Alicia Plemmons
Assistant Professor of General Business, John Chambers College of Business & Economics
Submitted and testified on: September 1, 2024
"Official State Seal of Texas" (photograph by J. Stephen Conn), published on StateSymbolsUSA (https://statesymbolusa.org/symbol-official-item/texas/state-seal/seal-texas), originally sourced from Flickr under CC BY-NC-ND 2.0.
Texas Senate Health & Human Services Committee Dear Chair Kolkhorst, Vice-Chair Perry and all distinguished members of the Texas Senate Health & Human Services Committee:
I appreciate the opportunity to attend the interim committee meeting to provide an educational overview of the large body of research on nurse practitioner effectiveness. My name is Alicia Plemmons, PhD, and I am an assistant professor, research fellow, and director of health research in the Knee Regulatory Research Center at West Virginia University. This comment is not submitted on behalf of any party or interest group.
My research studies patient outcomes in terms of safety, quality, cost and access under different practice arrangements for several types of non-physician providers. Twenty-seven states have a pathway for nurse practitioners to practice and prescribe independent of an expensive collaboration or supervision contract. Using large government and private claims databases spanning decades, my team has tested the validity of the safety concerns surrounding nurse practitioner independence. In our peer-reviewed publications, we find states with independent practice experienced:
- Increased rates of nurse practitioners moving into the state with full practice authority and a reduction of nurse practitioners leaving the state due to lack of job autonomy.1 As there is a growing physician shortage in Texas, the e expected six percent increase in providers will provide coverage in high-need urban and rural counties.
- Reductions in 30-day readmission resulting in overnight hospital stays or emergency room visits, as more primary care services are utilized.2 Patients are more likely to get recurring primary care, reducing strain on emergency departments.
- Reductions in healthcare amenable deaths, with the largest reductions in rural areas and elderly populations.3 This reduction in preventable deaths is due to nurse practitioners providing management-focused care for long-term health conditions such as diabetes.4
224 of Texas' 254 counties are designated as health professional shortage areas due to a lack of physicians providing primary care224 of Texas’ 254 counties are designated as health professional shortage areas due to a lack of physicians providing primary care. 45.43 percent of Texas residents live and work in areas that do not meet safe provider ratios, particularly in rural areas. The U.S. Department of Health & Human Services estimates that meeting the needs of these residents will require at least 881 new primary care providers.5 Allowing nurse practitioners and other advanced practice registered nurses to practice without expensive additional contracts with physicians, and to the fullest extent of their training, is a pathway that research finds to be effective in addressing this deficit without endangering the safety and quality of care provided to patients.
Collaboration contracts create several hurdles to maintaining consistent primary care for patients. For clarification and transparency, the lack of a contract does not prevent a nurse practitioner from collaborating. In the twenty-seven states that allow for nurse practitioner independence, almost all providers collaborate with their peer providers.6 The contract element only serves to create a binding financial relationship that cost a nurse practitioner between $500 and $5000 a month.7 This substantial financial cost prevents many nurse practitioners from seeing the most critically underserved patients.
The contract system has been associated with gaps in healthcare access for patients. These occur for several reasons. If a contracted physician retires, moves, or passes, patient appointments with the nurse practitioner must be halted until a new contract can be established, disrupting weeks or months of patient care. The delay or pauses in care affect underserved communities the most, as physicians are less likely to establish collaboration contracts in low-income or geriatric communities. In surveys of nurse practitioners, the majority of those who provide primary care plan to serve more Medicare and Medicaid patients upon gaining independence.
In summary, the proposed pathway for independent practice authority of advanced practice registered nurses represents an improvement in access to healthcare for Texans.
Best regards,
Alicia Plemmons
Works Cited
1 https://doi.org/10.1007/s12122-020-09308-1
2 https:///doi.org/10.1080/13504851.2021.1980486
3 https://doi.org/10.1016/j.jpubeco.2023.104901
4 https://doi.org/10.1111/jrh.12599
5 https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport
6 https://doi.org/10.1016/j.outlook.2014.08.008
7 https://doi.org/10.1016/j.outlook.2020.04.002