Wave after wave of white coats took to the microphone during a lengthy and intense hearing on a nurse scope bill, deflecting and derailing claims that such expansion is the magical, no-cost answer to solving Texas’ rural access-to-care shortages.
More than 30 Texas Medical Association physicians from across the state made the trek to the Capitol to testify in person early Monday, April 14, that House Bill 3794 would dismantle Texas’ longstanding physician-led care model and with it, patient safety. In addition, more than 100 physicians responded to TMA’s related action alert and testified online.
Joined in opposition with colleagues from emergency, anesthesia, pediatric, and other medical specialty societies, TMA began mobilizing late last week and through the weekend after the last-minute addition of the bill to the House Public Health Committee’s schedule on Thursday, April 10.
TMA was instrumental in establishing Texas’ current physician-led team-based care model dating back to 2013. That law, Senate Bill 406, afforded physicians and nurses the flexibility to collaborate without the prior site-based restrictions, and with a framework for supervision and prescriptive delegation by physicians that includes regular check-ins for quality assurance.
Leading off a cascade of physician testimony during the all-day hearing, TMA Board Trustee and Amarillo family physician Rodney Young, MD, told committee members access to care does not have to come at the cost of quality: “Texas’ physician-led team-based care models promote oversight and collaboration while keeping patient safety the priority.”
HB 3794, however, does away with that safeguard to give advanced practice registered nurses (APRNs) full authority to practice independently. The bill does so by expanding the definition of “nursing” for APRNs – which includes nurse practitioners (NPs), nurse midwives, nurse anesthetists, and clinical nurse specialists – to include diagnosing and prescribing therapeutic interventions – in other words, practicing medicine, Dr. Young said.
TMA has “always contended that APRNs are important members of the physician-led health care team. But removing physicians from that critical leadership role and allowing APRNs to effectively practice medicine – by formulating primary and differential medical diagnoses and prescribing independently as is proposed in this bill – will not improve patient access to care,” he testified.
Priority: Access and quality
Crested with white coats, the room was packed with representatives from medicine, nursing, academia, and patient advocates. The hearing was reminiscent of a similarly intense hearing in September 2024 during the legislative interim and a prime example of why stopping unsafe scope expansions is TMA’s number one priority this legislative session. As of this writing, all but one scope bill on TMA’s radar have been bottled up in committee thanks to tireless TMA advocacy that shined during Monday’s hearing.
Lawmakers again made clear during the hearing that they are eager to solve the state’s shortages, especially in rural and underserved areas.
Bill sponsor Drew Darby (R-San Angelo) characterized HB 3794 as a “reform” that would align Texas with 27 other states that allow independent APRN practice, all of which he said rank better than Texas in rural access.
HB 3794, if passed, would give APRNs full practice authority to:
- Formulate primary and differential medical diagnoses;
- Order and interpret medical tests;
- Prescribe therapies, devices, and medications, including controlled substances in Schedules II through V;
- Treat “actual and potential health problems;” and
- Serve as a patient’s primary care provider of record.
The Texas Board of Nursing would handle complaints and disciplinary actions. HB 3794 also allows APRNs to be counted toward certain health plans’ network adequacy standards.
Nurses – who also made a big showing at the hearing with support from some business and hospital groups – disagree the bill expands their scope. Instead, they say it removes outdated regulatory barriers and releases them from costly delegation agreements that hinder them from practicing as they are already trained to do, often (they claim) with minimal physician supervision.
“If that were the case, then we would have seen an increase [in rural APRN practice] from SB 406,” Dr. Young testified, after the law relaxed requirements physicians and nurses practice together on-site to increase access to care. “In fact, we haven’t,” he noted, despite Texas Department of State Health Services data showing an oversupply of nurses.
“It is a myth that allowing APRNs to practice without physician involvement will increase access to care in rural and underserved areas,” he said, highlighting American Medical Association research on the maldistribution of nurses, who tend to practice in the same areas as physicians, regardless of scope-of-practice laws.
Amid lawmakers’ keen interest in data, TMA Council on Legislation Chair Zeke Silva, MD, elaborated with additional studies within the Hattiesburg Clinic in Mississippi and Department of Veterans Affairs showing NPs who function independently prescribe more, order more tests, have higher referral and hospitalization rates, and perform worse on quality measures than physicians – all of which can lead to greater patient safety risks and health care costs.
“We share the common goal of increasing quality care, but it’s worth looking at the studies to inform that decision,” Dr. Silva told the house committee. “If this bill passed, no longer do you have that [overseeing] physician available. That safety net is no longer there by definition.”
On the other hand, scope researcher and Ft. Myers, Fla., family physician Rebekah Bernard, MD, pointed to an absence of large-scale published data showing the safety and efficacy of nurse practitioners, adding that most nursing education programs nowadays are completely online with little in-person clinical training.
