Blogged Arteries

The American Association of Nurse Practitioners (AANP) is obviously intent on picking a fight with physicians. No thanks. We’ll take the high road, fully aware of the dangers of their plans, and stick with what we know is best for our patients: the physician-led health care team. 

In a recent commentary published in USA Today, two of AANP’s allies repeated the trope that authorizing independent practice for nurse practitioners would somehow solve the shortage of physicians we all know America faces. In their misguided quest, the authors have twisted and misinterpreted the research they cite, and in the end hurt the very patients they say they want to help. 

I won’t rebut, point by point, the authors’ argument. I’ll leave it at this: My problem is not with NPs. They are an integral part of the health care team. We need them on the team to help with disease management and education. Indeed, it is hard to imagine our health care system without them. My problem is with independent practice and the false argument that this will somehow improve access to and decrease the cost of medical care for our patients. The data are clear: Regardless of whether or not they work in states that allow independent practice, the vast majority of NPs locate just where physicians do – in the big cities. Without appropriate supervision, they order more tests and consultations to compensate for a more limited diagnostic knowledge base.  

Meanwhile, members of the American Medical Association’s Scope of Practice Partnership shared an insightful slide presentation from a recent AANP meeting. I was drawn to one slide that lists AANP “Board Initiatives.” Parts of it are repeated in more detail in the AANP’s 2019 strategic plan. I call your attention to two bullet points on that slide: 

• “Patients nationwide will have full and direct access to high-quality care and will choose NPs as their health care provider” (emphasis added); and
• “NPs will have parity with physicians and other providers in reimbursement, payment, and government funding.” 

These kind of statements might be good for AANP membership, but they’re awful for our patients. A nurse is not a doctor. And a doctor is not a nurse or physical therapist or an audiologist or any other type of clinician on the team that has to work together on behalf of our patients. 

As I stated when I proudly took my oath to become your TMA president, “It is because we are professionals that we lead, supervise, educate, and monitor the other members of our health care team. They do not know what we know. They cannot do what we do.” 

Nonphysician practitioners work with physicians – but under our direction. That’s not a put-down. It makes little sense to create more fractionation in our already confusing health care “system.” That’s what we work for at the Texas Legislature, in the U.S. Congress, in the courts, and in regulatory agencies. That’s why we defeated more than 20 scope-of-practice expansion bills during the 2019 legislative session. Your association – and I – remain firm in this principle. (See our strong letter opposing President Trump’s plan to grant NPs payment parity in Medicare.) 

In 2013, with the full support of the nurse practitioners and physician assistants here, the Texas Legislature passed a groundbreaking law that replaced the old site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team-based care. 

Our legislators understand that our patients benefit when each member of the team brings his or her special talents, skills, and training to the bedside. They understand that the path to independence is through education, not legislation. We will not stand by and watch the AANP and their supporters try to pretend that our years of medical school training and residency do not make a difference. No one has the skills and education that physicians have that qualify us to lead the patient care team. And ultimately, we have the responsibility for our patients’ health. 

I won’t take the bait. I’ll just continue to stand up for Texas physicians and our patients. 

No one likes to be told what to do. 

We physicians, especially, are tired of government agencies and insurance companies and hospital administrators telling us how to take care of our patients. So I won’t be surprised if physicians around the state are feeling a little angst and anger over the coming March 1 requirement for physicians to check the Texas prescription monitoring program (PMP) before writing prescriptions for opioids, benzodiazepines, barbiturates, and carisoprodol. 

I don’t fault them one bit. This is just one more administrative burden placed on physicians. But I want all of you to understand just how much worse it would have been without the intervention of the Texas Medical Association. 

TMA began our work to simplify physicians’ administrative burden when prescribing opioids and other controlled substances early in the last decade. We claimed two important successes during the 2015 session of the Texas Legislature. Until that point, Texas doctors needed both a state controlled substances registration (CSR) permit and a federal Drug Enforcement Administration permit to write prescriptions for any controlled substance. Also, until that point, the state PMP was a law enforcement tool housed in the Texas Department of Public Safety. And, physicians who wanted to check a patient’s controlled substance history had to perform that task personally. 

Thanks to TMA's advocacy during the 2015 session, the CSR permit was eliminated, the PMP was moved to a new online system created by the Texas State Board of Pharmacy, and physicians were authorized to delegate checking the PMP to members of their staff. (That's a valuable time saver for our doctors that I encourage you to use.)

As the opioid abuse epidemic raged across the country, elected officials clamored for a crackdown on prescribing practices. In 2010, Colorado, Delaware, Louisiana, Nevada, and Oklahoma were the first states to require prescribers to search patients' drug histories before prescribing. By January 2017, when the Texas Legislature was ready to convene, 26 more states had imposed that mandate. (Currently, that number is up to 43 states.) 

Political pressure to do something was growing here in Texas. State lawmakers already had filed some extremely onerous pieces of legislation. It was obvious that Texas was about to join the list. It became TMA’s job to buy time for you and make sure the state was pushing a useful clinical tool for physicians, not another useless administrative burden. 

As we do so often, TMA and organized medicine went to work educating senators and representatives about the real-world impact of the bills they had filed. We pushed back hard against a proposed sweeping mandate for physicians to check the PMP before issuing prescriptions for any controlled substance. We persuaded lawmakers to limit the requirement to the four drug classes I mentioned above. And we won a two-year delay in the mandate so physicians, the Pharmacy Board, and other key players could prepare for this massive change. 

Finally, during the 2019 legislative session, we obtained two more big improvements for physicians. While at that point, most of the major electronic health record (EHR) vendors were working to integrate the PMP into their systems, they were not likely to be done with their work before the Sept. 1, 2019, deadline. We persuaded lawmakers to delay the mandate until March 1, 2020, to give physicians and EHR vendors time to properly integrate their systems with the PMP. Plus, the legislature appropriated an additional $5 million for the Pharmacy Board to upgrade the PMP to make it easier to integrate, as well as to cover the integration licensing fees for all state prescribers and pharmacists. 

To use a bad pun, this mandate is still a pain, but it hurts far less than it could have because TMA has been there for you. We also have a new PMP Resource Center on the TMA website that includes all the background on the mandate and a way to check if your EHR is connected to the PMP. We put together a webinar with 1.25 hours of CME (free to TMA members) to make using the PMP easier for you and the staff you delegate the task of checking the database, and more beneficial for you and your patients. We also are working on a public campaign to make sure your patients know the PMP mandate is coming and what it may mean the next time they visit their doctors. 

My hope is that because of all the work we’ve done, the PMP will actually be a valuable tool to help physicians prevent drug abuse, drug diversion, and doctor shopping, and that it will not delay, thwart, and complicate care for our patients.