On May 15, the Texas House of Representatives cast a unanimous vote to approve Senate Bill 406, a bill that will modernize team-based medicine in the Lone Star State. SB 406’s next stop is Gov. Rick Perry’s desk, where he is expected to sign the bill.
SB 406, authored by Sen. Jane Nelson and sponsored by Rep. Lois Kolkhorst, is the result of close collaboration between the Texas Academy of Physician Assistants, the Texas Medical Association and the Texas Nurses Association. While TAPA provided extensive information on the bill on its website, some of the improvements include:
• Reduced site-based language from 5 settings to 2 (community and facility-based).
• Allows for delegation of Schedule II medications to PAs working in hospitals or for patients in hospice.
• Increases the number of PAs that a physician can delegate prescriptive practice to from 4 to 7.
• Removes distance limitations for physician supervision.
• Removes the percentage of charts that a physician must review and co-sign.
• Removes requirements for a percentage of hours of operation that a physician must be present at a practice.
COOA Director Liz Roe recently sat down with TAPA leaders to discuss TAPA’s legislative success in 2013.
Bianca Belcher: Hi, my name is Bianca Belcher, and although I am a new graduate of the Northeastern PA Program, I’m not new to the role of advocacy. I was heavily involved in PA advocacy as a student, and continue to do so. Which is why I’m happy and proud to introduce AAPA’s new advocacy podcast.
Liz Roe: Hi, this is Liz Roe, the AAPA Constituent Organization Outreach and Advocacy Director. I’m here today with leaders from the Texas Academy of Physician Assistants. In May 2013, Texas lawmakers voted to support Senate Bill 406. This was a comprehensive bill to modernize physician delegation and team practice. With that said, I’m going to kick it over to Todd Pickard, the Texas academy’s legislative affairs chair. Todd, can you tell me how TAPA prepared for this effort?
Todd Pickard: Thanks, Liz. It’s our pleasure to be here with you today. TAPA started working on our legislative session approximately two years before the session. We realized that in the state of Texas, we are very unique. We have the largest medical society in the entire United States. TMA (Texas Medical Association) has 40,000 physicians. So we realized that as soon as we asked for anything, one of the first questions our legislators are going to ask us is, “What does TMA think?” So we knew that we had to work with them and negotiate with them. We had to start planting the seed of our ideas early. We had to get them accustomed to the thought of Schedule II delegation, PA ownership, and not having co-signature requirements from the state.
The things that we wanted to pursue took a little getting used to. You can’t just start at square one during the legislative session. You have to start early. So we met with them frequently. We had a task force, we met with them quarterly at the TexMed, and we went to where their meetings where. We’ve got a terrific executive director of our association, Lisa Jackson, and a great lobbyist, Jaime Capelo. They were fundamental in making sure we got the right people at the table and that when we ran into hiccups—when we weren’t getting the right people, when we weren’t getting the time we needed—they were able to facilitate making sure we got to meet with the right people, and lay all that groundwork. You have to do a lot of preparation before you get to the legislative session.
Legislative sessions are complete insanity. There’s so much posturing and so much politics going on, that if you haven’t done the foundational elements yet, you’re going to get totally lost and overwhelmed. So one of the most important things we did was prep early and get the right people and lay the groundwork.
We introduced the ideas to them slowly so there was no shock element involved.
Liz: Right. And Texas is also unique in that it’s the only state in the country where PAs and nurse practitioners are regulated under the same set of statutes and laws.
Karrie Crosby, TAPA president, why don’t you talk a little bit about the unique challenges that presented to the chapter?
Karrie Crosby: Well, first, for those who don’t know, Texas is a legislature that meets every other year. So that in and of itself is a roadblock.
But also, nurse practitioners in Texas, for the last several sessions, have sought independent practice through several bills. The value is that in Texas, PAs have always supported a team-based practice, but because we’ve typically been linked together in legislature, and because scope of practice bills were a big issue in our last session, the Senate chair of the Health Committee, Sen. Nelson, more or less preemptively said that legislation this year would not include independent practice and it had to be more of an agreed-to language between the TMA, nurse practitioner stakeholders and the PA stakeholders.
We were not a part of some of those initial negotiations, because at the outset, the TMA and others involved knew that we as PAs were on the same page with them but that the nurse practitioner colleagues would be at the other end of the spectrum. So the initial negotiations started there, and we were involved later in the process. And some language had already been written, developed, and drafted. When we got involved, we started saying, “This is not really the vision PAs have for a team-based practice model.” We had to start infusing language that we felt more comfortable with.
