A ‘turf battle’ between nurses and doctors: HEAL Texans Act aims to remove physician oversight of nurses in primary care


Boram Kim


Senate Bill 1700, which would expand the authority of advanced practice registered nurses (APRN) to allow them to independently provide primary care services without the supervision of a physician, has been sitting in the Texas Senate Health and Human Services Committee awaiting action since mid-March.


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Advocates for the bill, referred to as the HEAL Texans Act, contend that allowing APRNs to practice to the full extent of their license would expand access to primary care throughout Texas, especially in rural and underserved areas of the state.  

Current law requires APRNs to check in monthly with a physician as part of a delegation contract to be allowed to provide primary care services. Texas removed the on-site physician supervision requirement in 2013.

SB 1700 would free nurses from the burden of contractual administrative fees (nurses are required to pay physicians a portion of their nurse service fees through their contracts) and physician supervision related to the provision of services, such as preventative care, prescriptions, and treatment of common illnesses. 

Texas has the second highest number of total Primary Care Health Professional Shortage Areas in the nation, with 437 designations and a population impact of 7.4 million residents. 

According to the Texas Department of State Health Services (DSHS), 72% of Texas nurse practitioners (NP) are licensed in an area of primary care, whereas only 36% of physicians are. State data reveals a critical physician shortage that is expected to run through 2032, and shows that Texas ranks 41st in the number of active physicians per 100,000. NPs make up almost half of the primary care workforce in Texas.

An op-ed released on Monday by Texas Medical Association (TMA) President Gary Floyd, MD cited research that found NPs who deliver emergency care without physician supervision or collaboration “significantly increase resource utilization but achieve worse patient outcomes.” 

Data revealed that nurse-led care increased lengths of stay by 11%, raised 30-day preventable hospitalizations by 20%, and increased the cost of emergency department care by about $66 per patient, roughly $74 million annually. Highlighting the state’s progress in promoting the supply of doctors to shortage areas, Floyd advocated for policies that preserved patient care.

“Because of the work the legislature already has accomplished, Texas licensed more than 6,500 new physicians in 2022 and has more family physicians serving in rural areas than urban,” Floyd said. “Our Texas Legislature also is working with physicians and healthcare professionals to improve access to care through telemedicine and statewide broadband internet access; expansion of loan repayment programs for physicians and healthcare professionals who practice in rural and underserved areas; and stronger accountability measures for health insurance plans that don’t provide adequate access to in-network physicians.

The rigorous and lengthy training Texas requires of its physicians in medical school, residencies, licensing requirements, and in their oath to put ‘patients first’ and ‘do no harm’ is purposeful for our state’s physical and fiscal health. Let’s not undermine, or water down, Texas’s strong patient care protections.”

In response to TMA, the Texas Nurse Practitioners (TNP) said removing the state mandate on APRNs could alleviate the primary care provider shortage in Texas by 32%.

“Removing contract requirements would make no legislative change to the scope of work APRNs are licensed and allowed to provide,” Cindy Weston, president of TNP told State of Reform. “It would have zero impact on the team nature of healthcare. State-mandated contracts don’t require team-based care. In fact, they don’t even require APRNs and their contracting physicians to be in the same city.

What removing the contract requirements would do is eliminate the need for APRNs to maintain often costly, lifetime contracts with physicians who in return don’t have to provide care to patients or even be in the same city as the APRN, only requiring one phone call per month. It would eliminate the overhead cost of paying a contracting physician for care they aren’t delivering. It would incentivize much-needed APRNs to stay in Texas and practice while encouraging other quality APRNs to move to Texas. Most importantly, it would expand access to care for millions of Texans.”

She added the state’s “overly burdensome and costly regulatory climate” was encouraging APRNs in Texas to find opportunities elsewhere in other states.

A survey by Texans for Healthcare Access revealed 90% of respondents supported the provision of care from nurse practitioners and APRNs to help address the shortage of primary care physicians in rural and underserved communities. It showed that patient satisfaction, safety, and outcomes from care by nurse practitioners were equal to and in some instances improved when compared to a physician. 

In an interview with State of Reform, Alan Laufman, MD, a patient and medical advocate in the Dallas area, characterized the legislation as a “turf battle” between nurses and doctors. 

“Physical examination is a key element in a diagnosis of a patient as well as knowledge of disease,” Laufman said. “Nurses can be trained to do a pretty capable physical exam—it’s their knowledge base that is drawn into question. If a patient does not have an established diagnosis, that is a category unto itself, [and] that demands there be some consult with a physician.”

Speaking to State of Reform, Susan Cooley, PhD, RN, co-founder of Care Consultants of Texas, called the current system an administrative and financial burden for nurse practitioners.

“It costs at least $50,000 a year on top of the other normal expenses to abide by the law,” Cooley said. “And the current law says that a physician, depending on where your area of practice is, needs to review 10% of your charts, and in some cases needs to be on site. It does not require that the physician see the patients and so it is really an administrative burden more than anything else. And of course, if I have a question [or] if I am struggling with a diagnosis, I’m either going to refer or call my colleague who is a physician, or another

nurse practitioner. But usually, it’s going to be a specialist, a physician specialist, that I’m going to call—[someone] I have a working relationship with.”

Cooley, a licensed NP with over 40 years of experience, emphasized the importance of the nurse-physician relationship and that efforts to expand the scope of practice for nurse practitioners do not interfere with the existing professional collaboration. Chasity Appleton, RN, CEO of Excel Quality Care Advocates, reiterated those sentiments, saying her patients prefer to see NPs over doctors because nurses are more personable and less hurried. 

“The goal of this bill is to increase access to care, bridge care gaps, and limit health disparities that keep patients from achieving optimal health,” Appleton told State of Reform. “Nurse practitioners and APRNs do this every day. They too help to keep all patient populations healthy and do so safely—often at affordable costs that could potentially decrease system averages. The end goal is the same for both nurses and physicians. We are not in competition.”