Nurse Practitioners Win First Round In Fight For More Power

February 19, 2014

Despite opposition from physician groups, a House select committee Tuesday overwhelmingly approved a proposal that would give additional power to nurse practitioners — including allowing them to provide care without doctor supervision.

House Republican leaders have pushed the proposal, at least in part because they say it would help address a shortage of primary-care physicians in the state. Senate leaders have shown less enthusiasm, but Tuesday’s vote was a milestone for the group of health providers technically known as “advanced registered nurse practitioners,” who have long sought more authority.

“This debate will now be had because of the work we’ve done here,” said Rep. Jose Oliva, a Miami Lakes Republican who is chairman of the House Select Committee on Health Care Workforce Innovation.

Physician groups, such as the influential Florida Medical Association, are lobbying against the proposal. They point to years of additional training that doctors receive to provide care and raise questions about why students would want to take on huge amounts of debt to attend medical school if they could do much of the same work as nurse practitioners.

“We’re trying to solve a problem of access and affordability (of medical care), and I think this bill comes at it from a very wrong direction,” said Rep. Gayle Harrell, a Stuart Republican who was one of the lone dissenters in a 13-2 vote by the select committee.

Advanced registered nurse practitioners have more education and training than registered nurses and contend that they already provide much of the care envisioned in the bill (PCB SCHCWI 14-01). Along with applying to nurse practitioners who provide primary care, the bill would apply to specialists such as nurse anesthetists.

Under current law, nurse practitioners work under the supervision of physicians, receiving approval of what are known as “protocols” that outline care. The bill still would allow nurse practitioners to work under the supervision of physicians, but it also would free them to meet criteria to work independently. Also, they could get authority to prescribe controlled substances.

Rep. Cary Pigman, an Avon Park Republican and physician who is leading the House’s effort on the bill, rejected arguments about issues such as the proposed changes leading people to forgo becoming primary-care physicians.

“I see this as opening more doors,” Pigman said. “I see no doors closing.”

But the bill deals with what are known in Tallahassee as “scope of practice” issues, which physician groups typically watch very closely. Rep. Travis Cummings, R-Orange Park, described those issues as a “contact sport.”

Harrell and Rep. Elaine Schwartz, a Hollywood Democrat who cast the other dissenting vote, said they think the bill goes too far in expanding the nurse practitioners’ scope of practice.

“It is really much too broad for my comfort,” Schwartz said.

by Jim Saunders, The News Service of Florida

Comments

18 Responses to “Nurse Practitioners Win First Round In Fight For More Power”

  1. Chrissyxf on March 3rd, 2014 4:57 pm

    I am so tired of hearing all of these arguments. As one of the extremely rare individuals who practiced as both a physician assistant and now as a physician, I was amazed in medical school by how much information I was not aware of as a physician assistant. While physician assistants and nurse practitioners are not the same and have differences in training, they are both considered to be mid-level providers. Time and time again, I have been distressed by the overinflated egos of so many nurse practitioners and PAs who are unable to see their limitations in knowledge. This is not to sat that I have not encountered the same with physicians. Knowing one’s limitations, whether as a mid-level practitioner or as a physician, is perhaps the most important thing any one provider can do to care for his/her patients. One of the main differences in training between physicians and mid-level providers is that physicians, even after graduating from medical school are under the supervision of a more experienced physician for a minimum of three years and in many specialties, 6 to 7 years. Finally, mid-level providers were never designed nor trained to practice as so providers. While they are capable of taking care of relatively simple and straightforward cases which serve the vast majority of patients well, there will always be cases that they will be unable to handle due to a lack of knowledge of underlying pathophysiology.

  2. Jacquie on February 20th, 2014 4:43 pm

    I would like to address some of the comments made. One person reported that their medications had to be changed as the Nurse Practitioner (NP) could not prescribe them. They are talking about Narcotic medications most likely. As an NP in Indiana, I have prescriptive authority to write those medications, but that does not mean that I will allow every patient to have them or keep writing the script for them. Narcotics are meant for short term use. If a patient’s pain is not alleviated in a reasonable time frame, then the underlying cause of pain should be further investigated, not have narcotics to mask it. There are multiple ways, other than narcotics, to address pain issues, and can be as simple as timing of medications. I guarantee that NP’s are not asking to practice as physicians. NP’s may be called doctor as the term is not an exclusive term for physicians. Many spiritual leader have the title of Doctor but they are not physicians. So the lay person should not be confused by a simple term. I also agree that patients need to investigate the person providing medical care to them just as they would check out a mechanic before allowing them to work on their car. I guarantee you that there are physicians in this world that I would not see, as an NP patient, because they do not practice safe medicine. Note that you hear more about physicians getting into legal trouble over their prescribing practice of narcotics more frequently than NP’s. I also assure you that physicians and NP’s are people, just like everyone else. Everyone makes mistakes, thus the checks and balances that are in place to decrease them.

