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The House Committee on Public Health met on March 24 to take up a number of bills. In order, this report focuses on HB 2211 (Metcalf), HB 1434 (Oliverson), HB 2053 (Klick), HB 2052 (Klick), and HB 2029 (Klick).

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

Vote Outs

CSHB 723 (Patterson) 10-0

CSHB 1011 (Turner) 10-0

HB 1363 (Minjarez) 10-0

HB 1386 (Harris) 10-0

Bills on Agenda

HB 2211 (Metcalf) Relating to in-person visitation with hospital patients during certain periods of disaster.

  • Patients in a hospital can receive 1 visitor during public health disaster, must complete health screenings & follow infection protocols; can restrict a visitor based on health risk
  • Have been working with THA and TMA, added provisions that hospital not be required to provide PPE, health screening consistent with hospital standards
  • Applies to non-cancer patients
  • Working on CS for clarity, physicians will be included in liability protections, hospitals will be able to remove a visitor not complying with PPE requirements, attending physician can renew order that patient with infectious disease cannot receive visitors
  • Provision for daily updates consistent with HIPAA
  • Oliverson – Significant issue, spoke with a pastor who was unable to visit end-of-life patients
  • Collier – Would your bill apply to LTC?
    • Strictly for hospitals
  • Collier – Can we change the one visitor? E.g. family member one day, pastor the next
    • Currently written as “at least” one visitor, would like to leave this up to hospitals
    • Have had very good conversations with THA
    • Not a dedicated one person for the whole period of care
  • Price – Encouraged that we’ll get to a good place with this bill, issue was raised constantly from constituents during the pandemic

Cesar Lopez, Texas Hospital Association – On

  • On the bill as filed, excited for the CS, continuing to try and address issues
  • Appreciate concerns, want to make sure we strike the right balance between access and safety
  • Guerra – Kept hearing horror stories from South Texas; some hospitals had visitation protocols and some did not?
    • Hospitals have always had standard visitation policies in place, needed to account for HHSC emergency visitation rules, federal rules, etc.
  • Guerra – Was reported to me that some hospitals in the RGV had protocols differing from others
    • Every hospital in the state had to follow the HHSC emergency rule, every hospital also had general visitation policies that had to layer with this rule
  • Guerra – Asking that you look at this, had no answers at the time
  • Zwiener – Struggling with this bill a little bit, lost 47k Texans over pandemic; if this had been in effect would it have let hospitals allow visitation and be nimble enough to keep patients safe?
    • There are provisions for isolation, etc. when infectious diseases are circulating
  • Zwiener – But that’s just for that patient
    • Correct; there is also a provision saying that if a federal rule requires no visitors then that takes precedent
  • Zwiener – If this was narrowed to pediatric patients, etc., would it be safer?
    • Don’t know answer to that, there were pediatric hospitals that allowed visitation
    • State could also issue another emergency rule
  • Zwiener – Do you know how many employees your members have lost to COVID?
    • Can get this data
  • Oliverson – Why do we allow patients to have visitors?
    • Could be an essential caregiver, for support, decision making, etc.; ultimately helps the patient
  • Oliverson – Would you agree that being separated from loved ones increases suffering?
    • Would tend to agree with that, didn’t want to enact measures
  • Oliverson – Point of the bill is you can underreact and overreact

Troy Alexander, Texas medical Association – On

  • Testifying on the filed bill, changes in the CS look like they will thread the needle between concerns about infectious disease and wellbeing of the patient

Lee Spiller, Citizen’s Commission on Human Rights – On

  • Would also like to see this applied to psychiatric hospitals

Sheila Hemphill, Texas Right to Know – For

  • Patients in ICU need that reason to live, only granted visitation at time of death
  • Would like committee to look at policies of NIH on COVID prophylactics
  • Klick – Beyond the scope of discussions today

HB 2211 left pending

HB 1434 (Oliverson) Relating to limitations on pelvic examinations; authorizing disciplinary action, including an administrative penalty.

