Nurse Practitioners in Texas

[TWR]

Nurse practitioners again push for independence

Multiple bills filed in the Texas Legislature are seeking to give certain Texas nurses independence from costly contracts with supervising physicians.  

BY MARIANA ALFARO

FEB. 9, 2017   5:50 PM

 

State Rep. Stephanie Klick, R-North Richland Hills, with State Rep. Donna Howard, D-Austin, announcing the Coalition for Health Care Access that will work toward expanding access to health care in Texas this legislative session. Klick is introducing HB 1415 and SB 681 to remove outdated and costly regulatory barriers for APRN nurses.  Bob Daemmrich for The Texas Tribune

Texas nurse practitioners are once again seeking independence from costly agreements that require them to sign contracts with doctors in order to treat and write prescriptions for their patients. 

State Rep. Stephanie Klick, R-Fort Worth, introduced House Bill 1415 Thursday, saying the bill would get rid of so-called prescriptive authority agreements that require nurse practitioners — who have advanced degrees in a nursing speciality — to pay up to six-figure fees to "delegating" doctors. 

Currently, nurse practitioners are regulated by both the Texas Board of Nursing and the Texas Medical Board. Under Klick's bill, nurse practitioners would be regulated solely by the nursing board. 

Doctors' groups in Texas have said these nurse-physician contracts are necessary to ensure patient safety, because physicians have more expertise in treating patients. Primary care physicians must complete four years of medical school and three years of residency training, while nurse practitioners must complete four years of nursing school and usually two years in a graduate-level training program. 

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Nurse practitioners are often the primary health providers in many rural and low-income Texas communities. Under current regulations, the physicians they contract with don’t need to be in the same city as the nurse or see the patients the nurse treats. Experts say the contracts drive up clinic prices or push nurses to other states.

During a Thursday press conference, Klick said the contract fees can be as high as $120,000 per year in Texas, which is why many nurses opt to work in neighboring states that don't require delegating physicians. New Mexico’s government, Klick said, has even appropriated funds to recruit Texas nurses.

"This puts Texas at a competitive disadvantage,” Klick, a former nurse, said. “Texas simply cannot afford to waste precious dollars spent educating our healthcare workforce just to have them move out of state and help with healthcare providers elsewhere."

The bills  — Klick’s and Sen. Kelly Hancock’s Senate Bill 681 — are not the first seeking to end these nurse-doctor contracts. Similar bills over the past few legislative sessions failed to become law. 

This time around, however, the bills don't call for an expansion of a nurse’s scope of practice, and they are backed by a coalition of 20 organizations representing consumers, healthcare businesses and advocates, including the AARP, the Texas Association of Business and the Texas Public Policy Foundation.

"It's a powerful bunch, and it's not a bunch that you frankly see doing a lot of things together very often," said Bob Jackson, AARP’s state director.

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[mmiller3]

Contract fees up to $120,000? For what?

[Reality Check 2]

They did this to themselves back in the 1990s.

 

Right before I left Texas, PAs were actually getting licensed for the first time. Still no Rx rights.

 

We made a bill and took it to the legislature stating licensure and physician affiliation and working to get Rx privileges. It was congenial and worked to get our foot in the door nicely with a very stringent old world system. One step at a time. Texas has always been 5-8 years behind the national average for PAs.

 

The Nurses Association barnstormed the Texas Medical Association (a bunch of old men, by the way) and made demands for independence and full Rx authority and 100% reimbursement. Texas is not the place where you barnstorm an entrenched good ole boy system of 100 years running. 

 

The TMA laughed them out of the building.

 

In a midnight (literally) Hail Mary - the nurse practitioners agreed to sign onto the PA legislation that mandated physician attachment but gave them Rx privileges. They asked for this, they agreed to this and they signed on. They still did not get 100% reimbursement.

 

I moved away and heard peripherally from friends still in Texas. It sounds like it has been running this way going on 20 years.

 

Not sure what will happen to them. Again, Texas is a good ole boy system that doesn't take massive change very well. 

 

Hope they handle it well or they will be censured for years to come. One attracts more insects with honey than vinegar.

