Expanding Access to High-Quality Healthcare using Advanced Pract

Texas needs to develop a more efficient regulatory model when it comes to Advanced Practice Registered Nurses (APRNs). Currently, Texas law grants APRNs prescriptive authority under a site-based model first enacted in 1989 that included sites serving medically underserved populations. In the decades since, amendments added physician primary practice sites, then facility based practices and, finally, alternate practice sites. Each site has its own set of restrictions – for some sites it is the number of APRN FTEs, for others it is the geographical distance from the physician, number of hours open, number of charts that must be reviewed, where the charts must be reviewed, etc., etc. The result is a hopelessly complex model with multiple restrictions which have little to do with quality of care and actually reduce access to care, e.g., the time a physician spends traveling from site to site to provide on-site supervision is time not spent seeing patients; the APRN who wants to practice in an underserved area must find a physician in that area willing to comply with the numerous restrictions required.

Texas cannot maintain the current site-based model and expect APRNs to effectively contribute to Texas’ need for more providers – particularly primary care providers. Current Texas law allows a medical doctor to “oversee” up to 4 APRNs as long as the doctor’s primary practice is within a 75-mile radius and a retrospective review of a random 10% of the APRNs patient charts is completed each month. Does this sound like supervision? APRNs are free to work independently up to 90% of the time but required to have an agreement that takes a physician out of the office reducing patient load. In addition, the APRN must pay an exorbitant fee not reflective of the service the physicians provide. These physicians do not see the patients in the APRN’s practice nor do they oversee any aspect of that APRN’s practice.

These restrictions do nothing but increase cost for the state and for patients, limits patient choice, and prevents the full deployment of APRNs into the healthcare workforce.


Submitted by

Stage: Active

Feedback Score

112 votes
114 up votes
2 down votes
Voting Disabled

Idea Details

Vote Activity (latest 20 votes)

  1. Upvoted
  2. Upvoted
  3. Upvoted
  4. Downvoted
  5. Upvoted
  6. Upvoted
  7. Upvoted
  8. Upvoted
  9. Upvoted
  10. Downvoted
  11. Upvoted
  12. Upvoted
  13. Upvoted
  14. Upvoted
  15. Upvoted
  16. Upvoted
  17. Upvoted
  18. Upvoted
  19. Upvoted
  20. Upvoted
(latest 20 votes)

Similar Ideas [ 4 ]


  1. The idea was posted


  1. Comment
    Jeremy B. Mazur
    ( Pinned Moderator )

    How would this recommendation amend statute? It would be useful to know how the relevant statutes would need to be amended in order to implement this idea. Suggested bill drafts may be uploaded and discussed if needed.

  2. Comment
    ( Pinned Moderator )

    As a follow-up to the previous moderator comment, the Terms and Conditions of Use for the Texas Red Tape Challenge specify that this site is not an opinion blog or poll. The purpose of the Red Tape Challenge is to identify specific solutions, including amendments to the applicable statutes, for the Committee's consideration. While it is certainly useful to describe the problems that these changes may remedy, it is also important to describe, and collaborate on, a solution.

  3. Comment

    Outdated laws and an ongoing turf battle led by TMA seek to continue prohibiting nurse practitioners from serving as equal partners and to the full extent of education and certification. No one genuinely believes we have the capacity or resources necessary to educate and train enough physicians to cover our current shortfall, much less the addition of an ever-expanding population.

    Peer-reviewed research throughout the past 4 decades, show that NPs provide low-cost and high-quality primary care whose patient outcomes and satisfaction is at least on par with and sometimes exceeding that of a physician. Physicians want to solve the problem with adding more costs to the taxpayers while nurse practitioners want to solve the problem by lowering costs. TMA says that our system must change. Again, you are absolutely correct. But, nothing will change if we continue to limit the abilities and effectiveness of all providers. It is time for the physician organizations to work with their APRN colleagues to create a better situation for our citizens.

  4. Comment

    Texas, like other states around the nation is facing challenges to ensure patients have appropriate access to care. As a result, many states are modernizing regulations to reflect the expertise and skill of the existing nurse practitioner workforce and remove bureaucratic and competitive barriers that artificially impede care delivery. Statutory and regulatory modernization for nurse practitioner licensure is endorsed by multiple organizations including the Institute of Medicine, National Council of State Boards and the AARP. Underpinning this modernization are nearly fifty years of patient outcomes research showing nurse practitioners to be highly effective providers of health care. The professional regulatory body (Board of Nursing) should determine the licensure requirements and activities of practice that an individual licensee is allowed to provide, not another team-member--especially one from another discipline.