  • Currently legal for a patient to have multiple pelvic exams performed while under anesthesia without consent as part of medical training
  • HB 1434 establishes a consent process for pelvic exams while under anesthesia, allows for an opt-out
  • Collier – So if I go in for gall bladder removal or tonsils, someone might perform a pelvic exam?
    • Not typically the case, can occur as part of uterine fibroid removal as part of training; training is important, but asking for specific consent before this happens
  • Collier – Sometimes they’ll ask for consent for a medical student to be present, does this authorize these exams?
    • Typically, pelvic exams are assumed part of routine OBGYN procedures; shouldn’t be assumed
  • Guerra – Shocking that this occurs, this is for student training? How long has this been going on?
    • Hard to pinpoint exactly how long this has occurred, we know it does
    • All trainees are required to perform pelvic examinations
    • HB 1434 specifically deals with situations where someone is under anesthesia, looking for specific consent in these situations
  • Klick – Asks after consent portion
    • You see a lot of associated consent, most women have reported to prefer opt-out or consent needed

Juliana Gonzales, SAFE Alliance – For

  • In any other context this would be considered assault

Anna Bilts, Self – For

  • Surveys show high incidence of medically unnecessary exams and low rates of informing patients
  • HB 1434 would ensure bodily autonomy and uphold principles of informed consent
  • Guerra – Unnecessary?
    • Necessary for student training, not medically necessary

Claire Lowell, Self – For

  • Procedures performed without consent are tantamount to assault
  • Klick – Are there any other types of exams like this that might occur without consent?
    • Unsure, most other things asked for during operations are medically necessary

HB 1434 left pending

HB 2053 (Klick) Relating to the licensing and regulation of genetic counselors; requiring an occupational license; authorizing a fee.

  • Creates licensure process for genetic counselors, defines practice of genetic counseling, requires individuals seeking licensure to obtain related masters degree
  • 18 other states are in rulemaking process, remaining states are considering licensure regulation

Carla McGruder, TSGC – For

  • Provides overview of genetic counseling profession; can be associated with cancer, cardio, pharmacogenomics, prenatal, pediatric, etc.
  • Training required through licensure will ensure patients have access to qualified counselors & avoid harm
  • Oliverson – Discusses possibility of detecting harmful conditions, tailoring pain medications
  • Oliverson – Can you speak to how your services are paid and reimbursed? Cash and carry? Insurance?
    • Genetic counselors can’t bill on their own in TX, must be done through physicians
    • Without licensure it makes it more difficult to be credentialed which makes reimbursement harder
  • Oliverson – So you’re base out of facilities as an unlicensed provider; you have an access problem, not that you can’t bill, but that you can’t be credentialed
    • Right, something like this
  • Oliverson – Would reimbursement also help make services more available in the community?
    • Absolutely, institutions have the right motives, but sometimes can’t pay
    • Counselors are in high demand

Brian Francis, TDLR – Resource

  • No questions for the resource witness

Rep. Klick closes

  • Licenses for medical professionals in an emerging field that can and will expand as we understand more

HB 2053 left pending

HB 2052 (Klick) Relating to public access to certain hospital investigation information and materials.

  • Intent of HB 2052 is to increase transparency by making final investigative outcomes and how many times a hospital has been investigated open to the public
  • Some of the info is subject to the FIA and can be obtained
  • Agreed to bill, stakeholders have signed off on bill

Lee Spiller, Citizen’s Commission on Human Rights – For

  • Inspections for facilities are available in many other industries
  • Some reports are available from the feds, but takes time and costs money

Becky Berring, Self – For

  • Mother went to St. Luke’s for heart transplant & passed, outcomes were very low & information was not available until years later
  • Was never made aware of outcomes issues with St. Luke’s before choosing hospital

Cameron Duncan, Texas Hospital Association – For

  • Worked with Rep. Klick on this legislation to provide more information on hospital investigations
  • HB 2052 requires HHSC to post notices and other info of alleged violations publicly

Sheila Hemphill, Texas Right to Know – For

  • Public can only be informed currently about conditions in hospitals via media

Ware Wendell, Texas Watch – For

  • John Hopkins showed medical errors were the 3rd leading cause of death, New England Journal of Medicine reported that 1 in 4 patients may experience harm
  • Was a mistake that this information became confidential, patients have right to know where state identified problems

HB 2052 left pending

HB 2029 (Klick) Relating to the licensing and authority of advanced practice registered nurses.

