The recent passage of the Affordable Care Act (ACA) and the effort to provide healthcare for every American is expected to create a large influx of citizens seeking primary care providers. The current demand for primary care services has already burdened most states with a projection of more than 16 million individuals gaining health coverage by 2016, with a projection in Texas of more than 4.2 million (Schiff, 2012).
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Advanced practice registered nurses (APRNs) possess the training, experience and expertise in providing primary care services and can be part of the solution in solving shortages, but face unnecessary restrictions in Texas. Advanced Practice Registered Nurses (APRNs) are nurses possessing masters, post-masters or doctoral level education. An APRN holds national certification and in Texas is licensed by the state Board of Nursing (BON) (CNAP, 2013). A wealth of evidence suggests that APRNs have the skills and expertise to perform many of the primary care services that physicians perform with an equal or higher patient satisfaction rate (Humphries, 2007). The Institute of Medicine (IOM) has criticized states laws that prevented APRNs from practicing to the full extent of their training (2011). Therefore, removing these restrictions, will permit APRNs in Texas is a practical solution to help meet this shortage. In addition, APRNs will also enhance health delivery efficiency and provide economic benefit as well for Texas by creating nearly 100,000 permanent jobs for the state of Texas (Perryman, 2013). Action needs to be taken to remove restrictions that are preventing or delaying APRNs from caring for Texans.
As the population of Texas grows, this problem will only be compounded to a system that is already inadequate and overloaded. The laws and regulations concerning APRNs scope of practice varies by state, with 16 states permitting full practice authority, without physician oversight. This permits APRNs to practice to the full extent of their training. The remaining states (34) require some degree of physician oversight and involvement. States with only minimal restrictions have not reported any increased threat to patient safety (Texas Public Policy Foundation, 2013). Texas is one of the remaining states with a high level of oversight. Recent research indicates that APNs who live in states that allow full practice authority give more care (IOM, 2011). By removing these unnecessary restrictions, more NPs will be able to meet the healthcare needs of Texans.
Texas Public Policy Foundation (2013) reports that of Texas’s 254 counties, only 23 have an adequate number of healthcare professionals to serve their populations. In addition almost 90% of rural Texas counties are considered partially or completely underserved. Twenty-five Texas counties have no physicians at all and it is estimated that 20% of Texans (3.3 million) do not have access to a primary care provider. As the provisions of our national healthcare law go into effect we can expect this to worsen with an anticipated shortage of 44,000 to 46,000 primary care providers nationally by 2025. The severe PCP shortage has also been affected by a shrinking medical school enrollment and a decrease in the number of students choosing primary care as a specialty (Texas Public Policy Foundation, 2013).
Utilizing the expertise of APRNs as for primary care can lead to a more efficient delivery system that will provide significant savings. This would create almost 100,000 new permanent jobs by 2020, increase annual economic output (gross product) by $8 billion, and 16.1 billion in total expenditures within Texas (Perryman, 2013). In addition, this would stimulate the economy with yearly tax receipts of 483.9 million to the state of Texas and $233.2 million to local governments. These projections would be expected to rise each decade. Many studies over the last 40 years have indicated that APRNs are able to provide safe, high quality and low cost primary care to their patients (Perryman, 2013). Studies also indicate that patients report a similar if not better experience when they receive primary care from APRNs vs. physicians, and often at a lower cost (Brown & Grimes, 1992). In a research study of Medicaid patients, the cost- effectiveness of utilizing APRNs was evident as patients received the same high quality of care as physicians, while providing a discount of 8% from physician rates (Perryman, 2013).
Failure to make the necessary changes to our healthcare delivery system in Texas will result in a worsening of the primary care shortage compounded by the provisions of the affordable healthcare law and the influx of newly insured individuals (Schiff, 2012). In addition to restrictions this places on accessibility to primary care services, there is a potential for a rise in the already inflated healthcare costs for services (Perryman, 2013).
Changes in legislation are needed to address the removal of physician oversight restrictions on APRNs and to allow full practice authority in Texas. APRNs possess the training and experience to necessary to provide primary care services to Texas citizens and should be allowed to practice to the full extent of their education and training (IOM, 2011). This is vital and the best practical solution for addressing the healthcare needs of Texans.
Political Environmental Scan
Timing
The Coalition of Nurses in Advanced Practice (CNAP) has been working to improve the recognition, reimbursement, and utilization of APRNs since 1991. Their efforts have accelerated legislative policies for this cause (CNAP, 2013). The most recent legislative action put into effect in November 2013 was SB 406 in which a collaborative agreement was made among APRNs and medical groups. This bill was unanimously passed by both the House and the Senate of the 83rd Texas legislature. The bill expanded the number of APRN’s/PA’s that a physician can supervise, eliminated any limit for medically underserved populations, reduced the number of face-to-face meeting with the physicians, and permitted these to be done via video web conferencing. In addition the new law lifts restrictions on prescriptive authority in regard to site–based restrictions and introduces a Prescriptive Authority Agreement (PAA) (Nelson, 2013). Further clarifications are still needed related to the SB 406, in particular on issues related to contracting problems with certain managed care organizations (CNAP, 2013). It is the ANA’s and CNAP’s position that removing barriers of APRN’s is a vital measure that must be taken to promote universal accessibility of healthcare especially in light of current healthcare reform goals (Hutto, 2013).
The Texas legislature (84th) will meet again in regular session beginning January 2015 for 140 days. The CNAP continues to work on new legislative agenda during the interim. Since the last legislative session addressed these issues, it is unlikely this topic will be a priority for the 84th session. General elections are slated for November 2014, so the exact makeup of the next legislature is unknown, however, the Republican party has had a stronghold on both the Executive branch as well as the Legislative branch for the last decade and is likely to continue (UT Austin, 2009).
