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

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

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    Tafp 2011 multi state report Tafp 2011 multi state report Presentation Transcript

    • TAFPPOLICYWORKCommunicating FamilyMedicine’s Priorities in the82 Texas Legislature nd
    • PReP WORKDevelopment ofadvocacy iconfor session, andlaunched icon inadvocacy primerissue of TFP
    • A advanced grassroots advocacy for family docs s electoral waves of unbridled anti-gov- Report From TAFP Annual Session And Scientific Assembly ernment sentiment are somewhat un- evenly expressed against incumbents in both primaries, many physicians are likely to wave at the parade (or angry mobs), if not grab pitchforks and torches and join the procession. Physician frus- tration, broadly speaking, has reached a tipping point. The medical societies who have dared to conduct surveys of their member physicians have found unprecedented white-hot anger, cynicism, and a pessimism that runs as high as 8-to-1. But where are physicians putting all this righteous, and to some extent misdirected, anger? The art of politics, if that’s not an oxymoron, is chan- neling motivated voters into constructive results rather than merely a short-run tantrum that unhorses or simply GettinG antagonizes an incumbent. The end game isn’t the political assassination of an office holder. It is winning or leverag- ing an election so that the survivor/winner supports your well-reasoned ideas over your adversaries’ equally mad reasoned ideas, out of conviction or fear. Either motiva- tion works. After all, why engage in these often unsavory and disingenuous public affairs if your ideas don’t have consequences? In these times of incumbent rejection and unfocused resentment of all things governmental, a story often resur- faces as told by a longtime Capitol press corps reporter. It seems this reporter was attending a post-election in- isn’t terview with a newly elected governor who had just won back his former position from the same incumbent who, four years previously, had unseated him. The reporter asked the governor-elect in a post-victory press confer- ence, “What will be your top priorities this session?” The governor-elect stared for a moment, then asked, “What?” The consensus interpretation from the journalists in the enouGh room was that his agenda was avenging a previous defeat at the hands of the soon-to-be ex-incumbent. There was no other agenda, although there were plenty of well-heeled supporters of the challenger who had their own ideas already drafted in bill form. Legislative ideas, after all, arrive at their destinationsDEDICATED TO THE DELIVERY OF QUALITY HEALTH CARE VOL. 61 NO. 3 SUMMER 2010 The art of translating from a political process. They aren’t all that often born spontaneously from civic-minded public servants. They ideas into consequences: are turtles on fence posts. Someone put them there. Legislators, especially part-time state legislators, do not have the time or capacity to grasp every nuance of the How politics drives the more than 6,000 bills that are filed every session, nor, real- istically, the 1,000 or so that pass their desks on the House process that sets policy or Senate floor and that are voted for or against. Ideally and by their preference, they rely on guidance from local, credible sources who are also supporters. Lobbyists either direct that local traffic to the politician or inject their cli- ents’ opinions in its absence. By Kim Ross It should thus follow that if politics drives the process that sets public policy, how do physicians master the art of politics? What follows is a brief guide to the principles of political engagement, and how medicine’s ideas can have real-world consequences. It is in three parts—the basics Jonathan nelson of electoral engagement, how to be an advocate during the legislative process, and what constitutes effective policy development within the confines of a political process. 20 sUMMER 2010 | TExas FaMily Physician www.tafp.org | sUMMER 2010 21 SPECIAL ISSUE Grassroots advanced grassroots advocacy for family docs difference between the electoral risks of taking sides as compared to the personal or ideological beliefs of the legislator. For some issues, the legislator will bend to the ideological side, willing to take political risk because of personal conviction. Part 1 At the other end of the spectrum, the legislator may see the vote as potentially career-ending, or at a minimum calling in heavy artillery on his or her own posi- Electoral tion in the next election, by violating partisan doctrines that guarantee a primary engagement: opponent or by offending local constituencies capable of organizing a grassroots Advocacy offensive. The basics Calling on a legislator—really just showing up—is vital, if for no other reason that if absent, you forfeit your interest