  3. William on February 20th, 2014 9:30 am

    The United State’s biggest single-payer healthcare system – Military Medicine has utilized Nurse Practitioners, Physician Assistants and Physical Therapists to the full extent of their education and training for over 40 years. These “scope of practice” arguments are really about “big medicine’s” loss of hegemony over healthcare. We are now entering an era of collaborative clinical care, where the patient may select/direct their care.

  4. Frank on February 19th, 2014 9:44 pm

    I’ll spare everyone the argument and present the real issue that Laurie touched upon. MDs supervision/collaboration of ARNPs has everything to do with financial security for the MDs and absolutely nothing to do with the competency of ARNPs. The FMA is upset because now the possibility of ARNPs receiving 100% reimbursement for the work that they actually did completely on their own is clear and apparent. Subsequently, MDs will lose their nice salary they received from work they never did and will have to work more then 3-4 hours a day to make up for it. In closing, FL has one of the highest rates of prescription drug/substance abuse in the nation, but if ARNPs don’t have controlled substance prescriptive authority then there’s only one group to point the finger at…. And they still want to discuss patient safety and competence of ARNPs…?

  5. Thomasine S on February 19th, 2014 8:03 pm

    I am a nurse practitioner practicing in a rural clinic in New Mexico. This state grants NP’s full autonomy to practice and prescribe independently. Those who feel comfort because a nurse practitioner is supervised by a physician should be aware that supervision sometimes only amounts to an occasional retrospective chart review. A nurse practitioner’s supervision by or collaboration with a physician is determined by each state. There is ample research spanning more than 20 years that supports the safety and quality of care provided by NP’s. Florida has one of the most restrictive environments for NP’s. The state is graded F for access to care because of the restrictions (AANP.) Check the website, all states receive a grade. Florida is a lovely state, but is the last place where I would practice because of the restrictive environment. New Mexico is recruiting NP’s from states like Florida; inviting them here to practice to the full level of their education.

  6. Laurie on February 19th, 2014 4:52 pm

    Once again the only complaint against NPs is not the care they deliver, but the schooling. There are remarks that patients don’t want to see a nurse practitioner… But why can’t a patient have a choice. I am a nurse practitioner who does house calls. I have 7 nurse practitioners who service over 1000 elderly patients who can’t get to an office. (No physician is eager to do this job because the reimburse my is horrible). I pay physicians to collaborate in my practice almost $60k a year and yet not one of them
    Has ever seen my patients. Yet, I collaborate with doctors and other ARNPs everyday who are
    More than willing to assist with questions without me having to pay. The only patients who leave my practice are patients who die and patients I can’t write controlled substances for.
    I have a doctorate degree and 11 years of schooling and practice safely everyday. I would like to know how much of a primary care doctors schooling for 20 years ago is impacting his practice now…a primary care doctor doesn’t know how to read X-rays, deliver babies, or do surgery…… But yet their schooling teaches them to do so…. We learn how to practice everyday…..

    This current collaboration is simply opposed by physicians because physicians won’t be able to use ARNPs as a source of second income…..
    THERE IS NO EVIDENCE THAT SHOWS ARNPS ARE NOT SAFE… Yet there are several studies that demonstrate that ARNPs and physician outcomes are the same…. So really what is the reason for opposing this????

  7. No Excuses on February 19th, 2014 3:41 pm

    I think nurse practitioners do a fine job for family practice type care. However, that being said, I would not want a nurse practitioner who was not supervised by a doctor in any of the specialists’ offices that I use for various things. As for physicians running in and out so quickly, that has not been my experience. Many of them are happy to discuss medication, complications, etc. with me before moving on to the next patient. If they aren’t, I don’t stay with them. Most of my doctors and I have had a patient/doctor relationship for 10 to 20 years or more. I’m happy with things the way they are, and I have no problem seeing a nurse practitioner as long as they are supervised by a doctor.

  8. tom on February 19th, 2014 12:23 pm

    Janet wrote “Does the thought of a nurse practitioner treating you as a doctor worry anyone else besides me?”
    The licensed NP is as competent as any physician, for example, take a look at the HIV specialists, who must sit for the SAME examination, regardless of whether they are NP or MD. NP’s, in general, are more empathetic, than physicians:

    NP: How is Ms. Jones’ doing today?
    MD: How is the amputated leg responding to her antibiotic therapy?

    JJ wrote “In the hospital settings Doctors are normally the ones making mistakes to let the RN’s and NP’s be the safety nets to catch them……Just saying!”

    I disagree, as one who has worked as a physician. Everyone makes mistakes, especially in the hospital. Watch any episode of “House”, and you will see plenty of errors, by everyone.

    Free market: let the public choose!

  9. Laura Reyes on February 19th, 2014 11:40 am

    I’m currently attempting to obtain my master’s degree as a nurse practitioner. Some of the literature I have been reading indicates that there is a push to have entry level nurse practitioners have a doctorate in nursing practice as opposed to a master’s degree. Has this push been considered when initiating this bill?

