| Perspectives on Texas

Advanced practice registered nurses (APRNs) perform a vital, important function in our health care delivery system. I value them as members of my own care team and rely on them to provide excellent patient care. However, they are not physicians, any more than I am a nurse. Texas is correct to keep its team-based care approach. It ensures patients receive care from each member of the patient care team, based on his or her knowledge, training and expertise.

In 2013, physicians and nurses joined to help write a landmark state law that improved access to care and strengthened the team-based approach to providing health care to all Texans. Texas physicians still strongly support that collaborative care model, in which each team member practices to the top of his or her professional license. A collaborative model ensures patients receive safe, cost-effective and efficient care.

Yet now some nursing groups apparently reject that model. They want to practice independently as if they are physicians — without attending medical school. They claim more patients would receive care, at a lower cost, if lawmakers grant them independent practice authority.

First, there is no evidence — in Texas or elsewhere — to support the notion that granting nurse practitioners authority to diagnose and prescribe independently would improve patients’ access to care. States that have granted practice autonomy to nurse practitioners have not seen nurses rush out to rural communities to hang their shingles and start treating patients. Instead, most nurse practitioners continue to practice alongside physicians in clinics and hospitals as they always have, clustered in the same metropolitan and suburban communities.

In Texas, 52.5 percent of APRNs practice in the state’s five largest counties (Harris, Dallas, Bexar, Travis and Tarrant). Not surprisingly, 51.9 percent of primary care physicians practice in those same five counties. And while patients need primary care, only slightly more than half of America’s APRNs (52.5 percent) practice primary care. And the number of APRNs entering a primary care field has dropped by 40 percent since 2004.

Second, the evidence tells us that independent practice for these nurse practitioners actually will increase costs in our already overpriced system. Studies show nurse practitioners tend to order more expensive tests and diagnostic scans than doctors, and they are quick to refer patients to specialists — all of which drives up the cost of care. Research found that patients under APRNs’ care were hospitalized 41 percent more often than patients cared for in the same settings by physicians. And one-quarter more of the APRNs’ patients saw specialists than those under physicians’ care.

The nurses’ arguments simply do not hold water.

Meanwhile, collaborative care models such as the patient-centered medical home continue to prove their effectiveness. Nearly one-third (29 percent) fewer patients have visited emergency departments, almost 40 percent fewer patients have been hospitalized, and total medical costs are down nearly 9 percent since implementation of various patient-centered medical homes around the country.

What’s more, “primary care” often is acute, complex care, especially in rural areas. Primary care physicians (with the support of their health care teams, all working to the top of their training and abilities) care for car-accident victims, children with severe allergic reactions, people with chest pain, gunshot victims, burn victims and women about to deliver  babies. Those patients and the tens of thousands of others across Texas with similar complex needs require immediate help from people who know best what to do. 

The Texas Medical Association strongly opposes House Bill 1415 by Rep. Stephanie Klick, R-Fort Worth, and Senate Bill 681 by Sen. Kelly Hancock, R-North Richland Hills, which would broaden APRNs’ practice authority. Instead, TMA supports improvements to the current health care collaboration model as we work to improve access to care, especially in underserved areas.

Nurse practitioners are a vital part of Texas’ health care workforce. But as many nurses who’ve later gone to medical school readily admit, nurses simply do not know what they do not know; there are limitations built in to their training. 

APRNs are not “physician substitutes.”

The typical physician completes 12,000 to 16,000 hours of clinical training in medical school and residency. The typical APRN completes 500 to 1,500 hours. That foundation, while appropriate for the nursing field, is simply is not a substitute for the comprehensive care physicians are trained to — and expected to — provide.