FTC Staff Letter To The Honorable Rodney Ellis and The Honorable Royce West, The Senate of the State of Texas, Concerning Texas Senate Bills 1260 and 1339 and the Regulation of Advanced Practice Registered Nurses

UNITED STATES OF AMERICA
FEDERAL TRADE COMMISSION
WASHINGTON, D.C. 20580
Office of Policy Planning
Bureau of Economics
Bureau of Competition
May 11, 2011
The Honorable Rodney Ellis
The Honorable Royce West
The Senate of the State of Texas
P.O. Box 12068
Austin, Texas 78711
Dear Senators Ellis and West:
The staffs of the Federal Trade Commission=s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition1 (“FTC staff”) are pleased to respond to your invitation
for comments on Texas Senate Bills 1260 and 1339 (“S.B. 1260 and S.B.1339” or “the Bills”)
and the regulation of Advanced Practice Registered Nurses (“APRNs”).2 S.B. 1260 would
remove physician supervision and delegation requirements for APRNs, allowing these health
care professionals to practice to the full extent of their education and training. S.B. 1339
similarly would remove physician oversight requirements and grant diagnostic and prescription-
writing authority to APRNs,3 but prescription-writing authority would require 500 hours of
practice under the supervision of a physician or another APRN with full prescriptive authority.
You have asked FTC staff to analyze the “likely competitive impact” of S.B. 1260 and S.B.
1339. Based on current evidence, the Bills’ elimination of supervision and delegation
requirements appears to be a procompetitive improvement in the law that likely will benefit
Texas health care consumers, and FTC staff therefore urge the Texas legislature to adopt either
S.B. 1260 or S.B. 1339.
In fact, in its January 2011 report to the 82nd Texas Legislature, the Texas Legislative
Budget Board staff found that Texas’s “site-based, delegated model of prescriptive authority
limits patient access to affordable, quality healthcare providers, particularly in rural and health
professional shortage areas.”4 The Institute of Medicine (IOM) recently noted similar concerns
1 This letter expresses the views of the Federal Trade Commission’s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition. The letter does not necessarily represent the views of the Federal Trade
Commission (“Commission”) or of any individual Commissioner. The Commission has, however, voted to
authorize staff to submit these comments.
2 Letter from Hon. Rodney Ellis and Hon. Royce West, Texas State Senate, to Susan DeSanti, Director, Office of
Policy Planning, Federal Trade Commission (Apr. 6, 2011) [hereinafter Ellis/West Letter].
3 Id. (discussing requirements in Tex. Occ. Code Ann. § 157, which governs the conditions under which physicians
may delegate diagnostic and prescriptive authority to nurse practitioners and physician assistants).
4 TEXAS LEGISLATIVE B UDGET BOARD S TAFF , TEXAS S TATE G OVERNMENT EFFECTIVENESS AND EFFICIENCY:
S ELECTED I SSUES AND R ECOMMENDATIONS 297 (Jan. 2011) (submitted to the 82 nd Texas Legislature) [hereinafter
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with restrictive state scope of practice laws and specifically recommended that the FTC
“[r]eview existing and proposed state regulations concerning advanced practice registered nurses
[and urge states] with unduly restrictive regulations . . . to amend them to allow advanced
practice registered nurses to provide care to patients in all circumstances in which they are
qualified to do so.”5 We therefore urge the Texas Legislature to consider the impact of the
current restrictions on the scope of practice of APRNs, and to adopt either S.B. 1260 or
S.B. 1339. Doing so would allow APRNs to provide health care services in a manner consistent
with their training and the protection of patients.6
Interest and Experience of the Federal Trade Commission
The FTC is charged with enforcing the FTC Act, which prohibits unfair methods of
competition and unfair or deceptive acts or practices in or affecting commerce.7 Effective
competition is at the core of America’s economy;8 vigorous competition among sellers in an
open marketplace gives consumers the benefits of lower prices, higher quality products and
services, more choices, and greater innovation.
Health care competition is of particular importance to the economy and consumer
welfare. For this reason, anticompetitive restraints in health care markets have long been a key
focus of FTC law enforcement,9 research,10 and advocacy.11 Of direct relevance to the proposed
BUDGET B OARD S TAFF REPORT]. As you also noted in your letter, “physician supervision requirements vary based
on the APRN’s practice setting, . . . the various requirements create a complicated regulatory scheme,” and “APRNs
at an alternative practice site must find a supervising physician that lives or practices within 75 miles,” which may
exclude APRNs otherwise willing to practice in rural and underserved areas. Ellis/West Letter, supra note 2, at 1-2.
