By Alan Abraham
What is Texas waiting for?
While the demand for healthcare is ever rising, the supply of primary care physicians continues shrinking. According to the Association of American Medical Colleges, the shortfall of primary care physicians will reach 43,000 by 2030.
Eighty-four million Americans, one quarter of the U.S population, live in counties with a severe primary care physician shortage (U.S. Dept. of Health & Human Services).
The math is especially troubling for rural Texans. The State Office of Rural Health, part of the Texas Department of Agriculture, counts 177 counties as "rural," twenty-eight of those counties are without a practicing physician, and the Department of State Health Services designates over 300 areas in Texas, rural and non-rural, as "medically underserved."
I began thinking about answers to this access to primary care crisis back in 2013. Two solutions came to mind:
1. Expand Texas Loan Forgiveness programs for physicians who promise to spend at least part of their careers in underserved areas.
2 Create more physician residency programs in Texas to keep Texas-trained medical school students in Texas after graduation.
Both solutions are pragmatically possible but too expensive to implement. Then I learned about a well-trained care provider who is fairly new to the workforce. Their college degree title is Advance Practice Registered Nurse, but the common designation in the work place is Nurse Practitioner (NP).
The good news is that more than 80% of this growing workforce is trained in primary care and showing a 43% increased presence in rural America (Public Health, 2018). NPs are not necessarily inclined to favor a rural or medically underserved setting; but their training period is shorter and freer from debt than what physicians face at the end of their residencies, giving NPs more flexibility in choosing their practice locations when picking a clinic to join or where to establish an independent practice.
There is another cost differential between NPs and physicians, and this one rests with the Texas Legislature. Texas is among 12 of the most restrictive states when it comes to full practice authority for NPs. That is, in Texas, NPs cannot treat patients except under the formal supervision of a state licensed physician. They are the only health care professionals subject to regulations enforced by two different state licensing boards: the Texas Medical Board and the Texas Board of Nursing. This overregulation is duplicative and inefficient, hampering NPs in independent practices from administering timely care to their patients.
Physician supervision adds overhead costs as well! Each NP must secure and sign a contract, called a Delegated Authority Agreement, with a supervising physician for a negotiated amount paid annually by the NP to the physician. Thousands of dollars per Agreement, per year, is involved. This "pay to play" barrier can make a difference whether an NP stays in Texas or moves to practice in another state with a better regulatory environment.
Physician shortages in primary care is not going away. Encouraging NPs to stay in Texas is part of the solution to our growing crisis in access to care, and the Texas Legislature can help solve the problem by removing from statute the state's "pay to play' licensure restrictions.