[True Anomaly]

This won't pass.  I guarantee it

[UpRegulated]

 

Nurse practitioners again push for independence

Multiple bills filed in the Texas Legislature are seeking to give certain Texas nurses independence from costly contracts with supervising physicians.  

BY MARIANA ALFARO

FEB. 9, 2017   5:50 PM

 

State Rep. Stephanie Klick, R-North Richland Hills, with State Rep. Donna Howard, D-Austin, announcing the Coalition for Health Care Access that will work toward expanding access to health care in Texas this legislative session. Klick is introducing HB 1415 and SB 681 to remove outdated and costly regulatory barriers for APRN nurses.  Bob Daemmrich for The Texas Tribune

 

Texas nurse practitioners are once again seeking independence from costly agreements that require them to sign contracts with doctors in order to treat and write prescriptions for their patients. 

State Rep. Stephanie Klick, R-Fort Worth, introduced House Bill 1415 Thursday, saying the bill would get rid of so-called prescriptive authority agreements that require nurse practitioners — who have advanced degrees in a nursing speciality — to pay up to six-figure fees to "delegating" doctors. 

Currently, nurse practitioners are regulated by both the Texas Board of Nursing and the Texas Medical Board. Under Klick's bill, nurse practitioners would be regulated solely by the nursing board. 

Doctors' groups in Texas have said these nurse-physician contracts are necessary to ensure patient safety, because physicians have more expertise in treating patients. Primary care physicians must complete four years of medical school and three years of residency training, while nurse practitioners must complete four years of nursing school and usually two years in a graduate-level training program. 

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Nurse practitioners are often the primary health providers in many rural and low-income Texas communities. Under current regulations, the physicians they contract with don’t need to be in the same city as the nurse or see the patients the nurse treats. Experts say the contracts drive up clinic prices or push nurses to other states.

During a Thursday press conference, Klick said the contract fees can be as high as $120,000 per year in Texas, which is why many nurses opt to work in neighboring states that don't require delegating physicians. New Mexico’s government, Klick said, has even appropriated funds to recruit Texas nurses.

"This puts Texas at a competitive disadvantage,” Klick, a former nurse, said. “Texas simply cannot afford to waste precious dollars spent educating our healthcare workforce just to have them move out of state and help with healthcare providers elsewhere."

The bills  — Klick’s and Sen. Kelly Hancock’s Senate Bill 681 — are not the first seeking to end these nurse-doctor contracts. Similar bills over the past few legislative sessions failed to become law. 

This time around, however, the bills don't call for an expansion of a nurse’s scope of practice, and they are backed by a coalition of 20 organizations representing consumers, healthcare businesses and advocates, including the AARP, the Texas Association of Business and the Texas Public Policy Foundation.

"It's a powerful bunch, and it's not a bunch that you frankly see doing a lot of things together very often," said Bob Jackson, AARP’s state director.

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Why do you care?  PA's and NP's are entirely different professions, right?

[Katera]

Doctors are HYPER-territorial in Texas.  I mean....bad like.  The next gen of docs coming out are better, but the TMA is still run by 70 year-old "back in my day" men.  They care more about protecting their territory then patients access to care.  I've been dealing with these guys for over 20 years.  At least supervision requirements have gotten better.

[LKPAC]

Why do you care?  PA's and NP's are entirely different professions, right?

 

Are you kidding?  NPs are taking jobs nationwide that could go to PAs.   We congratulate ourselves for being better trained, but they have better politics.  Which do you think is winning: training or politics?

[sillycibin]

I love how they tried to construct some sort of equivalence by stating that nurses complete four years of "nursing school" like that even exists and is anywhere near comparable to four years of medical school.  And that the 2 year graudate NP programs and their 800 clinical hours compares to a three year residency and the 8000 hours a resident does.

[UpRegulated]

Are you kidding?  NPs are taking jobs nationwide that could go to PAs.   We congratulate ourselves for being better trained, but they have better politics.  Which do you think is winning: training or politics?

 

Not kidding.  My point is simple.  I'm an NP that think PA's are awesome.  Read my threads.  But I've said it many times and will continue to.  Too many PA's think there war is with NP's. IT IS NOT.  Every argument you make against NP's (e.g. supposed "lack of training") can be and IS turned back on you by physicians.

