NRP/508 Week 5: Health Policy Analysis and Advocacy, sample paper

After Two Supervised Years, Then On Your Own: Analyzing a Proposed Texas Transition-to-Practice Bill for Nurse Practitioners and Planning One Student's Part in Moving It

[Student Name]

University of Phoenix

NRP/508: Health Policy and Role of the Advanced Practice Nurse

Week 5 Assignment

[Instructor Name]

[Date]

The bill described is a composite based on transition-to-practice proposals in several states, written for a model paper. Students should analyze an actual bill in their state.

In my future clinic's county, there is one primary care physician for roughly every 4,000 residents, and the physician who would sign my prescriptive authority agreement is nearing retirement. The rule that ties my prescribing to a physician agreement is not only a professional question; it determines whether the clinic can stay open. This paper analyzes a transition-to-practice proposal of the kind introduced in several state legislatures and plans how I, as a student, can help move it.

The Problem

In Texas, a nurse practitioner needs a physician partner's written delegation before writing any prescription, and they are largely barred from prescribing Schedule II drugs outside hospitals and hospice. In rural counties with few physicians, finding a delegating physician can be difficult and costly, and the loss of one can halt a clinic's prescribing overnight. Patients bear the cost in longer travel and delayed care.

The Proposal

The composite bill would allow a nurse practitioner who has completed a set period of practice under a prescriptive authority agreement, such as two years or about 4,000 hours, to prescribe without an agreement, within the recognized role and population. New nurse practitioners would still practice under an agreement at first, and all nurse practitioners would remain licensed and disciplined by the Board of Nursing. Several full practice states use a similar transition period, which answers concerns about new graduates practicing alone.

Why the Issue Has Not Passed: Multiple Streams

Kingdon (2011) argued that policies reach the decision agenda when three independent streams come together: a problem that decision makers recognize, a workable policy solution and a political climate that favors action. When they converge, a policy window opens, often briefly.

The problem stream is strong: rural shortages are well documented, and hospital closures in rural Texas have drawn public attention. The policy stream is also ready: transition-to-practice models exist in other states and can be adapted. The political stream has been the barrier. Organized opposition from physician groups, concern among some legislators about patient safety and competing priorities in a short legislative session have kept past proposals from reaching a floor vote. The problem is recognized and the solution is drafted; what is missing is a political moment and enough legislators willing to use it.

The Evidence

Evidence on access and use supports broader scope. A systematic review associated broader nurse practitioner scope of practice with greater nurse practitioner supply and greater use of health services, without evidence of lower quality (Xue et al., 2016). Studying states that changed their laws, Traczynski and Udalova (2018) linked nurse practitioner independence to more routine checkups and to gains on some measures of access and care.

Evidence on cost is also favorable. Among Medicare beneficiaries, those assigned to nurse practitioners had evaluation and management payments 29% lower than those assigned to primary care physicians, with inpatient and office visit payments 11% and 18% lower, after adjustment for patient characteristics (Perloff et al., 2016). The authors concluded that expanding access to nurse practitioner primary care is not likely to increase Medicare costs and may save money.

The Opposition's Arguments

Opponents raise three arguments that deserve answers. First, they note that nurse practitioners complete fewer clinical hours in training than physicians. The transition period responds by requiring supervised experience before independence. Second, they argue that team-based care led by physicians is safer. None of the studies above found that quality fell where scope widened, and clinicians who choose to work as a team need no statute ordering one of them to supervise the other. Third, some argue that independence will not bring nurse practitioners to rural areas. This is partly true; law is necessary but not sufficient, and the bill should be paired with rural recruitment incentives.

Stakeholders

Supporters include the state nurse practitioner association, rural hospitals and clinics, some patient advocacy groups and business groups concerned about health costs. Opponents include the state medical association and some specialty societies. Neutral or persuadable parties include legislators from rural districts, whose constituents are most affected, and the state's health agencies, which administer workforce programs. Rural legislators of both parties are the most important audience.

My Advocacy Plan

As a student, I can act in five ways. I will join the state nurse practitioner association and its legislative committee, which coordinates testimony and messages. I will write to my own state representative and senator with a one-page letter describing my future clinic, the county's shortage and the evidence, asking for support. I will attend the association's legislative day at the capitol during the next session and, if the bill receives a hearing, submit written testimony. I will share the evidence with my clinical preceptors and ask physicians who support the change to say so publicly, since physician voices carry weight with legislators. And I will track the bill's progress through the legislature's public website and respond to calls for action.

Timing

Texas's legislature meets in regular session every other year, so the next opportunity may be more than a year away. The months between sessions are when interim committees study issues and when relationships with legislators are built. I will use that time to meet my representative's staff in the district office.

Measuring Success

Success in one session may mean a committee hearing rather than passage. Progress includes a hearing, amendments that address concerns while keeping the core change and a growing list of rural legislators willing to co-sponsor. Each step prepares for the next window.

Framing the Message

Different audiences respond to different arguments. For rural legislators, the message is access: residents driving an hour for a prescription refill and a clinic that could close if one physician retires. For fiscally minded legislators, it is cost, supported by the Medicare findings. For legislators worried about safety, it is the transition period and the quality evidence. For the public, it is a story: a named, consenting patient whose care was delayed, told briefly and accurately. Each message should end with a specific request, such as co-sponsoring the bill or voting for it in committee.

Building a Coalition

Nurse practitioners alone are a small voice. The bill's chances improve if rural hospitals, the rural health association, business groups and patient organizations speak together, and if the coalition includes physicians who work alongside nurse practitioners and support the change. My clinic's delegating physician has told me she would support a transition period; with her permission, I will connect her with the association's legislative team.

What I Will Not Do

Advocacy should be accurate. I will not overstate the evidence, dismiss physicians' concerns or imply that nurse practitioners do not value collaboration. Credibility is the advocate's main asset.

Conclusion

A transition-to-practice bill would let experienced Texas nurse practitioners prescribe without a physician agreement while keeping supervision for new graduates. Kingdon's model explains why a recognized problem and a ready solution have not yet become law: the political stream has not aligned. Evidence on access, quality and cost supports the change, and a student can contribute through the professional association, letters, testimony and accurate public argument.

References

Kingdon, J. W. (2011). Agendas, alternatives, and public policies (2nd ed.). Longman.

Perloff, J., DesRoches, C. M., & Buerhaus, P. (2016). Comparing the cost of care provided to Medicare beneficiaries assigned to primary care nurse practitioners and physicians. Health Services Research, 51(4), 1407-1423. https://doi.org/10.1111/1475-6773.12425

Traczynski, J., & Udalova, V. (2018). Nurse practitioner independence, health care utilization, and health outcomes. Journal of Health Economics, 58, 90-109. https://doi.org/10.1016/j.jhealeco.2018.01.001

Xue, Y., Ye, Z., Brewer, C., & Spetz, J. (2016). Impact of state nurse practitioner scope-of-practice regulation on health care delivery: Systematic review. Nursing Outlook, 64(1), 71-85. https://doi.org/10.1016/j.outlook.2015.08.005