Ask a Professor: How Florida’s NPs Are Fighting for Full Practice Authority
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“Once we achieve full practice authority, the doors are wide open. Instead of focusing on removing barriers to practice, we can focus on getting care to the people who need it.”
Stacia M. Hays, Clinical Assistant Professor at the University of Florida’s College of Nursing
America does not have enough healthcare providers to serve its population’s needs, and the gap is set to increase further as the Baby Boomer generation ages. The problem is particularly acute in Florida, which has the fifth-oldest population in the country, with a median age of over 42 years. The patients aren’t the only ones aging: half of Florida’s physicians will reach retirement age within the next ten years, and less than half of Florida’s physicians accept Medicaid.
A lack of healthcare access leads to increased emergency room visits, worse health outcomes, and increased taxpayer burden. That could be disastrous in a state like Florida, which is ranked 48th in the nation for healthcare overall, and 49th in access, quality, and use of healthcare.
Beginning to bridge the gap would require the state to add between 3,000 and 5,000 physicians in the next five to ten years. While medical schools can’t meet that level of demand at the necessary pace, Florida’s nurse practitioners (NPs) could be the answer.
Meet the Expert: Stacia M. Hays, DNP, APRN, CPNP, CCTC, CNE, FAANP
Dr. Stacia M. Hays is a board-certified Pediatric Nurse Practitioner (PNP) and the Coordinator for the Pediatric Primary Care Nurse Practitioner track at the University of Florida. She also practices in a federally designated rural healthcare clinic in Archer, Florida. Her scholarship areas focus on nursing quality and advocacy, as well as improving resiliency in children who have suffered trauma, disasters, and other high-risk conditions.
Dr. Hays serves as Treasurer on the Executive Board of the National Association of Pediatric Nurse Practitioners (NAPNAP) and is the Florida (north) representative for the American Association of Nurse Practitioners (AANP). Dr. Hays has been the regional lead for the Florida Action Coalition and the Florida Center for Nursing. She also serves as a faculty advisor to the UF Health Patient Safety and Nursing Quality Council. She is the recipient of state, national, and international leadership and advocacy awards.
Dr. Hays contributed to this article in her personal capacity. The views expressed are her own, and not that of her employers.
Strides to Improve Florida’s NP Practice Authority Laws
Florida has 18,000 nurse practitioners, and it graduates another 300 to 500 in-state each year. These are highly trained healthcare providers who are adept at diagnosing illnesses, prescribing medicines, and treating diseases in both acute and primary care settings. Studies have repeatedly shown that qualified NPs provide safe and effective care that’s equal to that of physicians.
“Many people still don’t understand what we do,” Dr. Hays says. “But for more than 50 years, nurse practitioners have been taking care of patients, demonstrating excellent outcomes, and achieving high levels of patient satisfaction.”
Florida is one of several states that still restricts an NP’s ability to practice to the full extent of their education and training. This manifests mainly in supervisory requirements, which necessitate a physician’s approval for certain procedures and prescriptions. Rarely is a physician actually on-site to validate individual decisions, thus creating an extra level of bureaucracy that hampers the quick and effective treatment of an NP’s patients.
“The states that have restricted practice authority for NPs, those are the states that have the worst health outcomes—and those are the states that are spending the most money,” Dr. Hays says. “Those numbers don’t lie.”
NPs have been fighting to get those numbers in front of legislators for a long time. Finally, after seven years of false starts, HB 607 passed the Florida Legislature, allowing qualified nurse practitioners to independently care for patients in primary care settings without physician supervision. During the legislative session, Dr. Hays was in Tallahassee almost every week, establishing important relationships with legislators, making calls, and talking to the Board of Nursing.
Passing the bill meant a bitter and protracted fight with the Florida Medical Association, who had endorsed Florida’s governor, Rick DeSantis, in his election primary. But Dr. Hays, Florida’s NPs, and the Florida Coalition for Advanced Practice Nurses (FCAPN) continued to push for the removal of barriers to NPs providing quality, patient-centered care to their fellow Floridians.
The Importance of Passing HB 607
“We didn’t do this on our own,” Dr. Hays says. “We partnered with business and healthcare organizations who support access to high-quality care, and did a lot of the legwork, but we had so many supporters out there.”