 

Your arguments against NP's vs. PA's is counterproductive.  I am trying to be helpful whether you accept that or not.  Who cares if "politics" is why NP's have more independence on average.  There are a ton more nurses than there are PA's.  That's reality.  Roll with it.  Better yet, USE IT.  Instead of criticizing NP's, which only undermines the PA profession (see paragraph #1), argue WITH them than PA's are every bit as qualified to have the same benefits as NP's.  For the life of me, I can't understand why PA's don't get this.

[LT_Oneal_PAC]

I hope they get it, though I agree the old guard is going to fight tooth and nail to the point I don't have high hopes. I have seen crazy wins before though by the nursing lobby.

[UpRegulated]

I hope they get it, though I agree the old guard is going to fight tooth and nail to the point I don't have high hopes. I have seen crazy wins before though by the nursing lobby.

 

Yep.  It's really simple.  NP's want and fight for what MD's have.  PA's want and fight for what NP's have.

[TWR]

UpRegulated,  I agree with your comments in above post.  But vehemently disagree with you that PAs are "as qualified as NPs".  Certainly not right out of school.  I have worked with several some seasoned some "new".  Yo can't equate 600 hours of clinical training an NP to over 2000 hours for a PA!  All the prior nursing years don give the experience of PA clinical training.  IMHO

[LKPAC]

Yep.  It's really simple.  NP's want and fight for what MD's have.  

 

Without earning it through medical school, internship and residency.

[Katera]

Not kidding.  My point is simple.  I'm an NP that think PA's are awesome.  Read my threads.  But I've said it many times and will continue to.  Too many PA's think there war is with NP's. IT IS NOT.  Every argument you make against NP's (e.g. supposed "lack of training") can be and IS turned back on you by physicians.

 

Your arguments against NP's vs. PA's is counterproductive.  I am trying to be helpful whether you accept that or not.  Who cares if "politics" is why NP's have more independence on average.  There are a ton more nurses than there are PA's.  That's reality.  Roll with it.  Better yet, USE IT.  Instead of criticizing NP's, which only undermines the PA profession (see paragraph #1), argue WITH them than PA's are every bit as qualified to have the same benefits as NP's.  For the life of me, I can't understand why PA's don't get this.

 

I think I agree with this lol

[GetMeOuttaThisMess]

Editorial article posted on Dallas Morning News website homepage today under title: These two bills could help solve Texas' health care access crisis. No mention of PA's.  Here's the link, though I'm not sure if non-subscribers will have access to the article: http://www.dallasnews.com/opinion/editorials/2017/02/16/texas-health-care-access-crisis-two-bills-help-solve

[Guest Paula]

So what are you Texas PAs going to do?  Go fight alongside the NPs, but first get a PA coalition together and go to your legislators.  I fear your TAPA and TMA will not support PAs to be included in the bill, but you must TRY and also shed light on the issue with your legislators.  Medical associations are the ones who kill the PA profession and have the "ins" with legislators and government.  PAs have no real "ins" due to lack of recognitions.  

 

NPs and nurses have the recognition for thousand of years  since Eve gave birth to Cain and Abel. They are the oldest profession in the whole world. 

[GetMeOuttaThisMess]

So what are you Texas PAs going to do? Go fight alongside the NPs, but first get a PA coalition together and go to your legislators. I fear your TAPA and TMA will not support PAs to be included in the bill, but you must TRY and also shed light on the issue with your legislators. Medical associations are the ones who kill the PA profession and have the "ins" with legislators and government. PAs have no real "ins" due to lack of recognitions.

 

NPs and nurses have the recognition for thousand of years since Eve gave birth to Cain and Abel. They are the oldest profession in the whole world.

Me personally? Retire. For those who have years left to go, I'd think that now is the time to at least say something. I've heard nothing out of Austin except cricket chirps to the best of my recollection. I'd have to go back and look at the last TAPA newsletter.

 

I'd be pushing the training model, cross-specialty education as opposed to one focused area of education, and the additional training hours, at least if a fairly new grad. Case in point. Heard an NP say yesterday that they didn't believe in evidence-based medicine but rather preferred to "look at the patient". They brought up the MMG screening age change as an example. Dollars be damned and false-positive associated risks not withstanding. Huh?

