Initial discussions regarding formation of a coalition of Texas advanced nursing practice nursing organizations occurred during summer 1991, after the third party reimbursement bill introduced in the 1991 Legislative Session died in committee. It became clear to many of those involved in APN organizations that more resources had to be dedicated to advanced practice nursing issues. Many groups also felt a need to have direct input into legislative and regulatory issues critically affecting their practices. At the time of CNAP’s formation, the accepted term for practitioners was “advanced practice nurses” or “APNs.” Today, the accepted terminology is “advanced practice registered nurses” or “APRNs.” In this report, the terms are interchangeable.
At this time, some advanced practice nurses (APNs) had dependent prescriptive authority if they practiced in a rural or medically underserved area. Family and pediatric nurse practitioners, certified nurse midwives, and certified registered nurse anesthetists were eligible to receive Medicaid reimbursement at 65% to 70% of the physician rate.
CNAP Formation and Structure
Four forward-thinking women are responsible for founding CNAP: Elaine Brightwater, CNM; Carol Cody, WHNP; Ira Gunn, CRNA; and Zo DeMarchi, WHNP. The original members of CNAP included the Consortium of Texas Certified Nurse Midwives (CTCNM), Greater Texas Chapter of the National Association of Pediatric Nurse Practitioners (Texas NAPNAP), Houston Area Chapter of the National Association of Pediatric Nurse Practitioners (Houston Area NAPNAP), Houston Association of Psychiatric Nurses (HAPN), Texas Association of Nurse Anesthetists (TANA), and Texas Nurse Practitioners (TNP). CNAP was officially incorporated as a 501(c)(6) organization in 1992.
CNAP representatives are responsible for the operations of the organization. The most important responsibility for each representative is ensuring their own organization’s board is aware of CNAP activities and involved in the decision making process. Most representatives also write newsletter articles for their organizational newsletters, and report on CNAP activities during state and local meetings. It is vital that the membership of each organization is aware of CNAP activities and that APRNs engage in the legislative process on behalf of the issues that affect their professional lives and the health of their clients.
One of the biggest issues for CNAP is raising funds for CNAP through individual contributions from APNs. Dues from member organizations only cover basic operating expenses and the contract with the Executive Director. The money necessary to contract with lobbyists, and fund special projects must be funded through individual contributions. CNAP requires substantial individual contributions. CNAP’s primary fund raising event is the annual reception in conjunction with the TNP Fall Conference. We urge APRNs to donate on an annual basis to this campaign, or to become a CNAP Partner by contributing the equivalent of one hour of their salary a month. Beginning in 2006, CNAP embarked on one of the biggest fund raising effort since 1994 when CNAP and TNA launched “The Campaign to Achieve Prescriptive Authority.” CNAP and its member organizations asked1,000 APNs to donate at least $30 a month through 2015. In order to reach this goal, major fund raising efforts will have to occur in every local APRN group.
CNAP Staff and Lobbyists
Coalition representatives hired Kathy Hutto as our lobbyist in December 1991. Kathy was a social worker for seven years and became interested in governmental affairs while earning her master of social work degree. Kathy was a Senior Analyst for the Texas Sunset Advisory Commission for five and a half years before beginning her association with Small, Craig & Werkenthin, now Jackson Walker, L.L.P. Kathy has approximately 10 – 12 clients in addition to CNAP. Kathy continues to serve as our primary lobbyist and works with the APRN lobby team.
During legislative sessions, CNAP may hire additional lobbyists to represent APRN interests. For the 1993 Legislative Session, CNAP hired Nub Donaldson, a partner with Small, Craig & Werkenthin. Before the 1995 Legislative Session, the Texas Association of Nurse Anesthetists (TANA) and CNAP cooperated with Texas Nurses Association to establish the Campaign to Achieve Prescriptive Authority. We raised $200,000 to hire Jack Roberts and Rusty Kelley for the 1995 session. In 1998, CNAP hired Lynda Woolbert, MSN, RN, CPNP, as the Director of Public Policy to perform both lobbying and organizational services. CNAP retained former Chair of the House Public Health Committee, Hugo Berlanga, to represent CNAP from 1999 – 2003. In 2009, CNAP hired Texas Capitol Strategies, a lobbying group that includes former state representatives, Stan Schlueter and Peggy Hamric, as well as experienced lobbyists, Eric Glenn, and Cissy Ellis.
