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Nurse practitioners caught between a doc and a hard place

A doctor in the Florida Legislature hopes to relax Florida's strict limits on what nurse practitioners can and can't do.

In the small northwest Florida town of Vernon, about 30 miles south of the Florida-Alabama state line, Dawn Frost operates a clinic that provides primary care for about 1,200 patients. Doctors are scarce in Washington County for a reason, says Frost, a nurse practitioner — they can't make money in a place where most of the patients are poor.

"Most of my patients, around 80%, are on Medicaid. I have people that live in tents on the river and in travel trailers," Frost says.

Getting paid for the care she provides is always a problem. Some patients, she says, pay for a portion of the care with barter, bringing her vegetables or fish.

The real issue is getting reimbursed from private insurers and the Medicaid program, however. At the heart of the problem are decades-old licensing restrictions in Florida that limit nurse practitioners' ability to diagnose, treat and prescribe medications without a physician's supervision.

Advanced registered nurse practitioners (ARNPs) like Frost are registered nurses with graduate-level degrees who have passed a national certification test. While 23 states allow nurse practitioners to practice independently of doctors while performing many of the same functions as family physicians, Florida requires nurse practitioners to Work under the direct supervision of a physician. Frost pays her supervising physician about $1,000 a month.

While Frost routinely diagnoses and treats common illnesses, she typically receives only about 80% to 85% of what private insurers and Medicaid pay to physicians providing the same care.

That's if she gets paid at all. Some health plans refuse to recognize and reimburse nurse practitioners as primary care providers. And as Florida has shifted its Medicaid population into state-authorized, for-profit HMOs and managed care networks, Frost has found it even more difficult to get reimbursed from the Medicaid program.

"It's been awful. I've had more rejections than payments on these people.If the patients come to me, I have to call my collaborating physician to get permission to see them because the patients are assigned to them," she says.Frost says she is barely scraping by and may be forced to shut down her clinic.

Florida is also the only state that prohibits nurse practitioners from prescribing controlled substances. Because She can't prescribe controlled substances, Frost can't get a controlled substance registry number from the U.S. Drug Enforcement Administration. Without that number, Frost can't order home care or durable medical equipment for her patients.

While Frost can prescribe some drugs, such as antibiotics or cholesterol medications, the e-prescribing software she integrated into her practice last year to comply with government mandates won't process her requests without a DEA number. Frost is left having to issue prescriptions the old-fashioned way, by pen and pad, and worries what will happen if she can't properly manage her digital record keeping. "I can't even use my electronic health record.If someone wants to see how compliant I am, I'm not. I don't have that ability."

Targeting regulation

Rep. Cary Pigman (R-Avon Park), a freshman legislator and emergency room physician, says such restrictions make no sense. He is pushing a proposal that would allow nurse practitioners to provide care without doctor supervision as well as prescribe controlled substances.The current regulatory scheme, he says, creates unnecessary barriers to care, particularly in rural areas, at a time when the state is looking for cost-effective ways to increase access to care delivery.

"I am righteously indignant that we have statutorily required this professional group, advanced practice registered nurses, to be subservient to another professional group, physicians, in order for them to do what they normally do," says Pigman. "That just upsets me as a good Republican, as well as a good physician."

Pigman's bill, supported by House leaders, sailed through the House Select Committee on Health Care Workforce Innovation in February, but faces opposition from physician groups, including the Florida Medical Association.Jeff Scott, the association's general counsel, says Pigman's bill would give nurse practitioners in Florida too much authority.

Scott says the current system is working well, arguing that the bill is so broad that it "would allow ARNPs to go out and set up practices as dermatologists and urologists and cardiologists. Since they didn't have nearly as high as cost for training, they could theoretically charge less and thus take some patients by charging less."

Scott also rejects the notion that giving nurse practitioners more autonomy would help ease the state's physician shortage and provide better access to care: "That's like saying we're not going to have enough airline pilots, so we're going to take air traffic controllers and have them fly the planes."

Betsy McCormack, a nurse practitioner who runs a practice that provides medical house calls for patients from Pensacola to Fort Walton Beach, says nurse practitioners have no desire to intrude on physicians' turf. She simply wants to be able to provide the care she has been trained to deliver.

While McCormack has served as a psychiatric nurse practitioner since 2010, current Florida law doesn't allow her to commit patients with mental illnesses who are threats to themselves or others into mental health facilities under the "Baker Act." Instead, she has to get her supervising physician to initiate involuntary psychiatric examinations.On at least two occasions, when she was unable to reach her supervising Physician, she says she has had to call law enforcement and have her patients escorted away in handcuffs, treating them more like criminals than patients.

The inability of nurse practitioners to sign a death certificate is also problematic, McCormack says. "I had a lady lie in the morgue for two weeks. Her family couldn't bury her for two weeks because they couldn't get in touch with my collaborating physician to sign it." McCormack says it turned out that the physician hadn't returned the calls because he hadn't recognized the patient's name.

Setting the record straight

Pigman, meanwhile, says he's been busy fighting misinformation being circulated about his bill. Some opponents have argued that allowing nurse practitioners to prescribe controlled substances will cause an explosion in opiate abuse. Data from states where nurse practitioners have prescriptive authority for controlled substances, suggest otherwise, Pigman says. "The data is overwhelming that these are safe, prudent and responsible practices."

Pigman says he hopes his colleagues will be able to help nurse practitioners such as McCormack and Frost.

"Think for a minute what a fantastic service (Frost is) doing for those 1,200 people in Vernon. The only thing she has to do is make sure that immunizations are given and blood pressure's checked and sugar's taken care of. She's probably going to save more lives in her career than the fanciest surgeon in the most urban, academic environment because she's touching so many lives."

"The data is overwhelming that these are safe, prudent and responsible practices." — Rep. Cary Pigman

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