CNAP 09 Legislative Update #2 Retail Clinic Bills

CNAP 09 Legislative Update #2 – Retail Clinic Bills

Lynda Woolbert, Executive Director

Coalition for Nurses in Advanced Practice

February 5, 2009

Clinic on the link to go directly toa particular article.
The Feb. 9th Legislative Day is full butAPNs have lots of opportunities to visit legislators atthe Capitol.
Senator Hegar filesSB 680, the companion to Representative Orr's HB 696.
Retail Clinic Billswould continuesite-based prescriptive authority for APNs.

Other hot topics in the 81st Session may interest APNs.

APNs need to take note of Senate committee assignments.

Full House for Legislative Day

After being tightly packed into the Omni for the past few years, APN Legislative Day 2009 is moving to a bigger and better facility, the brand new AT&T Executive Education and Conference Center. We did not expect to reach the maximum capacity of 410. However, registrations poured in and we are already beyond that number.

While we cannot accept any additional registrations for Legislative Day on February 9th that does not mean there won’t be plenty of opportunities for you to visit your legislators at the Capitol during the Session. We have a day planned each month specifically designated as APN Days at the Capitol. Those days are:

Wednesday, March 4th;

Thursday, April 2nd; and

Thursday, May 7th.

In addition any Tuesday through Thursday can be your APN Day at the Capitol by just emailing , and arranging your special day to visit your legislators in Austin. We really need lots of APNs at the Capitol all during the session, so please plan a date to take off work now.

For a few of you who registered online for Legislative Day, but did not receive information from Jan Allen last Saturday, you may have entered an invalid email address. Please email Jan at to report your correct email address. Jan will confirm your registration and send you the information.

We are looking forward to a great day next Monday, and a very exciting session.

Senator Hegar Files SB 680: Companion to HB 696

Prescriptive authority for APNs is a hot topic this session. Last week I wrote about a bill APNs will actively support this session, HB 696 by Representative Rob Orr (R – Burleson, HD# 56). This is the bill that would eliminate the current site-based system of prescriptive authority for APNs and PAs. Under this legislation, diagnosis and prescribing would remain delegated but it would allow individual physicians to determine where and what prescriptive authority the physician would delegate to an APN or PA, including Schedule II, Controlled Substances. We are calling this bill “Physician Determined Prescriptive Authority.”

This afternoon, Senator Glenn Hegar (R – Katy, SD #18) filed the companion bill, SB 680. This means the bill is identical to the one filed by Representative Orr. Having companion bills filed increases the chance that the bill will pass. If you live in Representative Orr or Senator Hegar’s district, please write or call and thank them for filing this bill.

Retail Clinic Bills Filed

On January 23rd, Senator Dan Patrick (R – Houston, SD #7) filed SB 532. SB 532 would relax some of the restrictions on physicians who delegate prescriptive authority to APNs and PAs. Three days later, Representative Rob Orr also filed the companion bill to SB 532, HB 800. APNs had no involvement in drafting these bills.

Persons representing the retail clinics negotiated with the Texas Medical Association (TMA) and the Texas Academy of Family Physicians on the language in these bills. It is specifically designed to address some of the problems the retail clinics encounter in meeting the requirements for physician supervision in an "alternate site." This is the designation retail clinics usually use for the NP’s prescriptive authority. It is clear that this is the only APN prescriptive authority bill that TMA wants to pass because it also includes a few other provisions that address some of the issues raised last spring and summer in CNAP’s and TNA’s negotiationswith the medical associations. Unfortunately they did not throw nearly enough in the bill for us to think it is a good deal for APNs, physicians or patients.

Outlined below are the major changes included in SB 532 and HB 800.

1. Allows physician delegation of Schedules III-V, Controlled Substances, to include 90 day refills (not just 30 days like now).

2. Requires a physician to register with the Texas Medical Board (TMB) the name & license # of the PA or APN to whom the physician delegates prescriptive authority. The provision allows the TMB to use an electronic online registration process for this.

3. Adds a new site under the definition of primary practice site that is defined as “a practice location providing care for established patients of an APN or PA who practices on-site with the physician more than 50% of the time." APNs would be able to practice at these sites with no additional physician supervision.