and influence to the other side. But, it isn’t a social call. Longtime University of Texas football coach Darrell K. Royal famously I said about his aversion to the forward pass, “three things can happen to you and n politics, relationships are as important, two of them are bad.” It can be also said of legislator contact or public testimony: if not more so, than issues, and as a corol- the legislator may agree, disagree, or simply not respond. your words have conse- lary, elected officials can trace many of their quences, but epiphanies are virtually nonexistent. I’ve never seen the Red Sea part most valuable relationships back to their or a blinding light hit a legislator after giving it our best shot, causing him to fall earliest electoral experiences. Running for of- to his knees and dramatically proclaim, “I see the light! All this time you were right fice, then hanging on to it, is not for the timid or and we were wrong. I am born again, and this time, I’m on your side.” Physicians those plagued by self-doubt. A politician rarely making those House and Senate calls will need some guidance from their lobby forgets or overlooks those who were there dur- or their peers who enjoy an organic or home-grown relationship to assess their For The FAmily DocTor ing that first, seminal election, or their first near- legislator’s disposition so as to know what to expect and how to temper their con- death experience during a re-election. versations. This prior assessment is crucial to assuring a productive contact and Who gets to cut in line at a legislator’s of- minimizing the possibility of a grenade going off in someone’s lap. fice? The physicians who have stayed out of To make things more linear in this chaotic world, here’s a simple typological the electoral process and never contributed guide to your legislator’s possible position before the vote. or worked in the incumbent’s campaign, or his local optometrist and longtime finance chair? • Kamikazes: Whether for your issue or against, conversation is at best What does one suppose is the predisposition of symbolic if not futile. Their disposition implies a risk-irrelevant stance that legislator on expanded scope of practice for Your Guide For Success to the point of self immolation. Though they may wrap their views in optometrists? Since most legislators didn’t go some rhetorical or partisan device, what they are really saying is they are to medical school, where do you suppose they intractable. If they are for you, one invokes the “strike oil, stop drilling” go to get some sense on how to vote on these rule. Say thank you and ask what they are hearing about your issue. For complex and intensely political matters? those against, say thank you and offer the vague hope there may be other issues where hearts and minds might otherwise converge. No reason to In The 82nd Legislature There are three types of grassroots relationships, as opposed to the time- share your playbook with the other team. honored lobbyist relationships of those who regularly haunt the halls, bars, and anterooms in Austin and Washington, D.C., and direct client support to those law- Part 2 • Ambivalents: Here is where all legislative traction is acquired and change makers. All have relative value, in descending order: is realized. These are legislators, often a substantial plurality of the Doctors as policy Legislature, who by definition are on the proverbial fence. There are two Given the extent • Organic: These relationships are of a more natural order, preceded their advocates: How kinds of ambivalents: moral and political. political careers, and are by definition relatively close: family members, of corporate classmates, physician-patient relationships, neighbors, or other commu- hard could it be? The moral ambivalents are high-centered because they have not heard a suf- interference nity-based relationships involving regular interaction. When managed ficiently persuasive argument from either side. This is very lucrative ground, and government methodically and ethically, they are by far the most influential during legislative cycles. where an evidence-based policy and well-reasoned arguments have immense con- sequence. It is also a rare circumstance. One can infer from the morally ambiva- involvement T o the extent physicians and their advocacy lent that the legislator does indeed want to do the “right” thing, has disregarded in health care, • Home grown: These are relationships acquired during an election cycle. organizations have invested in the political ideological, political, or partisan pressures, and considers the issue sufficiently physicians have a Physicians who engaged in all the basics of volunteer political action (not just making a contribution, however important this emphatically is) dur- process during successive election cycles, they will have accumulated the kind of po- relevant to everyday life to spend precious