Elishia Featherston, a nurse practitioner in Euless, opened her own pediatric clinic in 2017.
She wanted to make a space that would serve both the body and the mind, so with the help of a second nurse practitioner, she now provides primary and mental health care to roughly 7,000 patients across North Texas. Most are children, and Featherston worries if she’ll be able to continue to offer them care.
As a nurse practitioner in Texas, Featherston legally cannot practice independently. The state requires a physician to oversee her patient care through, at minimum, a monthly check-in.
But the requirement, Featherston said, feels more like a pricey permission slip than supervision, leaving her beholden to the physician she pays to oversee her. If the physician dies, retires, decides to raise her rates or no longer supervise, Featherston and her patients remain in limbo until she can find a replacement.
Throughout the 88th Legislature, she and other members of the professional organization Texas Nurse Practitioners advocated for bills that would allow independent practice. Twenty-seven states already do so, but by the session’s end on May 29, none of the bills had passed.
The issue cuts across partisan lines but is no less divisive. On the other side, the Texas Medical Association advocated against those same bills. Dr. Tilden Childs, a physician in Fort Worth who chairs the association’s council for legislation, said the supervision requirements should remain in place to protect patient care — and, if they’re serving merely as a permission slip, be made more meaningful.
In interviews with the Fort Worth Report, providers on both sides of the argument emphasize their respect for each other and their desire for patient access to quality care.
The disagreement lies merely in who should oversee it.
‘‘Supervision’ implies someone is looking over your shoulder’
The nurse practitioner role grew from supply and demand. In the late 1950s and early ’60s, more physicians pursued specialties beyond primary care. Subsequently, the creation of Medicare and Medicaid gave more people access to health care.
Increasing need amid a diminishing pool of providers spurred nurses to fill the gap. In 1965, a nurse and a physician collaborated to create the country’s first training program for nurse practitioners. Health care professionals, including nurses, pushed back, worried that nurse practitioners were not qualified to provide care without physician supervision and that the new title would confuse patients.
In the ensuing decades, nurse practitioners sought legitimacy by standardizing their licenses and securing payment for their services. Today, nurse practitioners can assess and diagnose patients, order and interpret diagnostic tests, and prescribe medicine. In most states, they can do so without the supervision of a physician.
Featherston, who has a doctor of nursing practice degree, decided to open her own clinic in 2017, after years of working in hospital systems across North Texas.
She wanted the freedom to make her own decisions about business and patient care, and in some ways, she has it. When the COVID-19 pandemic began, for example, she opted to keep her office open as others shuttered doors or services.
“We were there every day,” she said.
Her freedom, however, comes with a price tag. Texas law requires nurse practitioners to enter into a prescriptive authority agreement with a supervising physician, a contract that outlines a general plan for patient care, including which drugs the nurse practitioner may or may not prescribe.
The law requires physicians to review patient charts and meet monthly with nurse practitioners to discuss patient care. However, the law doesn’t specify how many charts, nor does it require supervising physicians to visit the practice.
Who’s liable under a prescriptive authority agreement?
According to Texas law, “unless the physician has reason to believe the (nurse practitioner) lacked the competency to perform the act,” the supervising physician is not liable for a nurse practitioner’s decision making solely because the physician entered into an agreement.
“Supervision implies somebody’s looking over your shoulder watching exactly what you’re doing. And that’s not what happens in our state with this prescriptive authority agreement,” said Cindy Weston, a nurse practitioner who serves as president of the professional group Texas Nurse Practitioners. “It’s the signature of a piece of paper outlining elements that are required in law — and then it’s an exchange of money.”
Weston, who’s recently been hired as the dean of The University of North Texas Health Science Center’s new College of Nursing, said she’s spoken with nurse practitioners across Texas who pay their supervising physicians thousands of dollars a month for that signature.
Featherston declined to share how much she pays her supervising physician, but said she could hire an additional medical assistant for the same amount.
The money doesn’t buy her peace of mind, however. Her previous supervising physician, with whom she said she worked well, sent her an email out of the blue: Featherston had three months to find a replacement or triple her supervisor’s pay.
Featherston chose the former, but securing a new physician has its own stressors: The physician shortage, as well as restrictions within health systems, make supervising physicians few and far between.
“We’re left, as a business owner, with a business we can’t operate,” she said. “And as a (provider), we cannot care for those patients anymore.”
‘The highest level of team-based care’
Childs, the physician with the Texas Medical Association, also said he worries about patient wellbeing.
He comes from a family of health care providers, including a cousin who is a nurse practitioner, and believes a team-based approach with physicians at the helm works best.
His experience is professional and personal. For years, he’s advocated against independent practice for nurse practitioners through his role with the medical association.
In April, he testified against one of the bills that would grant independent practice authority to nurse practitioners. “Physicians are united on the belief that, no matter where you live in Texas, you deserve the highest level of team-based care, led by a physician,” he testified. The bill was left pending in committee.
