tafp 2011 multi state report

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TAFP POLICY WORK Communicating Family Medicine’s Priorities in the 82 nd Texas Legislature

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TAFP's demonstration of "best practices" for the 2011 MultiState focused on the communications tools the Academy offers members in support of its advocacy work in the 82nd Texas Legislature

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Page 1: Tafp 2011 multi state report

TAFPPOLICYWORK

Communicating Family Medicine’s Priorities in the 82nd Texas Legislature

Page 2: Tafp 2011 multi state report

Development of advocacy icon for session, and launched icon in advocacy primer issue of TFP

PReP WORK

Page 3: Tafp 2011 multi state report

Presorted StandardU.S. Postage

PAID Austin, TXPermit No. 1450

D E D I C A T E D T O T H E D E L I V E R Y O F Q U A L I T Y H E A L T H C A R E V O L . 6 1 N O . 3 S U M M E R 2 0 1 0

Report From TAFP Annual Session And Scientific Assembly

PLUS: Nurse Practitioners Fire First Salvos In Campaign For Independent Practice

Texas Medical Schools Rank Low On Social Mission Scale

SPECIAL ISSUE

Grassroots Advocacy For The FAmily DocTor

Your Guide For Success In The 82nd Legislature

20 sUMMER 2010 | TExas FaMily Physic ian

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www.ta fp .o rg | sUMMER 2010 21

GettinG

mad isn’t enouGh

The art of translating ideas into consequences:

How politics drives the process that sets policy

As electoral waves of unbridled anti-gov-ernment sentiment are somewhat un-evenly expressed against incumbents in both primaries, many physicians are likely to wave at the parade (or angry mobs), if not grab pitchforks and torches and join the procession. Physician frus-

tration, broadly speaking, has reached a tipping point. The medical societies who have dared to conduct surveys of their member physicians have found unprecedented white-hot anger, cynicism, and a pessimism that runs as high as 8-to-1. But where are physicians putting all this righteous, and to some extent misdirected, anger?

The art of politics, if that’s not an oxymoron, is chan-neling motivated voters into constructive results rather than merely a short-run tantrum that unhorses or simply antagonizes an incumbent. The end game isn’t the political assassination of an office holder. It is winning or leverag-ing an election so that the survivor/winner supportsyour well-reasoned ideas over your adversaries’ equally reasoned ideas, out of conviction or fear. Either motiva-tion works. After all, why engage in these often unsavory and disingenuous public affairs if your ideas don’t have consequences?

In these times of incumbent rejection and unfocused resentment of all things governmental, a story often resur-faces as told by a longtime Capitol press corps reporter. It seems this reporter was attending a post-election in-terview with a newly elected governor who had just won back his former position from the same incumbent who, four years previously, had unseated him. The reporter asked the governor-elect in a post-victory press confer-ence, “What will be your top priorities this session?” The governor-elect stared for a moment, then asked, “What?” The consensus interpretation from the journalists in the room was that his agenda was avenging a previous defeat at the hands of the soon-to-be ex-incumbent. There was no other agenda, although there were plenty of well-heeled supporters of the challenger who had their own ideas already drafted in bill form.

Legislative ideas, after all, arrive at their destinations from a political process. They aren’t all that often born spontaneously from civic-minded public servants. They are turtles on fence posts. Someone put them there. Legislators, especially part-time state legislators, do not have the time or capacity to grasp every nuance of the more than 6,000 bills that are filed every session, nor, real-istically, the 1,000 or so that pass their desks on the House or Senate floor and that are voted for or against. Ideally and by their preference, they rely on guidance from local, credible sources who are also supporters. Lobbyists either direct that local traffic to the politician or inject their cli-ents’ opinions in its absence.

It should thus follow that if politics drives the process that sets public policy, how do physicians master the art of politics? What follows is a brief guide to the principles of political engagement, and how medicine’s ideas can have real-world consequences. It is in three parts—the basics of electoral engagement, how to be an advocate during the legislative process, and what constitutes effective policy development within the confines of a political process.

By Kim Ross

22 sUMMER 2010 | TExas FaMily Physic ian

In politics, relationships are as important, if not more so, than issues, and as a corol-lary, elected officials can trace many of their most valuable relationships back to their

earliest electoral experiences. Running for of-fice, then hanging on to it, is not for the timid or those plagued by self-doubt. A politician rarely forgets or overlooks those who were there dur-ing that first, seminal election, or their first near-death experience during a re-election.

