1. Health

Nurse practitioners seek more authority in Florida

Published Feb. 4, 2013

TAMPA — Beverly Douglas, 64, is not a physician. But she can do some of their work.

A nurse practitioner, Douglas can provide basic primary care. She can treat a flu patient, prescribe an antibiotic for an ear infection, perform a wellness exam or help a patient manage his diabetes. She can order tests and recommend follow-up care.

In Florida, her authority ends there. All those treatment plans require a physician's approval. And she can't prescribe more powerful drugs — from hydrocodone for pain to Ritalin for attention-deficit disorder to Ambien for sleeping disorders.

It wasn't like that in her home state of Colorado, where nurse practitioners work independently of doctors.

"I come to Florida," said Douglas, who works at a local hospice, "and it's as if my IQ just dropped."

Health experts long have warned that as the population ages and more people get access to insurance through the Affordable Care Act, there won't be enough primary care doctors. Already, the national shortage of such physicians has been projected to hit 90,000 in seven years.

In the past two years, a growing chorus of voices — from the National Governors Association to Florida TaxWatch — has promoted nurse practitioners as one possible solution. Nurse practitioners are registered nurses who have obtained a postgraduate degree in nursing. More than 80 percent of them are trained to provide primary care services, according to the American Association of Nurse Practitioners.

"Policymakers are searching for solutions that can be implemented today to deal with the primary care shortage," said Tay Kopanos, the association's vice president of state government affairs. "You have nurse practitioners who are educated and equipped to be frontline primary providers."

But it's a tough sell in Florida, one of only two states that do not allow nurse practitioners to prescribe controlled substances, which include many painkillers and psychotropic drugs.

The state is one of a dozen requiring physicians supervise nurse practitioners rather than collaborate with them, according to the nursing association. The remaining states' rules include a mix of requiring collaborative agreements with doctors and allowing nurses to operate autonomously.

Opposed primarily by the powerful Florida Medical Association, past efforts to loosen the restrictions have gone nowhere.

"We've been jousting at this windmill for 20 years," said Jeff Hazzard, a nurse practitioner who lives in St. Petersburg.

The more than 675 graduate students in the University of South Florida's College of Nursing get a sobering pep talk amid their epidemiology and health management courses: If they stay in the state, they will need to advocate for changes.

"We tell them, 'Talk about your role, contact your legislator and people in the community,' " said Dianne Morrison-Beedy, dean of the USF College of Nursing. "We have to get the word out."

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Only one bill to expand nurse practitioners' scope of practice has been filed for the upcoming legislative session. It would allow them to initiate involuntary psychiatric examinations under the state's Baker Act.

Yet medical literature seems to support the nurse practitioners' position. A review of 26 studies published since 2000 found that health status of patients, the course of treatment and prescription rates were consistent between nurse practitioners and physicians, according to an October report in the journal Health Affairs.

Insurers pay nurse practitioners less than doctors. In Florida, for instance, the Medicaid reimbursement for nurse practitioners is 80 to 85 percent of what a doctor would make providing the same care.

But doctors groups say there are good reasons to keep nurses tied to doctors, such as the difference in training and education — 11 years for a family doctor versus 5 1/2 to 7 years for a nurse practitioner.

They say solving the primary care shortage means changes such as increasing Medicaid and Medicare reimbursements to doctors and training more physicians. Last week, Gov. Rick Scott proposed a budget that includes $80 million to create 700 medical residency positions.

The FMA says the state's prescription drug abuse problem is reason enough not to let another class of health care workers prescribe addictive painkillers.

"I can't imagine what the situation would become if more people are able to write prescriptions," said Dr. Ajoy Kumar, chairman of Bayfront Medical Center's Department of Family Medicine.

Kumar said a growing consensus is building around a so-called "patient-centered medical home" model, which uses doctor-led teams of professionals who develop comprehensive plans for individual patients. In that model, nurse practitioners can provide basic care but "act as the eyes and ears" of the doctors on their teams.

Nurse practitioners in Florida say they aren't opposed to team models but that the current restrictions are creating unnecessary barriers. Hazzard, 49, said he tried to run his own occupational health clinic for a few years. But he couldn't make the economics work.

He paid a supervising physician a fee of $1,000 a month, plus about $15,000 a year for the doctor's malpractice coverage.

Hazzard said the physician was on the payroll to satisfy state law and fill out paperwork; the doctor rarely was at the clinic.

"The law is all about tying nurse practitioners to doctors, economically," he said. "It's not about patient safety."

So he gave up on his clinic. Now, he travels for contract work — in other states.

Jodie Tillman can be reached at or (813) 226-3374.