A mostly rural state, Texas is experiencing a shortage of family physicians and other primary care physicians. In response, both local and national organizations representing advanced practice registered nurses, or APRNS, have tried to obtain rights for these nurses to practice independently in the state, a move that has been strongly disputed by the Texas AFP, or TAFP.
In fact, the TAFP has been engaged in an ongoing struggle with the state's nurse practitioners about the issue of independent practice for the last two legislative sessions. Although the chapter recognizes the important role of APRNs, including nurse practitioners, in the physician-led medical home, it maintains that these nurses lack the experience to practice medicine independently and without the supervision of a physician. TAFP also argues that granting APRNs independent practice authority would further fragment a health care system already fraught with overlapping, duplicative, and unnecessary services and providers, thus hurting rather than helping patient care.
The viewpoint of the nurses, however, is that they can provide equal or better care than primary care physicians at a lower cost. At the same time, they contend that they are more likely to practice in rural and underserved areas if given independent practice authority and could help alleviate the state's growing primary care workforce shortage.
In 2009, groups representing APRNs tried but failed to enact legislation that would have given APRNs independent diagnostic and prescriptive authority. In 2011, the nurses tried again, launching a more coordinated and targeted campaign that tested the ability of the TAFP to reframe the issue of independent practice around the tenets of comprehensive, team-based care and to ultimately succeed in defeating the APRNs' legislative attempts.
- During the 2011 session of the Texas legislature, local and national representatives of advanced practice registered nurses introduced legislation that would allow them to gain independent diagnostic and prescriptive authority in the state.
- The Texas AFP swung into action to protect patients and employed a strategy that framed the issue of independent nurse practice authority around the tenets of comprehensive patient-centered care.
- Although ultimately successful, the Texas AFP expects to face the issue again during the 2013 legislative session.
"The APRNs made a really strong push in that 2009 legislative session," said Jonathan Nelson, communications director for the TAFP. "But we were able to turn them back, and keep all of their bills from coming to the floor in that session."
The nurses' failure in 2009 only seemed to strengthen their resolve for the 2011 legislative session, setting up an inevitable showdown with the TAFP and its members. During the latter half of 2010, the TAFP began noticing editorials in newspapers across the state that called on lawmakers to pass legislation that would grant APRNs independent diagnostic and prescriptive authority.
The editorials were written by representatives from both state and national APRN organizations, making this the first time the state nurses collaborated with their colleagues on the national level in pushing for independent practice authority in Texas. This, in turn, demonstrated that the APRNs had become more sophisticated in their efforts, according to Nelson.
"We have a significant primary care workforce shortage in Texas," said Nelson. "It has become much more evident as the population has grown across the state. Lawmakers are keenly aware of this workforce shortage, and as each year goes by, the shortage seems to get worse," so the argument that nurses can help fill that shortage carried some weight with legislators.
When confronting scope-of-practice issues, the Texas AFP relies on a set of core strategies to help shape the debate about independent practice based on the tenets of collaborative care and family medicine. These strategies include the following:
- Argue for a team-based, collaborative model. There is a wealth of studies and literature showing that team-based, physician-led care results in better quality outcomes, higher patient and physician satisfaction rates, and more cost-effective care, says Jonathan Nelson, communications director for the Texas AFP. This is especially true when comparing collaborative care with the type of independent practice sought by advanced practice registered nurses, or APRNs, that will result in segmented care, says Nelson. The argument for physician-led, team-based care should serve as the basis for opposing independent nurse practice.
- Ask the question: "What should be the minimum standard for who can practice medicine?" In seeking independent practice, APRNs, including nurse practitioners, argue that they can provide the same quality of care as family physicians. According to Nelson, the Texas AFP has a difficult time refuting this argument because there is not a lot of data showing that nurse practitioners provide care that is worse than the care provided by family physicians. Thus, the Texas AFP has reframed the issue by asking what should be the minimum standard required to practice medicine in the state. By asking this question, the Texas AFP can make the argument that lawmakers would be lowering the standards of education and training for practicing medicine in the state by granting independent diagnostic and prescribing authority to APRNs.
- Refute the claims of APRNs that they can solve the state's primary care workforce shortage. APRNs claim they are more likely to practice in rural and underserved areas if given independent practice authority. But in states where nurses have independent prescribing authority, the AAFP has data showing that nurse practitioners tend to practice in populated areas rather than underserved and rural regions. The AAFP also has data showing that family physicians are more likely to practice in rural and underserved areas than any other health care professional.
- Work with the AAFP. The AAFP has a raft of materials making the case for team-based care, as well as resources documenting the profound differences in the amount of clinical training and classroom education between family physicians and nurse practitioners.
The TAFP quickly developed a communications strategy that refuted the arguments of the nurses on a point-by-point basis and underscored the role of team-based care and the patient-centered medical home, or PCMH, in achieving higher health care quality, greater access and lower costs. As part of the communications strategy, the chapter put together three issue briefs and a more in-depth white paper(www.tafp.org) that it distributed to chapter members, as well as lawmakers and their staff members.
In addition, the chapter devoted the cover story in its 2010 fall issue of Texas Family Physician(www.tafp.org) to the topic of independent nurse practice, which gave its members the opportunity to share their own narratives about why APRNs should not be given independent diagnostic and prescriptive authority.
