Détente in Scope-of-Practice Issue for Physicians, APRNs?

Scope of practice for advance-practice nurses has been a toxic issue in recent legislative sessions. Nursing organizations have sought independent prescribing and practice authority; the powerful Texas Medical Association (TMA) has swatted away what it sees as a challenge to physicians’ oversight authority.

The TMA and the Coalition for Nurses in Advanced Practice appear to have reached a détente in advance of the 2013 legislative session.

Since 1989, Texas has had a site-based model for advanced practice registered nurses (APRN). More than 20 years created a polyglot of physician oversight regulations—some based on geographical distance, others based on care delivery, and still others based the number of APRNs. The inefficiency of current regulations for both nurses, who have been trained to prescribe independently, and physicians, who sometimes must travel to remote locations, is becoming more intolerable as the state faces increasing shortages of healthcare providers.

The so-called collaborative prescriptive authority model would require an APRN to be credential by the Texas Board of Nursing, which is already the case, and have a collaborative prescriptive authority agreement with a physician or physician group for consultation and referrals. The model exists in 17 of the 32 states that require physician involvement.

Bruce Malone, an Austin orthopedic surgeon and former TMA president, said scope-of-practice is “a big issue for us,” but that TMA would be amendable to a collaborative arrangement.

“We’re going to have no problems with it,” he said. “Things have changed since the agreement in the 1980s with electronic medical records and texting. We want the rules to reflect modern communications technology.”

According to a May report by Ray Perryman, a noted Texas economist, using APRNs under the collaborative would enhance efficiency, boost economic output by $8 billion and create nearly 100,000 more jobs. The report projected impact in 10-year increments through 2040. By that time, the total impact would be nearly 180,000 new jobs and more than $23 billion in additional economic output.

The report estimated Dallas-Fort Worth would gain more 32,000 additional jobs with fewer APRN restrictions and that would grow to more than 40,000 jobs by 2020. The additional DFW economic output would be more than $2.6 billion and grow to more than $4 billion by 2020.

The report emphasized savings by more fully using APRNs, who are less expensive to train and who can reduce the need for more costly treatment because they can provide more preventive care.

James Dickens, senior program management officer for the U.S. Department of Health and Human Services Dallas regional office, chaired a roundtable panel of Texas advanced practice nurse associations, the Texas Nurse Association (TNA) and Texas Team Advancing Health through Nursing address the Institute of Medicine’s recommendations that APRNs be allowed to practice at the full scope of their training.

Dickens said, “We want full autonomous practice but we believe the legislature won’t support that at this time. The consensus was that the timing is just not right. We believe the collaborative model was an opportunity to move the needle, streamline the process, and increase access to care. But that’s not the end goal.”

Alexia Green, a Texas Tech University nursing professor and co-leader of Texas Team, said, “There is plenty of evidence from unbiased groups that APRNs provide similar or higher quality care. The data support this. Professional dogma does not. We have to do what’s best for Texans.”

Jim Willmann, TNA general counsel and director of governmental affairs, said the advantage of the collaborative model is that it can be defined by the physician and nurse rather than overly restrictive external rules.

“If they have worked together for 20 years, the doctor needs to spend less time with them. Details of the relationship would be decided by them based on reality. The current restrictions are very costly and barriers to access to care. We are hopeful and optimistic we can move the ball forward,” he said.

Health reform could insure as many as 4.5 million through Medicaid expansion and insurance exchanges if Gov. Rick Perry’s decision not to participate in Medicaid expansion is overturned. The state has the nation’s fastest growth rate, with 5 million new residents expected to be added this decade.

Meanwhile, the physician population is aging even more swiftly than the general population. Nearly half of Texas physicians are over age 50 and 1 out of 4 are 60 or older.

Texas has 202 physicians per 100,000 residents, compared with the national rate of 257, according to the Centers for Disease Control. Texas has fewer physicians than the national average for 36 out of 40 medical specialty groups. Nearly half of Texas counties are classified as health professional shortage areas, and 29 counties have no PCPs.

APRNs could help stem a potential crisis in care access. A recent RAND Corp. study estimated that the nurse-practitioner (NP) population could nearly double by 2025.