  • 7 million Texans live in a primary care shortage area, APRNs have stepped in to fill gaps
  • Texas has grown dramatically in a short time, number of primary care doctors has not kept up
  • 31 other states have removed barriers allowing APRNs to fill gaps
  • Previously removed physician direct supervision, delegating physicians do not need to visit the APRN practice or provide care
  • Will see more APRNs working through telehealth in other states without delegation barrier; cannot lose these practitioners
  • Delegation agreements create hidden tax on health care, APRNs have reported spending up to $80k/year on contracts
  • Multiple APRNs work under one delegating physician, interruptions with that physicians can halt necessary care
  • Have heard of attacks against the bill and stories of patient harm, but nothing to do with physician delegation for APRNs which requires no direct supervision or physician checks

Holly Jeffreys, Texas Nurse Practitioners – For

  • Member practitioners sometimes the only care providers for certain counties
  • Highlights issues with delegation contracts, decision is often to pay outlandish fees or close shop
  • Continued practice for the APRN relies on continued practice of delegating physician
  • Delegation agreements do nothing to benefit patients; in 2013 direct supervision was removed
  • Continue to have large areas around the state with little or no access to health care
  • 31 other states have removed delegation
  • Klick – Does your delegating physician see your patients? Diagnose and prescribe? Step foot in your practice?
    • No
  • Klick – But you have to pay monthly for the contract to check a box
    • Correct
  • Klick – How far away is the nearest provider to your location?
    • 150 miles away in some cases, at least 60 miles minimum
  • Klick – And you do women’s health as well; if this legislation passed what would your practice look like tomorrow?
    • Nothing, agreements do not advance scope of practice
  • Collier – What training is required to become an APRN?
    • Graduate degree from an accredited school, required to obtain a state license
  • Collier – How many years for the graduate program? Online, in-person?
    • Different programs vary, 2-4 years, combination; many traditional programs are online partially due to COVID
  • Collier – Are there schools that do solely online classes?
    • Variety of different schools, can’t answer specifically
  • Collier – Do you do rounds?
    • Yes, do clinical time, wasn’t waivered during COVID; included in the graduate degree
  • Collier – Do you need to have liability insurance, would it go up under this bill?
    • We do, would not change; based on number of claims
  • Collier – Would newly licensed APRNs be qualified for independent practice?
    • Would be qualified to practice without a delegation agreement
  • Collier – Do APRNs formulate diagnoses, treat health problems, prescribe therapeutic and corrective measures?
    • Yes
  • Collier – Schedule II? Do you know the percentage
    • Some APRNs; Schedule II language won’t change
  • Collier – Yes, but what will change is delegation authority; is it possible more APRNs would prescribe Schedule II drugs?
    • Not really unless hospice or ERs increase number of APRNs hired
  • Collier – What’s the difference between APRNs and medical doctors besides surgery?
    • Bill is only for APRNs
  • Collier – Why would I go to a doctor if I could go to an APRN?
    • Patient’s choice, can visit a physician if there is one available
  • Collier – Can you have more than one delegation agreement?
    • You can
  • Collier – Does this bill also apply to nurse anesthetists?
    • Yes, all under APRNs
  • Collier – Do you know if the Texas Nursing Board has an APRN on it?
    • Multiple
  • Collier – Concerning you haven’t had conversations with delegating doctor; just because it isn’t happening doesn’t mean it’s not helpful
  • Price – Are delegation agreements typically standard agreements or tailored to whatever situation APRN is in?
    • There is a standard agreement, need to pinpoint location and specialty
  • Price – Some delegating agreements can be very broad, could include HB 2029 terms?
    • These are part of the Nursing Board scope of practice
  • Price – Are some agreements more restrictive than what is listed in the bill?
    • A physician and APRN probably could draft a unique agreement
  • Price – Don’t know we can generalize, is that correct?
    • Delegation agreements generally say we can do the job we’re trained to do
  • Price – So they don’t get prescriptive, sounded like physicians could restrict APRNs; important to understand if language in bill allows APRNs to do anything they can’t do already
    • Delegation agreement specifies where you will practice, to what population, scope of practice
    • Delegation agreements generally don’t restrict APRN practice capability
  • Price – How many APRNs with broadest level of authority under delegation agreements there are?
    • No, but if delegation agreements restricts even one patient from access to care than they are worth removing
  • Oliverson – Is there still a face-to-face meeting requirement in Texas?
    • Yes, we did
  • Oliverson – Regarding schedule II, are you licensed to prescribe narcotics right now?
    • No
  • Oliverson – Is any APRN able to prescribe in a freestanding clinic? My understanding is that this is against the law, there is separate legislation on this issue to give APRNs and PAs ability to prescribe
    • Correct
  • Oliverson – So the bill does move the ball
    • No, still will not be able to prescribe schedule IIs because I’m not in that setting
  • Oliverson – Are you aware that bills were filed previously to not allow physicians to charge for delegation agreements and APRNs opposed?
    • I would oppose; removal of agreements more about access to care
    • Money affects ability of APRNs to maintain a practice
  • Oliverson – No face-to-face meeting requirements, no need to travel, if we were to get rid of charging for delegation agreements would you support this?
    • I think you wouldn’t find many who are willing
  • Oliverson – How many states that removed delegation immediately removed APRNs from supervision
    • Research has shown this is not beneficial
  • Oliverson – I think I’ve seen research saying the opposite

