TMA’s Top Legislative Priorities: Guarding Against Scope of Practice Expansion
By Phil West

Priority: Protect patient safety and address health care workforce shortages in a way that ensures patients have access to physician-led care no matter where they live.  

Background: It’s not unusual for Lubbock pediatrician Celeste Caballero, MD, to see patients who’ve traveled to her clinic from rural areas surrounding the Hub City frustrated by prior, sometimes costly, episodes with nurse practitioners.  

In one case, a fourth-year medical student working with the associate professor at Texas Tech University Health Sciences Center School of Medicine assessed a patient and knew instantly what the issue was, leading to successful treatment.  

“It was amazing to me that a fourth-year medical student could [find solutions] that multiple nurse practitioners could not make,” Dr. Cabellero recalled.  

Her story echoes testimony the Texas Medical Association presented before a Texas Senate committee this past September, where TMA demonstrated, with a body of supporting research, that physician-led health care is essential to quality care, patient safety, and lower health care costs.  

TMA’s Chief Lobbyist Clayton Stewart expects numerous scope-of-practice bills to be filed in the upcoming legislative session that propose authorizing nonphysicians – including nurse practitioners, midwives, physical therapists, and pharmacists – to independently treat and prescribe to patients. TMA succeeded in warding off 140 scope bills during the 2023 legislative session.  

Legislative proposals to expand the scope of nonphysicians have come to the fore for lawmakers this session largely because of Texas’ nation-leading population growth and related access-to-care concerns, particularly in rural and medically underserved areas, Mr. Stewart says.  

“Nurses and others have put forth such expansions as a no-cost way to increase access to health care,” he said, a myth TMA has worked hard to debunk.  

Another myth: “When you look at data on where nurse practitioners and midlevels tend to work, they don’t tend to distribute themselves according to the population,” said Rodney Young, MD, chair of the Department of Family and Community Medicine at the Texas Tech University Health Sciences Center at Amarillo. “It’s not that you won’t find them in rural areas, but you won’t find them there in big numbers. There are 27 other states (plus the District of Columbia) that currently allow nurse practitioners to practice without supervision agreements, and their problems are not solved in this regard.”  

While nonphysicians are important members of the health care team, physicians are uniquely qualified to lead that team, says TMA President G. Ray Callas, MD, who testified as much to the Senate committee.  

“Physicians complete four years of college, four years of medical school, and three to nine years of residency,” Dr. Callas said. “The amount of education, especially hands-on clinical care education a physician has, does not even begin to compare to a nurse practitioner’s education.”  

Solutions: This session, TMA will again guard against expected scope creep attempts and any proposals that compromise patient safety, while monitoring and working toward solutions aimed at maximizing the physician workforce to expand access to care in Texas, including: 

• Increasing funding for graduate medical education;  

• Increasing Texas Medical Board funding to more expeditiously license physicians moving to Texas from other states; 

• Expanding telemedicine by enacting payment parity with in-person services; and  

• Investing in loan repayment programs and rural training program expansion.   

Dr. Caballero is proof such initiatives are working. Before moving to Lubbock, she lived in San Angelo on a four-year loan repayment contract and planted roots for eight years after she “fell in love with the medicine” there. 

“Those programs are the building blocks, and ... we’re going to continue to advocate for them,” said Michelle Romero, TMA associate vice president of public affairs. She added that a recently created TMA task force will generate additional strategies around access.  

TMA leaders say Texas is rising to the access-to-care challenge by recruiting and licensing historic numbers of physicians, and investing in what works will help the state meet its health care needs.  

Among physicians and lawmakers, “there’s a genuine want to find a solution, and the default does not have to be scope of practice [expansion] if we can bring something else forward,” Mr. Stewart said. “There is interest in everything we’re doing to build the pipeline.”