Should Texas Change the Rules for APRNs?
By Sean Price


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.


Last Updated On

November 13, 2018

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Sean Price


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Sean Price is a reporter for Texas Medicine and Texas Medicine Today. He grew up in Fort Worth and graduated from the University of Texas at Austin. He's worked as an award-winning writer and editor for a variety of national magazine, book, and website publishers in New York and Washington. He's also helped produce Texas-based marketing campaigns designed to promote public health. Sean lives in Austin and enjoys hiking, photography, and spending time with his wife and two sons.

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