5 I NSTITUTE OF MEDICINE, THE F UTURE OF N URSING : LEADING CHANGE, A DVANCING H EALTH 10-11 (2011)
[hereinafter IOM REPORT]. The IOM was established in 1970 as “the health arm of the National Academy of
Sciences” and “is an independent, nonprofit organization that works outside of government to provide unbiased and
authoritative advice to decision makers and the public.” About the Institute of Medicine, available at
http://www.iom.edu/About-IOM.aspx.
6 We do not offer an opinion as to whether S.B. 1260 or S.B. 1339 is a preferable regulatory environment for Texas.
7 Fed. Tr. Comm’n Act, 15 U.S.C. § 45.
8 See National Society of Professional Engineers v. United States, 435 U.S. 679, 695 (1978) (“The heart of our
national economy long has been faith in the value of competition.”).
9 See generally F ED. TR . COMM’ N, FTC A NTITRUST A CTIONS IN H EALTH CARE S ERVICES AND P RODUCTS (Sept.
2010), available at http://www ftc.gov/bc/110120hcupdate.pdf; Fed. Tr. Comm’n Website, Competition in the
Health Care Marketplace, available at http://www.ftc.gov/bc/healthcare/antitrust/index.htm.
10 See, e.g., F ED. TR . COMM’ N & U.S. D EP ’ T OF J USTICE, I MPROVING H EALTH C ARE: A D OSE OF COMPETITION
(2004), available at http://www.ftc.gov/reports/healthcare/040723healthcarerpt.pdf [hereinafter FTC/DOJ, A D OSE
OF COMPETITION ]; Fed. Tr. Comm’n, Centers for Medicare & Medicaid Servs., & Dep’t of Health & Human Servs.
Office of Inspector Gen’l, Workshop Regarding Accountable Care Organizations and Implications Regarding
Antitrust, Physician Self-Referral, Anti-Kickback and Civil Monetary Penalty (CMP) Laws (Oct. 5, 2010), available
at http://www ftc.gov/opp/workshops/aco/index.shtml; Fed. Tr. Comm’n, Workshops on Emerging Health Care
Competition and Consumer Issues (Oct. 30, 2008 & Nov. 21, 2008), available at
http://www.ftc.gov/bc/workshops/hcbio/index.shtml; F ED. TR . COMM’ N, EMERGING H EALTH CARE I SSUES : F OLLOW-
O N BIOLOGIC D RUG COMPETITION (J UNE 2009), available at
http://www ftc.gov/os/2009/06/P083901biologicsreport.pdf; Fed. Tr. Comm’n, Workshop on Clinical Integration in
Health Care: a Check-Up (May 29, 2008), available at http://www ftc.gov/bc/healthcare/checkup/index.shtm; Fed.
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Texas APRN legislation, the FTC has closely followed issues relating to competition by health
care providers such as nurse practitioners, physician assistants, and dental hygienists. Recently,
FTC staff urged several states to reject or narrow restrictions that curtail competition among
health care providers because they limit patients’ access to health care and raise prices.12 In
particular, staff examined APRN scope of practice restrictions that appear to have exceeded what
is necessary to protect consumers.13 As noted above, the recent IOM Report on the Future of
Nursing recognizes the importance of this competition perspective and, more specifically, the
Commission’s expertise and experience in addressing anticompetitive restrictions on the scope of
various healthcare professionals’ practice.14
I. 	Background
A. 	APRNs
APRNs are licensed under the Texas Nursing Practice Act.15 Under this Act, “advanced
practice nurse” means a registered nurse approved by the Texas Board of Nursing on the basis of
Tr. Comm’n, Workshop on Innovations in Health Care Delivery (Apr. 24, 2008), available at
http://www ftc.gov/bc/healthcare/hcd/index.shtm.