In 2004, facing continuing threats from Texas Society of Anesthesiologists TANA hired three additional lobbyists: Roland Leal, Patricia Shipton, and former state representative Arlene Wohlgemuth. All three worked for TANA under the leadership of CNAP’s primary lobbyist, Kathy Hutto. Roland Leal’s efforts were particularly helpful in achieving the increase in the Medicaid reimbursement rate to 92%. Arlene’s efforts during the Interim and 2009 Legislative Session to achieve Nursing-Board-Granted Prescriptive Authority were outstanding. When she decided to leave the lobby, TANA hired Trey Blocker; Roland and Trey continue as an integral part of the APRN lobby team and have led the efforts to defeat bills that would establish licensure for Anesthesiologist Assistants (AA’s). In 2011, Texas Nurse Practitioners (TNP) added more muscle to APRNs’ efforts with the hiring of Janis Carter and Rebecca Moss at Winstead, as well as Thomas Ratliff and Kevin Cooper with the Ratliff Company.
On November 30, 2011, after 20 years of dedicated services as both a volunteer and Executive Director/Public Policy Director, Lynda Woolbert, MSN, RN, CPNP decided it was time to begin the next chapter of her life as a consultant to APRNs, physician practices, hospitals and other health care delivery systems regarding the laws and rules surrounding APRN practice. CNAP hired Jennifer Fontana, CAE as Executive Director on November 15, 2011. Jennifer will handle all operational aspects of the organization. Pattie Featherston was hired February 1, 2012 as Director of Public Policy and resigned October 2012. Trish Conradt was hired November 2012 to serve as Public Policy Director and managed legislative issues, as well as grassroots efforts for CNAP. Trish resigned her position with CNAP effective October 31, 2013, due to a change in her family situation. November 1, 2011 Lynda Woolbert was rehired to review and manage all regulatory issues.
A continuing issue regarding Medicaid reimbursement is obtaining 100% of the physician reimbursement rate for APRNs who prefer that their rate not be based upon that of physicians. After working with the Medicaid staff in 1992, to develop an APN relative value scale, the staff preferred to continue with the present format. The Medicaid staff was supportive of increasing our reimbursement rate.
Kathy Hutto led our successful effort, in 1992, to increase Medicaid reimbursement to 85% and to make all categories of advanced practice nurses eligible for reimbursement. The Texas Department of Human Services administered the Medicaid Program, at that time. Now that function rests with the Texas Health and Human Services Commission, but our relationship with the Medicaid staff remains positive.
Before the 2003 Legislative Session, physician organizations agreed to support an increase in the Medicaid reimbursement rate for APNs to 92% of the physician’s rate. However, the agreement was contingent upon an increase in the overall funding for Medicaid Professional and Outpatient Services that would at least equal the estimated $1 million cost of increasing APNs’ reimbursement rate. Unfortunately, the state’s budget crisis during 2003 went from bad to worse, the funding for professional and outpatient services was cut, and we were not able to pursue the increase. In 2005, a rider was included in the Appropriations Bill that directed the Health and Human Services Commission (HHSC) to directly reimburse APNs and PAs. This ultimately led to HHSC increasing the reimbursement rate for APRNs to 92% beginning March 1, 2006.
Of course, as Medicaid in Texas is increasingly delivered through managed care, CNAP works with Medicaid managed care companies to ensure those companies include APNs on their managed care panels. Lynda Woolbert’s involvement in the 2003-2004 Governor’s Medicaid Reform Task Force ultimately lead to a provision in 2005 legislation that requires participating managed care organizations to include APNs on their provider panels as primary care providers.
CNAP’s Legislative Activities
CNAP limits its activities to legislative and regulatory issues within Texas. During each Texas Legislative Session (held for 140 days in January through May of every odd-numbered year), CNAP reviews and comments on proposed legislation that may impact APRN practice or clients’ health. The major goal are to see that legislation supportive of ARPNs is either passed or defeated in both houses of the legislature and either signed vetoed by the Governor as appropriate. These efforts involve grassroots organization. As part of this effort, CNAP sponsors a Legislative Day in January or February each session. Starting in 2004, CNAP Legislative Day became an annual event, and in 2005, CNAP representatives began lobbying at the Capitol once a month during each Regular session.