Some of those supporters included Speaker of the House Jose Oliva, who made healthcare access a priority for Floridians, and Representative Cary Pigman, an emergency medicine physician who supported independent practice for the past eight years. Other partners included the National Council of State Boards of Nursing (NCSBN), Floridians United for Health Care, the Associated Industries of Florida (AIF), the Florida Chamber of Commerce, Florida Blue, the American Association of Retired Persons (AARP), the American Association of Nurse Practitioners (AANP), and the Florida Nurse Practitioner Network (FNPN).
“We couldn’t have done it without them,” Dr. Hays says.
The result of that multi-stakeholder effort is that, as of July 1, Florida’s NPs will be a little freer to deliver the services they’ve been extensively educated and trained to give. Floridian NPs who have at least 3,000 hours of supervised experience, and who have completed a graduate-level education in differential diagnosis and pharmacology in the last five years, can now provide independent services in areas such as family medicine, general pediatrics, and general internal medicine.
Limitations of the New Bill
“This bill was a great step forward,” Dr. Hays says. “However, there are still a lot of limitations.”
The biggest limitation was in the bill’s scope being narrowed to primary care NPs, with primary care being a somewhat ambiguous term. Definitions of primary care vary between government reimbursement models and the NP consensus model, and primary care often overlaps with other facets of healthcare. Further clarification is needed to include as many NPs as possible.
“Some of the barriers we’re having are in changing old language,” Dr. Hays says. “As bills have been updated over the last 20 years, some of that language is left and is now outdated and obsolete. The word ‘physician’ is in there because that is where the focus was in times past, but NPs have been left out.”
A second limitation was the language of the educational requirements. For most medical doctors, nurse practitioners, and pharmacists, schools utilize a concept-based approach, wherein things like differential diagnosis are taught within the context of diagnostic practices. There isn’t necessarily a class on differential diagnosis alone. The five-year requirement is a factor, too: under the new bill, veteran NPs may be required to leave their rural and low-cost clinics in order to educate themselves in areas in which they’re already competent.
“I’ve been an NP since 2003 and I teach pharmacology and differential diagnoses,” Dr. Hays says. “But now I may have to take a graduate-level course in pharmacology, or take forty-five credits of continuing education, in order to meet the criteria of this bill.”
Looking Forward: Continued Advocacy For Florida’s Nurse Practitioners
The fight remains to push for full practice authority. Florida’s NPs are still struggling to get authorization to run rural care buses to improve access to care in outlying communities. Others are faced with the cost burden of paying supervising physicians. And board-certified Pediatric Nurse Practitioners like Dr. Hays are frustrated by regulatory barriers to treating common mental health issues like ADHD, anxiety, and depression, and forced to refer long-term patients to far-off providers that they don’t have any prior relationship with.
“The care is so fragmented,” Dr. Hays says.
The remaining restrictions aren’t just limiting the services that Florida’s NPs can provide; they’re also potentially incentivizing healthcare professionals to move out of the state. Graduating NPs in Florida find that their reimbursement is less than it is in other states, and that the fees they must pay to a supervising physician cut into the feasibility of opening their own practice. NPs from other states are also less likely to practice in Florida, where they’ll have less autonomy than they’re used to. Until full practice authority is realized in the state, brain drain is a legitimate concern.
“It’s definitely a stepwise approach,” Dr. Hays says. “You can pass these bills, but it’s the culture that needs to change.”
Conditions surrounding the global pandemic of COVID-19 are also a factor for Florida’s NPs—many of whom have gone to work in other states with high outbreak numbers. Some of those NPs will be getting their first experience of working in a state where they’re allowed to practice to the full extent of their training, and it remains to be seen how many of those NPs will decide to return to a state where they are faced with burdensome restrictions. Still, Dr. Hays remains optimistic.
“We’re going to look and see that with NPs providing care, the outcomes were just as good if not better,” Dr. Hays says. “That’s going to provide more research support and data to demonstrate that NPs can continue to provide high-quality care in all settings. Once we achieve full practice authority, the doors are wide open. Instead of focusing on removing barriers to practice, we can focus on getting care to the people who need it.”
Matt Zbrog is a writer and researcher from Southern California, and he believes a strong society demands a stronger healthcare system. Since early 2018, he’s written extensively about emerging topics in healthcare administration, healthcare research, and healthcare education. Drawing upon interviews with hospital CEOs, nurse practitioners, nursing professors, and advocacy groups, his writing and research are focused on learning from those who know the subject best.