Texas NPs

[Missy89]

Anyone currently practicing as an NP in Dallas or even Texas overall? Graduate next Dec and looking to relocate. How is the job market for new grads? Typical salary? Currently interested in surgery, derm or specialty care. Thanks!

[CrunchRN, ADN, RN]

I am not an NP, just an RN, but the NP's I know do not feel that way.

[nomadcrna, DNP, CRNA, NP]

I hate to break it to you. I ALREADY do the EXACT same job as the physicians. Absolutely no difference at all. I actually do many procedures that many FP physicians don't do. Oh my.

I'm not bemoaning, I'm actively fighting for our practice rights. All NPs should be doing the same thing.

Very sad.

The barriers are there because you are not an MD. Go be an MD and enjoy life with no barriers. Until then, stop bemoaning your profession. In my opinion, NPs like YOU are the ones who give our profession a bad name. The ones who *say* they want to be able to have no barriers, to do all the same things an MD does...and yet, don't want to put in the time. Stop whining and go to med school.

[dansamy]

This argument doesn't make sense considering that 18 states allow NPs to practice with no barriers. The research clearly shows that one does not need to attend med school in order to practice independently as well as safely. No one here is whining as far as I can tell, though you do seem awfully defensive.

I'm just curious. What states allow unrestricted practice?

[nomadcrna, DNP, CRNA, NP]

The states that I'm licensed in that NPs have unrestricted, independent practice are: Alaska, Arizona, Washington, Oregon, Montana, Idaho, Wyoming.

There are a total of 19 (Nevada was just added) and DC.

Health Policy Briefs

[TABLE=width: 100%]

[TR=bgcolor: transparent]

[TD=bgcolor: transparent, colspan: 3]t

What's the issue?

[/TD]

[/TR]

[TR=bgcolor: transparent]

[TD=bgcolor: transparent, colspan: 3]Nurse practitioners are a type of advanced-practice registered nurse. They are registered nurses who have also obtained a postgraduate nursing degree, typically a master's. So-called scope-of-practice laws in many states give these professionals the ability to perform a wide range of primary care services that may be offered when people make an initial approach to a doctor or nurse for treatment as well as ongoing care for chronic diseases.

With a predicted shortage of primary care as the population grows and as millions of people become newly insured starting in 2014, one proposed solution is to expand the role of nurse practitioners in many more areas of the country, and to allow them to provide a wider range of preventive and acute health care services.

Some physician groups oppose an expansion of nurse practitioners' scope of practice, citing concerns over patient safety. Much of the controversy plays out in state capitals, where medical boards and legislators determine scope of practice for nonphysicians, including nurse practitioners. There are also considerations at the federal level that bear on nurse practitioners' ability to be reimbursed for the care that they provide.

This brief examines the policy proposals for allowing nurse practitioners to practice to their full potential and the accompanying debate.

[/TD]

[/TR]

[TR=bgcolor: transparent]

[TD=bgcolor: transparent, colspan: 3]What's the background?[/TD]

[/TR]

[TR=bgcolor: transparent]

[TD=bgcolor: transparent, colspan: 3]Primary care comprises a broad range of services, including the initial evaluation of new symptoms, ongoing care for chronic diseases, and preventive services such as immunizations or screenings. The increased availability of primary care is associated with lower mortality and with reductions in emergency department visits and hospitalizations.

PROVIDING PRIMARY CARE: Primary care services can be provided by physicians and by a range of nonphysician practitioners, such as physician assistants and nurse practitioners, both of whom have graduate degrees and are authorized to examine, diagnose, and treat patients. Although physician assistants must practice in association with a physician, state law determines whether nurse practitioners can work independently of a physician.

In 2012, 18 states and the District of Columbia allowed nurse practitioners to diagnose and treat patients and prescribe medications without a physician's involvement, while 32 states required physician involvement to diagnose and treat or prescribe medications, or both (Exhibit 1).

Exhibit 1

Download Powerpoint Slide

[/TD]

[/TR]

[/TABLE]

[nomadcrna, DNP, CRNA, NP]

Note: The author is a bit confused about CRNA practice as the CMS opt out is ONLY for billing purposes. Another wards, you can still have independent practice but because the state has not "opted out" with CMS, CMS considers the surgeon to be "supervising". This is only for billing and has nothing to do with actual practice.

So its up to 22 states and DC.

http://www.nacns.org/docs/toolkit/3A-FAQScope.pdf

Which states allow APRNs to independently deliver a broad range of services?