Between legislative sessions, CNAP encourages APNs to visit their legislators in their home districts. Educating legislators about APNs and their practices requires an ongoing effort and is essential to our success. In addition to grassroots organization, CNAP monitors the rules and regulations written by each state agency to implement the legislation passed in the previous session. CNAP also monitors the work of interim legislative committees and arranges testimony on APN issues whenever appropriate. CNAP develops a legislative agenda for the following session, and works with the TNA’s Nursing Legislative Agenda Coalition (NLAC) and TNA staff in finalizing legislative goals and writing legislation. Then, both TNA and CNAP work with other provider groups and legislators to gain the needed support and sponsorship for the proposed legislation.
CNAP activities during each session are summarized.
1993 Legislative Session
Legislators introduced two pieces of legislation on CNAP’s behalf in the 1993 session. We felt successful that both the prescriptive and clinical privileges bills received hearings in committee, and many legislators and staff members were educated on our issues. The third party reimbursement issue was addressed by naming APNs as providers in the small business insurance legislation introduced by Representative Mike Martin in the House and Senator Carl Parker in the Senate. This legislation was passed and signed by the Governor. Kathy also successfully prevented TMA from amending the Appropriations Act to prevent any future increase in the Medicaid reimbursement rate for APNs.
1995 Legislative Session
As a result of problems experienced during the 1993 Legislative Session, it was evident to both TNA and CNAP that closer cooperation was critical for nursing’s legislative success. However, there are basic differences in our philosophies. Therefore, a mediator was hired and both groups worked to develop legislation and strategy that could be endorsed by both groups. The result was the Campaign to Achieve Prescriptive Authority and language in SB 673 to expand prescriptive authority to additional sites. Language assuring CRNAs could continue selecting and administering anesthetic agents for patients under an order from a surgeon was also included. One of the most important advancements from the 1995 session was formation of the Ad Hoc Committee on Collaborative Practice. This committee includes 5 physicians, 5 APNs, and 5 PAs that report to their respective organizations. The goal of the group was to work together to solve any problems resulting from implementing SB 673 and to determine what statutory changes were needed in 1997 that were mutually agreeable. However, the work of this group proved to be mutually beneficial continued through 2003.
1997 Legislative Session
The major accomplishment of this session was passage of HB 2846. CNAP and TNA, as well as TMA (Texas Medical Association), THA (Texas Hospital Association, and TAPA (Texas Academy of Physician Assistants) supported this bill. The provisions in HB 2846 expanded the sites at which APNs and PAs could apply for prescriptive privileges to include school-based clinics. The requirement for onsite physician’s visits in medically underserved clinics was also changed from once a week to once every 10 days the APN is on site. This bill also contained provisions which, for the first time, advanced third party reimbursement for APNs. Insurance companies must reimburse APNs for a covered service unless the insurance company specifically excludes services provided by an APN in the insurance policy. Managed care companies are also required to name the APN or PA on its provider panel if the collaborating physician is on the panel, and the physician and APN or PA request inclusion. Managed care organizations are also prohibited from refusing to reimburse APNs based on the fact that we are not listed in Article 21.52 of the Texas Insurance Code. However, this final provision is no longer applicable, since APNs were added to Article 21.52, Insurance Code, in 1999. (Article 21.52 is now codified in Chapter 1451, Insurance Code.)
CNAP representatives always review proposed legislation that might impact our interests or those of our clients. There was a high volume of such legislation in this session. Through great persistence, APNs were included in the protections afforded other provider groups and their clients in the managed care legislation, Senate Bills 382, 383, 384, 385, 386.
This was the first legislative session in which APNs were able to keep up to date on events during the legislative session through the Internet. CNAP provided weekly updates, so APNs from all over the State were able to respond to requests for support very rapidly.
1999 Legislative Session
Again, through the cooperative efforts of the organizations that developed the legislation in 1997, seven issues were agreed upon and served as the basis for CNAP’s primary legislation in 1999. The centerpiece for the 1999 Legislative Session was passage of SB 1131. It contains five provisions. It assures APNs minimum rights in hospital privileging, allows physicians to designate a LVN or RN or call prescriptions to the pharmacy for APNs, allows APNs to perform physicals for cosmetologists’ licenses (no longer required), directs state agencies to accept the APN’s documentation for services, and adds APNs to Article 21.52, Insurance Code. SB 1133 adds Registered Nurses to the Professional Procurement Act, and HB 1409 allows APNs to perform federal Department of Transportation physical exams for school bus drivers.