time studying the merits of the issue. The political ambivalents are uncommitted because they are simply indifferent moral obligation to ing a campaign: signing letters or ads; hosting events; block walking; trav- litical capital that has currency before and during a to the policy consequences and more interested in the political risk of taking sides. their patients and eling with the candidate; and any in-kind public, sustained gesture. They legislative session. That will be the time to expend This is by far the largest ongoing plurality in any debate preceding legislative ac- are the most numerous relationships and in most cases neutralize even that capital, but it should be spent judiciously, not tion. The more intense the party, local, and lobby pressure, the more a political to their profession the largest contributors’ efforts at bullying your legislator. murdering a bill that was already committing suicide ambivalent will be inclined to wait the issue out, hoping for a forced compromise to be active in or trying to persuade the unpersuadable. Whether (no one willingly gives ground—it is usually achieved at gunpoint) or for the arcane the political and • Artificial turf: These are the en masse responses rallied from your medi- the contact with their legislator is in their crowded twists and turns in the legislative process to kill the bill before it reaches his or cal organization where volume, in addition to personal contact, count. Capitol office during the biennial melee or the more her desk. This is a trickier encounter since the legislator will be reluctant to admit legislative process.” These are letters and e-mails. Some legislators are notorious for hiding quiet environs in their district, there are certain rules having political fears without incurring certain liabilities, including an implied behind perceived local doctor ambivalence. Lobbyists frequently hear of engagement and guiding principles to those con- quid-pro-quo transaction or one that explicitly ties a vote to promised support. It photo: Jonathan nelson Sen. Robert Deuell, M.D. from the uncommitted legislator, “I haven’t heard from my docs on this,” versations. regrettably happens on rare occasion in the privacy of an office or local venue, and PLUS: implying a lack of political interest among physicians and the politician’s it is also a criminal offense. Physician conversations in these circumstances are no R-Greenville proportionate disinterest in supporting the position, especially if the How legislators think different than the policy debate with the morally ambivalent legislator—succinct, Vice chair, Senate Committee other side is pounding his or her office with mail and calls. This isn’t an oxymoron. Every legislator runs leg- well-reasoned, evidence-based arguments. on Health and Human Services islation that has local backing or political muscle be- In the next part we’ll review how to apply these relationships in legislative battle. hind it through a rational calculus that measures the Nurse Practitioners Fire 22 sUMMER 2010 | TExas FaMily Physician www.tafp.org | sUMMER 2010 23 First Salvos In Campaign ACAdEMY UPdATE advanced grassroots advocacy for family docs For Independent Practice adVoCaCY Your advocacy encounter checklist to-do If a frog had a back pocket … Remember, during a session, you may be talking with policy staff in lieu LiSt iT’s TiME FoR a PoliTical REaliTy chEck Consider this: If of your legislator. By Tom Banning all 5,000 members Texas Medical Schools TAFP Chief Executive Officer/Executive Vice President 1. PrEPArE. Rehearse your issue talking points with your lobbyists. They of TAFP gave $100 Sign up to be a are professionals and spend a lot of time in that swamp. Get a profile of per year, a little your legislator, especially if you don’t have an organic or homegrown TAFP Key Contact. more than a quar- relationship in tow. This issue of TEXAS FAMILy PHySICIAN features a series of political ter a day, to our Sign up to serve as Rank Low On Social 2. DOn’T cuss THE AlligATOr bEfOrE YOu crOss THE swAmP. Physician of the Day. tutorials emphasizing the importance of grassroots activism and political action Never, ever, threaten, show anger, or imply you’d like to remove a favor- ite appendage without the benefit of anesthesia. The legislative process political action in order to build the kinds of relationships with committee, the assures many opportunities for instant karma payback, with no finger- Stay informed elected officials that get the interest, attention, and oftentimes PAC would match prints or smoking guns. on the issues. support of well-reasoned policy positions. Put another way, if you and even exceed Mission Scale 3. iT’s nOT PErsOnAl. The venal, mercenary, bottom-feeding, yellow- the political mus- page-advertising, ambulance-chasing personal injury lawyer’s vote is as want to affect health care policy, you must get involved in