Who gets to cut in line at a legislator’s of-fice? The physicians who have stayed out of the electoral process and never contributed or worked in the incumbent’s campaign, or his local optometrist and longtime finance chair? What does one suppose is the predisposition of that legislator on expanded scope of practice for optometrists? Since most legislators didn’t go to medical school, where do you suppose they go to get some sense on how to vote on these complex and intensely political matters?

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Part 1

Electoral engagement: The basics

There are three types of grassroots relationships, as opposed to the time-honored lobbyist relationships of those who regularly haunt the halls, bars, and anterooms in Austin and Washington, D.C., and direct client support to those law-makers. All have relative value, in descending order:

Organic: • These relationships are of a more natural order, preceded their political careers, and are by definition relatively close: family members, classmates, physician-patient relationships, neighbors, or other commu-nity-based relationships involving regular interaction. When managed methodically and ethically, they are by far the most influential during legislative cycles.

Home grown: • These are relationships acquired during an election cycle. Physicians who engaged in all the basics of volunteer political action (not just making a contribution, however important this emphatically is) dur-ing a campaign: signing letters or ads; hosting events; block walking; trav-eling with the candidate; and any in-kind public, sustained gesture. They are the most numerous relationships and in most cases neutralize even the largest contributors’ efforts at bullying your legislator.

Artificial turf: • These are the en masse responses rallied from your medi-cal organization where volume, in addition to personal contact, count. These are letters and e-mails. Some legislators are notorious for hiding behind perceived local doctor ambivalence. Lobbyists frequently hear from the uncommitted legislator, “I haven’t heard from my docs on this,” implying a lack of political interest among physicians and the politician’s proportionate disinterest in supporting the position, especially if the other side is pounding his or her office with mail and calls.

In the next part we’ll review how to apply these relationships in legislative battle.

Given the extent of corporate interference

and government involvement

in health care, physicians have a

moral obligation to their patients and to their profession

to be active in the political and

legislative process.”

Sen. Robert Deuell, M.D. R-Greenville

Vice chair, Senate Committee on Health and Human Services

www.ta fp .o rg | sUMMER 2010 23

To the extent physicians and their advocacy organizations have invested in the political process during successive election cycles, they will have accumulated the kind of po-

litical capital that has currency before and during a legislative session. That will be the time to expend that capital, but it should be spent judiciously, not murdering a bill that was already committing suicide or trying to persuade the unpersuadable. Whether the contact with their legislator is in their crowded Capitol office during the biennial melee or the more quiet environs in their district, there are certain rules of engagement and guiding principles to those con-versations.

How legislators thinkThis isn’t an oxymoron. Every legislator runs leg-

islation that has local backing or political muscle be-hind it through a rational calculus that measures the

Part 2

Doctors as policy advocates: How hard could it be?

difference between the electoral risks of taking sides as compared to the personal or ideological beliefs of the legislator. For some issues, the legislator will bend to the ideological side, willing to take political risk because of personal conviction. At the other end of the spectrum, the legislator may see the vote as potentially career-ending, or at a minimum calling in heavy artillery on his or her own posi-tion in the next election, by violating partisan doctrines that guarantee a primary opponent or by offending local constituencies capable of organizing a grassroots offensive.

Calling on a legislator—really just showing up—is vital, if for no other reason that if absent, you forfeit your interest and influence to the other side. But, it isn’t a social call. Longtime University of Texas football coach Darrell K. Royal famously said about his aversion to the forward pass, “three things can happen to you and two of them are bad.” It can be also said of legislator contact or public testimony: the legislator may agree, disagree, or simply not respond. your words have conse-quences, but epiphanies are virtually nonexistent. I’ve never seen the Red Sea part or a blinding light hit a legislator after giving it our best shot, causing him to fall to his knees and dramatically proclaim, “I see the light! All this time you were right and we were wrong. I am born again, and this time, I’m on your side.” Physicians making those House and Senate calls will need some guidance from their lobby or their peers who enjoy an organic or home-grown relationship to assess their legislator’s disposition so as to know what to expect and how to temper their con-versations. This prior assessment is crucial to assuring a productive contact and minimizing the possibility of a grenade going off in someone’s lap.