In addition to our primary legislation, SB 1340 became a very important bill for CRNAs. This bill, regulating anesthesia provided in office settings, is the first piece of legislation that clearly identifies the Board of Nurse Examiners as the regulatory agency for nurse anesthetists and the Board of Medical Examiners as the regulatory agency for anesthesiologists.
At the end of the 1999 session, SB 1468 passed, allowing physicians to participate in collective bargaining with managed care companies. CNAP spearheaded the addition of an amendment to prohibit physicians from negotiating to limit participation in health plans by other types of health care providers.
1999 marked a turning point for CNAP and advanced practice nurses in Texas. While much remains to be accomplished, it was the first session in which the term “health care provider or practitioner” became much more common. Fewer bills were introduced that referred only to physicians when other health care providers could also legally perform the services. In most of these instances, legislators were very cooperative in expanding the language in bills to include APNs. It was also the first legislative session in which APNs gained substantially more than we had anticipated at the beginning of the session.
2001 Legislative Session
Negotiations with medicine stalled early in the 2001 Legislative Session when medicine required that the items negotiated by the Ad Hoc Committee on Collaborative Practice were a package deal tied to nursing’s agreement to a 4-year moratorium. The moratorium proposed by medicine would have prohibited CNAP from seeking any legislative or regulatory changes that were not approved by medicine until December 31, 2004. CNAP and TNA declined medicine’s offer. In so doing, we lost medicine’s support for two issues: 1) a legislative change that would allow physicians to delegate prescription of Schedule III, Controlled Substances to APNS, and 2) a regulatory change to increase Medicaid reimbursement for APNs from the current 85% of the physician’s rate to 92%.
To foster a continued working relationship between medicine and nursing, CNAP and TNA proposed an exit strategy from the negotiations in hopes of re-establishing negotiations after the 2001 Legislative Session. In the end, medicine agreed to support two minor changes in law on delegated prescriptive authority. The result was SB 1166 authored by Senator Frank Madla (D-San Antonio) and Representative Jaime Capelo (D-Corpus Christi). SB 1166 allows a physician in a primary practice site to also delegate prescriptive authority in one alternate practice site where the physician only has to be on site 20% of the time. The bill also grants authority to the Texas State Board of Medical Examiners to waive some of the physician’s supervisory requirements that must be fulfilled in order to delegate prescriptive authority to an APN. The physician and APN must demonstrate that those requirements cause an undue burden without a corresponding benefit to patient care. Governor Rick Perry signed SB 1166 into law on May 11, 2001, and it went into effect immediately.
2003 Legislative Session
As usual, negotiations with medical associations through the Ad Hoc Committee on Collaborative Practice began several months before the opening of the 78th Texas Legislative Session. Those negotiations proved to be more difficult than getting the bill passed. It required many hours of intense negotiation and a mediator to help us reach an agreement.
Ultimately, medical organizations agreed to requiring hospitals, HMOs and PPOs to use a standardized credentialing form for APNs and PAs, and allowing physicians to delegate Controlled Substances, Schedules III – V, with three restrictions. Prescriptions for controlled substances signed by APNs are limited to a 30-day supply. No refills are permitted without prior consultation with the physician (consultation noted on chart). In addition the initial prescription for a controlled substance for children under 2 years of age will require prior consultation (consultation noted on chart). Representative Jaime Capelo filed HB 1095 and Senator Jane Nelson sponsored the bill. It flew through the legislative process and was signed into law by Governor Perry on May 20, 2003. The bill went into effect immediately.
In negotiations, physicians also agreed to support an increase of 7 percentage points in the Medicaid rate for APNs (from the current 85% to 92%). This would be an 8.2% increase in Medicaid payments to APNs billing under their own names. While this is an issue that the Health and Human Services Commission could approve without legislative action, we knew that no state agency would increase an item in their budgets unless there is a legislative directive in the Appropriations Bill to do so. Unfortunately, the budget cutbacks made it impossible to obtain funding for the Medicaid reimbursement increase.
To gain the physicians’ support, we agreed to a full moratorium on any further expansions in scope of practice through the 2007 Legislative Session. There was one exception. The Texas Society of Anesthesiology decided the moratorium on anesthesia issues should end after the 2003 Session, or any special sessions that followed. Since the threat of additional special sessions continued into fall 2004, the moratorium on anesthesia issues lasted through most of 2004, and set the stage for hot debate in 2005.
