Patient Care Protected: Scope Creep/GME Funding
By Emma Freer Texas Medicine August 2023


Related content: 
2023 Legislative Wrap-Up: TMA Secured Big Wins With a New Strategy

TMA Priority: Protect independent diagnosing and prescribing as the practice of medicine; address current workforce shortages in a way that ensures patients have access to the same standard of care, no matter where they live.

Physician-Led Results: The Texas Medical Association halted scope-of-practice expansion bills this session, preserving patients’ access to high-quality, physician-led care and sending a strong message to lawmakers that such legislation was a nonstarter.

Nonphysician practitioners (NPPs) spent the session arguing that scope expansion was a necessary response to physician workforce shortages, especially in rural and underserved areas. TMA not only debunked these claims but also advocated for the right solutions, including significant increases in graduate medical education (GME) funding, which help bolster the state’s physician workforce without jeopardizing patient safety.

TMA Immediate Past President Gary Floyd, MD, a pediatrician in Corpus Christi, says scope was the association’s top legislative priority this session because it affects all physicians, regardless of specialty, as well as their patients.

“We still believe that every patient deserves the best-trained people to be involved in their care,” Dr. Floyd told Texas Medicine. “Agreeing that a nurse practitioner would solve this [access-to-care issue] rurally, to us, would be giving up our protection of patients … and we’re not going to give that up.”

Perhaps TMA’s crowning achievement this session was killing House Bill 4071 by Rep. Stephanie Klick (R-Fort Worth) and a similar proposal, Senate Bill 1700 by Sen. Cesar Blanco (D-El Paso), which would have enabled advanced practice registered nurses (APRNs) to practice independently.

HB 4071 died in committee, as did most scope-related bills, including House Bill 4404 by Rep. Ryan Guillen (R-Rio Grande City). That bill would have created an interstate compact for APRN licensure that superseded Texas’ restrictions against independent practice. TMA worked closely with Representative Guillen, who was attentive to and recognized medicine's concerns regarding the bill's implications and did not pursue its passage.

Another compact bill for physician assistant licensure, House Bill 2544 by Rep. Elizabeth Campos (D-San Antonio), and one on the practice of nursing, House Bill 2726 by Representative Klick, sparked concerns about doubling as possible vehicles for scope expansion but also died.

The only scope-related bill to make it to the House floor, House Bill 2553 by Rep. Lynn Stucky (R-Denton), would have given patients direct access to a physical therapist without a physician referral for 20 business days, up from a recently negotiated compromise of 15 days of care from a physical therapist with the highest level of training and 10 days of care from a physical therapist without it. Like many of TMA’s efforts this session, the measure was roundly defeated through a robust campaign that included grassroots intervention by TMA member physicians.

Other notable scope legislation left on the cutting room floor includes:

  • House Bill 1105 by Rep. Four Price (R-Amarillo) and its companion, Senate Bill 749 by Sen. Pete Flores (R-Pleasanton), which would have allowed pharmacists to administer childhood vaccines;
  • House Bill 2079 by Rep. Jacey Jetton (R-Richmond), which would have allowed pharmacists to “test and treat” certain conditions – including influenza, strep throat, and COVID-19 – by prescribing drugs; and
  • Senate Bill 730 by Sen. Juan Hinojosa (D-McAllen) and its companion, House Bill 1767 by Representative Klick, which would have allowed podiatrists to access hospital privileges, regardless of medical staff decision-making.

TMA President-Elect Ray Callas, MD, an anesthesiologist in Beaumont, attributes part of TMA’s success to patient support along the political spectrum.

When asked if they would favor or oppose allowing nurses and other NPPs to treat patients and prescribe medicine without the oversight of a licensed physician, even if it saved money, more than two-thirds of primary voters from both parties said they were opposed, according to a TMA poll conducted in January and February.

“Patients want physicians leading their health care,” Dr. Callas said.

Benefiting from a record-breaking surplus in the state budget, TMA also won sustainable workforce solutions that expand access to care in the short term while shoring up Texas’ physician workforce in the long term. These include increased funding for GME, physician residency programs, medical school tuition loan repayment, telemedicine expansion, and broadband access.

Support from physician-legislators like Sen. Donna Campbell, MD (R-New Braunfels), and Reps. Tom Oliverson, MD (R-Cypress), and Suleman Lalani, MD (D-Sugar Land), was crucial in both fights – against scope and for necessary investments in the state’s physician workforce.

“The workforce shortage is not the real reason, when you get down to it, why people want scope-of-practice expansion,” Representative Oliverson told Texas Medicine. “It all comes down to ... a desire to do someone else’s job.”

Notably, state lawmakers budgeted $233 million in the 2024-25 biennium – up 17% compared with the 2022-23 biennium – for the GME Expansion Grant Program, which supports the creation of new residency slots necessary to maintain the target 1.1-1 ratio of slots to medical school graduates. The legislature also allocated $116 million – up 12% – to residency training programs sponsored by medical schools; this funding helps offset the cost of teaching residents.

Other winners include:

  • The Family Practice Residency Program, which will receive $16.5 million in 2024-25, up from $9 million in 2022-23. Its grants go to the state’s nationally accredited family medicine residency programs to increase the number of physicians who choose that specialty.
  • The Physician Education Loan Repayment Program, which will receive $35.5 million, up from $29.5 million. The program incentivizes primary care physicians and psychiatrists to practice in rural and underserved areas by paying off their student loans.
  • The Joint Admission Medical Program (JAMP), which will receive $11.7 million, up from $9.7 million. JAMP encourages economically disadvantaged students to pursue careers in medicine by offering scholarships, paid internships, mentorship, and other support.
  • The Rural Residency Training Program, which will receive an inaugural allotment of $3 million. TMA initiated the 2019 creation of this program, which will issue grants to fund new residency positions in nonmetropolitan areas.

Dr. Floyd points to recent research showing removing physician oversight of the health care team undermines access to quality care and drives up costs.

“The best way that we can prevent patients from suffering harm is to make sure that the best-qualified people are involved in their care, and that’s physicians, based on education, training, and experience,” he said.

Last Updated On

August 07, 2023

Originally Published On

August 02, 2023

Emma Freer

Associate Editor

(512) 370-1383

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

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