To make things more linear in this chaotic world, here’s a simple typological guide to your legislator’s possible position before the vote.

Kamikazes: • Whether for your issue or against, conversation is at best symbolic if not futile. Their disposition implies a risk-irrelevant stance to the point of self immolation. Though they may wrap their views in some rhetorical or partisan device, what they are really saying is they are intractable. If they are for you, one invokes the “strike oil, stop drilling” rule. Say thank you and ask what they are hearing about your issue. For those against, say thank you and offer the vague hope there may be other issues where hearts and minds might otherwise converge. No reason to share your playbook with the other team.

Ambivalents: • Here is where all legislative traction is acquired and change is realized. These are legislators, often a substantial plurality of the Legislature, who by definition are on the proverbial fence. There are two kinds of ambivalents: moral and political.

The moral ambivalents are high-centered because they have not heard a suf-ficiently persuasive argument from either side. This is very lucrative ground, where an evidence-based policy and well-reasoned arguments have immense con-sequence. It is also a rare circumstance. One can infer from the morally ambiva-lent that the legislator does indeed want to do the “right” thing, has disregarded ideological, political, or partisan pressures, and considers the issue sufficiently relevant to everyday life to spend precious time studying the merits of the issue.

The political ambivalents are uncommitted because they are simply indifferent to the policy consequences and more interested in the political risk of taking sides. This is by far the largest ongoing plurality in any debate preceding legislative ac-tion. The more intense the party, local, and lobby pressure, the more a political ambivalent will be inclined to wait the issue out, hoping for a forced compromise (no one willingly gives ground—it is usually achieved at gunpoint) or for the arcane twists and turns in the legislative process to kill the bill before it reaches his or her desk. This is a trickier encounter since the legislator will be reluctant to admit having political fears without incurring certain liabilities, including an implied quid-pro-quo transaction or one that explicitly ties a vote to promised support. It regrettably happens on rare occasion in the privacy of an office or local venue, and it is also a criminal offense. Physician conversations in these circumstances are no different than the policy debate with the morally ambivalent legislator—succinct, well-reasoned, evidence-based arguments.

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24 sUMMER 2010 | TExas FaMily Physic ian

Your advocacy encounter checklist

Remember, during a session, you may be talking with policy staff in lieu of your legislator.

1. PrEPArE. Rehearse your issue talking points with your lobbyists. They are professionals and spend a lot of time in that swamp. Get a profile of your legislator, especially if you don’t have an organic or homegrown relationship in tow.

2. DOn’T cuss THE AlligATOr bEfOrE YOu crOss THE swAmP. Never, ever, threaten, show anger, or imply you’d like to remove a favor-ite appendage without the benefit of anesthesia. The legislative process assures many opportunities for instant karma payback, with no finger-prints or smoking guns.

3. iT’s nOT PErsOnAl. The venal, mercenary, bottom-feeding, yellow-page-advertising, ambulance-chasing personal injury lawyer’s vote is as good as the white-gloved, afternoon-tea, gated-community debutante’s. Make no assumptions about where your support may come from, or indulge in personal opinions about any legislator’s life philosophies or lifestyles. Sam Rayburn said it more succinctly, but we can’t print it.

4. nO AD HOminEm ATTAcKs On THE OTHEr siDE. you may reference the canine ancestry of a rival profession only to find the legislator’s spouse or family member belongs to that tribe. Besides, it is non-persuasive and bad form, especially from a respected member of your learned profession.

5. DOn’T nEgOTiATE. The more clever of the ambivalents, in seeking to distract or find a way out, may ask for a trade or a downgrade of your request. Refer them back to your lobby.

6. ADDrEss lEgislATOrs bY THE TiTlEs THEY’vE EArnED. Nicknames like bubba, big guy, or cutie, even their given names, are off-limits un-less you enjoy that kind of intimate, organic relationship. Even then, it’s bestinthepresenceofotherstosay“senator,representative,ormister/madam chair.” your lobby can help you with protocol.

7. TrEAT sTAff wiTH THE sAmE DEfErEncE. They are the filter to the boss, and have no problem filtering your points. See also point No. 1 about doing your homework—they have personal physicians, friends who are physicians, and quite possibly good friends working against you.