In response, the nurses argued that they didn't want to practice medicine by obtaining independent diagnostic and prescriptive authority. But the Texas AFP pointed out that independent diagnostic and prescriptive authority are defined as medical acts by the Medical Practice Act in Texas and the Nursing Practice Act. If lawmakers granted APRNs independent diagnostic and prescriptive authority, they would be redefining and ultimately lessening the requirements for the practice of medicine in the state, resulting in a change that many lawmakers were not comfortable with, Nelson said.
"Little data exist comparing family physicians and nurse practitioners in the kind of care they deliver," said Nelson. "But we have plenty of evidence comparing the education levels for each."
Consequently, the first issue brief(www.tafp.org) put out by the TAFP compares the educational gaps between primary care physicians and APRNs, such as nurse practitioners. It points out that nurse practitioners undergo between 500 and 1,500 hours of clinical training during their education while family physicians have between 15,000 and 16,000 clinical hours by time they finish medical school and residency.
"By basing our argument on the definition of medicine, we were able to say, 'Look at what it takes to practice medicine today in Texas. Look at differences in education and the differences in the clinical hours of training,'" said Nelson.
The second issue brief(www.tafp.org) addresses geographic practice patterns, and shows that family physicians are the most likely of all health care professionals to practice in underserved and rural areas. The TAFP also pulled geographic practice pattern data from states that allow APRNs to prescribe and diagnose independently. That data show that APRNs, such as nurse practitioners, are likely to settle and practice in more populated regions rather than rural and underserved areas, thus nullifying the argument that APRNs could alleviate Texas' primary care shortage.
The third issue brief(www.tafp.org) talks about the cost of care, emphasizing the role of team-based comprehensive care and the PCMH in lowering costs and averting unnecessary care. The brief also argues that giving APRNs independent practice authority would create further fragmentation in the health care system, thereby leading to cost increases.
The white paper, meanwhile, tied all of the TAFP's arguments together in one place, and asked whether independent practice for APRNs was worth the risk.
In developing and carrying out its campaign, the TAFP was able to rely on the services of Marie Elizabeth Ramas, M.D., who was a third-year resident at the Conroe Family Medicine Residency Program in Conroe, Texas, at the time. Ramas was the first recipient of the James Martin Scholarship, a policy scholarship funded through the TAFP that enabled her to work with the chapter on scope of practice issues during the 2011 legislative session.
Ramas conducted extensive research on scope of practice issues, authoring the chapter's white paper and working on the issue briefs. She also met with lawmakers and their staffs.
"We wanted to present a hole-in-one for lawmakers in their review of scope-of-practice issues," said Ramas, who now is medical director of Mercy Community Health Center, a rural health center in Mt. Shasta, Calif. "We realized that, oftentimes, legislators have a very limited understanding of the ability of advanced practice nurses to fill in a job description that entails independent medical diagnosis and prescriptive authority."
With the white paper and issue briefs, lawmakers and their staff members were able to easily compare and contrast the issues and the differences between APRNs and family physicians.
"The legislators had the documents right in front of them and could look at the issue objectively," said Ramas.
In the white paper, Ramas showed that giving APRNs independent practice authority could be especially detrimental for patients living in rural and underserved areas because those patients tend to suffer from higher rates of comorbid conditions, making them more difficult to treat. When comparing the differences in training between family physicians and nurse practitioners, "nurse practitioners are not prepared for the complexities of care for (certain) patients," when they are finished with their training, said Ramas.
Chapter EVP: Tom Banning
Number of chapter members: 7,206
Date chapter was chartered: May 1948
Location of chapter headquarters: Austin, Texas
2012 annual meeting date/location: July 11-15, Austin, Texas
Despite the work of the TAFP, the APRNs managed to get six bills introduced in the 2011 legislative session that would have given them independent diagnostic and prescriptive authority. Tricia Elliott, M.D., director of the family medicine residency program at the University of Texas Medical Branch in Galveston, testified against the bills on behalf of the TAFP and two other organizations -- the Texas Medical Association and the Texas Pediatric Society -- which also opposed the legislation.
All of the scope-of-practice bills were referred to the House Public Health Committee, which was scheduled to hear the bills on April 20. But lawmakers did not address the bills until the early morning hours of April 21, forcing Elliott to wait from 9 a.m. until nearly 3 a.m. before she could testify.
"I was tired, but I was determined to get our points across," said Elliott. "I really feel committed to this issue."
In her testimony, Elliott relied on her own experiences as a family physician in describing APRNs as an "integral part" of the physician-led health care team while explaining why physician oversight of APRNs is crucial.
"In order to receive a Texas medical license, physicians are required to follow the same high-structured educational path, complete the same course work and pass the same licensure examination," Elliott said in her testimony. "There is no such standard to achieve nurse practitioner certification, as their educational requirements vary from program to program and from state to state."
In the final analysis, the Public Health Committee agreed with Elliott and the TAFP and did not approve any of the six bills, resulting in a profound victory for the chapter, family physicians and patients. But the TAFP is convinced that the APRNs will try again when the legislature reconvenes in 2013.
Unlike their past attempts, however, this time the APRNs may be armed with a document (www.iom.edu)issued by the Institute of Medicine, or IOM. The report on the future of nursing calls for expanding the role of nurses and eliminating scope-of-practice barriers.
The IOM released the report in October 2010, but surprisingly, the APRNs did not use or even reference the report in their 2011 attempts at legislation, Nelson said. However, they are already referring to the report as they prepare for the 2013 legislative session, he added. During the 2013 session, the nurses "are going to be wallpapering the legislature with the report," he said.
"We are going to have to make the argument that a medical degree is necessary to practice broad-spectrum, primary-care medicine," said Nelson. "That is where we are going to have to make our stand."
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