DFW News App

Nurse practitioner Kimberly Posey poses in an exam room at Preferred Primary Care at 1999 Forest Ridge Drive in Bedford on May 17, 2024. (David Moreno | Fort Worth Report)
” data-medium-file=”https://fortworthreport.org/wp-content/uploads/2024/07/DSC07669-scaled-e1720193059698.jpg?fit=300%2C198&ssl=1″ data-large-file=”https://fortworthreport.org/wp-content/uploads/2024/07/DSC07669-scaled-e1720193059698.jpg?fit=780%2C514&ssl=1″ tabindex=”0″ role=”button”>
Kimberly Posey waits by the exam rooms at Preferred Primary Care in Bedford, on the lookout for her next patient to arrive. She sports a white coat with a stethoscope hung around her neck. 

The patient walks through the door and Posey greets them with a smile. Posey guides the patient to an exam room to complete a check-up and routine screenings. 

Posey is a nurse practitioner at the clinic, bringing 24 years of experience to the role. As a nurse practitioner, she has received advanced education and training, enabling her to diagnose and treat illnesses, prescribe medications and offer more advanced interventions. 

But, she does not practice independently. Texas requires nurse practitioners to have a physician oversee their patients’ primary care through a monthly check-in. 

Posey said the requirement feels unnecessary. She is not alone in that belief. 

Alongside other Texas nurse practitioners, Posey is an advocate for legislation that would allow independent practice in the state. 

However, some Texas physicians disagree with the proposal. Dr. Ray Callas, president of the Texas Medical Association, is among them. 

“All nurses and nurse practitioners are a critical part of the health care team, period,” he said. “But, the best delivery of health care for the state of Texas is physician-led health care, but allowing practitioners to utilize the highest level of their license.” 

As lawmakers prepare to consider the issue next spring, the medical community continues to debate one major question: Would independent practice affect patient health outcomes?

Nurse practitioners ‘spend time with a patient’

Health providers on both sides of the argument emphasize their respect for one another, but note that their disagreement is rooted in who should have the authority to oversee care. 

Nurse practitioners can practice independently in most states. Twenty-seven states and Washington, D.C., allow nurse practitioners to practice without physician supervision. In 12 other states, they have reduced practice and can perform only some duties independently. In 11 states, including Texas, they must work fully under physician supervision.

Texas law requires nurse practitioners to enter into a prescriptive authority agreement with a supervising physician, which outlines a general plan for patient care and what the nurse practitioner can and cannot do. The law requires physicians to review patient charts and meet monthly with nurse practitioners to discuss patients’ care.

If a physician dies, retires or decides to no longer supervise, a nurse practitioner must find a replacement as soon as possible to continue providing care, said Posey, who also serves as the director of graduate nursing at Texas Christian University’s Harris College of Nursing & Health Sciences. 

If Texas nurse practitioners are allowed to practice independently, they can spend more time with patients and provide more personalized care through longer visits, Posey said. Physicians move in and out of appointments and aren’t able to connect with a patient at times, she added. 

“A nurse practitioner is more likely to spend time with a patient and explain what is going on,” she said. “Many of my patients have never seen the physician, and I’ve been taking care of them. … They value what we offer.” 

Posey said nurse practitioners end up paying supervising physicians thousands of dollars a month for a signature, a requirement that can serve as a financial burden. 

“A nurse practitioner may pay a physician collaborator around $50,000 a year, minimum, to sign off on things,” she said. “You can’t publicly tell exactly what you pay a physician. That physician sometimes has never stepped foot in that practice.” 

Independent practice can also alleviate staffing shortages across rural parts of Texas, which continues to be a challenge in health care, said Ann Eckhardt, chair of graduate nursing at the University of Texas at Arlington. 

There is research that shows how nurse practitioners having full practice authority can improve the overall health care of a patient, she said. The American Association of Nurse Practitioners publishes a list of studies that support the quality of nurse practitioner-led care. 

“A nursing model of care tends to be more holistic, so not only treating the acute illness, but also thinking in terms of ensuring that a patient has everything that they need,” Eckhardt said. “Then they transition to home, making sure that they understand their diagnosis as much as possible. (Nurse practitioners are) able to provide that care.”

Kimberly Posey sports her white coat while meeting with patients at Preferred Primary Care at 1999 Forest Ridge Drive in Bedford on May 17, 2024. (David Moreno | Fort Worth Report)

Dawn and Kristi Berndt have received primary care from a nurse practitioner for nearly 14 years. 

The North Richland Hills residents said their nurse practitioner has treated them with more kindness and empathy than any physician they have visited. Kristi has a history of medical conditions, and it’s great for the practitioner to take their time with every appointment, said Dawn Berndt. 