8. ArguE frOm EviDEncE, nOT bEliEfs. While avoiding jargon and ac-ronyms, cite the scientific evidence in a cause-and-effect linkage that ties the policy to the desired or undesired consequence. your position may involve three wise men and a virgin, and the other side may be agents of Satan, but that is in most cases an insufficient argument. Everyone likes to invoke a deity when backed into a legislative life-or-death corner. The ambivalents want probable outcomes.

9. TAKE THE DEbATE TO THE ExAm-rOOm lEvEl. Tell a story using real or redacted cases of the consequences of action and inaction.

10. sTAY insiDE YOur KnOwlEDgE. If you don’t know, just say you’ll check and get back. Don’t chase hypothetical questions.

11. rEPOrT bAcK. It’s okay to take notes, and vital you compare what you heard, thought you heard, and didn’t hear to your advocates. your intel will fit into a complex pattern across 181 votes, and provides valuable insights into your opponents’ strategy, progress against you, and the predisposition of your legislative contacts. And, drop a note to thank whomever you met with to memorialize the contact with them, but pres-ent that fairly. This gives you one more chance to reinforce your points.

The art of politics, if that’s not an oxymoron, is channeling motivated voters into constructive results rather than merely a short-run tantrum that unhorses or simply antagonizes an incumbent.

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adVoCaCY

to-doLiSt

Sign up to be a TAFP Key Contact.

Sign up to serve as Physician of the Day.

Stay informed on the issues.

Join the TAFP Political Action Committee.

Build meaningful relationships with your representative and your senator.

Need help with these? Contact TAFP at (512) 329-8666 or [email protected].

The unwritten laws of politics are as immutable as the laws of nature. As Voltaire put it perhaps more eloquently, “hawks have always eaten pigeons when they have found them.” Understanding these three, albeit cynical, rules will help you break the code to why some bills survive the legislative pro-cess and some die before ever being filed.

Politics drives process that sets policy. you’ve heard us preach this before, but this is the holy trinity of how things really work. Who we help elect and how strong our relationship is with them determines the rules of the legisla-tive process—whether or not a bill will get filed, set for hearing, debated on the floor, signed by the Governor, etc. In turn, this means our policy options are limited by political and legislative op-portunity. In other words, policy objectives—no matter how well-meaning—may only see the light of day if our politics are in proper order.

Legislative reforms are reactive, not proactive. Legislative policy changes occur after the pro-verbial train wreck, plane crash, biblical plague, financial meltdown, oil rig explosion—you get the picture.

A politician’s first duty is to get re-elected. Every legislative idea and every vote that is cast passes through a political filter that measures the potential electoral consequences of supporting or opposing one set of constituents while antago-nizing another. A legislator may not always be influenced by the politics, but they will invariably weigh the political consequences (a potential ca-reer-ending vote) against the policy implications (passing a tax bill to fund indigent health care).

Most physicians are understandably frustrated by the legislative process and think it is a fixed, in-sider game. I’ve heard it expressed many times from many different physicians: “If only they listened to me and supported my idea on how to fix health care, all would be right with the world.”

In a perfect world, our elected officials would make decisions based solely in the best interests of patients, but we don’t live in a perfect world and you can’t pass wishes. Politics and other con-siderations ultimately come into play. That’s how it works in the real world of practical politics and health care policy.

A veteran legislator, who to this day is still hand-ing out one-liners and hard-earned wisdom to his less experienced colleagues on the House floor, is fond of reminding them that “if a frog had a back pocket he’d carry a pistol and shoot snakes.”

What he means, in my words, not his, is that good ideas will be devoured by the reptiles in the legisla-tive swamp every time unless you can defend those ideas with more than mere words and good inten-tions. Or as Al Capone famously said, “you get more with kind words and a gun than kind words alone.”

Consider this: If all 5,000 members of TAFP gave $100 per year, a little more than a quarter a day, to our political action committee, the PAC would match and even exceed the political muscle of other influ-ential professions and businesses. If only one-tenth of our members developed personal relationships with their elected officials, our grassroots presence would be transcendent. A legislator couldn’t swing a dead cat without hitting an involved family physi-cian in his or her district armed and ready to work.