Dr. Troy Fiesinger, Texas Medical Association – Against

  • Addressing costs of health care should be the focus of policy changes
  • Concerned that expanding scope of practice for APRNs will not achieve this goal
  • APRNs are integral part of successes in patient care; care agreements and monthly visits help ensure high quality of care
  • Have never charged for prescriptive authority agreements
  • Klick – Do you currently have agreements in place?
    • Have 7 in place
  • Klick – Are they employees or independent contractors? Do they work in a specific setting or multiple settings?
    • Employees; depends, some work in clinic, do house calls, etc.
  • Klick – So the APRN work without a doctor on site in some cases?
    • In clinics there are physicians
  • Klick – Are the NPs operating under your supervision seeing patients today?
    • Yes
  • Klick – IS this typically how supervision works?
    • Supervision works in many ways, can see patients solo or in concert
  • Klick – Can your NPs work with other physicians
    • Can collaborate with whoever they need to in order to provide the best care
  • Klick – So the agreement doesn’t necessarily create collaboration
    • Establishes the importance of collaboration
  • Price – Regarding scope of practice written out in the bill, sounds very similar to practice of medicine; are there distinctions?
    • Description in bill is what I do practicing under physicians license in Texas
  • Price – Bill says APRNs are not considered to be practicing medicine without a license, can only assume it is there to avoid litigation, ambiguity in licensing, etc.; if the scope in the bill is the same as the practice of medicine should there be combined oversight between Nursing Board and Medical Board?
    • Can’t see any distinction in scope of bill from practice of medicine; if service being delivered is the same, then should look at regulation
  • Price – Is the standard of care the same under the Nursing Board as the Medical Board?
    • In other states they have unified these boards or they work in conjunction with each other
  • Smith – How long have delegation agreements been in place?
    • Current iteration was passed in 2013
  • Smith – So that was a pivotal session in connection with creation of agreements; prior to this how were NPs employed and practicing?
    • Work was similar, but there were different standards and expectations for different settings; agreements were designed to create a uniform that made sense
  • Smith – What has changed since 2013?
    • In terms of practice of medicine, nothing
  • Allison – What is delegated under the agreement?
    • Delegating practicing medicine, held responsible by Medical Board
  • Allison – Duties and performances are delegated by you as a physician? Bill takes away that delegation?
    • My reading is yes; eliminates need for delegation
  • Allison discusses Dr. Fiesinger’s care team operating under delegation agreements; team works under agreements as required by law
  • Allison – Bill is moving APRNs out of that care team?
    • Changing their regulatory position, yes
  • Allison – What board is referenced in the bill?
    • Nursing Board
  • Allison – Not the Medical Board even though under the bill they are practicing medicine; seems like the more appropriate board would be the Medical Board
    • Decision that should be discussed at length, I think the practice of medicine should be regulated by the Medical Board
  • Campos – Would changing the Medical Board to incorporate mid-level practitioners or moving APRNs to the Medical Board be enough to assuage issues with the bill?
    • Would not be enough