    Fifty years of studies have consistently demonstrated that nurse practitioners provide high quality, cost effective care to patients of all ages. It is crucial that licensure and regulation reflect the education, skill and expertise of clinicians to safely meet Texan’s growing healthcare needs. Texas legislature needs to remove these barriers as 18 states and District of Columbia have already done. A collaborative agreement model is being proposed. A collaborative agreement model requires that the Advanced Practice Nurse be credentialed by the Texas Board of Nursing to prescribe medications (already in place) and have a collaborative prescriptive authority agreement with a physician or physician group for consultation or referral services as needed. Doing so would improve access to health care for Texans; improve health care efficiencies while leading to significant health care savings for the State of Texas (AANP, 2012; Perryman Report, 2012).


  5. Comment

    Texas should the access to healthcare with the incorporation of NP. The abiltiy of a NP to perform at his or her scope of practice will improve the access to healthcare that patients require. It will decrease over use of ER.

  6. Comment

    The proposed model modernizes Texas legislation hopefully increasing access to care and still leaving safeguards for public safety. It is vital to the Texas economy to develop a proposal that allows greater access to care while providing for the public safety. Numerous studies indicate NPs provide safe care at a cost savings; check other states and with the federal government. Most of the elements TMA complaints about, liabiltiy, responsibility and cumbersome agreements that are time consuming are created by the legislation. Whether one reviews the Perryman report, Robert Wood Johnson Foundation, AANP or state board the research continues to bare out; NP can provide quality healthcare to the healthcare consumer, they are educated to a care for. Million of $$$ in federal funds to the underserved area are at risk of going to other states that allow NPs to practice with more security. I do no want to watch these dollars go to citizens of Oklahoma, New Mexico, Louisana, Arkansas, etc, because of Texas outdated antiquated legislation. NPs are only asking to perform within the boundaries of there education, experience and proven certification.

  7. Comment

    Texas is an anti-regulation state. This is a regulatory issue. Texans celebrate the free marketplace - let the marketplace decide.

    35 states and DC allow NPs to diagnose and prescribe under regulation of the nursing board.

    18 states, plus DC allow NPs to practice without physician involvement.

    Only Texas requires onsite physician involvement.

    13% of Texans do not have access to healthcare.

    Texas ranks 47th in the ratio of primary care physicians per 100,000 population.

    Texas ranks 42nd in the ratio of physicians per 100,000.

    Consumers should have the option to choose care provided by an NP. The above comments provide objective data from reliable sources surrounding the safety and quality of NP care.

  8. Comment

    I work in El Paso and have been trying to start my own practice for nurse practitioners who provide care to the poor and underserved areas. One of my problems is finding a physician who will support me. The first physician who agreed to be my delegating physician wanted to charge me every hour of the day. The second physician wanted 25% of everything I collect, the third physician had everything billed under his name and never paid me. Right now I am without a physician, unable to work in the state of Texas without a physician stating I can work. I am in the process of finding a new doctor developing a business proposal that we can all agree on, which will not put me out of business. The unfortunate part is El Paso is in need of providers. I have considered moving my practice 15 minutes away to New Mexico where I do not require a physician delegation. As a Texan I want to provide care to my people, however the legislation is making close to impossible for me to continue to have my business in Texas. I hope legislatures realize that nurse practitioners are leaving Texas to practice in areas that have less restrictions.

    Comments on this comment

    1. Comment

      I'm shocked and disgusted at how unethical these physicians are who claim to care about patients, yet only care about the $$$$ in their back account. These are the kinds of stories that need to be told to the FTC in Washington, D.C. again and again. They need to put an end to these ridiculous restraint of trade practices that only hurt patients and benefit doctor's bank accounts.

  9. Comment

    If the State of Texas really cares for its citizens then it will do what is best for them. How can lack of access to care, complicated by multiple regulations improve access? The reason I became an advanced practice nurse is because I care about my patients and want them to have the care that they need. Unfortunately, it is difficult to achieve this goal with the TMA wanting to control our profession. If there was not money involved the TMA would not be interested and not care about this issue

  10. Comment

    As an APRN/CRNA, the focus should be to educate legislators there are currently 18 states, plus DC allowing APRNs to practice without physician involvement. The data of quality of care of APRNs from these locations must be highlighted. When Texas ranks lowest on so many areas of healthcare, our State is in a healthcare crisis. There is an easy answer when politics is placed to the side.

