Published on March 05, 2014

Bill expanding nurse practitioner authority

By Beth Reese Cravey, The Florida Times-Union

In 26 years as a Navy nurse practitioner, Jacksonville’s Brad Briscoe functioned as an independent health care provider.

He and other Navy nurse practitioners, who have more education and training than registered nurses, provided health care for the military at home, aboard ships and deployed during wartime. They served as directors for medical or nursing services and as commanding officers in military medical treatment facilities and directed medical and nursing operations throughout the Department of Defense, Briscoe said.

And they were not required to be supervised by a physician.

In the Navy, Briscoe said he and other nurse practitioners “have helped maintain the pointed end of the spear … as independent providers for many decades.”

But when he retired from the military and began his civilian medical career with UF Health in 2011, he ran into the wall of Florida’s restrictions on nurse practitioner authority.

So Briscoe personally supports legislation that would allow nurse practitioners — technically known as advanced registered nurse practitioners — to provide care without a doctor’s supervision and prescribe controlled substances, among other things.

Making that change, he said, could help ease physician shortages, reduce costs and increase access to health care, which will be critical as baby boomers retire and new patients come into the system through the national health-care marketplace.

A majority of members of the Florida House Select Committee on Health Care Workforce Innovation agreed. The committee, which drafted the bill, approved it Feb. 18 on a 13-2 vote.

“Our mission is to increase the health-care workforce, accessibility and affordability,” said Rep. Jose Oliva, R-Hialeah, who chairs the committee. “This solution already exists in 23 states. It is supported by academic literature. We’re not trailblazing here; it’s already being done.”

How the bill will fare in the full House and Senate remains to be seen because it has some powerful opponents, including Senate President Don Gaetz, R-Niceville.

In hearings last fall and early this year, individual physicians and their lobbying groups told the committee that the bill could discourage primary care physicians from locating in the state and discourage Floridians from going into the field. Physician shortages could worsen, he said.

“We have major concerns,” said Jeff Scott, counsel for the Florida Medical Association. “We believe nurse practitioners have a valuable role in providing health care, but we don’t believe this role includes unfettered independent practice of medicine.”

Also, the quality of Florida’s health care could suffer because of the differences in education and training between doctors and nurse practitioners, said physician Linda W. Young. She is a certified registered nurse anesthetist and a second-year anesthesiology resident at the University of Florida College of Medicine at Jacksonville.

“The difference comes in the quality of care,” which could place Florida’s many elderly residents particularly at risk, she said. “One size does not fit all.”

Briscoe said there is no basis for such claims.

“Show me the scientific evidence,” he said.

None of the hundreds of studies that have been done on the topic “showed that care was better in states with more restrictions” of nurse practitioner authority, said Catherine Dower, health policy and law director of the Center for Health Professions, University of California San Francisco, who addressed the committee.

Patient safety and quality of care have not suffered in states that loosened the restrictions.

“The evidence is so weighty that the conclusions are not very disputable at this point,” Dower said. “The evidence is pretty strong that it is not a problem.”

Diane S. Raines, senior vice president and chief nursing officer at Baptist Health, agreed.

“Florida is one of the few states in the country that does not do this already and it puts us at a disadvantage when trying to recruit,” she said.

She knows there is concern that nurse practitioners with expanded authority will compete with physicians and may lessen the quality of care. But she said the actual experience in states where advanced practice registered nurses practice to the full extent of their license is just the opposite.

“Patients not only accept but often prefer the care of APRNs for their preventive care and management of chronic conditions and look to their physicians for diagnosis and treatment of more complex conditions,” she said. “Physicians practice collaboratively … and are able to extend their practice to more patients.”

Nurse practitioners “with full privileges in many settings — medical homes, extended-care facilities, home health care, behavioral health management — will only serve to provide high-quality, cost-effective care for many people who cannot access care now and will extend the reach of physician providers further,” she said.

Moody Chisholm, CEOMoody Chisholm, CEO of St. Vincent’s HealthCare, also supports the bill.

“I support expansion of their capability. It’s going to be critical to expand resources,” he said. “One of the most effective ways we can do that is to use nurse practitioners and expand their capability to provide care.”

Florida, he said, is the only state in the country that does not allow nurses to prescribe controlled substances.

“We don’t want to expand so much that we lower quality of care,” Chisholm said. “To my knowledge, the bill does not go too far.”

Representatives of other area hospitals either declined comment or could not be reached.

The two Northeast Florida members of the committee also supported the bill but said they want to study the issues more as the bill winds its way through the Legislature.

Rep. Travis Cummings, R-Orange Park, said emergency rooms are certainly not the solution to increase health-care access.

“The question is, how do we get there,” he said. “We are here to try to do the best we can for all the issues involved. I don’t know that the debate would be occurring without this committee.”

He encouraged physicians to “come to the table, show us how we can address these issues.”

Mia Jones, D-Jacksonville, also supports the bill but said she wanted “to address a few more things” in it before final passage.

“It helps to move Florida closer to the 21st century,” she said. “We could have taken steps necessary [earlier] to ensure that we have providers in place to address health-care needs long term. We did not.”

Now “the stars are aligning” for a solution, she said.

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