In Florida, which in 2019 allowed for nurse independent practice just in primary care, “what we are actually seeing is the loss of access,” as 60% of those nurses flock away from rural areas to more lucrative med spas, testified Dr. Bernard, author of Imposter Doctors: Patients at Risk.
Multiple physicians highlighted the vast differences between nurse and physician training, which, they noted – with its 10-plus years of medical school, residencies, and fellowships – is on the order of 20 times the clinical training of nurses.
Even at the top of his class, fourth-year medical student John Michael Austin attested he does not yet feel comfortable making complex medical decisions on his own. After tallying 11,500 hours of rigorous, high-caliber training, “I am number one in my class of 220 and I do not feel ready to take care of patients by myself.”
Better solutions
Physicians also took wind out of nurses’ argument they are minimally supervised despite burdensome delegation agreements that require quality check-ins. Doctors shared their personal stories of themselves having to consult colleagues on complicated cases and making or changing diagnoses in a short period of time.
That’s on top of daily supervision and communication with NPs reviewing cases, whether in a busy academic medical center as Dr. Young said he does while overseeing medical and nursing students at the Texas Tech University Health Sciences Center School of Medicine, or in an overrun pediatric emergency department, as Melissa Garretson, MD, explained.
“I’m not a phantom,” the Fort Wort pediatric emergency medicine specialist said, adding that she, too, has lost three NPs over the past few years to specialty care, not primary care, despite a lack of specialty training. If HB 3794 were a simple solution, then the 27 other states with independent nurse practice “would not have rural access problems.”
Similarly, Temple internist Jimmy Widmer, MD, emphasized that regular synchronous and asynchronous communication between physicians and nurses in his primary care practice is routine. The law’s once-a-month periodic meeting requirement for prescriptive authority delegation agreements is “let me be clear … a minimum,” he testified, buttressed by consultation and referral plans that also must be included in that agreement.
“Under the law’s current framework, a physician is involved before, during, and after care is provided by an APRN,” he said. By contrast, allowing nurses to practice independently with the minimal training they possess would create “two standards of care” in Texas, he said, when rural patients deserve the same level of care regardless of where they live.
A rural allergist and immunologist in Odessa, Vivek Rao, MD, testified he’s witnessed those differing standards. “I see the effects of removing physicians from the health care team” caring for misdiagnosed asthma patients he’s seen come across the New Mexico border, where nurse independent practice is allowed.
He also disputed the notion that some care is better than no care, especially in rural areas where patients do not always seek out timely treatment and may experience delayed complications. “In rural areas, we actually need to have a higher standard, I would say.”
But TMA physicians did not show up empty-handed, rather armed with robust solutions to Texas’ access challenges.
TMA President G. Ray Callas, MD, further discredited nurses’ arguments claiming that expensive delegation agreements are a major access-to-care barrier. He refuted those claims, pointing to 2019 National Journal of Nursing Regulation survey in supervisory states reporting 80% of nurse practitioners paid zero fees for physician supervision of their patient care; 14.4% said their employers paid the physician oversight fee; and only 5.6% reported paying for physician oversight fees, which average about $500 a month.
If removing such fees was a path the legislature wanted to take, he proffered to the committee, the legislature could enable the Texas Medical Board to retain physicians to provide state-regulated delegation and supervision of advanced practice registered nurses in rural and underserved areas.
“All Texas patients deserve that kind of [physician-led] health care,” Dr. Callas said. “It’s the right thing to do.”
Dr. Young also stressed during the hearing other pathways the legislature already is working on to improve access to care, including the TMA-initiated Rural Resident Physician Grant Program that finally received funding last session. He also urged the state to continue to prioritize funding for:
- Graduate medical education, or residency, programs, so Texas is prepared for the increased number of graduates coming from the new medical schools in the state;
- Programs that incentivize and support physicians going into primary care and practicing in underserved areas, such as the Family Practice Residency Program and the Physician Education Loan Repayment Program; and
- Expanded access to physician-led services by enacting telemedicine payment parity.
While united in their resolve to solve the state’s rural access-to-care crisis, lawmakers appeared divided on whether this bill was the right solution.
Still others like Rep. Jolanda Jones (D-Houston) expressed hesitancy with the inadequacy of nurse training to provide the same standard of care as physicians do, given, for instance, the online nature of most nurse training programs.
Rep. Katrina Pierson (R-Rockwall) found it equally “concerning” HB 3749 was asking “the state to lower its standards. … If we do this, why have doctors?”
“Thank you for reminding us of the care team,” Rep. Nicole Collier (D-Fort Worth) also told one of the physician panels. “It’s not just one, but the whole collective effort.”