Medical Authority Bills Spark More Doc Fights

Every two years, it seems, lawmakers are asked to recalibrate a few delicate balances between groups of health professionals trying to keep others from encroaching into their business. More than a dozen bills this year — some moving, some apparently stuck — would give professionals like nurse practitioners and physical therapists more autonomy to operate independently from medical doctors.

Others would expand the range of medical professionals like optometrists, allowing them to prescribe painkillers, or create new classes of non-doctor medical professionals, like dental hygiene practitioners.

Proponents of legislation expanding so-called scope of practice — generally widening the number of people who can perform routine tasks — say it would help alleviate the state’s doctor shortage and note that many of the bills have bipartisan co-authors. 

“Scope-of-practice bills as a policy matter is something that some conservatives and some liberals can make common cause about because, on the one hand, it increases access to care, which liberals like, and on the other hand, it can lower the cost of care and remove barriers to entry, which conservatives like,” said John Davidson, a health care policy analyst at the Texas Public Policy Foundation, a conservative think tank. “It’s an opportunity for both sides to work together.” 

But opponents of these kinds of bills — especially the Texas Medical Association, which represents doctors, and the Texas Dental Association, which represents dentists — say they jeopardize patient safety by placing too much trust in people who lack the necessary medical training.

Here’s a rundown of the biggest “doc fights” taking place in the Legislature this year. 

Doctors vs. Nurse Practitioners

Nurse practitioners in Texas have long fought against state regulations that link them financially and professionally to supervising physicians, a construct they say ties their hands and limits their ability to treat patients in a state with a looming shortage of primary care physicians. Texas lawmakers loosened some supervision requirements during the last legislative session following a compromise with physician groups, which argue that nurse practitioners do not have the training or experience to be entirely independent.

But nurse practitioners say that compromise didn’t go far enough. They have praised two bills filed this session — Senate Bill 751, co-authored by José Rodríguez, D-El Paso, and Konni Burton, R-Colleyville, and its companion, House Bill 1885, by Cecil Bell, R-Magnolia — which would allow them more freedom to diagnose and treat patients without a supervising doctor. Neither bill has been heard in committee. 

“Texas’ current requirement for mandated agreements cost advanced practice registered nurses and consumers money without any benefit to patient safety or health care access,” Rachelle Campbell, an advanced practice registered nurse, said in a statement last month about SB 751.

Doctors, meanwhile, say they think the current system is working fine.

“Advanced practices nurses and physician assistants are very integral parts of our medical teams, but we feel that those teams should be led and overseen by your best-trained, most qualified folks, and that’s the physician,” said Gary Floyd, a Fort Worth pediatrician and a member of the Texas Medical Association’s board of trustees. “That’s why we went to medical school.”

Eye Doctor Drama: Optometrists vs. Ophthalmologists

A new battle between optometrists, who provide primary vision care, and ophthalmologists, medical doctors licensed to practice eye medicine and surgery, has emerged this session.

Optometrists would like greater authority to prescribe painkillers like hydrocodone for short time period, and to treat glaucoma — a group of diseases that damage the eye’s optic nerve and cause blindness — independently of ophthalmologists. Senate Bill 577 by Charles Perry, R-Lubbock, and House Bill 1420 would loosen those restrictions.

“Optometrists take care of 70 percent of eye care in the state of Texas,” said Thomas Lucas, president of the Texas Optometric Association. The current regulations, he said, are “most onerous for patients, and that’s why we’re introducing the legislation.”

Ophthalmologists see it differently.

Determining if there is something wrong with a person’s optic nerve “takes a lot of training, like an incredible amount of training,” said Jane Edmond, an ophthalmologist in Houston. “I see patients with brain tumors and blindness or impending blindness that were managed by optometrists that were inappropriately managed.”

Optometrists should not be able to prescribe hydrocodone, Edmond said, because it is highly addictive and could cause pain arising from a more serious condition to go undiagnosed.

The Dentist Dilemma

Senate Bill 787 and House Bill 1940, by Senfronia Thompson, D-Houston, would create a new classification in the occupations code for “dental hygiene practitioners” — a profession that exists in some other states to provide primary oral health care without having gone to dental school.

The bills were endorsed by the Texas Public Policy Foundation as a “free-market solution that improves access to dental care, creates middle-class jobs and reduces health care costs.” Twenty percent of Texas counties have no dentists and 12 percent have only one dentist, and roughly a third of Texas counties have no dentists participating in Medicaid, according to the conservative think tank.

The Texas Dental Association opposes the bills.

“The data does not support the need for a new, lesser educated and trained oral health care provider that will remove the dentist from the patient,” said Richard Black, testifying on behalf of the association against HB 1940. “The data supports the need for 354 dentists in the right areas of our state. Let’s work together to make that a reality.”

Disclosure: The Texas Medical Association, Texas Public Policy Foundation and Texas Dental Association are corporate sponsors of The Texas Tribune. A complete list of Tribune donors and sponsors can be viewed here. 

This story was produced in partnership with Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.