One of the reasons for that explosive growth is that NPs and physician assistants (PAs) often earn more than $100,000 annually. Yale University researchers calculated that, for women, becoming a PA has a better return on investment for schooling than becoming a physician.

Nursing generally is a hot profession. Nursing represented the largest increase–40 percent–in hospital job openings from the first quarter of 2012 to the second quarter, according to the recruiting firm HEALTHeCAREERS Network. For NPs specifically, it was 16 percent. The U.S. Bureau of Labor statistics predicts that 1 out of 5 new jobs created this year will be in nursing.

In Texas, the demand for nurses is especially acute. As of May 2011, the demand for nurses exceeded the supply by 22,000. The Texas Nursing Workforce Shortage Coalition, which is composed of about 100 state medical centers and hospitals, warned in a letter that “without stable, continued funding for nursing education, this gap will widen by 70,000” by 2020.

There were fewer than 10,300 graduates from Texas RN programs in the 2010-2011 academic year, according to a report by the Texas Center for Nursing Workforce Studies. That report estimates the number would need to increase to more than 17,700 by 2015 and need to more than double by 2020.

Steve Jacob is editor of D Healthcare Daily and author of the new book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at steve.jacob@dmagazine.com.

Posted in News, Nursing, Physicians.
  • Sandy McCoy

    I would like to thank you for being objective and sharing the information that we have been trying to distribute to state leaders who need to be informed with facts about the severity of our current primary care shortage and how nurse practitioners can help with this shortage. We have made the compromise to keep physicians involved while streamlining the healthcare system, providing a cost savings and allowing advanced practice nurses to practice. Thank you again.
    Sandy McCoy, RN, MSN, FNP-BC
    President-Texas Nurse Practitioners

  • P Kelley

    I support more authority and autonomy for PA’s and Nurse Practictioners. We need to make sure that liability follows any shifts in autonomy.

  • James Karns

    APRN’s are already on the frontline, and study after study supports their safe outcomes. They share in medical liability, why not expand their scope of practice?

  • Gene Becker, M.D.

    We need great advanced practice nurses working as part of a physician-led healthcare team. They may share in some liability, but their physician supervisor is ultimately responsible for their mistakes.

    If you want to practice medicine independently, then go to medical school and residency after college. Don’t expect to take a less time consuming and less rigorous course of training and study to get the same rights, privileges and skills.

    You can quote ‘studies’, but as an Anesthesiologist, I work with CRNA’s daily. They do a great job, but there are times I have to rescue the patient. What would happen to those patients without proper oversight? Do you want that to be your family member?

    I realize situations in a primary care office are not as immediately life-threatening, but important decisions are made. I have also worked in the VA and Federal healthcare systems, which allow a geat deal of independent practice by APN’s. Ask a veteran what they think of the quality in some of those locations (of which I am also one).

    APN groups may say they want to cooperate with physicians, but they all (whether they admit it or not) seek full independent practice authority. In the State of Texas, the independent practice of medicine is by law restricted to licensed physicians. Trying to get regulatory expansion of scope is no substitute for proper training and education.

    We all want to expand access to health care, but it should be done in the safest manner possible, not just to potentially save money by using ‘mid-level’ providers without adequate supervision.

    • Cheryl Smitherman, DNP

      While I agree that we need great APRNs working as a part of a physician-led team, this does not require physicians to provide a “supervisory” role, but instead a “collaborative” role. APRNs are independent licensed practicioners who would not subject a physician to vicarious liability unless he/she is employed by the physician. May I refer you to the book by Marie Annette Brown & Louise Kaplan entitled “The Advanced Practice Registered Nurse as a Prescriber.” APRNs are liable for the care they provide as an independent practicitioner.

      Furthermore, we did not choose medical school. We deliberately chose nursing. APRNs have simply recognized the healthcare gap between the number of providers and the number of those in need, and are willing to ASSIST in helping narrow this gap. Our focus is on the patient, not ourselves.

