Texas is facing a chronic physician shortage, especially in
rural areas and urban cities. Some argue that giving advanced practice registered
nurses (APRNs) more leeway to prescribe and treat patients will help address
that shortage. But is that a workable solution?
A panel discussion at the Texas Public Policy Foundation
(TPPF), a conservative think tank in Austin, set out last week to address this
contentious issue. The panel's moderator, Deane Waldman, MD, director of TPPF’s
Center for Health Care Policy, pointed out that Texas' physician shortage is
bad and getting worse. Currently, 35 of the state's 254 counties have no
physicians at all.
"Places like the Panhandle and Hidalgo [County] simply
don’t have access to primary care," Dr. Waldman said.
In Texas, physicians can make agreements with seven to 10
APRNs that allow the nurses authority to prescribe and treat patients in
limited ways, Dr. Waldman says. He and APRN advocates say that fees from these delegation
agreements for APRNs in independent practice can cost APRNs up to $20,000 a
year. However, most APRNs are employed by physicians.
The Texas Board of Nursing recently proposed regulatory
changes that would make APRNs fully "independent practitioners." The
Texas Medical Association has asked the board to withdraw
these rules or revise them to comply with state law.
State Rep. Stephanie Klick (R-Fort Worth), a member of the
panel and a registered nurse, proposed legislation in 2017, which did not pass,
to reduce physician oversight of APRNs. Her bill would have consolidated
regulations — currently shared by both the Texas Medical Board and the Texas Board
of Nursing — under one regulatory body. It also would have done away with the
delegation agreements between physicians and APRNs.
"That is a barrier, financially, to opening
practices," Representative Klick said. "Also, the regulations that we
have as a state put us at a competitive disadvantage. The New Mexico
legislature has appropriated money to recruit Texas nurse practitioners because
they have a more favorable practice environment than we do."
While it is important to include APRNs more in team care,
removing or further limiting physician authority over APRNs would not solve
Texas' shortage of primary health care, says Dan Finch, TMA's legislative
affairs director.
Texas is behind in the number of primary care health care
providers in the state, but Texas is licensing physicians at a record pace, Mr.
Finch says. It currently licenses more than 5,000 a year, which is twice the number
from 2002. The state also is taking other steps to bring in more physicians,
such as opening three medical schools by 2020 and improving funding for
residency slots.
However, changing Texas' current regulations is unlikely to
cause APRNs to begin working in underserved areas. In fact, historically, APRNs
tend to work in the same places that physicians do — large cities, Mr. Finch
says. That is because those areas have the best infrastructure for any sort of
medical practice.
Meanwhile, rural areas are seeing
hospitals shut down, he says. Rural hospitals built in the 1950s and
1960s with federal dollars are aging out and shutting down, destroying the
infrastructure for rural health care. Without that infrastructure, doctors and
nurses move out of the area.
"Rural health care has many, many challenges, and I
think chief among them are the financial underpinnings for rural hospitals and
rural health care facilities," Mr.
Finch said.
Telemedicine is also one of the keys to improving rural
health care in all underserved areas, he says.
"Telemedicine gives us a real opportunity to extend
these kinds of services for both primary care and specialty
consultations," he said.
The discussion, which can be seen here,
also included Anne Dunkelberg of the Center
for Public Policy Priorities, a liberal think tank in Austin, and Holly Jeffreys
of Texas Nurse Practitioners, the APRN industry group in Texas.