The scope of practice for APRNs varies widely by state and specialty. For example, in the case of

nurse practitioners (NPs), the most numerous of APRN roles, 22 states and DC allow NPs to diagnose

and treat without physician involvement: (AK, AZ, CO, HI, ID, IA, KY, ME, MI, MT, NH, NJ, NM, ND,

OK, OR, TN, UT, WA, WV, and WY. In contrast, 24 states require a formal relationship, documented

in writing, between an NP and a physician: (AL, AR, CA, DE, FL, GA, IL, KS, LA, MD, MA, MS, MO, NE,

NV, NY, NC, OH, SC, SD, TX, VT, VA, and WI.) This relationship requirement varies from state to state

and could call for supervision, delegation, authorization, or more general direction and

collaboration. The remaining 4 states also require some form of relationship between NPs and

physicians, but do not require documentation of such relationship: CT, IN, MN, and PA. When it

comes to prescriptive authority, only 13 of the 23 jurisdictions that allow autonomous practice by

NPs allow them to prescribe medications for diagnosis and treatment without the involvement of a

physician: AK, AZ, DC, ID, IA, ME, MT, NH, NM, OR, RI, WA, and WY. The remaining 38 states all

require documented physician involvement for NPs to be able to prescribe medications.

In the case of certified nurse-midwives, 18 jurisdictions allow CNMs to diagnose and treat without

requiring physician supervision or formal collaborative agreements; other states vary as to

requirements for physician involvement. All states confer prescriptive authority to CNMs, although

11 require physician involvement.

For certified registered nurse anesthetists (CRNA) the ability to provide anesthesia in hospitals and

outpatient settings without supervision is controlled by both state and federal regulations. State

regulations have to allow CRNAs to practice in hospitals and outpatient settings without supervision

from physicians, and the state must also opt out of federal Medicare requirements for physician 3

supervision (otherwise hospitals will not be reimbursed for CRNAs’ services). Currently, 16 states

have state laws that do not require CRNAs to be supervised and have opted out of the federal

supervision requirements; other states either do not allow CRNAs to practice without supervision by

a physician or have not opted out of the federal Medicare requirement for physician supervision of

CRNAs.

[zenman]

I hate to break it to you. I ALREADY do the EXACT same job as the physicians. Absolutely no difference at all. I actually do many procedures that many FP physicians don't do. Oh my.

I'm not bemoaning, I'm actively fighting for our practice rights. All NPs should be doing the same thing.

Very sad.

Same here. I'm in a large group of social workers, psychologists, NP, and physicians. One interesting thing I've found out is that most of the questions anyone of us asks the others is not based on training but experience.

[midwestFNP]

You are insulting not only yourself, but all other NPs with that statement. Shame on you.

[midwestFNP]

I'm also the type of NP who, when referred to see a specialist.....refuses to see an NP who works in a specialty office. You would no doubt hate me! If I was referred to see a CARDIOLOGIST, I want to see the cardiologist.

Seriously? Insulting to yourself and all other NPs.

[orangepink, NP]

FYI: The state of Texas BON mandates that all NPs, working as a first assist in a surgical specialty, take a RNFA course. It'll be an extra hoop to jump through, here in Texas. Good Luck!

I would loooooovvvveee to be a RNFA but I don't have OR experience at all. Can you give me advice on that?

[TX RN]

Man o man, I missed a good discussion here.

I practice in Texas, both for a SPECIALTY group and I also have my own solo practice that I'm building.

I'd like to clarify a few innacuracies about our state practice rights that have been mentioned here.

1. Handicap parking: Yes, you can sign for it, the renewal, the initial, doesn't matter. It's been that way for at least 2 years now. To nomads (I think you raised the issue) credit, it hasn't been very long since this was changed to reflect APN's lawfully being able to sign for it.

However, it was never a "practice" restriction from the BON or TMB. It was due to DPS form did not previously include "non-physician" provider to the list of accepted singatures.

A few years ago, before the law was changed, I remember telling my wife this story of a patient coming in for results of her chest CT and biopsy results. She had metastatic CA, pretty much everywhere.

Aside from the details of a very difficult and emotional visit, there were 2 things I did for this patient. One was very easy. The other made me want to punch the wall.

1. Hospice referral.

This was the easy part.