the Join the TAFP Political cle of other influ- good as the white-gloved, afternoon-tea, gated-community debutante’s. Action Committee. political process. It is that simple and that important. Make no assumptions about where your support may come from, or ential professions indulge in personal opinions about any legislator’s life philosophies or and businesses. If lifestyles. Sam Rayburn said it more succinctly, but we can’t print it. Build meaningful only one-tenth of 4. nO AD HOminEm ATTAcKs On THE OTHEr siDE. you may reference relationships with The unwritten laws of politics are as immutable Most physicians are understandably frustrated the canine ancestry of a rival profession only to find the legislator’s spouse your representative as the laws of nature. As Voltaire put it perhaps by the legislative process and think it is a fixed, in- our members de- or family member belongs to that tribe. Besides, it is non-persuasive and and your senator. more eloquently, “hawks have always eaten pigeons sider game. I’ve heard it expressed many times from veloped personal bad form, especially from a respected member of your learned profession. when they have found them.” Understanding these many different physicians: “If only they listened to relationships three, albeit cynical, rules will help you break the me and supported my idea on how to fix health care, 5. DOn’T nEgOTiATE. The more clever of the ambivalents, in seeking to Need help with these? code to why some bills survive the legislative pro- all would be right with the world.” with their elected distract or find a way out, may ask for a trade or a downgrade of your Contact TAFP officials, our cess and some die before ever being filed. In a perfect world, our elected officials would request. Refer them back to your lobby. at (512) 329-8666 make decisions based solely in the best interests grassroots pres- 6. ADDrEss lEgislATOrs bY THE TiTlEs THEY’vE EArnED. Nicknames or tafppac@tafp.org. Politics drives process that sets policy. of patients, but we don’t live in a perfect world like bubba, big guy, or cutie, even their given names, are off-limits un- ence would be you’ve heard us preach this before, but this is and you can’t pass wishes. Politics and other con- less you enjoy that kind of intimate, organic relationship. Even then, it’s the holy trinity of how things really work. Who siderations ultimately come into play. That’s how transcendent. A best in the presence of others to say “senator, representative, or mister/ we help elect and how strong our relationship it works in the real world of practical politics and legislator couldn’t madam chair.” your lobby can help you with protocol. is with them determines the rules of the legisla- health care policy. swing a dead cat 7. TrEAT sTAff wiTH THE sAmE DEfErEncE. They are the filter to the tive process—whether or not a bill will get filed, A veteran legislator, who to this day is still hand- set for hearing, debated on the floor, signed by ing out one-liners and hard-earned wisdom to his without hitting boss, and have no problem filtering your points. See also point No. 1 about doing your homework—they have personal physicians, friends who the Governor, etc. In turn, this means our policy less experienced colleagues on the House floor, is an involved fam- are physicians, and quite possibly good friends working against you. The art of politics, if options are limited by political and legislative op- portunity. In other words, policy objectives—no fond of reminding them that “if a frog had a back pocket he’d carry a pistol and shoot snakes.” ily physician in 8. ArguE frOm EviDEncE, nOT bEliEfs. While avoiding jargon and ac- that’s not an oxymoron, matter how well-meaning—may only see the light What he means, in my words, not his, is that good his or her district ronyms, cite the scientific evidence in a cause-and-effect linkage that ties the policy to the desired or undesired consequence. your position may is channeling motivated of day if our politics are in proper order. ideas will be devoured by the reptiles in the legisla- armed and ready involve three wise men and a virgin, and the other side may be agents of voters into constructive tive swamp every time unless you can defend those to work. Legislative reforms are reactive, not proactive. ideas with more than mere words and good inten- Satan, but that is in most cases an insufficient argument. Everyone likes results rather than merely Legislative policy changes occur after the pro- tions. Or as Al Capone famously said, “you get more Permit No. 1450 to invoke a deity when backed into a legislative life-or-death corner. The ambivalents want probable outcomes. a short-run tantrum verbial train wreck, plane crash, biblical plague, with kind words and a gun than kind words alone.” financial meltdown, oil rig explosion—you get the Consider this: If all 5,000 members of TAFP gave Austin, TX 9. TAKE THE