11 Advocacy by the Commission and its staff may comprise letters or comments addressing specific policy issues,
Commission or staff testimony before legislative or regulatory bodies, amicus briefs, or reports. See, e.g., Letter
from FTC Staff to Hon. Daphne Campbell, Florida House of Representatives (Mar. 22, 2011) (regarding proposed
legislation to eliminate certain restraints on the scope of practice of Advanced Registered Nurse Practitioners),
available at http://www.ftc.gov/os/2011/03/V110004campbell-florida.pdf; Letter from FTC Staff to Hon. Timothy
Burns, Louisiana Legislature, (May 1, 2009) (regarding proposed restrictions on mobile dentistry), available at
http://www ftc.gov/os/2009/05/V090009 louisianadentistry.pdf; Fed Tr. Comm’n & U.S. Dep’t of Justice Written
Testimony before the Illinois Task Force on Health Planning Reform Concerning Illinois Certificate of Need Laws
(Sept. 2008), available at http://www ftc.gov/os/2008/09/V080018illconlaws.pdf; FTC Amicus Curiae Brief in In re
Ciprofloxacin Hydrochloride Antitrust Litigation Concerning Drug Patent Settlements Before the Court of Appeals
for the Federal Circuit (Case No. 2008-1097) (Jan. 2008), available at
http://www.ftc.gov/os/2008/01/080129cipro.pdf; FTC/DOJ, A D OSE OF COMPETITION, supra note 10.
12 See, e.g., Letter from FTC Staff to Hon. Daphne Campbell, supra note 11; Letter from FTC Staff to Hon. Timothy
Burns, supra note 11; Letter from FTC Staff to Elain Nekritz, Illinois Legislature (May 29, 2008) (regarding
proposed limited service clinic (LSC) regulations), available at http://www.ftc.gov/os/2008/06/V080013letter.pdf;
Letter from FTC Staff to Massachusetts Dep’t of Health (Sept. 27, 2007) (regarding proposed LSC regulations),
available at http://www ftc.gov/os/2007/10/v070015massclinic.pdf. Many of these advocacy efforts have been
influential in preserving competition. For example, following the above-referenced advocacy letters, the Louisiana
and Illinois legislatures rejected the proposed restrictions on competition, and Massachusetts followed FTC staff’s
recommendations in adopting its final LSC regulations.
13 See, e.g., Letter from FTC Staff to Hon. Daphne Campbell, supra note 11; Letter from FTC Staff to Kentucky
Cabinet for Health and Family Services (Jan. 28, 2010) (regarding restrictions on the scope of practice for nurse
practitioners, and others, that would have applied in LSCs but not in other limited care settings, such as urgent care
centers), available at http://www.ftc.gov/os/2010/02/100202kycomment.pdf; FTC Staff Comment Before the
Alabama State Board of Medical Examiners Concerning the Proposed Regulation of Interventional Pain
Management Services (Nov. 3, 2010) (regarding restrictions on the scope of practice of certified registered nurse
anesthetists, a specialized sub-category of APRNs), available at
http://www ftc.gov/os/2010/11/101109alabamabrdme.pdf.
14 IOM REPORT, supra note 5, at 5, 10, 105 (2011).
15 Tex. Occ. Code Ann. § 301.001 et seq. (2011) (Nursing Practice Act).
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the nurse having completed an advanced educational program, which must include
“pharmacology and related pathology education.”16 In addition, the Texas Board of Nursing has
promulgated rules requiring that the educational program, at a minimum, include a master’s
degree, and meet “certain standards set by the [nursing] board or by a national accrediting body
recognized by the board.”17 Nationally, “[m]ore than a quarter of a million nurses are APRNs . .
. who hold master’s or doctoral degrees and pass national certification exams.”18
According to the January 2011 Budget Board Staff Report, “Texas has some of
the most restrictive scope of practice guidelines in the U.S. for APRNs.”19 According to
the report, the number of advanced practice nurses is lower in states with restrictive
regulatory environments, and these restrictions may “limit the expansion of retail clinics,
which generally employ APRNs to provide a limited range [of] primary healthcare.”20
The Budget Board Staff Report also noted that approximately 26 percent of Texas’s
population lives in a health professional shortage area and that “Texas is below the U.S.
average in its primary care physicians-to-population ratio.”21 Finally, the report stated
that researchers “have compared physician and APRN patient outcomes and found them
comparable” and “no findings have shown better health outcomes for patients in states
with more restrictive regulatory environments.”22
B. 	S.B. 1260 and S.B. 1339
S.B. 1260 would remove physician supervision and delegation requirements, allow
APRNs to practice independently, and define an APRN’s scope of practice to include “advanced
assessment, diagnosing, prescribing, and ordering.” Under the new law, APRN status would be
based upon (1) successful completion of a graduate-level program accredited by a national
accrediting body and (2) current certification by a national certifying body recognized by the
Texas Board of Nursing.23
16 Tex. Occ. Code Ann. § 301.152(c)(1).
17 Texas Board of Nursing, Rules and Regulations, at Chapter 221, available at
http://www.bon.state.tx.us/nursinglaw/pdfs/bon-rr-0111.pdf.