When the pandemic began, Childs couldn’t secure an appointment with his own pulmonologist, who was swept up in the maelstrom of COVID-19 care. Childs decided to visit a nurse practitioner.
The visit didn’t move his care forward. Childs’ knowledge of his own condition, both as a patient and a physician, eclipsed the provider’s. In the end, he said, the encounter didn’t benefit him but added to the cost of his care.
“We (at the medical association) don’t think that someone who’s not gone to medical school and had postgraduate training in residency can provide the same level of care as a physician who has,” he said.
What does the research say?
A myriad research studies compare nurse practitioner-led care to physician-led care across multiple metrics and in a variety of settings. When it comes to patient outcomes and cost of care, research exists to support providers’ assertions on both sides of the conversation.
For example, the American Association of Nurse Practitioners maintains a lengthy list of studies that span decades and support the quality of nurse practitioner-led care.
One of the most recent studies on the list, from 2020, compared health outcomes, hospitalizations and cost of care for patients assigned to primary care nurse practitioners or physicians in VA medical facilities across the U.S. The authors included a physician and a nurse.
The study found that, in the early 2010s, patients achieved comparable outcomes at similar costs, regardless of how sick they were or which kind of provider managed their primary care.
Not long afterward, in 2016, the Department of Veterans Affairs gave nurse practitioners full practice authority, meaning they can practice in VA medical facilities without physician supervision regardless of state laws.
But in early May, the Texas Medical Association touted a 2022 study about patient outcomes in VA health care settings. This time, the authors drew emergency room data from the years after full practice authority became official VA policy.
“Compared to physicians,” the authors, one of whom is a physician, wrote in the study, “NPs significantly increase resource utilization but achieve worse patient outcomes.”
The study, which was published through the National Bureau of Economic Research, has not been peer-reviewed.
‘Every part of our team is necessary for health care to function’
In 2022, the Texas Department of State Health Services released a report about the state’s physician supply.
The numbers, which didn’t include pandemic-era data, were grim: Texas doesn’t have enough primary care physicians to meet demand, and that shortage will only increase in years to come. Furthermore, the issue “will not be remedied through current medical education in Texas alone,” according to the report.
Weston, with Texas Nurse Practitioners, is a sixth-generation Texan. “I love this state. And I love rural Texas,” she said. “I have a heart for filling the needs of the underserved.”
In her work with Texas A&M University School of Nursing, she helps lead a mobile clinic of nurse practitioners who rotate visits to six rural schools, “five of which have no other access points to care,” she said.
She’s confident that allowing nurse practitioners to practice independently will help grow that access further. “We have a health care workforce waiting in the wings to be unleashed to help Texas,” she said.
A 2016 study in the journal Medical Care found that primary care physicians were relatively more likely to work in urban areas than primary care nurse practitioners. Moreover, states that grant more independence to nurse practitioners had up to 40% more primary care nurse practitioners in some areas.
However, the authors, who included physicians and a nurse, concluded that granting nurse practitioners independence “may expand the overall capacity of the primary care workforce, but only modestly in the short run.”
When Kate Russell first heard about nurse practitioner independence, she was a master’s student in public health at Emory University. She was persuaded: “Anything that expands access is a great thing,” she said.
Medical school complicated her perspective. Russell is a third-year medical student at the University of North Texas Health Science Center’s Texas College of Osteopathic Medicine.
During this legislative session, she and some of her classmates accompanied Childs to Austin to share concerns about independent practice with lawmakers.
Medical training, Russell realized, is both wide and deep, and she’s aware of how much she doesn’t yet know.
“I’m about to start my fourth year of medical school, and I cannot imagine practicing independently (after this),” she said.
She knows comparing her own confidence to that of nurse practitioners, some of whom have years and years of experience, is imperfect. But she’s also grown to appreciate the sacrifices of time, money and relationships physicians make to become the top of their field.
“Every part of our team is necessary for health care to function. It’s a team sport,” she said. “But at the end of the day, there’s got to be leaders … That’s the role of the physician.”
With leadership, comes liability. Physicians have earned the responsibility to be accountable for decisions that affect patient care, Russell said. “We want to assume the risk,” she said. “We take on that risk for everybody else in the team, right? And we go through a lot of training to do that.”
Featherston, who leads her own clinic, said she refers patients to specialists like a physician would. She’d like to expand into East Texas, she said. But after another disappointing legislative session, she won’t be doing so.
Instead, she’ll return to her own clinic, where elephants paper the exam room walls. She’ll continue to make sure her paperwork is in order.
And, as long as she’s allowed, she’ll see patients.
Alexis Allison is the health reporter at the Fort Worth Report. Contact her at alexis.allison@fortworthreport.org or via Twitter.
Her position is supported by a grant from Texas Health Resources. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.
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