 

Update:  Looked at last newsletter under Legislative Update.  PA Day at the Capital and Sunset Commission statement.  That's it.  NADA.  We now return to our crickets.

[OneDayAPA_Maybe]

Me personally? Retire. For those who have years left to go, I'd think that now is the time to at least say something. I've heard nothing out of Austin except cricket chirps to the best of my recollection. I'd have to go back and look at the last TAPA newsletter.

 

I'd be pushing the training model, cross-specialty education as opposed to one focused area of education, and the additional training hours, at least if a fairly new grad. Case in point. Heard an NP say yesterday that they didn't believe in evidence-based medicine but rather preferred to "look at the patient". They brought up the MMG screening age change as an example. Dollars be damned and false-positive associated risks not withstanding. Huh?

 

Update:  Looked at last newsletter under Legislative Update.  PA Day at the Capital and Sunset Commission statement.  That's it.  NADA.  We now return to our crickets.

 

TAPA Spring conference is next weekend. I guarantee there will be an update. I want to preface that I am a student.

 

I believe independent practice in rural primary care is more feasible, but am fearful about independent practice in specialities because we do not receive the training. A push for independent practice for PA's would have to have a drastic change to the PA school model. This would lead to a longer education model that would mirror that of medical school. That would then probably lead to residency/fellowship requirements. Which then brings up the question, why PA and not MD?

[Katera]

NPs and nurses have the recognition for thousand of years  since Eve gave birth to Cain and Abel. They are the oldest profession in the whole world. 

 

 

 

2nd world's oldest profession......   ;)

[UpRegulated]

UpRegulated,  I agree with your comments in above post.  But vehemently disagree with you that PAs are "as qualified as NPs".  Certainly not right out of school.  I have worked with several some seasoned some "new".  Yo can't equate 600 hours of clinical training an NP to over 2000 hours for a PA!  All the prior nursing years don give the experience of PA clinical training.  IMHO

 

Fine.  That's a reasonable point of disagreement.  But here's the deal.  Summarize "academic clinical training" of each profession in say, family practice, side-by-side:

 

PA's:  2,000 hours in PA school, 2,000 hours in prior healthcare experience:  4,000 hours (FP is only 600 hours in PA school, but I'm crediting your other rotations).

NP's:  800 hours in NP school, 2,000 hours as an RN: 2800 hours

MD's: 2,000 hours in MD school, 9,000 hours in residency: 11,000 hours

 

Difference: 25% vs. 33% with NPs vs. PAs compared to an MD or DO.  You ain't winnin' no arguments with that (to use my native vernacular.).

 

Let's not debate PA vs. NP and whatever prior experience this PA had vs. this NP, and RN training vs. PT, OT, EMT, CNA, RT, yada, yada, just for the sake of this discussion.  The PA's argument that he/she is better qualified than an NP means NOTHING in light of the "academic clinical experience" of an MD/DO.  NOTHING.  Our academic clinical training pales in comparison (me being an NP and this board being PAs).  Yet all research shows (OK, maybe it is somewhat limited) that PA's and NP's still offer excellent care, perhaps care equivalent to or even exceeding that of an MD/DO, especially with the experienced NP/PA.

 

When you go after NP's, arguing that your training is superior to NP's, you are talking about a rough difference of 1,200 hours in academic clinical training.  How relevant is that 1, 2, 3, 5 years out?  But that is not even my point.  How relevant is it in light of the fact that the average MD/DO vs. PA has 8,000+ hours more clinical training than you?! 

 

SO THINK ABOUT IT.  You PAs have (maybe have) 1,200 hours more relevant (maybe) training experience vs. the NP, yet the MD/DO has 8,000 hours more academic clinical training than you!

 

When you bash an NP for not having enough clinical training, you are bashing YOURSELVES. 

 

Purely anecdotal, but in my short NP career, I have now had 3 physicians tell me that their academic residency experience (supervised) as opposed to real world practice (non-academic, unsupervised) was night and day.  In other words, it certainly helps but it strongly highlights the fact that supervised clinical experience vs. actual clinical experience cannot be compared.  But I digress.