DEbATE TO THE ExAm-rOOm lEvEl. Tell a story using real that unhorses or simply picture. $100 per year, a little more than a quarter a day, to or redacted cases of the consequences of action and inaction. antagonizes an incumbent. our political action committee, the PAC would match PAID 10. sTAY insiDE YOur KnOwlEDgE. If you don’t know, just say you’ll A politician’s first duty is to get re-elected. Every legislative idea and every vote that is cast and even exceed the political muscle of other influ- ential professions and businesses. If only one-tenth check and get back. Don’t chase hypothetical questions. passes through a political filter that measures the of our members developed personal relationships U.S. Postage 11. rEPOrT bAcK. It’s okay to take notes, and vital you compare what you potential electoral consequences of supporting with their elected officials, our grassroots presence heard, thought you heard, and didn’t hear to your advocates. your intel or opposing one set of constituents while antago- would be transcendent. A legislator couldn’t swing Presorted Standard will fit into a complex pattern across 181 votes, and provides valuable nizing another. A legislator may not always be a dead cat without hitting an involved family physi- insights into your opponents’ strategy, progress against you, and the influenced by the politics, but they will invariably cian in his or her district armed and ready to work. predisposition of your legislative contacts. And, drop a note to thank weigh the political consequences (a potential ca- In the synergistic combination of activism and whomever you met with to memorialize the contact with them, but pres- reer-ending vote) against the policy implications money, political action puts the pistol in the frog’s ent that fairly. This gives you one more chance to reinforce your points. (passing a tax bill to fund indigent health care). back pocket. : 24 sUMMER 2010 | TExas FaMily Physician 36 sUMMER 2010 | TExas FaMily Physician
    • LegIsLATIve PRIORITIes• Primary care workforce -- (budget) > Statewide Preceptorship Programs > State GME funding for residencies > Culture shift at medical schools• Scope of practice• Medicaid/CHIP funding -- (budget)• Corporate practice of medicine
    • COmmunICATIOn PLAn• Texas Family Physician -- (& webmag) > Scope of practice article in 4Q 2010 > Legislative Update departments in all• Capitol Update in QuickInfo• Capitol Report webcast video• Primary Care Coalition issue briefs • TAFP issue briefs• NEW: TAFP policy briefs on scope of practice and GME funding
    • PCC Issue bRIeF #1Protect preceptorship programs
    • PCC Issue bRIeF #1Protect preceptorship programs
    • PCC Issue bRIeF #2, 3, 4Scope of practice• #2 focuses on education differences• #3 focuses on geographic distribution• #4 focuses on cost effectiveness Primary Care Coalition Issue Brief: COLLABORATION BETWEEN Primary Care Coalition Issue Brief: COLLABORATION BETWEEN Primary Care Coalition Issue Brief: COLLABORATION BETWEEN PHYSICIANS AND NURSES WORKS PHYSICIANS AND NURSES WORKS PHYSICIANS AND NURSES WORKS Primary Care Coalition | 401 W 15th Street, Ste. 682, Austin, TX 78701 | (512) 370-1516 Primary Care Coalition | 401 W 15th Street, Ste. 682, Austin, TX 78701 | (512) 370-1516 Compare the Education Gaps Between Primary Care Physicians Are the Most Likely Health Care Primary Care Physicians and Nurse Practitioners Professionals to Practice in Rural and Underserved Areas Collaboration Between Physicians and Nurse While nurse practitioners are trained to emphasize health promotion, patient education, and disease prevention, they lack the broader and deeper expertise needed to recognize cases in which multiple symptoms According to the Robert Graham Center, people in non-metropolitan areas, especially in rural areas, depend on family physicians more than any other specialty. Despite claims by nurse practitioners that they will practice Practitioners Contains Health Care Costs suggest more serious conditions. The primary care physician is trained to provide complex differential in rural and underserved communities if granted the ability to diagnose and prescribe independently, the data diagnosis, develop a treatment plan that addresses multiple organ systems, and order and interpret tests within suggest otherwise. the context of the patient’s overall health condition. Bringing down the cost of care must be a major goal of any change in health care policy in Texas. The • Practice mapping research conducted by the American Medical Association shows that patterns in practice integrated, well-coordinated care provided in a physician-led, patient-centered medical home has This expertise is earned through the deep, rigorous study of medical science in the classroom and the thousands locations for nurse practitioners in states with independent practice are no different from those in states proven time and again to