposed H.B. 1415 which would eliminate the prescriptive delegation requirement, thereby granting NPs autonomous prescribing privileges. She noted that physicians sometimes receive up to six figures for being “delegating doctors.” Not surprisingly, the main opponents to granting NPs full practice privileges are physicians’ organizations who would stand to lose these lucrative contracts. Since finding a supervising physician is so costly, Klick argued that many TX NPs chose to work in neighboring states such as New Mexico with more friendly practice environments.

As of June 2017, NursePractitionerSchools.com has interviewed 20 NP professors on their views on independent practice. All but one stood firmly in the camp of granting NPs nationwide full practice authority in accordance with their level of training. In interviews with two prominent NP professors in Texas, this article attempts once again to make the case for FPA to address the looming healthcare shortage in this state and across the country.

Interviews with Two Renowned NP Professors in Texas

Dr. Cara Young, Assistant Professor at the University of Texas, Austin

After earning her Ph.D. and completing a postdoctoral fellowship at Vanderbilt University, Dr. Young joined the faculty at UT Austin. She’s an expert in mental health promotion and mental illness prevention, particularly among adolescents. Her research has focused on depression and anxiety in this vulnerable population, as well as provider stigma and mindfulness treatments for at-risk youth. In addition to her numerous prestigious publications in her focus area, she has received several fellowships and research grants to fund her important work.

What is your view on moving toward full practice authority for Texas’s NPs?

I think it is a major step towards improving access to quality healthcare, particularly for the uninsured and underinsured and those living in rural and frontier areas. Full practice authority allows NPs to practice to the full extent of their education. NPs are more likely than physicians to work in rural areas and in underserved areas; removing the unnecessary regulations of the collaborative practice agreement will expand access to high quality health care in the areas of highest need. In the U.S., 22 other states and D.C. do not require this agreement and research has shown that states with NP full practice have lower hospitalization rates and improved health outcomes in their communities.

Has there ever been a time where you felt limited by TX’s NP practice laws?

Many times. The clinic in which I currently work is the only provider of pediatric healthcare in the community and our clients are more than 85 percent on Medicaid, C.H.I.P., and other forms of public insurance. The restrictive nature of the collaborative practice agreement has limited our ability to provide healthcare to this incredibly underserved community. Another example comes from my program of research. I am involved as a co-investigator in a novel use of a calcium channel blocker for smoking cessation. I am providing medical oversight, but I had to find a physician to be my “collaborator” in order to follow the regulations; and yet it is my license and certification under which I practice.

What are some actionable steps NPs and others can take to advance the cause?

We should educate ourselves and everyone that we know regarding the roles of APRNs and the data showing increased satisfaction and improved outcomes when compared to physicians. We should then contact our local representatives with our concerns. Becoming active in your local area with campaigns and grassroots efforts can help to spread the word before the 2019 legislative session begins. Educate your students on why being active in politics and in local and state organizations is crucial to their profession.

Dr. Suzanne Alton, Assistant Professor at the University of Texas Medical Branch

Dr. Alton serves as both a distinguished teaching professor and the chair-elect of UTMB’s faculty senate. Her research interests include integrative healthcare and medication adherence among patients. She teaches family nurse practitioner courses as well as nursing theory and pharmacology. Notably, she was designated a Future Leader by the American Association of Nurse Practitioners (AANP); a Sigma Theta Tau member; and a recipient of UTMB’s faculty achievement award.

What is your view on moving toward full practice authority for Texas’s NPs?

I think in order to have Texas meet the needs of its population and come into the fold of the current century, Texas needs to allow full practice for NPs. Not allowing NPs to practice to the scope of their authority is one of the reasons that Texas ranks so poorly on health indicators for its citizens.

Has there ever been a time where you felt limited by TX’s NP practice laws?

Yes, I would have opened an independent practice when I was younger but the issues of oversight and the amount I’d have to pay for a physician for this service stopped me. Currently I practice in urgent care and have to meet once a month with my collaborating physicians, which is time-consuming for them and me; it’s a waste of all our time.

What are some actionable steps NPs and others can take to advance the cause?

Support the Texas Nurse Practitioners and Coalition for Nurses in Advanced Practice!

Advancing Toward Full Practice Authority for Texas NPs

Not allowing NPs to practice to the scope of their authority is one of the reasons that Texas ranks so poorly on health indicators for its citizens.
Dr. Suzanne Alton, University of Texas Medical Branch

Given the inevitable shortage of healthcare providers in Texas and the abundance of evidence demonstrating that NPs offer quality and cost-effective services, it’s disappointing that this battle for independent practice continues. Highly trained and credentialed NPs are limited by expensive collaborative agreements with physicians; in effect, they’re denied the ability to autonomously prescribe treatments and to make decisions about the care of their patients. There’s limited evidence that this extra layer of bureaucracy actually protects patients; on the contrary, clinically disenfranchising NPs can have negative consequences.

Dr. Cara Young—the assistant professor from the University of Texas, Austin who graciously agreed to be interviewed for this article—recommended a 2014 study titled The Impact of Nurse Practitioners on Health Outcomes of Medicare and Medicaid Patients. Lead researcher Dr. G.M. Oliver found that states with full practice authority for NPs actually had lower hospitalization rates and improved healthcare outcomes. The study pointed out that the barriers to APRN full practice should be removed in order to improve Americans’ access to high-quality and affordable healthcare, particularly among underserved patient populations.

The results of this study and many others illustrate why there’s a growing list of groups—including many non-nursing organizations—which support moving toward FPA for NPs nationwide. These include:

  • American Association of Retired Persons (AARP)
  • Department of Veterans Affairs (VA)
  • National Governors Association (NGA)
  • National Conference of State Legislatures
  • Bipartisan Policy Center (BPC)
  • Institute of Medicine (IOM)
  • Federal Trade Commission (FTC)

The main opponents of extending full practice to NPs remain the physicians’ groups. In the aforementioned 2017 Texas Tribune article, Don. R. Read, MD—the president of the Texas Medical Association—stated that the TMA still believes that the “team care” approach (i.e., paying physicians for collaborative agreements) “serves patients best.” Texas nurse practitioners agree that they’re part of a healthcare team; however, their concept of “team care” is more mature, moving beyond the expensive, prohibitive contracts they’re expected to keep with supervising physicians. Texas NPs can only flourish fully when they’re granted the legal right to practice autonomously. Are doctors ready to relinquish costly collaborative agreements to expand access to healthcare? That would be a truly patient-centered approach.

Dr. Alton stated poignantly, “I would have opened an independent practice when I was younger but the issues of oversight and the amount I’d have to pay for a physician for this service stopped me.” How many other NPs in Texas have been discouraged from setting up clinics due to these baseless and costly regulations? The time is now for nationwide full practice authority.

Jocelyn Blore

Jocelyn Blore

Editor

Jocelyn Blore is the Managing Editor of NursePractitionerSchools.com. After graduating from UC Berkeley, Jocelyn traveled the world for five years as freelance writer and English teacher. After stints in Japan, Brazil, Nepal, and Argentina, she took an 11-month road trip across the US, finally settling into lovely Eugene, OR. When Jocelyn isn’t writing about college programs or interviewing professors, she satirizes global politics and other absurdities at Blore’s Razor (Instagram: @bloresrazor). Thank you for being interested.

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