Nurse-Power Bill Gets Its Start
A bill that would expand the authority of nurse practitioners and open a door for some to practice independently of physicians was approved by the Florida House Select Committee on Health Care Workforce Innovation on Tuesday evening.
The vote drew bipartisan support, with only two "no votes" on a board of more than a dozen. But several members said their support was tentative, that they wanted to see further debate and some tweaks.
State Rep. Dwight Dudley, D-St. Petersburg, said he had "trepidation and concern" over the enormous impact the bill could have, for good or ill. He added, "I reluctantly will vote for it because I think in fairness we should have nurse practitioners doing more."
All credited their faith in the hard work and good intentions of state Rep. Cary Pigman, R-Sebring, an emergency room doctor who has spent months researching and crafting the bill.
"What it really comes down to, Rep. Pigman, is I trust you," said state Rep. Ross Spano, R-Riverview.
The bill would change the title of what are usually called nurse practitioners -- registered nurses who have post-college education, usually at least a master's degree -- to Advance Practice Registered Nurses, or APRNs (which a few lawmakers pronounced "Aprons"). They would gain some modest new powers, such as the ability to sign documents that now require a physician's signature, and the opportunity to go for the title "Independent Advance Practice Registered Nurse" after a certain amount of training and experience. They would no longer have to contract with and pay a "supervising" physician.
The bill would grant independent status to three categories of APRNs: certified registered nurse anesthetists, called CRNAs; certified nurse midwives, and certified nurse practitioners, who usually work in primary care.
The main stated aim of the bill is to increase access to primary care, particularly in rural areas. But Pigman said it would also remove some barriers to practice that add costs and complexity to the health-care system, and would redress years of unfairness.
Nurse practitioners have been practicing safely and competently for many years, Pigman said, but always under the contractual "supervision" of physicians. The requirement is so loose, however, that Pigman said he could officially "supervise" a nurse practitioner in Okeechobee while he was at the podium in Tallahassee, 350 miles away. And he would be paid for that long-distance "supervision," he said.
"Nothing in this bill takes away from teamwork; in fact, it's what we do all the time," he said. "What I'm getting to is the mandate to supervise." Pigman offered this analogy: If he sees a patient with a complex heart problem in the emergency room, he'll ask for a consult from a cardiologist. But that doesn't mean the cardiologist is "supervising" him, Pigman said, and he wouldn't put up with such an arrangement.
"That gets to the heart of what we're talking about," he said.
During the three-hour hearing Tuesday, typical political party alignments fell away, as did some professional ones.
Pigman is pushing it forward with unmistakable passion at the same time that some of his fellow physicians -- at least the ones in organized medicine -- oppose it fervently.
The two committee members voting against the bill opposed it for different reasons.
State Rep. Gayle Harrell, R-Stuart, offered a couple of unfriendly amendments, including one that would move licensure and regulation of the newly-empowered APRNs to the purview of the Florida Board of Medicine, rather than the Board of Nursing.
“The most appropriate place is for those individuals to come under the Board of Medicine because they (would be) indeed practicing medicine,” she said. The amendment failed.
State Rep. Elaine Schwartz, D-Hollywood, voted against the bill as a protest. If the intent of the bill is to improve patients’ access to primary care, she said, then the best way to do that would be to vote for Medicaid expansion for the poor.
Under the Affordable Care Act, the federal government would provide Florida an estimated $51 billion over a decade, for health coverage for almost 1 million low-income uninsured adults.
Last year Gov. Rick Scott and the Florida Senate voted to accept the funds – provided it could be used to buy private coverage for the uninsured instead of funding the traditional Medicaid program – but the House said no. There has been little optimism that House Speaker Will Weatherford, R-Wesley Chapel, will change his mind.
Schwartz said she was voting no because “I want Medicaid expansion!” She knocked on the table as she said each word, to ensure that other members on the committee (and others watching it on The Florida Channel) paid attention.
One aspect of Pigman's bill – allowing APRNs to prescribe certain controlled drugs, which Florida law now prohibits – drew warnings from Harrell and a speaker from the Florida Medical Association, Dr. Joshua Lenchus, chief of the Jackson Health System medical staff in Miami.
Lenchus rattled off a fusillade of statistics at the committee about the prescription-drug horrors of the past decade, suggesting it was unwise to increase the number of caregivers who can prescribe controlled drugs.
Rep. Harrell agreed, noting there will be a constitutional amendment on the ballot in November to allow prescription of marijuana for certain medical conditions. “If you think we had a problem with pill mills," she said, "wait until we have pot mills on every corner and 18,000 more prescribers out there.”
Several members of the committee chided FMA for “trying to scare the public,” as Rep. Dudley put it. “I don’t think that’s a winning issue for doctors.”
State Rep. Matt Hudson, R-Naples, countered that the state’s three-year-old Prescription Drug Database has been doing a good job controlling the illegal sales of narcotics and other drugs with street value.
“The pill-mill problem was not created by nurse practitioners,” Hudson said. “It was because we had physicians writing prescriptions and acting as legal drug dealers.”
Some opponents of the bill were still in medical school or in residency.
"Medicine should be practiced by licensed physicians," said John Dudley, a second-year medical student at Florida State University who already has $120,000 in college-loan debt. "I'd choose not to become a physician if I could do the same things as a nurse,” he said, referring to Independent APRNs.
Rep. Hudson said he detected notes of “turf protection” in the arguments from physician groups. But physicians testified that their concern is patient safety.
Internist Michael Zimmer of St. Petersburg, speaking on behalf of the American College of Physicians' Florida chapter, said the nurse practitioners in his office "have tremendous clinical knowledge," but have to consult him for help with complex cases.
"Our patients have an expectation that they have access to a physician-led team," Zimmer said.
But Elizabeth McCormack, a nurse practitioner from Pensacola, said she goes "places where physicians don't go," including assisted-living facilities and patients' home.
Both Pigman and Hudson repeatedly reminded the committee that other states, as well as the military services and the Veterans Administration Health System, already allow nurse practitioners to prescribe controlled drugs. Some allow independent practice.
If there were resulting hazards from this, Pigman said, "It would be in the headlines. It would be studied. It would be published. It would be on the television news."
It’s not likely that the other states are wrong and Florida is right, Hudson said. “Could it be that we’re stuck in the mud?”
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