result in healthier populations while saving money. The patient-centered of hours of clinical study in the exam room that medical students and residents must complete before being that require collaboration between nurse practitioners and physicians. medical home depends on the skills, education, and expertise of a team of health care providers, allowed to practice medicine independently. including nurse practitioners, caring for patients under the medical direction of primary care • If granted independent practice, nurse practitioners would be practicing in the same economic physicians to succeed. Because primary care physicians throughout the United States follow the same highly structured educational environment as family physicians, and the factors that make opening and maintaining a rural medical path, complete the same coursework, and pass the same licensure examination, you know what you’re getting practice will discourage nurse practitioners as well. with a physician. There is no such standard to achieve nurse practitioner certification, as their educational Contrary to the claims of nurse practitioner organizations, independent practice by nurse requirements vary from program to program and from state to state. practitioners would not lead to more efficient or cost-effective care; in fact, studies show the GeoGraphic DistributioN of The location of one or more actively practicing opposite would be the likely outcome. primary care physicians (n = 14,837) primary care physiciaNs aND Degrees requireD anD Time To CompleTion Nurse practitioNers iN texas The location of one or more actively practicing advanced practice nurses (n = 6,560) Because they lack the training and medical education of physicians, nurse practitioners tend to refer In Texas in 2009, the ratio of Full Health Professional Shortage Area county patients to specialists and order expensive diagnostic tests at a higher rate when they are not working Undergraduate Entrance exam Post-graduate Residency TOTAL TIME FOR degree schooling and duration COMPLETION primary care physicians per Partial Health Professional Shortage Area with physicians. 100,000 people in counties Family physician Standard 4-year Medical College 4 years, doctoral REQUIRED, 11 years (M.D. or D.O.) BA/BS Admissions Test program 3 years minimum designated as Health Profes- A comparison of utilization rates among physicians, residents, and nurse practitioners in the same (MCAT) (M.D. or D.O.) sional Shortage Areas was setting showed that: 32.8, while the ratio of nurse Nurse practitioner Standard 4-year Graduate Record 1.5 – 3 years, NONE 5.5 – 7 years practitioners per 100,000 • Utilization of medical services was higher for patients assigned to nurse practitioners than for BA/BS* Examination (GRE) master’s program & National Council (MSN) people in those same counties patients assigned to residents in 14 of 17 utilization measures, and higher in 10 of 17 measures Licensure Exam for was 10.4. when compared with patients assigned to attending physicians.1 Registered Nurses (NCLEX-RN) required • There was a 41% increased hospitalization rate in the nurse practitioner group, or 13 more for MSN programs hospital admissions per 100 patients per year than the group receiving care from physicians.1 • There was a 25% increase in specialty visits in the nurse practitioner group, or 108 more visits meDiCal/professional sChool anD resiDenCy/posT-graDuaTe hours for CompleTion per 100 patients per year than the group receiving care from physicians.1 Lecture hours Study hours Combined hours Residency hours TOTAL HOURS The researchers stated that the findings suggest that increased use of nurse practitioners as primary (pre-clinical years) (pre-clinical years) (clinical years) care providers may lead to increased ordering of expensive diagnostic tests and higher rates of specialty Family physician 2,700 3,000** 6,000 9,000 – 10,000 20,700 – 21,700 visits and hospital admissions for patients assigned to nurse practitioners. Doctor of Nursing 800 – 1,600 1,500 – 2,250** 500 – 1,500 0 2,800 – 5,350 • From the study: “The higher number of inpatient and specialty care resources utilized by Practice patients assigned to a nurse practitioner suggests that they may indeed have more difficulty with managing patients on their own (even with physician supervision) and may rely more on other Difference between 1,100 – 1,900 750 – 1,500 4,500 – 5,500 9,000 – 10,000 15,350 – 18,900 Number of Nurse practitioNers per 100,000 FP and NP hours of more for FPs more for FPs more for FPs more for FPs more for fps services than physicians practicing in the same setting.”1 professional training populatioN iN texas iN 2009 * While a standard 4-year degree, preferably a BSN, is recommended, alternate pathways exist for an RN without a bachelor’s degree to enter some Metropolitan non-border areas: 25.1 master’s programs. Metropolitan border areas: 17.0 ** Estimate based on 750 hours of study dedicated by a student per year. 1. Hemani A, Rastegar DA, Hill C, et al. “A comparison of resource utilization in nurse practitioners and physicians.” Eff Clin Non-metropolitan non-border areas: 15.5 Pract. 1999 Nov-Dec; 2(6):258-265. Sources: Vanderbilt University Family Nurse Practitioner Program information, http://www.nursing.vanderbilt.edu/msn/fnp_plan.html, and the Vanderbilt Non-metropolitan border areas: 8.3 University School of Nursing Handbook 2009-2010, http://www.nursing.vanderbilt.edu/current/handbook.pdf. American Academy of Family Physicians, Primary Health Care Professionals: A Comparison, http://www.aafp.org/online/en/home/media/kits/fp-np.html. • over • • over • • over •
