FL House Considering Bill To Give NPs More Autonomy
By Dr. James Palermo // February 8, 2014
PHYSICIANS AND NURSES AT ODDS OVER LEGISLATION
Jim Saunders of The News Service of Florida Contributed to This Story
On Monday the Florida House Select Committee on Healthcare Work Force Innovation will take up a controversial 155-page bill that would give nurse practitioners independence to provide medical services without physician supervision.
Healthcare facilities in Florida and nationwide are gearing up to meet the enhanced demand for primary care physicians that has begun with millions of people obtaining health insurance through the Affordable Care Act (ACA, aka Obamacare), and House leaders say giving more authority to nurse practitioners is one way to address an anticipated shortage of primary-care physicians in Florida.
The bill applies to a group technically known as “advanced registered nurse practitioners” (ARNP), who have more advanced education and training in direct primary medical care than registered nurses, and to nurse practitioners, called certified registered nurse anesthetists (CRNA), who specialize in administering anesthesia.
PHYSICIANS AGAINST EXPANDING ARNP/CRNA ‘SCOPE OF PRACTICE’
Physicians, however, are very reluctant to relinquish control and authority over ARNPs and NAs. These types of “scope of practice” issues have historically been highly controversial, and groups such as the powerful Florida Medical Association (FMA) oppose lifting physician-supervision requirements.
“We’re against it (the House bill),” Florida Medical Association General Counsel Jeff Scott said after reviewing the newly filed proposal Thursday.
Scott, said the new House bill is the broadest scope-of-practice expansion he has seen, and physician groups are already preparing to fight it.
The House Select Committee on Health Care Workforce Innovation has been studying the practice issues in recent weeks, including holding a lengthy hearing last month.
Physicians told the committee that ARNPs and CRNAs were valuable members of the healthcare delivery team and that they agree on the need for new approaches to expand primary care. However, the FMA staunchly opposes giving ARNPs and CRNAs autonomy and said “the best solution is physicians and nurses working collaboratively in a way that does not jeopardize patient safety.”
Primary care physicians are perceived as the “quarterbacks” of the healthcare team who are responsible for enhancing quality and reducing costs, two hallmarks of healthcare delivery in the post-reform era. Doctors argued that they receive more training than nurse practitioners and that care should be offered through a collaborative approach led by physicians.
ARNPs AND CRNAs MAKE A CASE FOR DERUGULATION
Jorge Valdes, president of the Florida Association of Nurse Anesthetists, told lawmakers during the hearing that members of his group have the training to provide anesthesia without physician supervision.
Also, backers of the changes say nurse practitioners, including specialists such as the nurse anesthetists, already provide services without doctors being present, though they have to get approval from physicians for what are known as “protocols” that outline care.
“In Florida, anesthesiology is delivered by both anesthesiologists and CRNAs ” Valdes said. “I’m a CRNA. I’m a professional. I’m not asking for anything additional than something I already do, (and that) is to practice my profession.”
HOUSE BILL CREATES TWO CATEGORIES OF CLINICAL AUTONOMY
The House bill, which will be discussed during a committee workshop Monday, would create two categories of nurse practitioners: “independent advanced practice registered nurses” and “advanced practice registered nurses.”
The advanced practice registered nurses would continue providing services under physician supervision, though they would receive additional authority to prescribe controlled substances. Nurse practitioners currently can prescribe other types of drugs, such as cholesterol medication or antibiotics.
The independent advanced practice registered nurses, including the specialists, would be able to provide services without supervision if they meet criteria for experience and pharmacology training. Along with being able to prescribe controlled substances, they would have authority to make a wide range of other decisions, such as admitting and discharging patients from hospitals.
IMPETUS FOR BILL: PROJECTED INCREASED DEMAND FOR CARE
Part of the impetus for the House taking up the issue is legislative leaders’ concern about a combination of factors.
Not only does the ACA’s newly insured create a significant challenge to meeting the increased demands for healthcare, but a growing state population, aging baby-boomers and the fact that primary care practitioners are also aging and their ranks may not be adequately replenished also add to the impending primary care shortage.
Both the House and Senate are also considering other steps to address the issue of a primary care shortage, such as development and expansion of telemedicine, which has the potential to provide needed healthcare professional resources using the latest digital technology.
“As we move into (the legislative) session, this committee will be proceeding with a bold initiative to expand access to care to Florida’s workforce and to increase the competitiveness of that workforce market,” select committee Chairman Jose Oliva (R-Miami Lakes) told the House panel last month.
SENATE BILL DELAYS CHANGES AND EXCLUDES CRNAs
Senate Health and Human Services Appropriations Committee Chairwoman Denise Grimsley (R-Sebring) said Thursday she is working on a bill that would make far less-dramatic changes than the House measure.
“The Senate bill would not allow nurse practitioners to immediately work without physician supervision, though it would allow them to prescribe controlled substances,” Grimsley said. “The bill likely will set a time in the future, possibly five years, when nurse practitioners could work independently if they meet criteria.” However, she said her bill would not allow nurse anesthetists to work independently.
“There is no compelling health care policy goal, realized financial incentive, or access to care reason to eliminate the nearly nationwide gold safety standard of anesthesia physician supervision,” anesthesiologist Jay Epstein, president of the Florida Society of Anesthesiologists, said in a prepared statement Thursday.
LEGISLATIVE FOCUS MUST BE SAFE, HIGH QUALITY CARE
The committee will continue to deliberate over the question: “To innovate, do we need to deregulate?” The debate leading up to the regular session, which starts on March 4, will continue to hinge on what services that trained doctors and nurses in the appropriate settings can deliver to meet the increasing demands for primary care and ensure safe, high quality healthcare.”