 

When you, or your groups, are fighting for more rights (as you absolutely should), you will never win arguing that you are better than NP's.  You must argue that your experience, training, etc. yields equal (better?) results to that of NP/MD/DOs.  There are NP studies (yeah, they can be questioned, but they're actually fairly decent and rigorous) that show that NP care is as good or perhaps even better than MD/DO care.  PA's could then point to those studies to legislators, and then note that not only do NP's provide equivalent care, but PA's have even more training (academic training of course) than NP's!

 

Obviously, I'm not talking about PA's and NP's in true specialties and sub-specialties.  And there's a bazillion arguments that can stem from this post in all sorts of ways (my math, "equivalent" training, these hours vs. those hours, this vs. that, etc.).  Maybe we hash those out in another thread.  But my point is simple:  You go after NP's for their supposed lack of training, and medical boards will use your arguments against NP's against you as PA's.  

 

You can choose to believe that or not.

[runforhotdogs]

Not kidding.  My point is simple.  I'm an NP that think PA's are awesome.  Read my threads.  But I've said it many times and will continue to.  Too many PA's think there war is with NP's. IT IS NOT.  Every argument you make against NP's (e.g. supposed "lack of training") can be and IS turned back on you by physicians.

 

Your arguments against NP's vs. PA's is counterproductive.  I am trying to be helpful whether you accept that or not.  Who cares if "politics" is why NP's have more independence on average.  There are a ton more nurses than there are PA's.  That's reality.  Roll with it.  Better yet, USE IT.  Instead of criticizing NP's, which only undermines the PA profession (see paragraph #1), argue WITH them than PA's are every bit as qualified to have the same benefits as NP's.  For the life of me, I can't understand why PA's don't get this.

Me neither. I'd take policy wins any day. Then again, I've had classes in health policy so we are used to arguing these points. These NP/PA battles remind me of the old DO vs MD battles. Ironically, both are held hostage by insurance companies and what they will pay them.

[sas5814]

This is the very topic I came back to see. NPs have been attempting to gain some type of independence for a long time and have been thwarted each time. It won't last forever and the political winds are blowing in such a way as to make some type of significant change to their supervision requirements likely if not probable and it will be the 1st step in what will eventually become independence. To believe otherwise is just magical thinking. Anyone who "guarantees" this won't pass is kidding themselves. TMA has had less and less influence in the legislature as it has become more and more obvious that their motivation is control and turf and not what is best for patients. They trot out tropes like "people will die" so often and for so long they have lost a lot of their credibility. Anything is possible and politics and political moves are distant from reality.

There are so many aspects of this to consider. 1)Nurses are a powerful political lobby with big numbers and a lot of money. Numbers and money talks in politics. 2) WHEN nurses gain independence (not if because they have done it elsewhere and will do it here) we will be sitting here sucking our thumbs and holding hands with the physicians who, by the way, are not our political friends.3) When they gain independence they will be able to employ PAs because...see comment two. 3) It will have a further deleterious effect on hiring PAs because of the now significant difference in time and administrative overhead to employ and supervise PAs. Do not believe for a moment there will be some revolt against the NPs and nobody will use them. Decisions are driven by money and convenience and are made by administrators not physicians. 4) More physicians are becoming employed themselves so their impact our our salaries and hire-ability will continue to decline. 5) The public perception will shift. NPs are qualified to work independently and PAs are not therefore PAs are less qualified.5) Being the mortal enemy of the physician lobby hasn't slowed the nurses much at all and certainly hasn't limited their employment.

It just goes on and on from there. Being the physicians faithful servant has served us but the times they are a-changing and if we don't adapt we are going to be left far far behind. Other states have developed autonomy for PAs and more are following. Does Texas really want to be the 50th to do it? I am going to try and be at at least part of the TAPA conference to visit with as many people about this as possible but practical matters may make that impossible. 

[GetMeOuttaThisMess]

Well articulated.

[Boatswain2PA]

welcome back SAS!

[sas5814]

welcome back SAS!

Thanks. I have enjoyed a sabbatical from health care politics in Texas but this came up and is just too important to shrug off.