2005 Legislative Session
TANA hit the 2005 Legislative Session with an organized effort to deter any legislation from being filed that would require physician supervision for CRNAs. As the session progressed, the weekly visits to the Capitol continued and the focus shifted to deterring any amendment being offered that would require supervision. Not only was TANA successful in any language that would require physician supervision, CRNAs were very successful in educating legislators about CRNAs with their campaign, “How do you say quality anesthesia care? Certified Registered Nurse… A-nes-the-tist.” Another slogan was also quite effective. “If youcan say methodtist, you can say anesthetist.”
Despite the moratorium, and resulting fact that there was no legislation filed on behalf of APNs, the was a very successful session. APNs focused on lobbying for a rider to the Approporations Bill that would require the Medicaid Program to reimburse APNs at 92%. The resulting rider in Article II (two) was not what we expected. At the top of page 88 in Article II, item 72 states:
Advanced Practice Nurse and Physician Assistant reimbursement. The Health and Human Services Commission shall adopt rules to provide that the Commission shall not pay for any Medicaid service provided by an Advanced Practice Nurse or Physician Assistant unless it is billed under the Advanced Practice Nurse’s or Physician Assistant’s provider number.
At the time, we assumed this would eliminate the HHSC rule that allows physicians to bill for services provided by APNs and that all APN services would be reimbursed at 92%. HHSC staff did increase the reimbursement rate to 92%. However, HHSC rules continue to allow physicians to bill for services provided by NPs, CNSs and CNMs using an APN modifier andto be reimbursed at 100%.
The 2005 Session was also the year that the issues involving RN First Assistants were finally settled. HB 1718 allows APNs who successfully complete an RN First Assistant course to first assist within their scope of practice without being certified as an operating room nurse (CNOR).
In all there were nine bills that became law that specifically mentioned APNs. Among these was a bill that established a pilot clinic in a state office complex staffed by an NP. If the clinic results in cost savings, the bill allows expansion of the program.
The 2005 Session ended on an exciting note. An amendment was offered on the House Floor that would have gutted the language in SB 1188 requiring HHSC to include language in its contracts with Medicaid managed care companies to include APNs as primary care providers. We were overjoyed when the original language was restored when the bill went to conference committee.
2007 Legislative Session
This was the final session under which we were constrained by the moratorium. None the less, it was a busy session. The salary grade for state-employed NPs was raised and for the first time it equals that of physician assistants. Eight bills were passed that included amendments proposed by CNAP. The Texas Association of Nurse Anesthetists also had a busy session and successfully defeated bills that would have licensed anesthesiology assistants. The nursing board was under review by the Sunset Advisory Commission so there were also some major changes in the Nursing Practice Act, including adoption of the APRN Compact and changing the name of the Board of Nurse Examiners for the State of Texas to the Texas Board of Nursing.
2009 Legislative Session
CNAP continues to be committed to work with medical organizations. Prior to the 2009 session, CNAP participated in talks with medical organizations to explore if there was a possibility to reach an agreement on legislation for 2009. We knew that medical organizations would not agree to end delegated prescriptive authority but physicians indicated they would consider ending site-based restrictions. The groups met five times from February through September 2008. Negotiations at the May and June meetings appeared hopeful. However, in the end, the medical organizations insisted that physicians must be limited to delegating prescriptive authority in only certain sites and negotiations ended. This set the stage for APNs to pursue legislation that did not include physician delegation.
Consequently, 2009 was the first legislative session in 14 years in which a bill was introduced that would include diagnosis and prescribing in the APN scope of practice . The Texas Board of Nursing would grant prescriptive authority rather than having the authority stem from delegation by a physician. Therefore we referred to the legislation as “Nursing Board-Granted Prescriptive Authority.” Rep. Wayne Christian filed HB 1107 and Rep. Eddie Rodriguez signed on to also author the bill. While the bill did not emerge from committees in the House or Senate, HB 1107 had a good hearing by the House Public Health Committee. Late in the session, the issue was passionately debated on the House Floor when Rep. Christian offered an amendment to substitute the language from his bill into SB 532. While his amendment was ultimately killed on a point of order, it was the first time in history that the full House heard a debate involving independent prescriptive authority for APNs.
Sen. Glenn Heagar and Rep. Rob Orr filed middle ground legislation that reflected many of the concepts negotiated with physicians prior to the session. SB 680 and HB 696 continued physician delegation but would end site-based and controlled substances restrictions on a physician’s authority to delegate prescriptive authority. Both bills had committee hearings, but neither committee passed the bill.