18 IOM REPORT, supra note 5, at 23; see also BUDGET B OARD S TAFF REPORT, supra note 4, at 299 (although
certification exams are administered nationally, licensure requirements are determined on a state-by-state level and
may vary widely). Different states refer to advanced practice registered nurses by various names and abbreviations,
including “APRNs,” “ARNPs,” “nurse practitioners,” etc. For an overview of nurse practitioner requirements
generally, see IOM REPORT, supra note 5, at 26, table 1 (types of practice) and 38-45.
19 BUDGET BOARD S TAFF REPORT, supra note 4, at 299 (further noting “[t]wenty states and the District of Columbia
allow APRNs to practice as autonomous, or very nearly autonomous, healthcare providers”). See also IOM REPORT,
supra note 5, at 157-61 (chart summarizing the state practice regulations for nurse practitioners).
20 BUDGET BOARD S TAFF REPORT, supra note 4, at 300.
21 Id.
22 Id.
23 These amendments would be to Chapter 301 of the Occupations Code, the Nursing Practice Act, as well as
conforming amendments and deletions to other chapters, including Chapter 157 of the Occupations Code (governing
the authority of physicians to delegate certain medical acts).
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S.B. 1339 also would revise current Texas law to allow APRNs to make diagnoses and to
prescribe and order prescription drugs and medical devices. Unlike S.B. 1260, however, S.B.
1339 would require APRNs seeking independent prescriptive authority to first practice with
prescriptive authority for a minimum of 500 hours under the supervision of a physician or APRN
who already has prescriptive authority.24
II. 	Likely Effects on Texas Health Care Consumers
Texas health care consumers are likely to benefit from the passage of either S.B. 1260 or
S.B. 1339 for several reasons, including lower health care costs, greater access to care, and
greater choice among settings where health care is provided.
Both S.B. 1260 and S.B. 1339 are likely to reduce the cost of basic health care services
in two important ways. First, APRN care is generally less expensive. As noted by the Texas
Legislative Budget Board staff, “[a]ll APRNs who bill the Texas Medicaid Program are directly
reimbursed at 92 percent of the physician’s rate” and if they bill Medicare “they are paid 85
percent of the fee paid to physicians.”25 Second, the cost of APRN care itself would be
decreased; under the current law, supervision and delegation requirements create administrative
costs for APRNs, and these costs would be reduced under either of the Bills. Some of these cost
savings may be passed on to public and private third-party payers, and ultimately to Texas health
care consumers, in the form of lower prices.
Both S.B. 1260 and S.B. 1339 likely will encourage greater usage of APRNs, which will
also play an important role in improving access to health care services by Texas consumers. The
Texas Legislative Budget Board staff noted that APRNs “have helped mitigate the effects of a
general practice physician shortage” and that reduced restrictions on APRNs “would increase the
availability of lower-cost primary healthcare providers.”26 The IOM, too, recently recognized
the important role that APRNs can play in improving access to health care.27 Among other
things, the IOM observed that “[r]estrictions on scope of practice . . . have undermined the
nursing profession’s ability to provide and improve both general and advanced care.”28 FTC
staff agree that the Bills likely will reduce barriers to entry and permit health care providers
greater flexibility to offer basic health care through APRN-staffed offices and clinics.
To the extent both S.B. 1260 and S.B. 1339 would increase the deployment of APRNs in
a variety of health care delivery settings and thereby widen the range of choices available to
consumers, both Bills also are likely to spur innovation in health care delivery and increase
competition to provide basic health care services. This may generate additional benefits for
24 See S.B. 1339, amendments to Tex. Occ. Code Ann. §§ 301.152, 301.357, and 157.051.
25 BUDGET BOARD S TAFF REPORT, supra note 4, at 302.
26 Id. at 297.
27 See generally IOM REPORT, supra note 5 (especially Summary, 1-15).
28 Id. at 4.
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Texas health care consumers. For example, APRN-staffed clinics generally offer weekend and
evening hours, which provides greater flexibility for patients, and may provide competitive
incentives for other types of clinics to offer extended hours as well.29
In addition, APRNs have played an important role in the recent increase in so-called
limited service clinics (“LSCs”) in many states. LSCs typically are staffed by APRNs30 and
offer consumers a convenient way to obtain basic medical care at competitive prices.31 As the
January 2011 Budget Board Staff Report noted, restrictions on APRNs’ scope of practice may
limit both the number and types of LSCs available to Texas consumers.32
III. 	Potential Consumer Protection Concerns Raised by Reduced Scope of Practice and
Supervision Requirements
Patient safety or consumer protection concerns may justify licensure requirements and
scope of practice restrictions.33 FTC staff recognize that particular health care procedures may
require specialized training or heightened supervision if they are to be safely administered.