Erin Sing, Consortium of Texas Certified Nurse-Midwives – For

  • Delegation agreements may seem like they are beneficial, but statistics show reductions in outcomes and increased care disparities; states with delegation agreement systems saw higher pre-term birth rates overall and then even higher for certain demographics
  • March of Dimes has stated that increasing access to midwife services would increase outcomes; would lead to cost savings
  • Diagnosis and prescription are not exclusive to practice of medicine
  • Won’t hear evidence of how these types of agreements improve outcomes or improve disparities because they do not; fix is to remove restrictions
  • Oliverson – Are you trained to do c-sections?
    • No
  • Oliverson asks after delegation authority and collaboration
    • Many seem to think delegated authority helps collaboration or APRNs don’t want collaboration, but this is untrue
    • Collaboration and delegation are completely separate, APRNs collaborate constantly
  • Oliverson – Possible that APRNs would practice independently
    • I don’t want to practice independently and don’t want to practice medicine; not what this bill is about
  • Oliverson – I think it is; we’re severing link between Medical Board and Nursing Board; difficult to imagine a situation where midwives or nurse anesthetists are practicing separately
    • That would not happen
  • Oliverson – But delivering babies is the practice of medicine
    • Texas law is clear that midwifery is not medicine; physicians practice medicine
  • Zwiener – What would change for you in day-to-day practice if delegation agreements were removed?
    • Because I’m in a large practice it wouldn’t change a lot; wouldn’t have the hassle of pinning down physicians to do chart reviews
    • Main change would be to bring more midwives into the state and this is when you see the improved outcomes; current system discourages this
  • Klick – Does your delegating physician see your patients with you?
    • No
  • Klick – Do they review all charts and prescriptions?
    • No, 3 charts a month at our facility
  • Klick – How much time is involved with reviewing charts?
    • Typically done on her own
    • Don’t have a delegating agreement right now, working as a hospitalist

Mia McCord, Texas Conservative Coalition Research Institute – For

  • TCCRI has been supportive of removing unnecessary and outdated mandates for APRNs over the last decade
  • Access to care issue; does not expand scope of practice for APRNs
  • Highlights Texas’ physician shortage which affects access, removing barriers is a no cost solution to this access to care issue; voters largely support removing these restrictions
  • States with no restriction on APRN practice have seen significant Medicaid savings
  • APRNs are not required to be collocated, no significant oversight measures; removing agreements with no practical oversight would not change safety

Dr. Debra Patt, Texas Medical Association – Against

  • TMA strongly supports increased access and lowered care costs; solutions incl. bolstering loan repayment programs, rural care training, investment in graduate education
  • Could also look to decreasing number of uninsured individuals in the state; Medicaid alone is not adequate
  • Does change current practice, does involve schedule IIs; worry about future where APRNs are prescribing independently without delegation
  • Many APRNs go into specialty care, not necessarily an increase to primary care access
  • Delegatory agreement is structured by the state; issues with high costs are likely due to separately negotiated contracts
  • By statute supervision is done monthly, but in practice this is often much more common
  • Don’t want to see physicians removed from practice; does change practice of medicine and bill text does involve schedule IIs
  • Klick – Your NPs in your clinic are employees, correct?
    • Yes
  • Klick – Other settings have NPs practicing independently, one of the differences

Dr. Jaime Estrada, Texas Doctors for Social Responsibility – For

  • Organization’s mission is to fight for access to care regardless of income, one goal is removing restrictions to practice for APRNs & improve access in rural and medically underserved areas of the state
  • Klick – How does collaboration work in health care and do these contracts create collaboration?
    • Have worked with APRNs since training
    • Don’t see a reason for delegation agreement to exist, will not change APRN or physician practice, definitely makes APRNs think twice about coming to Texas

Laura Greek, Coalition for Nurses in Advance Practice – For

  • Shares experience as an APRN in rural communities
  • Scope of practice is well-defined for APRNs, want to practice as nurses and bridge care gap
  • Smith – Sounds like you’ve had good collaboration with physicians; how would you collaborate without an agreement?
    • Collaboration is something that we need, formality of the agreement isn’t crucial to having a collaborative avenue
    • More than likely will be working in a setting where physicians are identified and form relationships naturally
  • Smith – Concerned with rural areas with limited physician access; have suggested removing the fee before, but have heard that physicians wouldn’t be responsive in that instance
    • Monthly phone call can be beneficial
  • Smith – Trying to figure out how this bill doesn’t further isolate nurse practitioners