In the synergistic combination of activism and money, political action puts the pistol in the frog’s back pocket. :

If a frog had a back pocket …iT’s TiME FoR a PoliTical REaliTy chEckBy Tom BanningTAFP Chief Executive Officer/Executive Vice President

ACAdEMY UPdATE

This issue of TEXAS FAMILy PHySICIAN features a series of political tutorials emphasizing the importance of grassroots activism and political action in order to build the kinds of relationships with elected officials that get the interest, attention, and oftentimes support of well-reasoned policy positions. Put another way, if you want to affect health care policy, you must get involved in the political process. It is that simple and that important.

Consider this: If all 5,000 members of TAFP gave $100 per year, a little more than a quar-ter a day, to our political action committee, the PAC would match and even exceed the political mus-cle of other influ-ential professions and businesses. If only one-tenth of our members de-veloped personal relationships with their elected officials, our grassroots pres-ence would be transcendent. A legislator couldn’t swing a dead cat without hitting an involved fam-ily physician in his or her district armed and ready to work.

36 sUMMER 2010 | TExas FaMily Physic ian

Page 4: Tafp 2011 multi state report

• Primarycareworkforce-- (budget) > Statewide Preceptorship Programs > State GME funding for residencies > Culture shift at medical schools

• Scopeofpractice

• Medicaid/CHIPfunding-- (budget)

• Corporatepracticeofmedicine

LegIsLATIve PRIORITIes

Page 5: Tafp 2011 multi state report

• TexasFamilyPhysician-- (& webmag) > Scope of practice article in 4Q 2010 > Legislative Update departments in all• CapitolUpdateinQuickInfo• CapitolReportwebcastvideo

• PrimaryCareCoalitionissuebriefs

• TAFPissuebriefs

•NEW:TAFPpolicybriefsonscopeof practiceandGMEfunding

COmmunICATIOn PLAn

Page 6: Tafp 2011 multi state report

PCC Issue bRIeF #1Protectpreceptorshipprograms

Page 7: Tafp 2011 multi state report
Page 8: Tafp 2011 multi state report

PCC Issue bRIeF #1Protectpreceptorshipprograms

Page 9: Tafp 2011 multi state report
Page 10: Tafp 2011 multi state report

PCC Issue bRIeF #2, 3, 4Scopeofpractice• #2focusesoneducationdifferences• #3focusesongeographicdistribution•#4focusesoncosteffectiveness

• over •

Primary Care Coalition | 401 W 15th Street, Ste. 682, Austin, TX 78701 | (512) 370-1516

Primary Care Coalition Issue Brief: COLLABORATION BETWEEN PHYSICIANS AND NURSES WORKS

Compare the Education Gaps Between Primary Care Physicians and Nurse Practitioners

While nurse practitioners are trained to emphasize health promotion, patient education, and disease prevention, they lack the broader and deeper expertise needed to recognize cases in which multiple symptoms suggest more serious conditions. The primary care physician is trained to provide complex differential diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within the context of the patient’s overall health condition.

This expertise is earned through the deep, rigorous study of medical science in the classroom and the thousands of hours of clinical study in the exam room that medical students and residents must complete before being allowed to practice medicine independently.

Because primary care physicians throughout the United States follow the same highly structured educational path, complete the same coursework, and pass the same licensure examination, you know what you’re getting with a physician. There is no such standard to achieve nurse practitioner certification, as their educational requirements vary from program to program and from state to state.

Degrees requireD anD Time To CompleTion

Undergraduate Entrance exam Post-graduate Residency TOTAL TIME FOR degree schooling and duration COMPLETION

Family physician Standard 4-year Medical College 4 years, doctoral REQUIRED, 11 years(M.D. or D.O.) BA/BS Admissions Test program 3 years minimum (MCAT) (M.D. or D.O.)

Nurse practitioner Standard 4-year Graduate Record 1.5 – 3 years, NONE 5.5 – 7 years BA/BS* Examination (GRE) master’s program & National Council (MSN) Licensure Exam for Registered Nurses (NCLEX-RN) required for MSN programs

meDiCal/professional sChool anD resiDenCy/posT-graDuaTe hours for CompleTion

Lecture hours Study hours Combined hours Residency hours TOTAL HOURS (pre-clinical years) (pre-clinical years) (clinical years)

Family physician 2,700 3,000** 6,000 9,000 – 10,000 20,700 – 21,700

Doctor of Nursing 800 – 1,600 1,500 – 2,250** 500 – 1,500 0 2,800 – 5,350Practice

Difference between 1,100 – 1,900 750 – 1,500 4,500 – 5,500 9,000 – 10,000 15,350 – 18,900FP and NP hours of more for FPs more for FPs more for FPs more for FPs more for fpsprofessional training * While a standard 4-year degree, preferably a BSN, is recommended, alternate pathways exist for an RN without a bachelor’s degree to enter some

master’s programs.** Estimate based on 750 hours of study dedicated by a student per year.

