Physician Organizations Oppose Independent Practice Legislation

A dozen healthcare advocacy groups are banding together as a coalition to ask the Tennessee General Assembly to reject legislation that would sever critical relationships between physicians and advance practice registered nurses and threaten patient safety and quality of care.

The bill, SB 2110 / HB 2203, is sponsored by Sen. Jon Lundberg and Rep. Bob Ramsey. The sponsors and proponents, including the Tennessee Nurses Association, propose to change state law to remove requirements for nurses to maintain a collaborative relationship with a physician.

Tennessee doctors say that while the current regulatory environment may be improved to create more efficiency for healthcare teams, existing laws provide a necessary framework for physicians, nurses and other healthcare providers to work together in delivering patient care.

"Each member of the healthcare team plays a vital role and should be able to work to the fullest extent of his or her education and training, but team members are not equivalent or interchangeable. Doctors have much more education, training and experience than any other team members and should remain responsible for determining safe, appropriate levels of autonomy," said Dr. Elise Denneny, a Knoxville otolaryngologist and current President of the Tennessee Medical Association.

SB 2110 / HB 2203 is the linchpin of a renewed push by the Tennessee Nurses Association that seeks complete independent (unsupervised) practice for advance practice nurses in Tennessee. TNA has been unsuccessful in its repeated attempts for independent practice since 2014. TMA and other physician advocacy groups, meanwhile, are calling for more integrated and coordinated healthcare delivery, not more silos.

"Allowing nurses to diagnose and treat patients and prescribe medications without any collaborative relationship with a physician would create more fragmentation in healthcare when the entire industry is moving in the opposite direction. Teamwork helps prevent misdiagnoses and missed diagnoses. It increases the capacity of our limited healthcare manpower in Tennessee. It makes us more efficient and effective in delivering quality care at the lowest possible cost," added Dr. Denneny.

Scope of practice is one of TMA's top legislative priorities in 2020. The state's largest physician advocacy organization has assembled a coalition of medical specialty associations to identify and promote best practices for physician-led, team-based healthcare delivery in Tennessee. The Coalition for Collaborative Care spent the past several months meeting with representatives of the nursing profession in good faith efforts to modernize collaboration rules but was unable to reach an agreement, as APRNs made clear they are unsatisfied with anything less than independent practice.

The Coalition now has turned its efforts to educating lawmakers and the general public about the unnecessary risks associated with nurse independent practice, and alternative solutions for more efficient healthcare, particularly in rural, underserved areas of the state.

The emergence of telemedicine, for instance, allows for more frequent and effective collaboration between physicians and the rest of the healthcare team despite geographic challenges. TMA is part of another coalition supporting a bill (SB 1892/HB 1669) that would define certain regulations and reimbursement protocols for telehealth in Tennessee.

In 2019, TMA also led advocacy efforts that added $8.7 million in graduate medical education funding to the state budget. The additional funding will allow Tennessee to train and retain more doctors in Tennessee instead of exporting them to other states, and improve primary care access in underserved areas.

The Coalition is also working on ways to address specific complaints by nurses about the availability and cost of collaborating physicians in rural areas. The vast majority of nurse practitioners in Tennessee practice in hospitals or group medical practice environments where team-based structures are the norm. The faction of APRNs who choose to establish their own clinics, however, are required by law to have a formal, collaborative working agreement with a physician and claim that they have difficulty finding doctors in rural areas to review charts and oversee patient care, or that the negotiated fees are unreasonable. The Coalition is advocating for the state medical boards to maintain a registry of physicians who are willing to collaborate with nurses in rural areas, and for the boards to set some parameters for appropriate fees.

"We are confident that the Tennessee General Assembly will seek a more reasonable, comprehensive solution for expanding access without compromising patient safety or quality of care. Our state lawmakers have asked for solutions to protect patients and set policies that strengthen interprofessional relationships, not weaken them," added Dr. Denneny.

The Coalition for Collaborative Care is actively lobbying against the nurse independent practice bill on Capitol Hill and expects more than 300 physicians to attend TMA's Day on the Hill on March 25.

• Tennessee Academy of Family Physicians
• Tennessee Academy of Ophthalmology
• Tennessee Chapter of the American Academy of Pediatrics
• Tennessee Chapter of the American College of Physicians
• Tennessee Chapter of the American College of Surgeons
• Tennessee Dermatological Society
• Tennessee Group Practice Coalition
• Tennessee Medical Association
• Tennessee Orthopedic Society
• Tennessee Osteopathic Medical Association
• Tennessee Psychiatric Association
• Tennessee Society of Anesthesiologists

Related story: THA, TMA, TNA Outline Legislative Priorities