Dr. Tina Philip, Texas Medical Association – Against

  • Provides an overview of full-scope family practice
  • Advocates claim HB 2029 would increase access to care, but APRNs don’t necessarily go out to rural areas any more frequently than physicians
  • Also have concerns with Nursing Board overseeing this, Nursing Board doesn’t really have the resources to deal with this, only one member is an APRN
  • Oliverson – Full-scope implies that 4 years of residency after 4 years of medical school prepares you to handle anything that presents itself; essentially preparing yourself to be the sole provider in a rural area
    • Correct

Dr. Cynthia Peacock, Texas Medical Association, American College of Physicians – Against

  • Practiced as an RN before becoming trying to become an NP, left NP program due to training deficiencies to enter medical school
  • TMA is only supporting scope of practice changes that preserve patient safety and retain appropriate oversight from the Medical Board

James Dickens, Texas Nurse Practitioners Association – For

  • Delegation agreement has been a barrier during the public health emergency
  • APRN scope of practice remains the same under HB 2029, rural and urban Texans need expanded access to care, & nurse practitioners are leaving the state
  • 31 states have eliminated delegated authority
  • Private practice NPs can often need to pay fees into perpetuity
  • Klick – Discusses Gov waiver of some APRN requirements during the pandemic
    • Learned lessons during Harvey, out of state practitioners were unable to come to assist in Texas due to delegation agreements
  • Klick and Dickens discuss how health care response teams were deployed to several areas of the state during the public health emergency

Matthew Lovitt, NAMI Texas – For

  • Mental health workforce is not sufficient to meet needs, rural Texas needs help
  • Burdensome regulations limit ability of APRNs to provide care; to improve access to mental health services Texas must loosen regulatory restrictions on APRNs

Gregory Collins, Texas Association of Nurse Anesthetists – For

  • Anesthesia care currently falls under dual regulation via the Nursing Board and Medical Board; Medical Board tries to manipulate environment to support physician anesthetists, have made statements designed to create confusion about CRNAs; HB 2029 will put an end to this
  • If the state wants to continue to rely on CRNAs to provide care for rural areas, HB 2029 must pass
  • Nurse anesthesia practice is already sufficiently governed by Nursing Board, rural hospitals rely heavily on CRNAs
  • Klick – If this legislation passes, will this change the way anesthesia is provided?
    • Will not change practice, will only change mountain of regulatory work
  • Klick – Will it cause hospitals to change bylaws?
    • Not if they’re employing CRNAs
    • Facility still has ultimate decision on protocols

Dr. David Bryant, Texas Society of Anesthesiologists – Against

  • Physician anesthesiologists have extensive training after college, CRNAs have far less
  • Regarding access, CRNAs are involved in practice today; no access or financial issues have changed in the health care market

Dr. Anna Allred, Texas Society of Anesthesiologists – Against

  • Anesthesia monitoring is complex with significant risk; HB 2029 allows CRNAs to be solely responsible for anesthesia plan of patients
  • Preventable events are higher without physician anesthetists involved; trained in the practice of medicine

Dr. Zachary Jones, Texas Society of Anesthesiologists – Against

  • Data showing CRNAs cause no harm uses flawed methodology, Texas Society of Anesthesiologists has studies with different results
  • Price – Asks for clarification
    • Texas Society of Anesthesiologists studies have been stricter on comparative analysis on CRNA versus physician anesthetists
  • Zwiener – Lot of claims going either direction, haven’t seen as much back up on either position as I would like to; asks for clarification on the study
  • Zwiener – In states with independent practice of CRNAs, how often are CRNAs treating patients without physician anesthesiologists?
    • Hospital policy guided as well; even though regulation may allow, hospitals policy may not
    • Texas Society of Anesthesiologists study does show a difference in outcomes between collaborative practice and independent CRNAs; increase of 2.5 deaths per 1,000 anesthetics, 6.9 failure to rescue events per 1,000 when anesthesiologists were not involved