Sources: Vanderbilt University Family Nurse Practitioner Program information, http://www.nursing.vanderbilt.edu/msn/fnp_plan.html, and the Vanderbilt University School of Nursing Handbook 2009-2010, http://www.nursing.vanderbilt.edu/current/handbook.pdf. American Academy of Family Physicians, Primary Health Care Professionals: A Comparison, http://www.aafp.org/online/en/home/media/kits/fp-np.html.

• over •

Primary Care Physicians Are the Most Likely Health Care Professionals to Practice in Rural and Underserved Areas

Primary Care Coalition | 401 W 15th Street, Ste. 682, Austin, TX 78701 | (512) 370-1516

Primary Care Coalition Issue Brief: COLLABORATION BETWEEN PHYSICIANS AND NURSES WORKS

According to the Robert Graham Center, people in non-metropolitan areas, especially in rural areas, depend on family physicians more than any other specialty. Despite claims by nurse practitioners that they will practice in rural and underserved communities if granted the ability to diagnose and prescribe independently, the data suggest otherwise.

• PracticemappingresearchconductedbytheAmericanMedicalAssociationshowsthatpatternsinpracticelocations for nurse practitioners in states with independent practice are no different from those in states that require collaboration between nurse practitioners and physicians.

• Ifgrantedindependentpractice,nursepractitionerswouldbepracticinginthesameeconomicenvironment as family physicians, and the factors that make opening and maintaining a rural medical practice will discourage nurse practitioners as well.

The location of one or more actively practicing primary care physicians (n = 14,837)

The location of one or more actively practicing advanced practice nurses (n = 6,560)

Full Health Professional Shortage Area county

Partial Health Professional Shortage Area

Number of Nurse practitioNers per 100,000 populatioN iN texas iN 2009

Metropolitan non-border areas: 25.1Metropolitan border areas: 17.0Non-metropolitan non-border areas: 15.5Non-metropolitan border areas: 8.3

GeoGraphic DistributioN of primary care physiciaNs aND Nurse practitioNers iN texas

In Texas in 2009, the ratio of primary care physicians per 100,000 people in counties designated as Health Profes-sional Shortage Areas was 32.8, while the ratio of nurse practitioners per 100,000 people in those same counties was 10.4.

• over •

Primary Care Coalition Issue Brief: COLLABORATION BETWEEN PHYSICIANS AND NURSES WORKS

Collaboration Between Physicians and Nurse Practitioners Contains Health Care Costs

Bringing down the cost of care must be a major goal of any change in health care policy in Texas. The integrated, well-coordinated care provided in a physician-led, patient-centered medical home has proven time and again to result in healthier populations while saving money. The patient-centered medical home depends on the skills, education, and expertise of a team of health care providers, including nurse practitioners, caring for patients under the medical direction of primary care physicians to succeed.

Contrary to the claims of nurse practitioner organizations, independent practice by nurse practitioners would not lead to more efficient or cost-effective care; in fact, studies show the opposite would be the likely outcome.

Because they lack the training and medical education of physicians, nurse practitioners tend to refer patients to specialists and order expensive diagnostic tests at a higher rate when they are not working with physicians.

A comparison of utilization rates among physicians, residents, and nurse practitioners in the same setting showed that:

• Utilizationofmedicalserviceswashigherforpatientsassignedtonursepractitionersthanforpatients assigned to residents in 14 of 17 utilization measures, and higher in 10 of 17 measures when compared with patients assigned to attending physicians.1

• Therewasa41%increasedhospitalizationrateinthenursepractitionergroup,or13morehospital admissions per 100 patients per year than the group receiving care from physicians.1

• Therewasa25%increaseinspecialtyvisitsinthenursepractitionergroup,or108morevisits per 100 patients per year than the group receiving care from physicians.1

The researchers stated that the findings suggest that increased use of nurse practitioners as primary care providers may lead to increased ordering of expensive diagnostic tests and higher rates of specialty visits and hospital admissions for patients assigned to nurse practitioners.

