CNAP Legislative Update # 6 – Fight AA License

Lynda Woolbert, Director of Public Policy

Coalition for Nurses in Advanced Practice

March 11, 2007

Filing Deadline

On Wednesday, I was wondering what to write in the update. By Thursday afternoon, I had plenty to say. That is a typical scenario when the bill filing deadline approaches. Friday, March 9, 2007, was the last day that bills could be filed in both the Texas House and Senate without suspending the normal rules. Bills are rarely filed in the House after the deadline. In the Senate, filing after the deadline is more common but only bills with a lot of momentum can pass both houses of the legislature when less than 80 days remain in the legislative session. As stated in the last update, we anticipated that at least 2,000 bills would be filed last week. In fact, 2,428 bills were filed, and some of them were the most important bills of the session for APNs.

Anesthesiologist Assistant Licensing Bill: Immediate Action Needed

Senator Carlos Uresti (D – San Antonio, SD #19) filed SB 1314on March 7th and Representative Fred Brown (R –Bryan, HD #14) filed the companion bill, HB 3313, on March 8th. CNAP and the Texas Nurses Association are opposing these bills and asking for your help.

Most people are unaware of the existence of Anesthesiologist Assistants (AA), and for good reason. We think there are less than 20 AAs working in Texas, most in the Houston area.

AAs are not PAs with special training. They are distinctly different allied health professions. However, there are some similarities. Both PA and AA schools accept applicants with no previous health care experience. However, applicants must have certain pre-requisite math and science courses. There are four anesthesia assistant schools in the country and they are master level programs. The length of the programs range from 24 to 28 months. Two of those programs have been in existence for about 35 years and have graduated about 800 students. The other programs are relatively new. For more information on AAs, go to American Society of Anesthesiologists’ Website, http://www.asahq.org/career/aa.htm.

The push for AAs is supported by the American Society of Anesthesiologists. AAs may only assist anesthesiologists. Therefore, anesthesiologists have identified AAs as a way to maintain income and reduce competition. Anesthesiologists working in the anesthesia care team model can reap 200% of the reimbursement per hour by directing four concurrent procedures as opposed to delivering the anesthesia service themselves. No other medical specialty has this type of reimbursement cash cow, and it is part of the reason that anesthesiologists consistently average the highest salaries of all medical specialties.

The current debate really does not center on whether AAs are qualified to provide anesthesia or not. AAs are trained to assist anesthesiologists. That means AAs are clearly NOT an answer to any shortage that may exist in anesthesia providers. While CRNAs can provide anesthesia in any of the 254 Texas counties, whether an anesthesiologist works in that county or not, AAs can only work if a board certified anesthesiologist is also in the facility.

In addition, the proposed licensing bill would require an already overburdened Texas Medical Board (TMB) to develop rules and licensing processes for about 20 people. The TMB is currently requesting a supplemental appropriation because it cannot process all the applications it has for medical licenses. This is clearly not a time to add to that agency’s responsibilities.

There are also some very troubling aspects to the licensing bill that belie the real motivation behind this legislation. If you read SB 1314 or HB 3313, on page 4, lines 17 – 20, it reads as follows:

(c)The medical board is responsible for the ongoing examination of the scope of practice and promoting the continuing role of anesthesiologist assistants in the delivery of health care services.

I have never read a practice act that directs the responsible agency to promote the profession. That is the role of professional organizations. The role of state health care licensing agencies is to protect the public.

I was equally shocked to read page 7, lines 4 -5 that describe the method for designating the majority of members who would serve on an Anesthesiologists Assistant Board if this legislation passes.

(c)At least 90 days before the expiration of a term of a member who is an anesthesiologist or anesthesiologist assistant or as soon as possible after a vacancy occurs, the president of the Texas Society of Anesthesiologists, or its successor, shall submit a list to the medical board of not more than three qualified and willing individuals for each vacancy with a request and recommendation that the governor appoint one of the individuals listed to each vacancy as indicated on the list.

This is bad legislation, and even if the most offensive portions of the language were changed, it should not pass. It is the clear intension of the Texas Society of Anesthesiologists (TSA) to hijack and maintain control of the board this legislation would create.

With the intentions of TSA so clearly scripted in this legislation, it is obvious that TSA plans to increase the numbers of AAs in Texas. It is reasonable to expect that plan would include an AA educational program in Texas. Instead of putting more funds into educating the two proven types of anesthesia providers, nurse anesthetists and anesthesiologists, eventually educational funds will be diverted for this third type who will not be able to address the issues of access in underserved areas.

CNAP asks all APNs to call and write their state representatives to make them aware of HB 3313 by Representative Fred Brown and ask them to OPPOSE the bill and NOT sign on as a co-sponsor. Likewise, APNs should call or write their state senator opposing SB 1314 by Senator Carlos Uresti and impart the same message. Licensing anesthesiologist assistants is bad for Texas because:

- Anesthesiologist assistants (AAs) will NOT improve access to anesthesia services in underserved areas. (AAs can only work under the direct supervision of a board certified anesthesiologist, and therefore AAs can only practice in the 70 counties where anesthesiologists currently provide services.)

- Requiring an overburdened medical board to adopt rules and processes to issue 20 or less licenses is NOT a good allocation of resources. (The Texas Medical Board is already asking for a supplemental appropriation because it has a backlog of over 2,500 applications for medical licenses.)

You can also assure your legislator that the office will be given additional information soon.

How To Find Your State Representative and State Senator and What to Write.