Drew Riddle, Texas Nurses Association – For

  • Texas Society of Anesthesiologists was dismissed by some due to flaws in methodology
  • Highlights CRNA education, must be board certified and must maintain certification; training, education, and experience allows CRNAs to be eligible for licensure
  • HB 2029 does not expand scope of practice, subject to licensure requirements via the Nursing Board
  • CRNAs always practice as part of a team
  • Klick – Clarifies that clinical practice cannot be done online
    • Nothing in the bill affects this, cannot learn how to perform anesthesia online
  • Klick – Important that clinical experience is necessary
    • There are online programs, but these are for those already with masters degrees who want additional training
  • Zwiener and Riddle discuss care models; incl. anesthesia care teams, independent practitioners, etc.
  • Zwiener – Are there situations in Texas where CRNAs are providing anesthesia without an anesthesiologist present?
    • Yes
  • Zwiener – Asks after delegation authority
    • Receive delegation authority from a physician; can be an anesthesiologist, can be surgeon performing operations
    • Ability to practice also up to facilities; some facilities may not credential CRNAs
    • HB 2029 does not prohibit facilities from controlling how anesthesia is delivered, but does remove delegatory requirement from operating physician
  • Zwiener – Do you think there are bright lines in providing anesthesia between a CRNA and an anesthesiologist
    • Standard of care is the same, facilities may have differing standards
    • If CRNAs feel like a case is not within their expertise, they will refer to someone else

Jorge Martinez, LIBRE Initiative – For

  • Health care matters to Hispanic community, pandemic has affected the community greatly; primary care physicians are in short supply in many counties
  • HB 2029 would remove unnecessary barriers and allow APRNs to practice according to their education and expertise

Samuel Sheets, Americans for Prosperity – For

  • Organization opposed to barriers in many areas, including barriers to access to care
  • Many primary care shortage counties across the state
  • 31 other states have removed this requirement & none have put it back into place
  • Taxpayers could save millions on state-run health plans by expanding access in this way
  • Minimal fiscal note to the state
  • Oliverson – Regarding the savings and other states; in a lot of situations the savings are partly attributed to the fact that different systems pay mid-level practitioners less than physicians for the same service
  • Oliverson – In many of these states, shortly after it is done there is a demand for equal pay for equal work; know that there is a federal move for pay parity as well
    • Great question, would need to look at this

Dr. Cathy McLaughlin, Urologic Surgeon – Against

  • Stringent standards exist for physicians & practice of medicine; under HB 2029 APRNs performing the same tasks as physicians is not considered practice of medicine
  • Much of the research showing equivalent levels of care is based on APRNs working under physician supervision; new data shows APRNs are 20x more likely to overprescribe opioids when practicing alone
  • Does not make sense to put an APRN with less training in the role of a physician; physicians are overseen by the Medical Board
  • True that no delegation agreement is required in VA hospitals, but have seen that sometimes these practitioners do not know when to refer and collaborate with specialists
  • Studies have shown that more deaths are attributable to lack of quality care rather than lack of access

Erin Lincoln, Medical Resident- Against

  • Significant breadth and depth of info taught in medical school
  • Shares story of misdiagnosis by NP; gap in training that exists between physicians and APRNs can lead to potentially critical conditions being missed

Dr. Ellis Doan, Primary Care Physician – Against

  • Highlights significant training involved in specialized practice & professions
  • Essentially allowing a shortcut for non-physician-led care

Dr. Patricia Aronin, Physicians for Patient Protection – Against

  • Legislates right to practice medicine to people who didn’t go to medical school and receive training to practice medicine
  • APRNs and physicians are complementary, but not interchangeable; team-based approach provides best care for patients
  • More and more online nursing programs lacking in rigorous training
  • Many APRNs appreciate working in team environment, many benefits to the delegation system

Jeremy Wattenbarger, Self – Against

  • Child passed away due to APRN misdiagnosis; no referral was made and acting outside scope of practice

Blake Hudson, AARP – For

  • One of the reasons for support is that many APRNs do house calls
  • 31 states have removed delegation, becoming attractive for APRNs to move out of Texas; other states removing delegation have seen increased numbers of APRNs in rural areas
  • Delegation requirement isn’t what’s bringing value in the health care system; biggest benefit from removing delegation requirement is to access
  • Zwiener – Asks for data on access increases in other states
    • Can bring that, much of the data is state made
  • Zwiener – 31 states have removed delegation, my understanding is some states have found middle ground between no delegation and delegation by having a transition to practice
    • Have supported other states who have implemented this model, sweet spot seems to be 2 years
    • Not sure physicians would be supportive of this
    • Some states don’t have it, NM has done this for about 30 years

HB 2029 left pending