    • Roland Goertz, M.D., M.B.A., Installed As AAFP PresidentDEDICATED TO THE DELIVERY OF QUALITY HEALTH CARE VOL. 61 NO. 4 FALL 2010 NURSE PRACTITIONERS SEEK INDEPENDENT None address PRACTICE quality question. The 82nd Legislature Will Determine Who Can Practice Instead we Medicine In Texas package them PLUS: Primary Care Preceptorships Under with the magazine The Knife Again CMS Recovery feature in which Audit Contractors: What You Need To Know physicians tell their horror stories. Permit No. 1450 Austin, TX PAID U.S. Postage Presorted Standard
    • TAFP POLICY bRIeF #1The Question of Independent Diagnosis and Prescriptive Authority for Advanced Practice Registered Nurses in Texas: Is the Reward Worth the Risk?By Marie-Elizabeth Ramas, M.D.3rd-year resident and recipient of James C. Martin, M.D., Scholarship intended for policy research
    • TAFP POLICY BRIEFThe Question of IndependentDiagnosis and PrescriptiveAuthority for Advanced PracticeRegistered Nurses in Texas: Is theReward Worth the Risk? • 3,000 words By Marie-Elizabeth Ramas, M.D.Texas faces a growing demand for primary careservices, particularly in rural and underserved regions. to extend independent diagnostic and prescriptive authority to APRNs in the state of Texas. While such • 8 pagesThe Texas Department of State Health Services re- action may be politically expedient in the short term, • Thoroughly citedports that 16,830 primary care physicians were in active the risks outweigh what may be a hollow reward.practice in Texas in 2009, or approximately 68 for ev- Many reforms implemented by the Texas Legis-ery 100,000 people. The national average is 81 primary lature in recent sessions are successfully shifting thecare physicians per 100,000 population. This short- state’s health care delivery system in a direction sup-age is compounded by a prevalent maldistribution of ported by acclaimed medical and economic research,physicians across the state. Of Texas’ 254 counties, toward the integration of care in a collaborative, team-118 were considered whole county health professional based model in which all aspects of a patient’s care • Contains graphs,shortage areas, or HPSAs, and 71 contained either spe- are coordinated across multiple settings and variouscial populations or geographic areas that qualified for health care providers. Such an efficient system basedthe designation of partial-county HPSA. Twenty-six on a solid primary care foundation leads to improvedcounties had no primary care physician in 2009.1 quality, reduced errors, and fewer instances of unnec- In recent years, organizations representing ad- essary care and duplication of services, resulting in charts, and mapsvanced practice registered nurses, or APRNs, have lower costs.2, 3, 4, 5 Allowing APRNs to practice medicalpursued policy changes that would allow these practi- acts independently would fracture that transition, in-tioners to provide medical services independently, ar- creasing the fragmentation of care Texans experience.guing that such changes would help alleviate physician Furthermore, redefining the educational and li-shortages. Despite assertions that APRNs function as censure standard required to conduct medical acts so from issue briefseffectively as physicians, there exists little if any sub- that APRNs can practice independently will not guar-stantial objective information to support these claims. antee that Texans will have greater access to primary Given the impending addition of even greater care. No data exists to support claims that APRNs arestress on the state’s health care delivery system, it is more likely to practice in underserved areas, thoughclear that a comprehensive discussion of how to in- significant evidence shows they tend to preferentiallycrease access to primary care throughout the state is distribute in metropolitan and suburban communitiesnecessary. One seemingly logical solution would be at a similar rate to other health care providers. Published by the Texas Academy of Family Physicians, Feb. 16, 2011. This research was made possible in part by the TAFP Foundation through the James C. Martin, M.D. Scholarship. © 2011 Texas Academy of Family Physicians.