Ultimately, the bill that passed in 2009 was one negotiated by representatives of major retail clinics, Texas Medical Association and the Texas Academy of Family Physicians. Rep. Orr offered some amendments on the House Floor that improved the bill, but SB 532, authored by Sen. Dan Patrick and sponsored by Rep. Garnet Coleman, primarily relaxed requirements for physicians in alternate practice sites. It also allows physicians to delegate to 4 APNs and/or PAs in sites that had previously been limited to 3 thanks to the amendment offered by Rep. Orr. APNs and PAs are able to prescribe a greater quantity of controlled substances, a 90-day supply instead of 30 days. For more details on SB 532, see information on the 81st Legislative Session.
2011 Legislative Session
In preparation for the 2011 Session, CNAP invested substantial resources to develop the right message for legislative change and to deliver that message effectively. We contracted with Southwest Stratagem, L.L.P. (Matt Mathers and Blanton Moore). An editorial tour of major daily newspapers resulted in favorable editorials in the Austin American Statesman, the Dallas Morning News and the San Antonio Express.
The session began with good news when the Texas Legislative Budget Board issued its 2011 Government Efficiency and Effectiveness Report. The LBB recommended that the Legislature change the laws on prescriptive authority to allow APRNs to diagnose and prescribe independently. Ultimately, 5 bills were filed by Representatives Wayne Christian, Kelly Hancock, Garnet Coleman, and Senators Rodney Ellis and Royce West.
CNAP also saw a long-term goal come to fruition by gaining the support of 13 Texas organizations for our legislation. APRNs had more lobby support than ever before. CNAP contracted with Diedra Garcia to support Kathy Hutto and Lynda Woolbert’s efforts. TNP contracted with 2 lobby firms, Winstead and the Ratliff Group, and TANA brought Roland Leal and Trey Blocker to the team.
APRNs were at the Texas Capitol visiting legislators almost every week. For the fourth session in a row TANA was successful in defeating legislation to institute licensing Anesthesiologist Assistants. However, even though our legislation in the Seante was referred to the Senate Finance Committee, we were unsuccessful in getting any of the five bills to either Floor of the Legislature.
2013 Legislative Session
Kathy Hutto and the lobbyists for the other APRN groups worked hard during the interim of the 82nd Legislature in 2011 to prepare for the 83rd Legislature that convened in January 2013 to craft a strategy to increase prescriptive authority for APRNs in Texas. It was clear after the 2011 session and discussions with key legislative staff during the interim, that legislators were not willing to discuss, much less enact an independent practice statute for APRNs. The APRN groups adopted a strategy calling for a “collaborative agreement” between physicians and APRNs similar in at least 17 other states.
In May 2012, the noted economics firm, The Perryman Group from Waco, released its report, The Economic Benefits of More Fully Utilizing Advanced Practice Registered Nurses in the Provision of Health Care in Texas:
An Analysis of Local & Statewide Effects on Business Activity. Here is a link: http://www.gandd.net/uploads/8/2/8/2/8282021/short_version_of_perryman_report_2012.pdf.
Some of the report’s key observations and findings state:
- One proven strategy for both improving patient care and reducing costs is greater utilization of Advanced Practice Registered Nurses (APRNs) including nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and clinical nurse specialists.
- A number of empirical studies support the conclusion that greater utilization of Advanced Practice Registered Nurses can both improve patient outcomes and reduce overall health care costs. In addition, many areas are facing shortages of primary care physicians; APRNs can help alleviate these problems.
- When Advanced Practice Registered Nurses are utilized within the systems of health care provision more efficiently, the economic benefits to the state are substantial. The Perryman Group estimates that the total current impact of enhanced efficiency includes $16.1 billion in total expenditures and $8.0 billion in output (gross product) each year as well as 97,205 permanent jobs in Texas.
