Moving Time for Nurses Who Don’t Need Doctors

(Texas Tribune) 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.

The clinic’s owners, Christina Blanco, left, and Marila Taylor, are advanced practice nurses.

“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 midlevel health care practitioners like advanced practice nurses and physician assistants. The changes have cut operating costs and improved work flow in nurse-managed clinics like Ms. Jeffrey’s. But some nurse practitioners argue that lawmakers should have allowed them to practice independently, saying they could fill a need for primary care. 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 trying to run an independent practice, Ms. Blanco became fed up with Texas’ laws. Most physicians she consulted about supervising her practice requested 25 percent of the profits or $5,000 to $10,000 a month in payment, she said.

“Finally, we were like, why are we trying so hard in Texas? We could just drive 20 minutes to Las Cruces, N.M.,” she said.

Gov. Susana Martinez of New Mexico announced in November that she planned to push for a $220,000 nurse practitioner recruitment campaign. New Mexico is among the 17 states, along with the District of Columbia, that 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.

Gary Floyd, the chief medical officer of the J.P.S. hospital network in Tarrant County and an adviser to the Texas Medical Association’s council on legislation, said Texas’ law provides needed support to midlevel practitioners because physicians have more training and experience and can help the practitioners when needed.

“The spirit of our supervision is that they’re never left out on a limb,” Dr. Floyd said. (The Texas Medical Association is a corporate sponsor of The Texas Tribune.)

Despite claims by physician groups that doctor supervision improves patient safety and lowers operating costs, multiple studies have shown that 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 that advanced practice nurses and primary care physicians used similar amounts 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 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 that allowing independent practice nurses would not necessarily shore up access to care in rural areas, because physicians and nurses are equally unlikely to practice in rural settings.

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