Relationships/Reputation
Political relationships have been formed between nursing organizations like the CNAP and Texas legislators and include lobbyists who discuss these important issues. This coalition of advanced nursing organizations includes all statewide APN organizations. Their focus is to expand prescriptive authority, ensure clinical privileging, increasing third party reimbursement, improve the recognition of APN’s, and keep APN’s informed on laws and regulations (CNAP,
The major stakeholders are the organizations and groups that have a vested interest in the issue. APRN’s will most definitely benefit from the elimination of oversight since it will allow them to practice to their full potential. Hospitals, insurers and managed care facilities will also benefit from cost savings and improved quality of patient-centered care. In addition, the taxpayers and the State of Texas will benefit from the decreased healthcare costs and increased economic output (Perryman, 2012). The stakeholders with opposing viewpoints include the AMA, Texas Medical Association (TMA), Texas Academy of Family Physicians, American Society of Anesthesiologists, and American Academy of Pediatricians. These groups will most likely continue to resist changes that they feel infringe on their scope of practice and will be reluctant to agree to the removal of barriers that restrict APRNs from practicing to their full potential (CNAP, 2013).
Resources
Much research has been done to support this issue and according to the CNAP, there is no evidence that patient outcomes in states that mandate physician delegation are better than in states where APRNs are allowed to practice independently (CNAP, 2013). In a review of literature by Brady (2000), comparisons were made regarding the performance of nurse practitioners and physicians on three key patient outcome measures: patient satisfaction, health status, and service utilization. Researchers investigated the primary care given by NPs using the traditional medical model and found no difference in effectiveness or quality when compared to that of physicians (Brady, 2000).
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To support advancement of this issue, several other organizations are also lobbying for these proposed changes. These include organizations like the ANA and the Veterans Administration (VA), who are pushing for policy changes. The VA has in fact revised its nursing handbook, allowing APRNs to practice as independent practitioners throughout the Veteran’s Health Administration system, even in states where laws require physician oversight (ANA, 2014). The ANA has supported this change within the VA system, since the change is congruent with the 2010 Institute of Medicine’s recommendation that nurses should practice to the full extent of their education and training (ANA, 2014). On the state level, the TNA supports the elimination of MD oversight of APRNs as well. According to the TNA, removal of practice barriers for APRNs will alleviate the shortage of primary care providers, especially in rural areas (TNA, 2014).
Communication
Several media platforms can be utilized to creating public awareness of an APRN’s role and as a viable option for primary care. These can be used to increase public awareness and gain support for the removal of the practice restrictions currently in place in Texas. An increased public awareness can also assist the policy process by creating grass-roots approaches to this issue. The use of PSA’s via social media sites can encourage the general public to send emails, letters, and support for candidates, nursing organizations and action committees that work to advance the nursing agenda. A media strategy has been proposed to include the following communication tools: 1) a PSA using a PowerPoint delivered via popular media sites like YouTube that can provide public information regarding the need for immediate changes to this health policy issue and can encourage support, 2) a social media approach utilizing a Facebook page for the same intent, and 3) a pamphlet/flyer to be distributed to Texas US Senators and Members of the House, outlining the key talking points and urging support for the policy changes and future legislation on the issue. (See Appendix A for links)
Included in each of the different media strategies, key aspects will be addressed using these talking points:
- What is the role, education and training of an APRN?
- What is the impact of the ACA on the existing shortage of primary care providers in Texas?
- How will allowing full practice authority for APRNs benefit Texas?
The recent passage of the Affordable Care Act (ACA) is expected to create a large influx of citizens seeking primary care providers. The current demand for primary services has already burdened most states with a projection of more than 16 million individuals gaining health coverage by 2016, with projections in Texas of more than 4.2 million.
Advanced practice nurses (APRN) possess the training, experience, and expertise in providing primary care services. The Institute of Medicine has urged states, like Texas, to change laws that place unnecessary restrictions on APRNs, as part of a solution to these shortages. Removing these restrictions will allow APRNs to be more fully utilized in Texas to serve the healthcare needs of Texans.
As the population of Texas grows, the efficiency of a healthcare system that is already inadequate and overloaded will worsen. Reports indicate that of Texas’s 254 counties, only 23 have an adequate number of healthcare professionals to serve their populations. Nearly 90% of rural Texas counties are considered partially or completely underserved. Furthermore, 20% of Texans (3.3 million) do not have access to a primary care provider. As the provisions of our national healthcare law go into effect we can expect this to worsen with an anticipated shortage of 44,000 to 46,000 primary care providers by 2025. The severe physician shortage has also been affected by a shrinking medical school enrollment and fewer opting for a primary care specialty.
APRNs can enhance health delivery efficiency and provide economic benefit by creating nearly 100,000 permanent jobs by 2020, increase annual economic output (gross product) by $8 billion, and 16.1 billion in total expenditures within Texas. This would also stimulate the economy with yearly tax receipts of 483.9 million to the state of Texas and $233.2 million to local governments by 2020, with projections continuing to rise every decade. A large number of studies indicate that patients have similar if not better experience when they receive primary care from APRNs vs. physicians and often at a lower cost.
In the US, 33 states grant APRNs the freedom to diagnose and prescribe, 11 without physician collaboration. Failure to make changes in Texas will result in a worsening of the primary care shortage, compounded by the influx of newly insured individuals. In addition, there is a potential for an increase in the already inflated healthcare costs for services.
Please support legislation that addresses the removal of physician oversight restrictions on APRNs currently in place in Texas. APRNs possess the training and experience necessary to provide primary care services to Texas citizens and should be allowed to practice to the full extent of their education and training. This is vital and the best practical solution for addressing the healthcare needs of Texans.
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