    Comments on this comment

    1. Comment

      CRNAs do not need anesthesiologists. Most of them "oversee" or "supervise" only (from the call room, or the break room, or home). They then pay the CRNA a salary and pocket the rest of the money the CRNA earns. Sounds like the government doesn't it ???

  11. Comment

    In response to Mr. Mazur and Mathers agreed, and starting with a simplistic answer; some solutions are in correcting duplication. In the process of testing, obtaining credentials,being recognized by the Board of Nursing, getting DPS certification, going online and filling out your information to DPS then the supervising physician must log in and sign his/her name to you application and approve and submit his information. The supervising physician must make sure he/she has the right number of hours allocated to each NP or site he/she supervises. This very time consuming, then on to DEA application. This process takes literally 4-6 months, that is if your physician is computer savvy, and doesn't forget passwords or accounts and then they jiggle the hours for each NP or for some environemnts the miles. so, streamlining processes which the legislation appears to do cuts cost and possibly of errors. I believe this legislation will also allow for a more direct pathway to solving problems in the relationship and practice of both physician and NP. Today when problems arise, the practices of both are in conflict, and threats of litigation and neglect to patients begin which further the cost to taxpayers and licensing bodies. The new legislation appears to allow a gentler, fairer dissolution of that relationship.

  12. Comment

    It's time to make the provision of health care efficient and cost effective. The studies are in that show this is a viable solution.

  13. Comment

    It seems the statute should be amended to remove the need for physician supervision over the APN's. Patients are free to decide who they want to see for their health care needs and they are not placed in any danger when treated by APN's-as the list of published works demonstrates. Wait times to see healthcare providers continues to rise, especially in rural areas and by removing this supervision requirement, APN's will be able to open practices in under-served areas that will provide much better access to patients. Patients may have to travel many miles to get care that could be provided close to home if APN's were not so limited by the physician supervision rule.

    If the supervision rule can be removed, patients will benefit, access to care will be greater, more quality APN's will choose to work in Texas, and money will be saved by all-except those Doctors who are making money for not working.

  14. Comment

    While I agree patients need access to health care, I do not agree that NPs need autonomy. If they wish to be a doctor than they should apply and go to medical school. If you see a patient and diagnose as well as order tests and prescribe you are practicing medicine, not nursing. Also, so many NPs practice outside of their area of cerification. I do not believe that a lifetime license should be granted and re-certification by EXAM should be performed. Taking classes or weekend party meetings should not count as the only requirment. NPs are just after the same dollar as physicians but without the requirement of education, clinical exposure, residency and proficiency/knowledge proven by exam for certification and renewal.

    Comments on this comment

    1. Comment

      Research, for decades, has shown NPs and physicians have statistically equal abilities to diagnose, order tests and prescribe. Unfortunately, it takes time to educate legislators the quality healthcare NPs provide to the community. If research from the 18 states, which allow complete autonomy from physicians indicated NP were practicing outside of their training, I would agree with you. Fortunately for NPs and their patients, high quality healthcare and safety have been demonstrated. Tim Jones, CRNA, D.N.P.

  15. Comment


    Read the original idea posting where you will see that nurse practitioners are not proposing autonomous practice. The proposal is called a collaborative prescriptive authority model that requires a nurse practitioner to have a collaborative agreement with a physician before exercising prescriptive privileges.

  16. Comment


    NPs are recertified every 5 years. We are required to complete 1,000 practice hours and 150 CEUs, if we don't, then we retake the certification exam (not a watered down version of it). NPs don't practice medicine, we practice ADVANCED NURSING. Multiple studies have proven that one doesn't need all that extra education in order to provide high quality primary care services. As a business owner, I can assure you, my reimbursements are much less than physicians, so I AM saving the system money and providing high quality health care services.

    Furthermore, are you not aware that about half the physicians in this state never completed a residency? However, even after finishing that mandatory 1 year of residency, they can practice in any field they desire. NPs are trained in a specific specialty, i.e. Pediatric NPs treat ages up to 18, Geriatric NPs ages 55 and up, Psych NPs treat pts with psych related illnesses, etc.

    Granting full independence to experienced NPs (and PAs) will most certainly reduce the cost of health care in this country.