And so there was an extremely large amount of long hours and meetings and discussions and deliberations. The idea was that there were certain key points that we felt that we could not give up on. And then there were similar ideas with the nurses and the TMA. I’m very proud to say that I think that we were able to preserve in the bill the points that mattered the most to PAs and to some degree level the playing field for us and our nurse practitioner colleagues as to a very healthy and productive team-based practice model.
Todd: What was so great for us during the session is there were a couple of things that kind of fell into line for us. One was Sen. Nelson basically telling everybody, “We cannot continue doing what we’ve been doing.” That was one of the key facilitators for getting anything done. The legislators were sick and tired of everybody fighting and sniping and not getting anything done.
Liz: Can’t we just all get along?
Todd: Exactly. The other thing that was really important was when TAPA got involved, we were really the voice of reason between the nurse practitioners and the TMA. Both of those parties were trying to anchor things of opposite sides of each other. We can in and said, “Look, we’ve got some great solutions and we can please everybody. Everybody can have a little bit of a win, but not everybody going to get exactly what they want.”
Liz: Lauren (Fallis Dobbs), you were TAPA’s president when all this was going on. Can you name the top three or four key elements that made this work for TAPA? What was in place to make it all work?
Lauren Fallis Dobbs: What really helped us is that we planned. Since legislative sessions are every two years in Texas, we had a whole year of “proper prior planning,” as I say, to get things in place so that we could have a productive session.
We also had a good relationship with our medical association. TMA and TAPA have a really great relationship—some of us even serve on their committees right now.
And then of course we have Lisa Jackon, our executive staff, and Jaime Capelo, our lobbyist and general counsel. They were both instrumental in getting us the contacts we need and the appointments that we need. Jaime is very well integrated into the state capital system, which helps us out immensely.
In addition to that, we have some really good leaders this year on the TAPA board that really pushed and worked hard and stayed for about 10 hours locked in a room working on this, wordsmithing and trying to get things rolling the way we wanted them. And also, as Todd mentioned, being the middle man in this situation. All of the ideas we generated in a 10-hour, lock-down work session helped us out.
So I think those are four key things. Of course, there are other things such as the relationships that we have with the legislators.
It all just came together in one big, tremendous bill.
Liz: Excellent. Great job.
Karrie: One of the key things is having people available to testify with a very dynamic and challenging schedule. Some of our House legislators are there from 6 a.m. till late into the early morning hours the next day. As practicing PAs who are still trying to maintain that practice, it’s hard to be accessible and available. We were able to do so because of the people we had engaged.
It gives us credibility when we’re there to testify. I personally testified at 12:30 a.m. having been there since 8 a.m. the day before. Then I drove home, slept for an hour or two, and went to work. I felt like it was those days 22 years ago when I was in PA school. But when you look around, and there’s people who decided it wasn’t important enough to stay engaged in the process, and you’re still there and you’re proving to the legislators that you are engaged, it makes a big difference. And I think it gave us a lot of credibility that on each of our bills, we had someone there to testify on, and we were prepared, and we had the key information to be the source of information for our legislators instead of allowing someone else to speak on our behalf.
Todd: Stamina is definitely key. You have to keep going, and be willing to do it. This legislative session, we set records for a variety of things. I had the longest drive to and from the state capitol for the shortest testimony. I drove 3 hours from Houston to give 10 minutes of testimony and do 15 minutes of visits. And then I drove 3 hours back.
Lauren had the most contentious testimony. She was essentially drawn and quartered by the committee. It was all part of the political process—nobody was actually opposed to what we were saying or what we were doing. There was a key legislator who was there who was on the Calendars Committee. So everybody who was on the committee we were testifying in front of needed to please that individual or else their bills wouldn’t get on the calendar. Lauren suffered through the most difficult testimony ever, and of course, Karrie just alluded to the fact that she had the longest wait for testimony in the history of TAPA, getting there at 8 in the morning and then not finishing her testimony until 12:30 a.m. the next day.
It takes a team, and it takes a lot of stamina.
Liz: I would say in this instance, PAs demonstrated that they can translate their clinical team skills to the legislative arena. So congratulations again, TAPA, and thanks for sharing your story.
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