You may find this information through voterVOICE. Go to CNAP’s home page, www.cnaptexas.org, and click on “voterVOICE.” If you have not previously registered, enter your contact information. Be sure to enter a suffix that includes your advanced practice nursing credentials (e.g. RN, FNP). Your state representative is listed as the last entry under “Your State Elected Officials.” Your state senator is listed next to last. It is only appropriate to send this message to these two officials. You will find a model message that you can send as an email or download, print and mail as a letter. Please modify the message, font and format. Remember that form letters and emails are not given as much consideration as letters and messages that are clearly individualized.

If you prefer to phone your state representative or senator’s office, you can find their Austin phone numbers by entering your home address in the Texas Legislature Online page, “Who Represents Me?” Click on the link, http://www.fyi.legis.state.tx.us/. Please be sure to scroll down the list far enough to find your state representative and state senator. Your US Congressman is at the top of the list and that is not the person to contact for this issue.

Do Your Patients Need Disabled Parking Placards?

Several times each year for the past 8 years, I have had a NP or CNS mention that they need to be able to sign the statement or prescription that permits their patients to get a disabled parking placard. It is one of those little changes in the law that never reaches the top of the priority lists and is an irritating barrier to efficiently meeting patients’ needs.

Thanks to the Rural Health Care Association, Senator Glenn Hegar (R – Katy, HD #18) and Representative Geanie Morrison (R – Victoria, HD #30), that barrier may finally be removed. At the suggestion of a NP practicing in a rural health clinic, the RHCA worked with TMA to develop the language for the bill, and Senator Hegar and Rep. Morrison agreed to file it.

The language in SB 985 filed by Senator Hegar and HB 2370 filed by Rep. Morrison is not all that we would hope, but it will get the job done. The language in the bill has been agreed to by TMA and that normally means that the bill will pass, especially if APNs put their considerable momentum behind the bill.

The bill amends §681.003(c), Texas Transportation Code, by adding the underlined language included below.

(c)Subject to Subsection (e), the first application must be accompanied by a notarized written statement or written prescription of a physician licensed to practice medicine in this state or a state adjacent to this state[,] or authorized by applicable law to practice medicine in a hospital or other health facility of the Veterans Administration or a person acting under the delegation and supervision of a licensed physician in conformance with Subchapter B, Chapter 157, Occupations Code, certifying and providing evidence acceptable to the department that the person making the application or on whose behalf the application is made is legally blind or has a mobility problem that substantially impairs the person's ability to ambulate.

Subchapter, B, Chapter 157, Occupations Code, is the portion of the Medical Practice Act that permits a physician to delegate prescriptive authority. The persons that would be permitted to sign prescriptions based on this legal citation are advanced practice nurses and physician assistants. CNAP thinks it would be much clearer to the average reader if “a person” were replaced with “an advanced practice nurse or physician assistant”. We will ask the bill authors to make that change.

In a session in which the moratorium on expanding legal authority for APNs is still in force, a lot of APNs would be relieved to make this small advancement even with the language in the bill as filed. From a pragmatic point of view, the bill enables APNs to sign prescriptions for disabled parking placards, and that is the most important thing. It will just be another statement that needs to be added to your practice protocol.

SB 985 is scheduled for a hearing in the Senate Transportation and Homeland Security Committee at 8:30 A.M. this Wednesday, March 14. If you are in the district of a member of this committee, you will receive an email asking you to email, call or fax your senator and ask that he/she votes in favor of SB 985 at the committee meeting on Wednesday.

Other Bills of Interest

HB 2939 and SB 1907 – Texas Health Professions Commission

Of course, other bills were filed this week that will require our attention. Among them is the bill being backed by the Governor that would consolidate all the health care licensing boards under a Texas Health Professions Commission (THPC). Representative Bill Callegari (R – Houston, HD #132), chair of the House Government Reform Committee, filed the HB 2939. Senator Rodney Ellis (D – Houston, SD #13), Chair of the Senate Government Organization Committee, filed the companion bill in the Senate, SB 1907.

The bill would continue the Board of Nurse Examiners and all other health professional licensing boards, but the agency would exist as a division under the THPC, and the BNE Executive Director would become an Associate Commissioner of THPC. The THPC would assume all the financial and administrative functions for all the health licensing agencies. The THPC would also assume the functions of the current Health Professions Council. While CNAP and TNA have concerns about this legislation, we have not taken a position.

The biggest item of concern to nursing and many other health professionals has been addressed in this bill. The Commission of Health Professions is prohibited from being a licensee of any of the boards or from having a spouse who is a licensee. We think this is very important to ensure that the Commissioner is unbiased in dealing with any scope of practice issues. Watch for more information on this bill, as well as CNAP’s position, in future updates.

HB 2426 and SB 907 - BNE Sunset

The long awaited Board of Nurse Examiners Sunset bills were filed last week. These are the bills that continue the BNE through 2017 and make changes to the Nursing Practice Act. Representative Vicki Truitt (R – Southlake, HD #96) filed the House version of the bill, HB 2426, and Senator Bob Deuell (R – Greenville, SD #2) filled the companion bill, SB 907. Both of these legislators are currently serving on the Sunset Commission.

The bill changes or adds some provisions to the Nursing Practice Act as outlined below.

- Requires the BNE to specify offenses resulting in criminal conviction or deferred adjudication against which the BNE can take action against the nurse. (page 7, SECTION 8)

- Requires that diploma programs have an agreement with an accredited BS nursing program by 2014. (page 8, SECTION 9)