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The litany of regulations can be staggering. Reviewing and cosigning at least 10 percent of charts every 10 days for patients cared for by physician-supervised midlevel practitioners. Keeping track of which advanced practice registered nurse (APRN) or physician assistant (PA) has the delegated authority to pre- scribe medications, which physician oversees each practitioner, and whether the doctor is on site. Spending at least 10 percent of practice time alongside midlevel practitioners at alternate sites, often miles apart in rural areas, and calculating the mileage allowed between locations.


Yet the decades-old regulations — based in a world of paper charts and no cell phones or electronic health records — still govern the team-based care model in Texas today. “Reviewing charts can be done, but we would be much bet- ter off having a regulatory mechanism that reflects best prac- tices. Instead of counting charts and initialing them, let’s look at quality of care — that’s what we are after,” Dr. Fiesinger said. “If Dr. X is out one day, and Dr. Y is on site but he’s not the supervising physician, all of a sudden [a clinic] is out of compliance, not because anyone is doing anything wrong or unsupervised, but because that physician is not the name on paper. And we don’t want to say [to patients], ‘sorry we can’t see you today’ because that doctor is on vacation.” What if instead of counting charts, hours, and miles, physi- cians could meet monthly or quarterly to go over quality assur- ance with the APRNs and PAs they supervise? What if multiple physicians and midlevel practitioners in the practice could sign


A Sen. Jane Nelson


s former medical director of a federally quali- fied health center in Conroe and past region- al clinic director for quality and safety at Scott & White Memorial Hospital and Clinic in Temple, family physician Troy Fiesinger, MD, (shown on pages 14–15) is familiar with those kinds of rules. He says they make care often inefficient, sometimes inaccessible.


on to a single prescriptive authority delegation agreement for all to refer to? What if they could devise a plan that fits the geographic and access needs of the practice? “If I started over and designed the rules to handle oversight, this is how I would set it up. These kinds of rules reflect the spirit of how doctors, nurses, and PAs already practice team- based care and would trade technical oversight requirements for a more practical and relevant system,” Dr. Fiesinger said. Such improvements are close to becoming reality under Senate Bill 406, spearheaded by Sen. Jane Nelson (R-Flower Mound), chair of the Senate Health and Human Services Com- mittee. The bill unanimously cleared the committee in Febru- ary and won full Senate approval in early March. Senator Nelson sees the measure as part of a larger strategy


to improve access to care and says she is “confident this bill will advance all the way through the legislative process.” If passed and the governor signs it, the legislation takes effect Sept. 1. The measure would replace what physicians, nurse practi- tioners, and PAs agree is an outdated system of site-based reg- ulations for delegating and supervising prescribing authority with one that reflects a more cooperative, efficient, and qual- ity-based approach to team care. Supporters say the changes also add needed flexibility, particularly for rural areas. But Texas Medical Association leaders emphasize the bill maintains the current physician-led team model, which, along with other safeguards, would still apply to a new provision al- lowing doctors to delegate prescriptive authority for Schedule II drugs only in hospitals and hospice care. Despite the changes reflected in the legislation, one thing


remains the same, says Fort Worth pediatrician Gary Floyd, MD, a consultant to the TMA Council on Legislation and a former chair.


Rep. Lois Kolkhorst 16 TEXAS MEDICINE May 2013


Sen. Charles Schwertner, MD


“Medical practice is medical practice. Physicians are still the ones who are trained to diagnose and treat, and the statute still places physicians in a supervisory role to ensure patients get adequate, evidenced-based care. That fundamental prin-


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