As health care costs rise and access to care becomes more challenging, is Texas missing an opportunity by maintaining highly restrictive laws that exclude advanced practice registered nurses (APRNs) like nurse practitioners from having a prominent role in our health care system? Reform for a Healthy Future: Expanding Scope of Practice for Nurse Practitioners in Texas, a new report from the Texas Public Policy Foundation, explores the advantages APRNs offer and how those in Texas are being lured away by states with relaxed scope of practice regulations.
APRNs’ current status
Advanced practice registered nurses generally fall into one of these areas of specialization: nurse practitioners, clinical nurse specialists, nurse anesthetists or nurse midwives.
Texas is one of a dozen states with restrictive scope of practice regulations. While Texas requires nurse practitioners (NPs) and other APRNs to practice with some form of supervision, delegation, or physician team-management, per the report, sixteen other states and Washington D.C., allow these professionals to evaluate patients, diagnose, initiate and manage treatments, and prescribe medications — all under authority of the state board of nursing.
Last session’s ‘reform’ still left unhelpful limits
In 2013, the 83rd Texas Legislature’s passage of SB 406 expanded APRNs’ and physician assistants’ (PAs) scope of practice, but restrictions remain.
The bill loosened APRNs/PAs independent prescribing of legend and other controlled drugs, devices and supplies, but the changes are far short of actions producing positive outcomes in other states.
SB 406 also did nothing to change current regulations that keep NPs from receiving Medicaid managed care organizations (MCOs) reimbursements unless the supervising physicians accepts Medicaid or has a contract with a patient’s MCO. This provision results in Texas NPs seeing fewer patients.
Physician shortages to impact health care access
With the Patient Protection and Affordable Care Act (ACA) subsidizing coverage for low-income Texans thereby bringing increased primary care demands, new physician shortages are a given. Without expanding Medicaid, the U.S. Department of Health and Human Services (HHS) estimates up to 2.8 million Texans might gain coverage through the ACA exchange. With a Medicaid expansion, 4.2 million new enrollees are expected.
Physician shortages are nothing new in Texas. HHS has designated 126 of Texas’ 254 counties as Health Professional Shortage Areas (HPSA), areas lacking primary care physicians based on a doctor-patient ratio of about one per 3,000 residents. Texas additionally has 295 Medically Underserved Areas (MUA), more than any other state in the country.
Though two new medical schools – one in Austin and the other in the Rio Grande Valley – will help, the report cautions that “simply graduating more primary care physicians will not necessarily mean increased access to primary care in Texas” as “graduating medical students can always move elsewhere.”
The use of alternative providers like APRNs can help accommodate this new care access demand.
Nurse-led clinics offer alternative
Allowing patients the flexibility to rely on nurse-led clinics for primary care services can help offset physician shortages. The TPPF report cites data showing not only that increasing nurse-led clinic numbers helps reduce demand for primary care physicians, but that Medicare patients accessing primary care through NPs rose fifteen-fold between 1998 and 2010.
Additionally, data does not support concerns that NP primary care is inferior or producing sub-standard outcomes (over primary care physician services). Per the report:
A survey of 37 articles published between 1990 and 2009 on the quality, safety, and effectiveness of primary care provided by NPs compared to physicians found that outcomes were comparable across all categories, including health status, satisfaction with care, ER visits, hospitalizations, blood pressure, and others.
Economic benefits realized
Eliminating scope of practice restrictions could offer cost savings as basic NP-provided health care services performed in retail clinics generally have lower per visit costs.
Aside from addressing Texas’ provider shortages, a relaxation of APRN scope of practice laws has economic benefit. One 2012 study found “the effect of increasing the efficient use of APRNs in Texas would be $16.1 billion in total expenditures and $8 billion in gross product annually, as well as the creation of more than 97,000 jobs.”
A more open approach to APRNs is occurring in other states – and occurring with positive results. Texas’ health care challenges will only increase as our population grows as well as ages. The APRN model offers the means to ensure the delivery of quality, cost-effective care to all Texans.
Failure to incorporate this approach is truly a missed opportunity.