Despite Changes, Nurses Push for Independence

As an advanced practice nurse specializing in family medicine, Holly Jeffreys operates the only medical clinics in two rural Texas Panhandle counties. The state requires that she have a contract with a physician to supervise both clinics, but she operates the facilities almost independently.

“It would be easier to work in a practice where you just had to come in and work and take control of everything, just like a business owner,” she said.

In the 2013 legislative session, Texas lawmakers loosened supervision requirements and broadened the drug-prescribing authority for mid-level health care practitioners like advanced practice nurses and physician assistants. The changes have cut operating costs and improved workflow in nurse-managed clinics like Jeffrey’s. But some nurse practitioners argue lawmakers should have allowed them to practice independently, saying they could fill a need for primary care. And with recruitment campaigns by states like New Mexico, which has more lenient laws, some see an incentive to leave the state.

“We don’t have to worry that if a physician backs out, we’re out of a business,” said Christina Blanco, an advanced practice nurse specializing in women’s health who moved her business to New Mexico from El Paso in October. After two years of attempting to run an independent practice, Blanco became fed up with Texas’ laws, as most physicians she consulted to supervise her practice requested 25 percent of her profits — meaning she was paying them anywhere from $5,000 to $10,000 a month.

“Finally we were like, 'Why are we trying so hard in Texas? We could just drive 20 minutes to Las Cruces, New Mexico,'” she said.

New Mexico Gov. Susana Martinez announced in November that she plans to push for a $220,000 nurse practitioner recruitment campaign. New Mexico is among the 17 states that, along with the District of Columbia, allow advanced practice nurses to provide health care without physician supervision. In Texas, practitioners with the same amount of training and experience must have a contract with a supervising physician and be delegated authority by that physician to prescribe Schedule II controlled substances.

Texas’ new law grants mid-level practitioners more autonomy by reducing requirements for face-to-face meetings between the physician and practitioners to once a month for the first year, after which they can meet quarterly with monthly check-ins via the phone or internet. Previously, supervising physicians were required to be on-site every 10 days. While New Mexico also allows advanced practice nurses to prescribe Schedule II controlled substances, Texas’ law only allows advanced nurses who’ve been granted authority by a physician to prescribe those drugs in a hospital-based or hospice care setting.

Gary Floyd, the chief medical officer of Tarrant County’s JPS Health Network and an adviser to the Texas Medical Association’s council on legislation, said Texas’ law provides needed support to mid-level practitioners because physicians have more training and experience and can help the practitioners with something they might not be able to handle.

“The spirit of our supervision is that they’re never left out on a limb,” Floyd said.

Primary care physicians undergo four years of medical school, plus three to four years of residency training, while advanced practice nurses usually spend four years in nursing school and two years in a graduate training program. While physicians have more comprehensive education and can perform surgeries, nurse practitioners only offer clinic-based medicine, and must specialize in a particular field, such as family medicine, geriatrics or women’s health.

Despite claims by physician groups that doctor supervision improves patient safety and lowers operating costs, multiple studies have shown advanced practice nurses and physicians offer comparable primary health care. The most extensive trial study, published in the Journal of the American Medical Association in 2000, found advanced practice nurses and primary care physicians used similar numbers of diagnostic testing and emergency care, and had similar patient outcomes.

Although there are fewer advanced practice nurses than primary care physicians in Texas — 12,000 advanced practice nurses, including 7,000 specializing in family medicine, compared with 18,600 primary care doctors — the supply of nurse practitioners increased 87 percent between 2000 and 2009, while the supply of primary care physicians increased 18 percent.

David Williams, a spokesman for the Texas Nurse Practitioners, said the growing supply of advanced practice nurses could fill Texas’ primary care access gap — if they choose to practice in Texas.

But physician groups argue allowing independent practice would not necessarily shore up access to care in rural areas, as physicians and nurses are equally as unlikely to practice in rural settings. 

“What’s going to fulfill that is more training spots for general practice physicians and nurse practitioners,” said Dr. John Frederick, chief medical officer at Premier Family Physicians in Austin.