2. Parking placard for handicap parking. She couldn't walk very far without getting winded.

Without NP as an acceptable signature on the form, I had to explain to the patient my signature on her printed application would not help her with this problem.

I was going to have to forward this to the MD/DO.

This was the hard part.

This was about as underminded as I have ever felt in my life. An incredulous look from the patient and daughter swept over me when I declined to sign the form.

And I didn't blame them.

Unbelievable.

I'm sure they went shaking their heads thinking, OK, this NP just explained to me I have terminal CA, made referrals for me to go home and die with decency.

But he can't sign for a parking placard?

Parking placards may seem like a trivial thing but it's the little things that undermine NP practice, but more importantly it saboutages the trust the public has about NP's.

2. FNP's in Hospitals, acute care settings, ER, yes, even critical care settings.

Not an issue of practice restrictions with scope of practice laws from BON.

This is site based and completely up to each individual hospital or hospital system.

In my specialty practice I see patients in hospitals.

In some the NP can do initial H&P, initial consult note.

In others hospital bylaws specify PA and NP's CAN NOT do this, only MD's/DO's.

Local politics.

3. Independent practice.

True, Texas is not on the list of indepent NP practice states. However, collaborative practice is in place. It has been a major headache to have to abide by this practice restriction.

But not for the issues that were raised here. Or at least the most critical aspect of this restriction was not mentioned.

Site based supervision.

This has been the major road block to "independent-minded" NP's, the entrepreneur's like me, and not like other NP's.

Site based supervision required MD's to be at the pracitce site of NP's and review 20% of cases. Not only is this time consuming for MD's, it's an additional cost NP's incur as part of the cost of doing business. Also a restriction imposed without any supporting scientific evidence it is beneficial and with an arbitrary value assigned to it.

Needless to say, very few practice sites/groups actually keep a detailed log or do this at all.

4. Schedule II drugs:

Yep, a no-no here in Texas for NP's. Even in hospital settings it's not recognized by BON.

However, hospitals don't necessarily follow this. I have ordered sched 2 drugs in the past for procedures without incident.

Is it within the scope of the law? No.

Was it medically necessary and appropriate? Yes.

I will always follow medical necessity, it trumps legislation in my book.

However, this doesn't happen often and is very unnerving. It's not something I take lightly. There are many things to consider, most importantly the patient, but next is your livelihood and the liability you take on as a consequence of bucking the system.

A way around this has been to write (TO orders), telephone orders with my collaborating MD. A necessary evil to make my life less stressful.

Prescriptive authority is DELEGATED in Texas. But so is the authority to DIAGNOSE. This isn't talked about enough by NP's. Most will mention prescriptive authority, but the legal ability to diagnose is just as important, even more so in my opinion. Without the legal ability to diagnose what good is prescriptive authority?

Can't put the cart before the horse right?

There is hope yet for Texas NP practice.

There have been some meaningful steps taken to improve NP practice, particularly by CNAP (coalition for nurses in advanced practice). Thank to their efforts the 2013 state legislative session included SB 406 being approved by House and Senate, leading to the governor singing into law.

Independent practice did not survive, but some important changes did.

Here's a summary taken from the CNAP website.

• Eliminates the current site-based requirements and replaces them with a standardized prescriptive authority agreement that requires practitioners (physicians, advanced practice registered nurses and/or physician assistants) to develop and sign an agreement that is best for their practice as a professional team. -
  
• Establishes minimum standards for prescriptive authority agreements but gives the practitioners flexibility to determine the specifics of the agreement.-
  
• Allows hospital-based practices and practices serving medically underserved populations to remain unlimited in the number of APRNs and PAs to which a physician may delegate prescriptive authority.-
  
• Increases from four to seven the number of individuals to whom a physician may delegate prescriptive authority at all other practice sites.-
  
• Improves coordination between the boards: Texas Medical Board, Texas Board of Nursing and the Texas Physician Assistants Board.-
  
• Allows physicians to delegate prescriptive authority for Schedule IIs
  
• Controlled Substances to APRNs and PAs in hospitals and hospice.
  

http://www.cnaptexas.org/

[labries]

Zenman, I don't participate enough to send a private message. I see you work for the military and I would just like to ask some questions. I'm in the Army and starting my PMHNP clinical next semester, and I'm at the crossroad of getting out or staying in. I'm trying to make the best informed decision since military is all that I know! My email is [email protected] and I would appreciate picking your brain. Thanks

[zenman]

Email on the way.