    • TAFP Issue bRIeFKeep Texas-trained IMGs Practicing in Texas Texas Academy Issue Brief: improving texas’ primary of Family Physicians care physician workforce 24 states require fewer than 3 years of residency for iMG Medical licensure Texas Academy of Family Physicians | 12012 Technology Blvd. , Ste. 200, Austin, TX 78727 | (512) 329-8666 | www.tafp.org Keep Texas-trained International Medical Graduates Practicing in Texas Texas faces a current and impending shortage of physicians—particularly primary care physicians—to meet the health care needs of our growing population. Yet an impediment in the licensing of a significant number of practice-ready new physicians presents many with a tough choice: accept a costly delay or abandon Texas to begin practicing medicine elsewhere. International medical graduates, or IMGs, cannot receive medical licenses IMGs COMPRISE A GROWING PORTION OF TEXAS’ in Texas until they have completed PRIMARY CARE WORKFORCE three years of residency training, while physicians who graduated from U.S. medical schools can apply after only one year of residency. This re- One out of every PERCENTAGE OF TEXAS FAMILY four physicians in PHYSICIANS WHO ARE IMGs BY quirement reduces the supply of new YEAR OF RESIDENCY COMPLETION 3 years required physicians in Texas. America is an IMG. In Texas, 38% of family 2 years required 2010 • It discourages employers from medicine residents 1 year required offering IMGs positions right in training today are 2009 out of residency because they IMGs. Considering 2008 don’t yet have their licenses, the increase in the 2007 thus encouraging them to leave the state in search of work. number of IMGs 2006 going into family 2005 • Because physicians must medicine over the 2004 have a medical license to be last decade, it is credentialed by Medicare and clear that Texas 2003 private insurers, it further depends on IMGs for 2002 delays the date after which a significant portion 2001 they can be paid for their work. of our primary care 2000 Recommendation: Amend the state statute to allow IMGs to receive medical • Because they must have a physician workforce. licenses after completing two years of residency training 0 10% 20% 30% 40% 50% medical license to take their board examinations for Given the critical importance of improving access to cost-efficient, high-quality care across the state by certification by most medical increasing Texas’ primary care physician workforce, this small change will have a tremendous effect. Practice- specialty boards, including the ready, Texas-trained primary care physicians who would prefer to remain in Texas are leaving the state, and this American Board of Family Medicine, it delays their ability to achieve board certification, a requirement unnecessary restriction is often to blame. Furthermore, state agencies employing these physicians are losing for insurance credentialing and hospital privileging. money due to the related credentialing delays. This action will result in a savings to these agencies and remove an arbitrary impediment to practicing primary care in Texas. For IMGs, these impediments could add up to months of unnecessary and costly delays before they can begin caring for patients. While they are unable to practice, their substantial medical education debt mounts. Many IMGs obtain licenses in states like Oklahoma and New Mexico that require fewer residency years for The Texas Academy of Family Physicians is joined by several organizations in support of this change. licensure. These physicians are more likely to move to these states to practice, taking with them the substantial They are: investment Texas has made in their education. Texas Medical Association Teaching Hospitals of Texas Texas Pediatric Society Texas Association of Community ► By changing the number of years of residency training IMGs must complete for medical licensure from Health Centers three to two years, the Legislature can ensure that these physicians can start caring for patients as Texas Chapter of the American quickly as graduates of U.S. medical schools, thus improving Texans’ access to care. College of Physicians Texas Organization of Rural and Community Hospitals • over • Legislative advertising paid for by the Texas Academy of Family Physicians. For more information, contact Tom Banning, CEO/EVP, 12012 Technology Blvd., Ste. 200, Austin, Texas, 78727.
    • WhAT’s nexT?• Issue brief on state GME funding > Include number of FM residencies & residents trained > Amount of funding cut from programs and how that is likely to affect programs > Double hit from Medicaid cuts• Policy brief on medical education > 2nd Jim Martin resident paper is almost complete
    • dIsTRIbuTIOn PLAn• www.tafp.org/advocacy > Press-optimized, so high def for color copies, printing, etc. > Launch to members in QuickInfo > Links in all stories relating to topics• Distribute to websites of partnering organizations• Printed handouts for legislative visits
    • • Facebook = facebook.com/txafp• Twitter = TXfamilydocs• Links from new blog at http://txfamilydocs.org• Turn all documents into slideshow presentations and make available on Slideshare.comWant your own copies? Go to: www.tafp.org/advocacy/resources