Recent projections from the Florida Office of Economic and Demographic Research estimate that the state’s population will grow by nearly three million over the next 10 years. Over that same period, Florida’s population that is over the age of 65 is expected to grow by 35 percent.
Rapid growth, particularly among the elderly population, is expected to significantly strain the existing physician workforce. In fact, Florida could need as many as 4,671 additional primary care physicians by 2030 to meet the demands of its growing population.
Non-physician providers like advanced practice registered nurses (APRNs), physician assistants (PAs), and pharmacists could alleviate the state’s potential physician shortage, but anti-competitive scope of practice laws and supervision requirements limit their ability to practice to the full extent of their training and education.
The Florida legislature is currently considering legislation (HB 607) that would allow APRNs and PAs to practice independently and expand their scope of practice by authorizing them to sign documents otherwise requiring the signature of a physician. Another bill (HB 389) under consideration would expand pharmacists’ scope of practice to include testing and initiation of treatment for influenza and streptococcal pharyngitis.
Advanced Practice Registered Nurses (APRNs)
Advanced practice registered nurses are registered nurses who receive advanced training through graduate-level programs. The maximum range of services an APRN may perform— referred to as their scope of practice— is defined in statute. Florida law also requires all APRNs to work under collaborative practice agreements with supervising physicians. Collaborative practice agreements outline the duties of an APRN, which may be more limited than the maximum scope of practice permitted by state law. For example, a supervising physician may limit the types of medication an APRN is allowed to prescribe.
There are generally four categories of APRNs: nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and clinical nurse specialists.
Nurse practitioners (NPs) are a subset of APRNs who, depending on the state in which they practice, are able to provide many of the same services as physicians. A report from the former congressional Office of Technology Assessment concluded that NPs could perform a substantial proportion of tasks normally provided by primary care physicians and “as much as 75 percent of the well-person care for both adults and children.”
Twenty-four states allow full independent practice for nurse practitioners without the supervision of a physician. NPs in these states often play an important role in rural communities, which may be without adequate access to physician offices. A recent report from the U.S. Department of Health and Human Services indicated that Florida has 182 primary care Health Professional Shortage Areas (HPSAs) covering more than six million Floridians. HPSAs are geographic areas, populations, and facilities in which the need for care exceeds the supply of care providers. Allowing nurse practitioners to practice independently could expand access to care in these communities.
Certified registered nurse anesthetists (CNRAs) work with surgeons, anesthesiologists, and other health care professionals to administer anesthesia and provide care to patients before, during, and after medical procedures. Federal law requires that CNRAs work under the supervision of physicians, but a rule promulgated by the Centers for Medicare and Medicare Services in 2001 allows states to opt-out of this requirement. Since then, 17 states have opted to allow CNRAs to practice without supervision. Moreover, research suggests that the odds of a complication occurring are virtually the same regardless of whether anesthesia is provided by a physician, CRNA, or in collaboration between the two. With more than 15 percent of physician anesthesiologists planning to retire in the coming years, Florida should allow independent practice for certified registered nurse anesthetists to ensure adequate access to anesthesia-related care.
Certified nurse midwives (CNMs) provide care to women, including gynecological exams, family planning services, and prenatal care. They may also act as primary care providers to women and newborns. While CNMs are sufficiently trained to care for patients before, during and after delivery without supervision, Florida does not allow them to practice independently. Meanwhile, 24 states and the District of Columbia allow CNMs to practice without supervision with no negative impact on patient outcomes.
Clinical nurse specialists (CNSs) play a unique role in the health care system. While they are capable of providing direct patient care, they often also take on leadership positions advising fellow nursing staff and identifying strategies to improve practices. Research on clinical nurse specialists is limited, but the broader literature on APRNs as a whole suggests that eliminating supervision requirements in Florida would expand access to care without compromising quality.
Physician Assistants (PAs)
Physician assistants (PAs) are trained through graduate-level programs modeled after traditional medical school curriculums. PAs generally work under the supervision of physicians, but supervision requirements, scope of practice laws, and prescriptive authority vary across states. In 47 states, including Florida, scope of practice for PAs is determined through collaborative practice agreements with supervising physicians rather than being defined by law. Florida is also among the 44 states that allow PAs to prescribe schedule II-V medications. However, Florida’s supervision requirements are more restrictive than many other states. Physicians in Florida may only supervise a maximum of four PAs at any one time. Meanwhile, eight other states allow physicians to supervise more than four PAs, and 12 states place no limits on the number of PAs a physician may supervise. Allowing physicians to supervise more physician assistants or eliminating limits altogether would help ensure adequate access to care, particularly in light of the looming physician shortage in Florida.
Pharmacists primarily dispense prescription medications and provide guidance on their safe use. All 50 states also allow pharmacists to administer immunizations, but state laws vary widely in terms of which vaccines may be administered, requirements for physician oversight, and the minimum age at which a patient may receive vaccines from a pharmacist. Nonetheless, pharmacy-based immunization is common practice. According to the National Community Pharmacists Association, 76 percent of community pharmacies provide flu immunizations and 69 percent provide non-flu immunizations.
While Florida requires a written protocol between pharmacists and supervising physicians for all immunizations, 17 states allow pharmacists to independently administer select vaccines without protocols or physician-issued prescriptions.
In addition to providing immunizations, pharmacists may also administer tests and initiate treatment for certain conditions such as influenza and streptococcal pharyngitis. Currently, 18 states allow pharmacists to administer tests and, if the result of a test is positive, to prescribe treatment under collaborative practice agreements with supervising physicians. In eight other states, pharmacists may administer tests, but patients must be referred to a physician for treatment. Florida does not allow for testing or treatment by pharmacists. Considering that nearly 90 percent of Americans live within five miles of a community pharmacy, expanding the scope of practice for pharmacists in Florida would significantly expand access to care.
Florida’s growing, aging population will soon outpace the supply of physicians. Expanding the role of non-physician providers including advanced practice registered nurses, physician assistants, and pharmacists through comprehensive scope of practice reform would help ensure adequate access to health care.