      There is an intentional difference between the scope of care of an APRN and a physician. The APRN scope is limited to knowledge and skills of a “mid-level” provider. That is, care which can be safely provided at a level of care beyond that of a registered nurse, but beneath the level of a physician. It is the role of the APRN to recognize the limits of his/her knowledge & ability and “consult” with a physician when the need arises just as another physician would “refer” to a specialist when necessary. I am sure you would agree that there are aspects of your care that you feel require lesser experience or skill which could be successfully handled by a healthcare provider with the knowledge and training. THIS is the intent of the mid-level provider; NOT to replace your knowledge, skill and experience.

      I would also like to request that you to reconsider the term “rescue” by asking yourself if the APRNs in these cases consulted you based on your expertise or care beyond their scope, or whether the APRNs did not have the knowledge & skill that they were trained to have. If you were asked by the APRN to step in and “rescue”, they were doing their job. If you “rescued” the patient because the APRN lacked skill, this should be addressed individually rather than making a generalization that physicians must “rescue” patients from APRNs.

      Likewise, the generalization that lawful authorization of independent practice somehow elevates the quality of phyician care is absurd, and the recommendation that we ask a veteran about the quality of care received by APRNs is insulting. Each practitioner, physician or otherwise, has a level of skill and knowledge which is exclusive of the law. Authorization for independent practice does not exclude one from poor quality care. It just means they are legally able to provide it. Have you not ever heard of a poor quality physician? That’s why we have malpractice! Physicians (including you) and APRNs are human! The law does not ensure quality.

      We are not asking for regulatory expansion of scope without proper training and education. We are asking for regulatory expansion of scope BECAUSE of our, proper training and rigorous education. We are not asking for the same rights, priviledges & skills. We are asking for the rights, priviledges & skills WITHIN our scope.

    • Lisa Ferguson

      Dr. Becker,
      I agree that our education and training is quite different, but that is because we offer care from differing perspectives. I, as an advanced practice registered nurse, am perfectly satisfied to give my patients quality care that is within my education, clinical training, and practical experience. I don’t want to expand my scope of practice beyond my education and clinical training, but I would like to practice to the extent of that training. I also appreciate and fully utilize the collaborative relationship I have with my physicians to provide the best care I can while enhancing my education, training, and abilities. I don’t want to step outside of my education or training in order to help my patients, I want to be able to operate within that education and training. That is all I am asking as an APRN, to practice within my education and training to serve the people I am licensed to serve.

      I believe the best way to serve patients is to work together to deliver the highest quality care, patient education, and preventive services available. The most efficient way we can do this is to work in tandem to provide these services. We (physicians and nurse practitioners), with our unique education and training, can be synergistic in providing care to our patients. Our energy is much better expended to this end, rather than fighting one another.
      You mention having to rescue patients. Although my practice mellieu does not involve life or death situations, I too have had to correct mistakes of my colleagues. Correcting inappropriately prescribed therapies or catching “misses” occurs in all of our practices. There are bad apples in all professions, NPs are not unique in this. We are all human, fallible and subject to mistakes. In my experience, the difference in how mistakes made by physicians and NPs are handled is that NPs are more deeply scrutinized, while physicians are less so.
      I am also a 20 year veteran of the United States Air Force, where I spent 10 years as a NP. I have had to fight the negative connotation attached to “military medicine” as being far inferior to our civilian counterparts. After 10 years of practice as a NP and 2 deployments to Iraq, I can unequivocally state that the collaborative environment in which we practiced was far and away the best environment for the patient, the physician and the nurse practitioner. The level of knowledge, expertise, and care provided in the armed forces has surpassed my own experience in the civilian medical community. Please, ask a veteran about the care provided by their nurse practitioner. I believe you will find they are satisfied with their experience and care.
      I propose a halt to the “us vs them” attitude that has become so prevalent between our two professions, in lieu of a more collaborative relationship where the physician, nurse practitioner, and patient all benefit. Use of terminology such as ‘mid level’ can only be divisive and counter to collegial relationships. You are a physician, I am a nurse practitioner, and we both deserve to be referred to appropriately. I look forward to a future that contains a more collaborative relationship with my physician colleagues.

  • Victoria Tyra

    Finally! keeping up with these inane restrictions is costing us in access to care, fear that the confusing regulations are going to come back and haunt both the physician and the NP or PA, and putting the decision making back in the hands of the people on the front line… an idea that makes some sense! Thank you for communicating it well.

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