There does not appear to be any evidence, however, that the safety of care provided by APRNs
varies according to differences in physician supervision or scope of practice requirements.34
29 Cf. Rena Rudavsky, Craig Evan Pollack, & Ateev Mehrotra, The Geographic Distribution, Ownership, Prices,
and Scope of Practice at Retail Clinics, 151 A NNALS I NTERNAL MED. 315, 317 (2009) (“In a random sample of 98
[limited service] clinics, all had weekday and weekend hours and 95 (97%) had evening hours (after 6 p.m.) on
weekdays.”).
30 See generally William M. Sage, Might the Fact that 90% of Americans Live Within 15 Miles of a Wal-Mart Help
Achieve Universal Health Care?, 55 U. K AN. L. REV. 1233, 1238 (2007) (describing the size and scope of LSCs);
Mary Kay Scott, Scott & Company, Health Care in the Express Lane: Retail Clinics Go Mainstream, at 22 (Sept.
2007) (report prepared for the California HealthCare Foundation), available at http://www.chcf.org/publications.
31 See Massachusetts Dept. Pub. Health, Commonwealth to Propose Regulations for Limited Service Clinics: Rules
May Promote Convenience, Greater Access to Care (Jul. 17, 2007), available at
http://www mass.gov/?pageID=pressreleases&agId=Eeohhs2&prModName=dphpressrelease&prFile=070717 clini
cs.xml. The types of care offered at LSCs are similar to those offered in urgent care centers and other limited care,
outpatient settings. See, e.g., Ateev Mehrotra et al., Retail Clinics, Primary Care Physicians, and Emergency
Departments: A Comparison of Patients Visits, 27 H EALTH A FFAIRS 1272, 1279 (September/October, 2008).
Evidence shows that the quality of care provided by APRNs in retail clinics is “similar to that provided in
physician offices and urgent care centers and slightly superior to that of emergency departments.” Ateev Mehrotra
et al., Comparing Costs and Quality of Care at Retail Clinics with that of Other Medical Settings for 3 Common
Illnesses, 151 A NNALS I NTERNAL MED. 321, 326 (2009) (analysis of 14 quality metrics for commonly treated
ailments, including ear, strep, and urinary tract infections, and finding “[f]or most measures, quality scores of retail
clinics were equal to or higher than those of other care settings”). Id.
32 BUDGET BOARD S TAFF REPORT, supra note 4, at 300.
33 In competition terms, licensure requirements or scope of practice restrictions may sometimes offer an efficient
response to certain types of market failure that can occur in professional services markets. See CAROLYN COX &
S USAN F OSTER , F EDERAL TRADE C OMMISSION, BUREAU OF ECONOMICS , THE C OSTS AND BENEFITS OF
O CCUPATIONAL REGULATION , 5-6 (1990), available at
http://www ftc.gov/be/consumerbehavior/docs/reports/CoxFoster90.pdf.
34 FTC staff have not found empirical studies indicating a relationship between additional APRN supervision
requirements and greater safety. See IOM REPORT at 85-161, 98-99 (discussing nursing scope-of-practice issues and
quality of care, and noting “[n]o studies suggest that care is better in states that have more restrictive scope-of-
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Available evidence suggests that APRNs generally are safe providers of health care
services when they provide services consistent with their training.35 More broadly, the available
empirical evidence indicates that APRN-delivered care “across settings, is at least equivalent to
that of physician-delivered care as regards safety and quality,”36 and that increased APRN care
may even be associated with improved outcomes for particular disease indications or patient
populations.37 Studies of LSCs – which, as discussed above, offer certain basic primary care
services and tend to be staffed by APRNs without direct on-site physician supervision – indicate
that the clinics provide high-quality health care.38 In addition, studies of APRN subspecialties,
such as certified registered nurse anesthetists, suggest safe delivery of care.39
practice regulations for APRNs than in those that do not”); Brian Dulisse & Jerry Cromwell, No Harm Found When
Nurse Anesthetists Work Without Supervision by Physicians, 29 H EALTH A FFAIRS 1469, 1474 (2010) (reviewing
Medicare data for more than 480,000 patients and finding “data do not support the hypothesis that patients are
exposed to increased surgical risk if nurse anesthetists work without physician supervision”).