• Fromthestudy:“Thehighernumberofinpatientandspecialtycareresourcesutilizedbypatients assigned to a nurse practitioner suggests that they may indeed have more difficulty with managing patients on their own (even with physician supervision) and may rely more on other services than physicians practicing in the same setting.”1

1. HemaniA,RastegarDA,HillC,etal.“Acomparisonofresourceutilizationinnursepractitionersandphysicians.”EffClinPract.1999Nov-Dec;2(6):258-265.

Page 11: Tafp 2011 multi state report

None address quality question. Instead we package them with the magazine feature in which physicians tell their horror stories.

Presorted StandardU.S. Postage

PAID Austin, TXPermit No. 1450

D E D I C A T E D T O T H E D E L I V E R Y O F Q U A L I T Y H E A L T H C A R E V O L . 6 1 N O . 4 F A L L 2 0 1 0

Roland Goertz, M.D., M.B.A., Installed As AAFP President

PLUS: Primary Care Preceptorships Under

The Knife Again

CMS Recovery Audit Contractors:

What You Need To Know

NURSE PRACTITIONERS SEEK

INDEPENDENTPRACTICE The 82nd Legislature

Will Determine Who Can Practice Medicine In Texas

Page 12: Tafp 2011 multi state report

TAFP POLICY bRIeF #1TheQuestionofIndependentDiagnosisandPrescriptiveAuthorityforAdvancedPracticeRegisteredNursesinTexas: IstheRewardWorththeRisk?

ByMarie-ElizabethRamas,M.D.

3rd-yearresidentandrecipientofJamesC.Martin,M.D.,Scholarshipintendedforpolicy research

Page 13: Tafp 2011 multi state report

Texas faces a growing demand for primary care services, particularly in rural and underserved regions. The Texas Department of State Health Services re-ports that 16,830 primary care physicians were in active practice in Texas in 2009, or approximately 68 for ev-ery 100,000 people. The national average is 81 primary care physicians per 100,000 population. This short-age is compounded by a prevalent maldistribution of physicians across the state. Of Texas’ 254 counties, 118 were considered whole county health professional shortage areas, or HPSAs, and 71 contained either spe-cial populations or geographic areas that qualified for the designation of partial-county HPSA. Twenty-six counties had no primary care physician in 2009.1

In recent years, organizations representing ad-vanced practice registered nurses, or APRNs, have pursued policy changes that would allow these practi-tioners to provide medical services independently, ar-guing that such changes would help alleviate physician shortages. Despite assertions that APRNs function as effectively as physicians, there exists little if any sub-stantial objective information to support these claims.

Given the impending addition of even greater stress on the state’s health care delivery system, it is clear that a comprehensive discussion of how to in-crease access to primary care throughout the state is necessary. One seemingly logical solution would be

to extend independent diagnostic and prescriptive authority to APRNs in the state of Texas. While such action may be politically expedient in the short term, the risks outweigh what may be a hollow reward.

Many reforms implemented by the Texas Legis-lature in recent sessions are successfully shifting the state’s health care delivery system in a direction sup-ported by acclaimed medical and economic research, toward the integration of care in a collaborative, team-based model in which all aspects of a patient’s care are coordinated across multiple settings and various health care providers. Such an efficient system based on a solid primary care foundation leads to improved quality, reduced errors, and fewer instances of unnec-essary care and duplication of services, resulting in lower costs.2, 3, 4, 5 Allowing APRNs to practice medical acts independently would fracture that transition, in-creasing the fragmentation of care Texans experience.

Furthermore, redefining the educational and li-censure standard required to conduct medical acts so that APRNs can practice independently will not guar-antee that Texans will have greater access to primary care. No data exists to support claims that APRNs are more likely to practice in underserved areas, though significant evidence shows they tend to preferentially distribute in metropolitan and suburban communities at a similar rate to other health care providers.

The Question of Independent Diagnosis and Prescriptive Authority for Advanced Practice Registered Nurses in Texas: Is the Reward Worth the Risk?

By Marie-Elizabeth Ramas, M.D.

Published by the Texas Academy of Family Physicians, Feb. 16, 2011. This research was made possible in part by the TAFP Foundation through the James C. Martin, M.D. Scholarship. © 2011 Texas Academy of Family Physicians.

