2019 Texas Legislature: Mid-Session Checkup
More than halfway into the 86th Texas Legislature, scope of practice and maternal health have medicine playing defense and offense, respectively. Check out Texas Medicine’s Bill Watch on these issues, while brushing up on TMA’s overall Healthy Vision priorities for the 2019 legislative session. Plus … See how physicians use TMA’s monthly megaphone to amplify that advocacy agenda to lawmakers as Texas Medicine takes you inside this year’s first First Tuesdays at the Capitol lobbying event.
Public Health: AIMing to Save Lives
Legislative Affairs: Medicine’s Monthly Bullhorn
Team pursuits — whether in sports or in team-based health care — require knowing your role.
But if a legislative session is under way in Texas, you can count on health care professionals mounting another effort to expand their role — which Texas Medical Association team captains say endangers the effort to deliver championship-quality patient care. It’s like a basketball team’s best rebounder or shot-blocker, who’s never taken a 3-point shot, deciding to fire away from deep at a crucial moment.
In basketball, that could mean losing a game or the end of a season. But for patient care, the implications are much more serious. That’s why, when nonmedical professionals ask the Texas Legislature for the authority to practice medicine, TMA mounts a full-court press, letting lawmakers know why there are some roles only physicians can fill.
It’s happening again in 2019 with a number of bills that seek to expand the scope of practice for psychologists, nurse practitioners, and physical therapists. That’s alarming for doctors like Bridge City family physician and hospitalist Amy Townsend, MD. She’s a TMA member and a board member for Physicians for Patient Protection, a nationwide nonprofit group that advocates for physician-led care, and in particular targets practice overreach by nurse practitioners.
“The common thread is that we’re seeing multiple injuries and harm [that are] from midlevels, as well as some other practitioners, trying to push their way into the practice of medicine,” Dr. Townsend said.
For TMA, that trend requires careful monitoring of the dozens of scope-of-practice bills filed and working to maintain appropriate care collaboration. Several 2019 bills have medicine’s unequivocal opposition for failing to meet that standard. (See “Bill Watch: Scope of Practice,” page 18.)
“Medical care is a team sport,” TMA lobbyist Dan Finch said. “The old model of a family doctor and a registered nurse and a part-time receptionist/bookkeeper taking care of 1,800 patients [now] gives way to a family doctor, a nurse practitioner, a [physician assistant], a handful of registered nurses, and an entire billing department. And it’s not 1,800 patients; it’s 4,000 or 5,000 patients. And it’s not one doctor; it’s five doctors, it’s 10. That’s medical practice in 2019. This is not 1970 anymore. And it also means that every member of the team brings a valuable skill set. It truly is a collaborative, team-based approach to patient care. But it is physician-led.”
Medicine has consistently maintained that for advanced practice registered nurses (APRNs), independent practice authority represents a bright, uncrossable line. Physicians can delegate prescribing to nurse practitioners, for example, but must supervise because ultimately physicians are accountable, Mr. Finch says.
But multiple bills this year seek to expand APRNs’ practice authority. House Bill 1792 by Rep. Stephanie Klick (R-Fort Worth) is the most sweeping, striving to grant APRNs full independent practice and prescribing authority without physician delegation and supervision. It’s similar to House Bill 1415, which Representative Klick filed in 2017 — one of a long list of overreaching scope bills TMA helped stop in recent sessions.
House Bill 927 by Rep. James White (R-Hillister) specifically seeks to address physician shortages in rural Texas. The measure would grant independent practice authority to APRNs in rural counties that the Office of Rural Affairs determines to be health shortage areas.
Both HB 1792 and HB 927 are troubling for Dr. Townsend. She says Physicians for Patient Protection began about two years ago as a Facebook group for physicians to share stories about care mismanagement and patient harm resulting from nurse practitioners who were practicing either with minimal supervision or outside the scope of their training. Today, she says, the Facebook page has almost 10,000 members nationwide, including practicing and retired physicians, residents, and medical students.
HB 1792’s requirements for an APRN to practice independently include practicing for at least 2,080 hours under a physician.
“The issue with that is that supervision is not anywhere close to being the same as the educational experience that you get with a residency program,” Dr. Townsend said. “Supervision is basically a nurse practitioner, when they have questions, bringing the issue to the supervising physician. Residency training, on the other hand, is a very intensive experience where you have someone there teaching you the practice of medicine and learning how to make clinical decisions.
“The two experiences are not even close to being similar, and definitely, 2,000 hours of what is [considered] supervision would not prepare a nurse practitioner to practice independently.”
TMA leaders say the goal of supervision is just that — to supervise the work of another health care professional.
As for HB 927, Dr. Townsend says it would create a two-tiered medical system, with nurse practitioners obtaining independent authority in rural areas while not having it in the rest of the state.