35 See, e.g., BUDGET BOARD S TAFF R EPORT, supra note 4, at 300 (discussing research demonstrating safety of
APRNs); Florida House of Representatives Staff Analysis, Bill # HB 699 CS Health Care (Mar. 8, 2006), at note 5
and accompanying text (citing Linda Aiken, director of the University of Pennsylvania's Center for Health
Outcomes and Policy Research, for the proposition that “over 100 studies have examined the care delivered by nurse
practitioners and none demonstrated a negative impact of their care on health”).
36 Eileen T. O’Grady, Advanced Practice Registered Nurses: The Impact on Patient Safety and Quality, in AGENCY
FOR H EALTHCARE R ESEARCH AND Q UALITY , P ATIENT S AFETY AND Q UALITY: A N EVIDENCE-BASED H ANDBOOK FOR
N URSES (ed. Ronda G. Hughes) 2-606 (2008). The study surveys empirical research on APRN quality and safety
generally, id. at 2-605 – 2-607, as well as research regarding safety and quality of care for APRN subspecialties. Id.
at 2-602 – 2-604 (regarding nurse midwives, nurse anesthetists, and clinical nurse specialists). See also Sue
Horrocks et al., Systematic Review of Whether Nurse Practitioners Working in Primary Care Can Provide
Equivalent Care to Doctors, 324 BMJ 819 (2002) (British review of 11 trials and 23 observational studies finding
increased satisfaction and no health disparities for patients treated by nurse practitioners versus physicians).
37 See, e.g., Mary D. Naylor et al., Transitional Care of Older Adults Hospitalized with Heart Failure: A
Randomized, Controlled Trial, 52 J. A M. G ERIATRIC S OC ’ Y 675, 682-684 (2004) (AP[R]N-directed intervention
associated with increased time to first readmission or death and reduced total number of rehospitalizations in care of
older adults and management of heart failure); cf. Jack Needelman et al., Nurse-Staffing Levels and the Quality of
Care in Hospitals, 346 N. ENGL. J. MED. 1715, 1719-20 (2002) (increased care by registered nurses – which include
APRNs as subset – associated with improved outcomes/reduced adverse events for medical and surgical patients).
38 Ateev Mehrotra et al., Comparing Costs and Quality of Care at Retail Clinics with that of Other Medical Settings
for 3 Common Illnesses, 151 A NNALS I NTERNAL MED. 321, 326 (2009).
39 See, e.g., A.F. Smith, et al., Comparative Effectiveness and Safety of Physician and Nurse Anaesthetists: A
Narrative Systematic Review, 93 BRIT. J. A NAESTHESIA 540, 544 (2004) (review article examining U.S. and foreign
studies finding “no recent, high-level evidence that there are significant differences in safety between different
anaesthesia providers”); Paul F. Hogan, et al., Cost Effectiveness Analysis of Anesthesia Providers, 28 N URSING
ECON. 159, 161 (2010) (“there are no studies that show a significant difference between CRNAs and
anesthesiologists in patient outcomes.”); Dulisse & Cromwell, supra note 34 (no increased surgical risk when
unsupervised CRNAs are used); Michael Pine, et al., Surgical Mortality and Type of Anesthesia Provider, 71 A M.
A SS ’ N N URSE A NESTHETISTS J. 109, 116 (2003) (“After adjustment for differences in case mix, clinical risk factors,
hospital characteristics, and geographic location, the current study found similar risk-adjusted mortality rates
whether anesthesiologists or CRNAs worked alone.”).
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Page 8 of 8
Conclusion
Requiring physician supervision of APRNs imposes costs on Texas health care
consumers. Both S.B. 1260 and S.B. 1339 would reduce those costs, and the Bills likely would
improve access and increase choices for Texas health care consumers as well. Absent evidence
that the current statutory restrictions are required to address patient harms, FTC staff urge the
Texas legislature to enact either S.B. 1260 or S.B. 1339 to remove those restrictions. If
particular medical procedures require heightened supervision requirements, staff recommends
the legislature tailor supervision requirements to address those particular services.
We appreciate your consideration of these issues.
Respectfully submitted,
Susan S. DeSanti, Director
Office of Policy Planning
Joseph Farrell, Director
Bureau of Economics
Richard A. Feinstein, Director
Bureau of Competition