TAFPPOLICYBRIEF

• 3,000 words

• 8 pages

• Thoroughly cited

• Contains graphs, charts, and maps from issue briefs

Page 14: Tafp 2011 multi state report

TAFP Issue bRIeFKeepTexas-trainedIMGs PracticinginTexas

Issue Brief: improving texas’ primary care physician workforce

Texas Academy of Family Physicians | 12012 Technology Blvd. , Ste. 200, Austin, TX 78727 | (512) 329-8666 | www.tafp.org

Keep Texas-trained International Medical Graduates Practicing in Texas

Texas faces a current and impending shortage of physicians—particularly primary care physicians—to meet the health care needs of our growing population. Yet an impediment in the licensing of a significant number of practice-ready new physicians presents many with a tough choice: accept a costly delay or abandon Texas to begin practicing medicine elsewhere.

International medical graduates, or IMGs, cannot receive medical licenses in Texas until they have completed three years of residency training, while physicians who graduated from U.S. medical schools can apply after only one year of residency. This re-quirement reduces the supply of new physicians in Texas.

• Itdiscouragesemployersfromoffering IMGs positions right out of residency because they don’t yet have their licenses, thus encouraging them to leave the state in search of work.

• Becausephysiciansmusthave a medical license to be credentialed by Medicare and private insurers, it further delays the date after which they can be paid for their work.

• Becausetheymusthaveamedical license to take their board examinations for certification by most medical specialty boards, including the American Board of Family Medicine, it delays their ability to achieve board certification, a requirement for insurance credentialing and hospital privileging.

For IMGs, these impediments could add up to months of unnecessary and costly delays before they can begin caring for patients. While they are unable to practice, their substantial medical education debt mounts.

Many IMGs obtain licenses in states like Oklahoma and New Mexico that require fewer residency years for licensure. These physicians are more likely to move to these states to practice, taking with them the substantial investment Texas has made in their education.

► By changing the number of years of residency training IMGs must complete for medical licensure from three to two years, the Legislature can ensure that these physicians can start caring for patients as quickly as graduates of U.S. medical schools, thus improving Texans’ access to care.

Texas Academy of Family Physicians

• over •

IMGs COMPRISE A GROWING PORTION OF TEXAS’ PRIMARY CARE WORKFORCE

One out of every four physicians in America is an IMG. In Texas, 38% of family medicine residents in training today are IMGs. Considering the increase in the number of IMGs going into family medicine over the last decade, it is clear that Texas depends on IMGs for a significant portion of our primary care physician workforce.

PERCENTAGE OF TEXAS FAMILY PHYSICIANS WHO ARE IMGs BY YEAR OF RESIDENCY COMPLETION

0 10% 20% 30% 40% 50%

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

24 states require fewer than 3 years of residency for iMG Medical licensure

Legislative advertising paid for by the Texas Academy of Family Physicians. For more information, contact Tom Banning, CEO/EVP, 12012 Technology Blvd., Ste. 200, Austin, Texas, 78727.

Recommendation: Amend the state statute to allow IMGs to receive medical licenses after completing two years of residency trainingGiven the critical importance of improving access to cost-efficient, high-quality care across the state by increasing Texas’ primary care physician workforce, this small change will have a tremendous effect. Practice-ready, Texas-trained primary care physicians who would prefer to remain in Texas are leaving the state, and this unnecessary restriction is often to blame. Furthermore, state agencies employing these physicians are losing money due to the related credentialing delays. This action will result in a savings to these agencies and remove an arbitrary impediment to practicing primary care in Texas.

The Texas Academy of Family Physicians is joined by several organizations in support of this change. They are:

3 years required

2 years required

1 year required

Texas Medical Association

Texas Pediatric Society

Texas Chapter of the American College of Physicians

Teaching Hospitals of Texas

Texas Association of Community Health Centers

Texas Organization of Rural and Community Hospitals

Page 15: Tafp 2011 multi state report

• IssuebriefonstateGMEfunding >IncludenumberofFMresidencies & residents trained

> Amount of funding cut from programs and how that is likely to affectprograms

>DoublehitfromMedicaidcuts

• Policybriefonmedicaleducation >2ndJimMartinresidentpaperis almost complete

WhAT’s nexT?

Page 16: Tafp 2011 multi state report

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Page 17: Tafp 2011 multi state report

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