Despite the above findings, there was not the legislative will to again pursue independent practice in the 2013 legislative session. The lobbyists for the APRN groups met numerous times together and with the lobbyists for the Texas Medical Association (TMA) and the Texas Academy of Family Physicians (TAFP) during the summer and fall to try to identify an agreed-upon strategy addressing increased prescriptive authority. Progress was limited so a joint meeting of the boards of these organizations met in early December 2012 to try and find common ground. After a day-long meeting, there were still many disagreements on issues but the groups agreed to meet again. This meeting never occurred.The APRN lobbyists team continued to meet but efforts shifted to working more intensely with key legislators and their staffs. On-going discussions between these groups and the chairs of the Senate Health & Human Services Committee, Senator Jane Nelson, R-Flower Mound, and the House Committee on Public Health, Rep. Lois Kolkhorst, R-Brenham, began to make some progress.
Chair Nelson’s committee staff worked hard with the APRN and medical groups’ lobbyists to craft an “agreed-to bill” early in the session. Senator Nelson was very enthusiastic that “finally” nursing and medicine had agreed to the principles in SB 406, which she introduced in early February and passed the substitute out of her Committee on February 18, 2013. Senate Bill 406 passed the full Senate on March 13, and was sent to the House of Representatives where it was finally referred to the House Committee on Public Health on April 2.
All along the way, the nursing and medical groups continued working with legislators to address any outstanding issues to ensure that the bill stayed an “agreed-to bill” and would not be stalled by any of the physicians in either the Senate or House. These efforts paid great dividends when the amended SB 406 received a unanimous vote in the House (146-0) and when the Senate unanimously (31-0) approved the House amendments to SB 406 on May 20, when it was sent to the governor who signed the bill into law on June 14, 2013.
During the session, there were a total of 5,868 House and Senate bills filed and 1,437 (24.4%) passed, which is average for the number of bills filed and passed each session. The governor vetoed 26 of the bills that made it to his desk. For more information on bills passed, see http://www.lrl.state.tx.us/sessions/sessionYears.cfm.
Though SB 406 was the major legislative effort in 2013, many other bills were monitored by CNAP, including bills that were enacted and those that were not.
After three called special sessions called by the governor over the summer, the legislature has finally entered its interim period. Legislators can expect interim assignments to be issued later this fall by the Lieutenant Governor and the Speaker of the Texas House of Representatives. These charges, while giving an early indication of what these two leaders think are priorities for their bodies for the 84th Legislature when it convenes in January 2015, they also give legislators a chance to study issues more thoroughly than they have a chance to during the heat of a legislative sessions. The work by the legislative committees on their interim charges also gives members of the public and issue experts a chance to attend and participate in the public hearings to give public testimony to create a public record on the many challenges facing the state of Texas.
Ad Hoc Committee on Collaborative Practice
As previously stated, the Ad Hoc Committee on Collaborative Practice consisted of five APNs, five PAs, and five physicians. The physicians represented the Texas Medical Association and various physician specialty organizations, including Texas Society of Anesthesiologists (TSA) and the Texas Academy of Family Physicians (TAFP). Two APNs represented the Texas Nurses Association and one nurse midwife, one nurse anesthetist and one nurse practitioner represented CNAP. The five PAs represented the Texas Academy of Physician Assistants. All of the representatives were required be practicing in a collaborative arrangement with physicians and APNs or PAs. The primary lobbyists and attorneys for these organizations also usually attended meetings. In addition, the Texas Hospital Association (THA) often sent representatives.
From 1995 – 2003, the Ad Hoc Committee continued to develop legislation and worked cooperatively with many state agencies to resolve problems affecting the practice of APNs and PAs. Because of TAPA’s involvement in the Ad Hoc Committee, most APN legislation currently includes PAs. There are differences in the practices of APNs and PAs, however. PAs are legally required to be supervised by a physician in all aspects of their practice and are regulated by the Texas Medical Board (TMB). As long as the APN is functioning within the scope of his or her practice, APNs perform most functions under their own RN licensure and APN authority. Only certain aspects of medical care are delegated by a physician, primarily the authority to make medical diagnosis and sign prescriptions. Of course, APNs in Texas are regulated by the Board of Nursing.
As stated above, the Agreement with Medical Organizations (moratorium) resulted from the work of the Ad Hoc Committee on Collaborative Practice. Our organizations agreed to a full moratorium on any further expansions in scope of practice through the 2007 Legislative Session. There are only two exceptions. The Texas Society of Anesthesiology decided the moratorium on anesthesia issues should end after the 2003 Session. The agreement also permitted discussions after the 2005 Session on a physician-based model for delegating prescriptive authority. However, in 2006, the medical organizations were not interested in opening serious discussions on expanding prescriptive authority beyond the current site-based model, and medical organizations’ commitment to restricting physicians who want to work with APNs continues to be a stumbling block.
