State Representative Stephanie Klick says she will push in 2019 to grant advanced practice registered nurses (APRNs) independence from physicians, allowing them to care for patients and even prescribe medicines without physician oversight.
This kind of independence – known as “full-practice authority” – has eluded APRNs for years in the face of opposition from the Texas Medical Association, which represents physicians.
Many APRNs practice in group settings under direct physician oversight. Others practice individually under a 2013 Texas law (SB 406) that authorized “prescriptive authority agreements” between nurse-run private practices and supervising physicians. In agreements of this kind, doctors remotely delegate their prescribing powers to APRNs in return for a fee.
Klick introduced legislation last year to eliminate the requirement for these agreements and allow nurse specialists to practice as licensed independent practitioners under the oversight of the Texas Board of Nursing. Her bill would have consolidated regulations under this one board, eliminating the role of the Texas Medical Board, which currently shares oversight.
“I think that we need to remove barriers so that all of our healthcare professionals are practicing at the full level of their education and training,” the lawmaker said at a panel event November 8th at the Texas Public Policy Foundation, a conservative thinktank. “That will improve access to care not only in rural Texas but also medically underserved communities.”
Klick, a Republican of Tarrant County, is a former long-time nurse and works as a nursing consultant. She serves on the House Human Services Committee. Her bill, HB 1415 (85R), went to a public hearing last year but was left in committee following opposition from the Texas Medical Association. Other supporters of HB 1415 included Donna Howard, a Democrat of Austin, Drew Darby, Garnet Coleman, and at least 20 others, including Travis Clardy, Evelina Ortega, and Jonathan Stickland, House members who span the ideological spectrum.
According to Anne Dunkelberg, a healthcare researcher at the Center for Public Policy Priorities, bills like HB 1415 attract supporters on both ends of the political spectrum because they hold the promise of reducing the overall cost of care. “My work is on advocacy for access to care, particularly for low-income Texans: concerns about Medicaid, concerns about CHIP, concerns about the uninsured and about low-income people who are insured but still have access issues,” she said, speaking alongside the lawmaker at the same event last Thursday.
“So there are some different issues for those different groups – but even, for example, in our marketplace for individual insurance now, we have people below the poverty line or just above it getting private insurance and it’s really important to them to be able to buy a health insurance product that has really low out-of-pocket costs and that means we need to optimize competitiveness and productivity in the healthcare marketplace.”
She concluded, “In my opinion, this is one of the factors that is limiting access to care, particularly for low- and moderate-income Texans who really need to have that more affordable access available.”
“We’re not just here to say no,” said Dan Finch of the Texas Medical Association
Dan Finch, Legislative Affairs Director at the Texas Medical Association, who also took part in the panel discussion, expressed openness to dialogue on full-practice authority but was non-committal about specific legislative changes.
“This is the balloon that you squeeze and you don’t know where it’s gonna pop out,” he commented. “But we are committed to working on (these issues) … We will not always agree on stuff but we are always open to have the conversation. We are trying to find ways that we can all move forward together. We’re not just here to say ‘no.’”
Finch acknowledged the expanding the role of APRNs in the healthcare system and pointed to the potential for APRNs to play a bigger role in battling the opioid crisis as well as “rebuilding a frayed mental health infrastructure.”
According to Merritt Hawkins, a Dallas-based firm that specializes in healthcare recruitment, demand for advanced practice nurses is accelerating nationwide. Last year, APRNs were the third most sought-after medical role after family medicine doctors and psychiatrists.
A report by the firm about its own recruitment services notes, “The number of search assignments Merritt Hawkins conducts for nurse practitioners (NPs) reached a record high as tracked by the 2018 review, and was up 61% year-over-year… Ten years ago, Merritt Hawkins conducted only a handful of searches for (nurse practitioners).”
Klick believes that eliminating the mandatory delegation agreements will help meet demand by encouraging more APRNs to open practices in Texas: “That is a barrier, financially, to opening practices.” She adds, “The regulations that we have put us, as a state, at a competitive disadvantage. The New Mexico legislature has appropriated money to recruit Texas nurse practitioners, because they have a more favorable practice environment than we do.”
“You could have the bill for motherhood & apple pie and if it came out of the House you still might not get a Senate hearing.”
Politically, support for the idea is growing, according to Dr. Deane Waldman, who studies healthcare policy at the Texas Public Policy Foundation. “The coalition to release the APRNs is now up to 23 different entities in Texas across the political spectrum,” he said. “We are unified that this is a good move and are trying to encourage the legislature to move in this direction.”
“What it takes is 76 votes in the House, and a majority in the Senate to pass it. And we need it desperately,” commented Klick.
Yet there remains uncertainty whether other lawmakers during the 86th Legislative Session will see the issue as a priority. Dunkelberg commented, “I think that everyone’s concern going into the 86th is to what extent we see a repeat from the 85th which was there was so much rancor between the two chambers – not even partisan rancor but just House versus Senate.”
“You felt like you could have the bill for motherhood and apple pie and if it came out of the House you still might not get a Senate hearing. So I think that that’s affecting many issues and finding an issue that that will not touch going into the 86th is a challenge for all of us.”
Photo: Dan Finch of the Texas Medical Association and House Representative Stephanie Klick