Reform Update: Texas moves to avert access issues

With the anticipated arrival of some 14 million newly insured individuals into the nation's healthcare system in 2014, a major concern that remains is whether coverage will equal access. Texas lawmakers, physicians and nurse practitioners have taken a step forward on that problem while many other states remain at an impasse.

As Michael Gelder, a senior healthcare policy adviser to Illinois Gov. Pat Quinn, said last year, Medicaid expansion could turn into a situation where everyone gets a library card but there are not enough books in the library.

This concern over access has led to a call for greater independence for nurse practitioners and physician assistants. This has led to fierce legal and legislative scope-of-practice fights in states across the country including California, Michigan, Nevada and Virginia.

In Texas, however, both sides worked together to craft legislation to increase healthcare access that they all could live with. The new law, signed by Gov. Rick Perry on June 14, loosens physician supervision requirements for NPs and physician assistants, increases from four to seven the number of NPs or PAs a doctor to whom can delegate prescriptive authority, and allows physicians to delegate Schedule II controlled-substance prescribing in hospital and hospice settings.

The Texas Medical Association called it “a landmark bill” that establishes physician-led teams and “creates a more collaborative, delegated practice among physicians and advanced practice registered nurses or physician assistants."

“Diagnosing and prescribing remain the practice of medicine, which only physicians are trained and authorized to do by Texas law,” Dr. Stephen Brotherton, president of the TMA, said in a news release. “But the good news is that by working together as a team—doctors, nurses and physician assistants—we can take care of more patients and do a better job of it.”

Sandy McCoy, president of Texas Nurse Practitioners, said in an interview that both sides were motivated by a CMS listing that ranked Texas 47th in the nation for access to primary care.

“Everyone came to the table and realized that we had a problem,” said McCoy, a bariatric nurse practitioner with the Baylor University Medical Center in Dallas. “We realized we had to make some compromises—deeper compromises than we had made in the past.”

She said state restrictions on NP practices had led to some providers in El Paso and the western edge of the state to set up shop in New Mexico where they could practice more freely.

McCoy cited estimates that healthcare reform may eventually add as many as 6 million Texans to the ranks of the insured. That prompted everyone to seek compromise. “Eventually, we'd like to see full prescriptive authority (for NPs),” she said. “Eventually, we will come back and ask for more.”

Although the CMS says up to nine of the 32 provider organizations involved in the Medicare Pioneer accountable care organization program may withdraw from the program, private-sector payer-provider system ACOs continue to form at a rapid pace.

Within the last week, Cigna Corp. has formed collaborative “accountable care initiatives” with the Lehigh Valley, Pa.-based Valley Preferred health network; the NYU Langone Medical Center and its University Physicians Network; and, most recently, with the Gastonia, N.C.-based CaroMont Medical Group.

Also, Seton Health Alliance, an Austin, Texas-based division of Ascension Health, entered into an ACO contract with UnitedHealthcare, while Aetna entered into an agreement with Mariottsville, Md.-based Bon Secours Health System and its Good Help ACO.

Business owners participating in the Small Business Health Options Program, or SHOP insurance exchange, created as part of the Patient Protection and Affordable Care Act, are facing “a steep learning curve” in figuring out their options, according to a tracking report on the implementation of business exchanges in six states.

The report, produced by the Urban Institute with support from the Robert Wood Johnson Foundation, tracked the progress of efforts in Colorado, Maryland, New Mexico, New York, Oregon and Rhode Island.

The report found that smaller states have more uniformity in payer participation; brokers and agents are key to maximizing SHOP enrollment; insurer interest is high but often has been demonstrated with only nonbinding letters of intent; communication efforts are just getting started; and implementing effective small business outreach strategies poses a significant challenge for the states.

Follow Andis Robeznieks on Twitter: @MHARobeznieks