Participation in the Texas RN/APN PAC
CNAP is also one of three participating members in the Texas RN/APN PAC. When the RN PAC became the RN/APN PAC in late 1995, TANA chose to remain an individual member of the PAC. The other members include TNA and CNAP. A Political Action Committee raises funds from individuals and unincorporated groups. These funds are then contributed to political candidates who support nursing issues. CNAP helps determine which candidates receive these funds, and in turn, is responsible for a proportional share of the administrative costs for the PAC. CNAP member organizations are asked to meet yearly PAC fund raising goals by soliciting their own members, and it is the organization’s responsibility to pay the costs of those fund raising activities. The Texas RN/APN PAC contribution form is online.
Participation in the Patient Choice Alliance
In 2004, the lobbyists and executive directors for several organizations started meeting on a regular basis. The foundling organization was a coalition of providers whose practices overlap with medicine, and called itself the Coalition of Independent Health Care Providers. The coalition included the following organizations.
Texas Optometric Association
Texas Nurses Association
Texas Podiatric Medical Association
Texas Chiropractic Association
Texas Psychological Association
Coalition for Nurses in Advanced Practice
In response to growing threats posed by two medical association coalitions, the Scope of Practice Partnership on the national level and PatientsFIRST on the state level, in 2006, the Independent Health Care Providers Coalition decided to become a formal organization called the Patient Choice Alliance (PCA). The Patient Choice Alliance is a coalition of independent health care provider associations supporting the rights of patients to choose their own health care practitioners. The stated purpose of the organization is to “promote patient choice in health care, to improve patient access to quality care, to remove artificial barriers to safe, well-educated and cost-effective health care providers.
CNAP Membership, Outreach and Education through 2014
In 2014, members of CNAP included the Consortium of Texas Certified Nurse Midwives (CTCNM), Greater Texas Chapter of the National Association of Pediatric Nurse Practitioners (Texas NAPNAP), Gulf Coast Gerontological Nurse Practitioners, Houston Area Chapter of the National Association of Pediatric Nurse Practitioners (Houston Area NAPNAP), Psychiatric Advanced Practice Nurses of Austin (PAPNA), Texas Association of Nurse Anesthetists (TANA), Texas Association of Neonatal Nurse Practitioners (TxANNP), Texas Clinical Nurse Specialists, and Texas Nurse Practitioners(TNP).
For over two decades CNAP printed two brochures. One explained the purpose of CNAP and was distributed to APRN groups and students. It explained CNAP’s mission and solicited the individual contributions that CNAP depended upon to fulfill its mission. The second brochure is designed to distribute to legislators, employers, or managed care organizations to explain the role of Rin Texas health care delivery.
From 1997 – 2015, CNAP e-mailed weekly Legislative Updates to any APRN requesting those updates. It was a very effective tool for keeping APRNs up-to-date on Texas legislative issues. In 1999, the communication efforts expanded to include occasional CNAP Interim Updates.
CNAP representatives and staff testified (or found APRN experts totestify) before legislative and regulatory bodies. Lynda Woolbert, CNAP’s Executive Director, also lectured in many APRN role courses and spoke at many APRN conferences throughout the state.
In 2006, CNAP expanded its outreach and grassroots organization by adding voterVOICE as a feature on its website. Through voterVOICE, CNAP sent messages to APRNs, even targeting APRNs in particular legislative districts.
Also in 2006, CNAP started holding annual stakeholder retreats to develop and refine its legislative agenda for to begin the legislative initiative in 2009 to end physician-delegated prescriptive authority. In April 2008, CNAP held its third stakeholder retreat and fine tuned its tactical plan to achieve this goal. Starting in 2007, CNAP representatives and staff made presentations at local groups and APRN conferences to educate APRNs about the legislative initiative to achieve full practice and prescriptive authority. CNAP’s. CNAP continued holding annual retreats to allow its member organizations to develop a unified legislative agenda through 2014.
CNAP produces documents and manuals to educate APRNs, employers, hospitals and managed care companies about the legal requirements of practicing in Texas. CNAP publishes a sample Prescriptive Authority Agreement (PAA) and sample Facility-Based Protocols. Since September 2006, CNAP and Texas Nurse Practitioners has published A Guide for APN Practice in Texas, now in its 5th edition. All CNAP publications are electronic documents and may be purchased online.