Nurses Seek to Fill Primary Care Gap

Ilana Panich-Linsman for AARP

By Thomas Korosec

When Elizabeth Ellis, a nurse practitioner, opened the B.I.S. Community Clinic last year, she became the first primary care provider based in the small town of Bedias in more than 80 years. “Rural health is why I became a nurse practitioner,” said Ellis, 53.

During flu season this past winter, she saw about 160 patients a month—most either under 15 or older than 50, and mostly from rural Grimes County (pop. 26,000).

Advanced practice registered nurses (APRNs) like Ellis are knowledgeable about primary and preventive care and are recognized under Texas law for their extensive training. APRNs are trained to diagnose and treat patients for specific medical needs, including annual physicals, immunizations and illnesses such as the flu.

But state law prohibits APRNs from prescribing medication unless they enter into an often costly contract with a physician, who delegates prescriptive authority and periodically reviews the nurse’s charts.

Ellis, who has been practicing for 23 years, says the mandate is not needed and the fees she pays for physician oversight—a total of $800 a month—could better be used to support her clinic.

Proposals to end that rule, which failed in the Legislature’s 2017 session, are supported by AARP Texas and 20 other organizations across the political spectrum, including business groups, rural hospitals and think tanks.

“There’s too much need that our medical system can’t fill. There have to be other options,” said Blake Hutson, associate state director of AARP Texas. He points out that 22 states, including New Mexico and most other Western states, allow full practice authority for nurse practitioners.

Increasing access to care
Deane Waldman, director of the Center for Health Care Policy at the Texas Public Policy Foundation, a conservative think tank, said: “We think releasing our APRNs from this requirement will increase access to care for those who have trouble getting care or can’t get care at all. We don’t think it will have a negative fiscal impact on doctors.”

Doctors’ groups have opposed giving APRNs more independence, a position they say is based on concern for patient safety.

“Nurses simply do not know what they do not know. There are limitations built in to their training,” Don Read, M.D., then-president of the Texas Medical Association, wrote in a piece last year on the group’s website.

APRNs are not “physician substitutes” because doctors complete far more clinical training, he added.

But Waldman, a retired pediatric cardiologist, said “hard scientific evidence” in more than 100 medical and nursing journal articles demonstrates that APRNs practice very safely and patients do well under their care. “The safety argument just doesn’t hold water,” he says.

Millions of rural and inner-city residents lack care because doctors aren’t practicing in those areas or will not accept Medicaid insurance, Waldman said. “Releasing nurses to practice independently will only help patients.”

Ellis agrees. Among the largely older population she serves, “a lot of them have not received health care in a long time, or they get it sporadically. There are a lot of chronic health conditions and poor health conditions.

“As big as Texas is, as big as our health care needs are, we need to get with the future,” she added.

Thomas Korosec is a writer living in Dallas.