4. Makes several changes to the restrictions on alternate sites including:

(a) allowing the alternate site to be 75 miles from the delegating physician's primary practice site or residence (Now the alternate site must be within 60 miles of the physician’s practice.);

(b) requiring the physician to be on site 10%, instead of 20%, of the "hours of operation of the site each month that the PA or APN is acting with delegated prescriptive authority." This paragraph also adds some rather strange language stating the physician "is available while on-site to see, diagnose, treat, and provide care to those patients for services provided or to be provided by the PA or APN to whom the physician has delegated prescriptive authority" and the contract cannot prohibit the physician from doing this; and

(c) allowing the 10% chart review to be done electronically at a remote site.

6. Adds language that if the TMB determines that the types of services provided at the alternate site are limited in nature and duration, within the scope of delegated authority as defined by board rule, and patient health care will not be adversely affected, the TMB may modify or waive the mileage limit, some supervision requirements, and the limit on the number of PAs or APNs to whom a physician may delegate, but not more than a 6 to 1 ratio. Then there is some strange language in this waiver section that is unclear, but appears to mean that if a waiver of one requirement is granted, the TMB cannot make another requirement “more stringent.”

7. If the physician delegates prescriptive authority to the APN or PA in another site, the bill authorizes the physician to delegate prescriptive authority to the same APN or PA in a charity care site. The APN or PA must be providing care without pay at a clinic run by or sponsored by a nonprofit organization. The delegation does not require any on-site supervision or chart review.

As I discussed in the CNAP 09 Legislative Update #1, we anticipate three types of bills this session dealing with prescriptive authority for APNs. We will support all three, but the retail clinic bill is definitely our third choice. HB 696 by Representative Orr and SB 680 by Senator Hegar would be our second choice.

Until the bill we really want is filed, the one that allows the Board of Nursing to grant authority to diagnose and prescribe, we need to keep a low profile concerning SB 680, HB 696, SB 532, and HB 800. If anyone asks, CNAP supports HB 696 and SB 680 as it improves the current system by getting rid of the unnecessary and burdensome site-based restrictions, but we wished it went further. APNs in 33 other states have prescriptive authority under their own licensure and we know Texas APNs are as smart as the APNs in those states since all APNs have to pass the same national certifying exams. We support SB 532 and its companion, HB 800, as those bills will help some APNs, primarily those working in retail clinics or other alternate sites. However, it leaves a convoluted and confusing system of site-based prescriptive authority in place and, actually, SB 532 and HB 800 make the process even more complex. It certainly does not go far enough to truly address the issues of lack of access and high cost of health facing Texas.

Other Topics for the 81st Legislature

While APN issues are at the top of our legislative agenda, there will be a number of hot topics discussed by legislators this session. The House Research Organization (HRO) summarizes many of those topics is its publication titled, “Topics for the 81st Legislature.” Most APNs will be particularly interested in the health and human services topics on pages 8 -12. One of the topics mentioned is scope of practice and “the extent to which physicians must oversee the care provided by advanced practice nurses….” While this characterization is not quite accurate since the bills have to do specifically with the extent to which a physician must oversee an APN’s prescribing, it further reinforces that the profile of Advanced Practice Nurses continues to rise at the Capitol.

Lt Gov Announces Senate Committee Assignments

Announcement of committee assignments is always an awaited landmark each legislative session. The Senate reached that landmark on Friday, January 30th. For APNs, there is one Senate Committee that hears the majority of legislation affecting our interests. That committee is Senate Health & Human Services. The committee will again be chaired by Senator Jane Nelson (R – Lewisville, SD #12) and co-chaired by Senator Bob Deuell (R – Greenville, SD #2). Other senators named to this committee include Senators Joan Huffman (R – Houston, SD #17), Robert Nichols (R – Jacksonville, SD #3), Dan Patrick (R – Houston, SD #7), Elliott Shapleigh (D – El Paso, SD #29), Carlos Uresti (D – San Antonio, SD #19), Royce West (D – Dallas, SD #23), and Judith Zaffirini (D – Laredo, SD #21).

Please take special note if your Senator is included as a member of the Senate Health & Human Services Committee. You are likely to be called on frequently to contact your senator about bills that are important to APNs and their patients as they move through the committee process in the Texas Senate.

Other Senate committees that often hear bills of interest to APNs are State Affairs, Business & Commerce and Finance. For a complete listing of all the Senate committees and the members of each, go to

We anticipate that Speaker Joe Straus will announce his committee assignments next week. Stay tuned. I hope to see you at the Capitol, next Monday or on another day in the very near future.