“She listens to all our concerns and takes them seriously, whereas (doctors) don’t pay attention,” she said. “We went to this neurologist who sat down, clicked on his keyboard and didn’t even look at us. It’s just a different level of care.”

Physicians ‘are trained at a higher level’

Callas disagrees with the argument that nurse practitioners should practice independently. His main focus is the well-being of patients, he said.

Nurse practitioners state they are a solution to staffing shortages, but most of them don’t actually go to work in underserved and rural areas, Callas said. Regardless of scope of practice laws, nurse practitioners tend to practice in the same areas of the state as physicians, and most work in urban areas, according to data collected by the American Medical Association. 

“They rather stay or migrate to suburban areas with strong payer mixes,” he said, referring to payers and insurance reimbursements. “They’re not going to underserved areas. They’re going and opening their own Botox clinic. They look at other ways to increase revenue, and a lot of these are doing esthetics (skin care) and stuff on the side.”

Physicians not only go to medical school to receive proper training, but they must complete residencies that last between three to seven years. Someone with less training and education cannot provide better or equivalent care, which can have detrimental effects on a patient’s health outcomes, said Callas. 

“I’m not saying that they should not be allowed to see or touch patients, but to have the overall direction and the lead of delivering that care, it needs to be a physician at the helm,” he said. “We are trained at a higher level of education.”

What’s the difference in training between nurse practitioners and physicians?

Physicians are required to receive a medical degree. Between medical school rotations and residency, they must complete between 12,000 and 16,000 hours of clinical contact, according to the American Medical Association. 

Nurse practitioners are required to complete a master’s degree. They must complete a minimum of 500 supervised hours of clinical contact.

Callas pointed to a 2022 study conducted by Hattiesburg Clinic in Mississippi that analyzed if adding nonphysician practitioners to its care team would keep costs stable and provide similar quality of care. After 15 years, the Mississippi clinic concluded that health care teams should be physician-led, and that “we failed to meet our goals in the primary care setting of providing patients with an equivalent value-based experience.” 

Nancy Coram, who lives in the Texas city of Burnet, has a different experience with nurse practitioners. 

Coram used to seek care from a physician and his team in Houston. After moving to Burnet, her main provider became a nurse practitioner. 

After Coram was diagnosed with cellulitis on her leg, she would regularly schedule appointments with the nurse practitioner to treat it. After a few visits, the leg did not get any better. 

Coram began to question whether the nurse practitioner had the proper training to manage her health. The incident reaffirmed her belief that physician oversight is necessary, said Coram. 

“She struck me as less competent,” said Coram. “I just didn’t feel as comfortable with her or as confident in what she did. That’s not to say other nurse practitioners are not competent, but I would really rather see a physician that’s in the office.”

Could laws change in Texas?

During the 88th Legislature in 2023, members of the professional organization Texas Nurse Practitioners advocated for bills that would allow for independent practice. The Texas Medical Association was a vocal advocate against those bills. 

By the end of the session on May 29, Texas Nurse Practitioners was successful in getting passed into law a bill that increased funding for nursing education.

“We did get some lift on some things, but it was never full practice,” said Posey. “I kind of had hopes. I thought this was our time.” 

The first day of the 89th Legislative Session is set for Jan. 14, 2025, and Texas Nurse Practitioners will continue to advocate for full access. 

The Texas Medical Association has strong bipartisan support against any changes, said Callas. 

In 2023, the Texas Medical Association conducted a survey with primary voters asking them to express their opinion about who should oversee their medical care. About two out of three people oppose allowing nurses to diagnose, treat and prescribe medicine without the oversight of a physician, according to the TMA. (Courtesy image | Texas Medical Association)

(function(d,c,j){if(!document.getElementById(j)){var pd=d.createElement(c),s;pd.id=j;pd.src=’https://app.crowdsignal.com/survey.js’;s=document.getElementsByTagName(c)[0];s.parentNode.insertBefore(pd,s);}}(document,’script’,’pd-embed’));

Posey continues to advocate for independent practice and keeps her ear to the ground in hopes that, one day, laws may change in Texas. 

Still, she loves working alongside physicians at Preferred Primary Care and strives to put her patients first. 

“I’m really invested in what (patients) want and not just quick in and out visits,” she said. “I’ve got some patients that I’ve been taking care of for 20 years, which is pretty fun.” 

David Moreno is the health reporter for the Fort Worth Report. His position is supported by a grant from Texas Health Resources. Contact him at david.moreno@fortworthreport.org or @davidmreports.

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.