  10. randy on February 19th, 2014 10:57 am

    It comes down to choice. If ARNPs go solo and the insurances give the choice to the patient and the patient chooses the ARNP, so be it. If the insurance/payor limits the choices to ARNPs, then the level of care (by definition) is being downgraded (even if the particular ARNP is very competent, which no one knows before hand). Also, if the ARNPs and the insurance can stand alone in court, that will help. But if hospitals will place ARNPs to “work independently” but by protocol have physicians seeing their patients after a number of visits, the ARNPs are just being told they are “independent” when in fact they are being indirectly supervised; in this, case both the physicians and the ARNPs are being exploited by the institution. If ARNPs want to go solo, then physicians should not see their patients unless there is a transfer of care, not just physicians providing a safety net for the ARNPs. The next thing is a referendum: Do the people of Florida want the change, possibly a downgrade, in their care? It could be that the legislators voting “Yes” for this bill are beholden to some interest group intent in making more money at the expense of patient care.
    To the person above that says that nurses/ARNPs catch physicians errors, let us reverse the roles. Let us have ARNPs driving and have doctors just “backing them up” and see which one leads to more deaths and worsening situations to the patients. In all cases, it would be the patients that pay with his own life/limb/health the ARNPs’ desire to be physicians when they are not trained thus.

    Ciao!

  11. Ajhenn on February 19th, 2014 10:47 am

    I have been taking my daughter to a neurology nurse practitioner for 16 years, and I have been very, very pleased with her care and knowledge. I also have been taking my family to a nurse practitioner for family care and physicals for the last 5 years and have been very pleased with his care and knowledge as well. Both these nurse practitioners have master’s degrees and many years of hands-on experience in the medical field as well as years of research in their specialty. I would not want to switch over to a doctor at this point when I’ve had outstanding service from both these nurse practitioners.

  12. Tom on February 19th, 2014 10:11 am

    My Physician was recently replaced with a Nurse Practioner to cut down on cost within the office I go to in doing so I have also incured changes to my medications that were unexpected due to the fact the Nurse Practioner was not able to prescribe all medications that my normal Primary care Physician was able to. So from my observation it appears the quality of services has declined now that I would have to seek a new Doctor were I to continue my previous treatment of years past. Require primary care doctors and nurse practitioners to pass the same certification test would be a good start for equal treatment.

  13. DJSheffield on February 19th, 2014 10:11 am

    @ Janet…..absolutely NOT! Do your homework on the medical staff before you chose to go there. I went to one doctor in particular for years, when their nurse practitioner left to go to another office, many of the doctor’s patients followed, my family and I being one of them. Keep in mind…not every nurse practitioner is the same…that’s why it’s important to do your own personal background check. I wouldn’t trade my doctor’s office and staff for nothing. They all work well together and most importantly they all communicate with one another.

    Here’s to open minds, research, and not judging…

  14. AAM on February 19th, 2014 8:36 am

    Nurse Practioners have their place in the health care field, determining where that is comes from such discussions. My daughter is a Nurse Practioner and people think that just means a specialized nurse. The pecking order is Doctor, Nurse Practioner, Physicians Assistant. Most Practioners don’t want to go out on their own because of the liability and would rather work under the umbrella of Doctors. Please understand that most Hospitalist and those that work under the Doctor will see patients for days without a Dr/Pt contact. They still review and discuss Pt care every day. Competence is competence and their are mid level providers that catch stuff Dr.’s don’t also. All that to say lets have the discussion without predjudice and see where it shakes out. Remember Dr.’s make money off these people too.

  15. JJ on February 19th, 2014 8:16 am

    Just want to add something here, for all who have not been in the field and gone through steps of becoming an RN, then becoming a Practitioner. The road is a long one in itself!! This is a profession, not a job at your local fast food joint. Just an associates as RN is very difficult and in clinical settings you are very hands on. To continue education and become a Practitioner is something people don’t realize is more than most doctors know. Have you ever noticed in a medical setting who does most of the leg work? RN’s and if you see a NP you can actually get to talk and discuss most signs and symptoms. Doctors are in and out so fast they tend to incorrectly diagnose. In the hospital settings Doctors are normally the ones making mistakes to let the RN’s and NP’s be the safety nets to catch them……Just saying!

  16. Joe Bagofdoughnuts on February 19th, 2014 8:05 am

    Janet, You do have a choice in who you seek medical treatment from.

    If this helps make treatment available to more people, what is the harm to you?

  17. Janet on February 19th, 2014 6:44 am

    Does the thought of a nurse practitioner treating you as a doctor worry anyone else besides me? Doctors make mistakes with all of their education— how much bigger of a mistake can be made without the added years of being taught. This really doesn’t set well with me and I think if will make some very interesting medical malpractice cases for our lawyers and courts.

  18. Star on February 19th, 2014 5:50 am

    Thank you for following the progress of this bill. If the bill passes the Senate, it may increase the possibility for improved primary care services, both in choice and availability, especially for the underserved.





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