“But the question is, why would you have two different standards depending on where you live?” she said. “Do the people in rural areas not deserve to have a physician that is adequately trained to practice medicine? Are you going to settle for a lesser quality of care just because you’re rural?”
In an interview with Texas Medicine, Representative White passionately defended HB 927. He’s also a coauthor of HB 1792. While he supports the medical tort reforms of 2003 that increased physician supply in Texas overall, Representative White cites statistics showing that in the five counties in his district, the supply of primary care physicians fell by more than 9 percent from 2003 to 2018.
“I’ve got to show my constituents — like hopefully doctors try to show their patients — that I care and that I’m working towards something,” he said.
Representative White read excerpts of several letters from TMA members, including one that urged him not to create a two-tiered system where people with adequate finances can see a trained physician “and others have to see non-experts.”
“I think I have that now,” Representative White said, “except the two-tiered system is, you either see somebody, or you don’t, and you die. I already have that in rural East Texas.”
He says he does support increasing physician payments in Medicaid and expanding access to telemedicine, two TMA objectives this session to increase access to care in rural areas.
Prescriptive authority for other nonphysicians is on the table, too, but TMA is fighting to knock it off.
Senate Bill 268 by Sen. Jose Rodriguez (D-El Paso) would allow the state’s psychology board to issue certificates of prescriptive authority to psychologists who meet several eligibility requirements, including completing a training program in psychopharmacology and passing “a nationally recognized examination approved by the board in the area of prescriptive authority.”
Noting that “the brain is connected to the rest of the body,” Houston psychiatrist Richard Noel, MD, says giving psychologists prescriptive authority is “a dangerous experiment.” He has no shortage of patient anecdotes to illustrate why he thinks so.
“One person came in ostensibly depressed, but a telltale part of that hourlong evaluation: He had to go to the bathroom three times, which is kind of odd,” Dr. Noel said. “I checked the blood sugar, and sure enough, he had a blood sugar of nearly 900 (milligrams per deciliter), which is just ungodly. Needless to say, all the antidepressants in the world would not have treated that guy. He had to get his diabetes fixed.”
Dallas psychiatrist Les Secrest, MD, a member of TMA’s Task Force on Behavioral Health, says the bill shows a lack of appreciation for the complexity involved in prescribing.
“It gets to be complex enough that you see primary care physicians who are saying, ‘I’m a little reluctant’ to prescribe some of these medications because of the complexity of their interactions with disease states and physiological response to those disease states.
“[The bill is] all based on the idea that prescribing medications is not complex. It’s simply, ‘If you’re depressed, you get an antidepressant, and if you’re psychotic, then you get an antipsychotic.’”
Some of the never-ending efforts to expand scope of practice, Dr. Secrest adds, often are driven by an effort “to make the health care delivery system as efficient as it can be.
“I think then other times, it’s [a situation] where people begin to feel that they have a familiarity with things, then you could expand the scope and feel comfortable with it,” he added. “I think it’s rather naïve to think that someone without training in cardiology would be able to select and prescribe the cardiac medications for a heart patient without significant understanding of the overall physiology of one’s body.”
In a statement provided to Texas Medicine, Senator Rodriguez says it is critical to “enable those with the appropriate training to serve more Texans, especially in rural and border areas, in light of Texas’ serious primary care provider shortages.
“I believe that we can come to a balance that affords the appropriate safeguards while filling a critical mental health care need,” Senator Rodriguez said. “Many nonphysicians prescribe, and psychologists, with appropriate training, have prescribed in New Mexico since 2002 with no incident. Psychologists also can prescribe in the military and in the [U.S.] Public Health Service/Indian Health Service.”
Among the other scope-of-practice efforts that are concerning for medicine: House Bill 29 by Rep. Ina Minjarez (D-San Antonio). That measure would allow physical therapists to treat patients without a referral if the physical therapist: has been licensed to practice for one year; is covered by a minimum amount of liability insurance established by the Texas Board of Physical Therapy Examiners; and either has an accredited doctoral degree in physical therapy or “has completed at least 30 hours of continuing competence activities in the area of differential diagnosis.”
Killeen internist Richard Avery, DO, says one of his patients with middle-back pain is a perfect example of why that bill poses a risk. A physical exam of the patient only revealed muscular tension, so Dr. Avery first thought she had a simple muscle strain. But before referring the patient for physical therapy — his initial instinct — he decided to send the patient for X-rays to rule out other causes. The X-rays revealed the patient had two acute vertebral fractures, drastically changing her course of treatment. An immediate referral to a physical therapist wouldn’t have revealed the fractures, and might have hurt the patient further.
With the risks involved as a result of those fractures, he said, “you don’t want to put your patient through range of motion exercises. You need to complete the evaluation to determine which therapy is appropriate, such as surgery or vertebroplasty.”
Dr. Avery also is concerned patients being able to see physical therapists without referral would drive up utilization rates, which in turn would drive up costs.
Tex Med. 2019;115(4):16-19
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