In a move that physicians say could undermine access to quality care and drive up health care costs, some state lawmakers are pushing a pair of bills that would remove physician oversight of the health care team and allow advanced practice registered nurses (APRNs) to practice independently.
The Texas Medical Association has defeated similar bills in previous sessions and expected this latest push. But TMA Board Chair G. Ray Callas, MD, an anesthesiologist in Beaumont, warns the stakes remain sky high.
“We are in complete opposition to these bills,” he said. “There are two things I always want to drive home: education and patient safety.”
This time around, nurses argue they’re the solution to Texas’ primary care physician workforce shortage, especially in rural and underserved areas. But Michelle Romero, TMA associate vice president of public affairs, says the bills would risk patients’ access to physician-led care.
“No matter who you are or where you live, you deserve the highest standard of care,” she said.
Although not identical, Senate Bill 1700 and House Bill 4071 would enable APRNs to:
- Diagnose and treat patients;
- Prescribe drugs, including controlled substances, and devices; and
- Serve as the primary care clinician of record, among other provisions.
TMA experts are analyzing the differences in the two pieces of legislation, but HB 4071 notably would add APRNs as mental health professionals.
TMA President Gary Floyd, MD, also balks at nurses’ claim that they are adequately trained to practice independently.
“There’s significant exaggeration as to what they could do if they’re independent,” he said. "They don't have the training to back that up.” He also cites research showing physicians and nonphysician practitioners (NPPs) tend to practice in the same areas, regardless of state scope laws.
Additional studies have documented negative patient outcomes and higher medical utilization and costs when physician oversight is removed. Among a growing body of research, TMA points to studies that have found NPPs are more likely than physicians to overuse diagnostic imaging and other services, overprescribe opioids and antibiotics, and over-engage specialists, all of which drive up health care spending.
The recent experience of Hattiesburg Clinic in Mississippi bolsters TMA’s case that health care teams should be led by physicians. After 15 years of growing its care teams by adding NPPs because of a shortage of primary care physicians, the clinic analyzed data for its accountable care organization, hoping to find it had been able to stabilize costs, preserve quality of care, and maintain patient satisfaction.
Instead, clinic physicians found the model had “failed to meet [its] goals in the primary care setting of providing patients with an equivalent value-based experience,” they wrote in the January 2022 issue of the Journal of the Mississippi State Medical Association.
A 2022 study of Veterans Health Administration data by the National Bureau of Economic Research similarly found that, compared with physicians, nurse practitioners who treat patients in the emergency department “significantly increase resource utilization but achieve worse patient outcomes.”
Corpus Christi ophthalmologist Jerry Hunsaker, MD, emphasized the stark discrepancies in education, training, and exposure to a diverse range of patients between physicians and NPPs.
“Until you’ve been through medical training, you don’t know what you don’t know,” he told Texas Medicine Today in the Texas House gallery during TMA’s signature First Tuesdays at the Capitol event on March 7. “That’s dangerous for patients and expensive for anyone paying for health care.”
A physician completes four years of medical school plus three to seven years of residency, including up to 16,000 hours of clinical training, according to the American Medical Association. In contrast, a nurse practitioner completes only two to three years of graduate-level education and 500 to 720 hours of clinical training.
Physicians aren’t alone in their opposition to nurses expanding their scope of practice. When primary voters from both parties were asked if they would favor or oppose allowing nurses or other NPPs to treat patients, and prescribe medicine without the oversight of a licensed physician, even if it saves money, more than two-thirds said they were opposed, according to a TMA poll conducted in January and February.
TMA is championing more sustainable solutions to physician workforce shortages, such as expanding funding for graduate medical education, rural loan forgiveness programs, telemedicine and broadband expansion, and the Texas Medical Board, which requires additional staff to process historic numbers of medical licensure applications.
Fortunately, preliminary budget bills from both the House and the Senate include funding to sustain GME residency positions created in recent years and to create new ones, which are critical to protecting the state’s substantial investment in medical education and to growing Texas’ physician workforce.