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Nurse Practitioners Offer Prescription for Medicaid
Group says broader role would curb costs; Florida Medical Association has different diagnosis
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Stan Whittaker, chairman of the Florida Council of Advanced Practice Nurses PAC, said, "Utilizing (nurse practitioners) has significantly reduced costs to Medicaid programs in other states. We are ready and able to do the same for Florida. It is in the public interest for this to happen, and really the better question is why it hasn't happened already."
Whittaker made his comments during Friday's Medicaid reform hearing in Tallahassee, where lawmakers are exploring ways to contain costs of the $14.7 billion program.
The Institute of Medicine recently released a report that recommends full utilization of nurse practitioners as a way to drive down expenses, while increasing high-quality access to primary health care.
Tennessee, which moved to a managed-care model for its Medicaid program, cut costs by 23 percent when nurse practitioners were used as full-scope, primary-care providers, according to a Vanderbilt University study. The study also said that nurse practitioners saved the state 40 percent on drug utilization and 30 percent on labs.
Other research continues to show that nurse practitioners can deliver high-quality care within their scope of practice with outcomes that equal their physician colleagues.
“We can also create jobs if we are allowed to practice independently like many states,” contends Whittaker. “We estimate that 3,000 ARNPs would open their own practices and each of these would employ two to three support staff, creating 9,000 jobs."
There are 12,000 nurse practitioners in Florida.
All nurse practitioners in the United States receive the same basic education and training via a national curriculum. To begin practice, applicants must be registered nurses from a four-year BSN program. They must complete a minimum of three to five years as a practicing R.N. before entering a two-year master's level nurse practitioner program.
In addition to serving some 800 hours in supervised clinic practice, nurse practitioners also must pass a national certification exam.
Though Florida's nurse practitioners must meet the national standards, the state is one of just two that severely restricts their scope of practice, says Susan Lynch, a nurse practitioner in Orlando.
"When you're told how, when and where to practice, that puts a great strain on nurse practitioners," she says. Uniquely, Florida and Alabama bar their nurse practitioners from prescribing certain medicines or committing psychiatric patients.
Lynch argues that such rules restrict health-care access for indigent patients while leading to more emergency-room visits and their attendant higher costs.
Citing the Tennessee model, Lynch believes that a $1 billion Medicaid cost reduction is conservative for Florida. If Tennessee's experience were matched, Florida's savings would top $3 billion annually.
But Lynch and Whittaker said their organization has heard nothing from state lawmakers about their proposal.
"The delay is political and administrative," Whittaker said.
Timothy J. Stapleton, executive vice president of the Florida Medical Association, countered with a statement, saying:
"The FMA fully supports allowing nurses to go to medical school if they want to practice medicine. Due to increasing demands on our health-care system, we will need more nurses, physicians and other health-care professionals in Florida.
"However, we wouldn't want to put unqualified people in a position to provide day care for our children, construct our homes or enforce our laws just in the name of creating new jobs -- because we know how devastating the outcome could be. Allowing nurses to essentially serve as physicians is even worse, because millions of people's lives are at stake.”
Stapleton added:
Comments (64)
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I have been seen by nurse practitioners who are very professional and knowledgeable. They provide excellent care since they are trained to look at all systems of the body. Physicians have talked about the medication errors, blaming nurse practitioners for the increase. The truth, physicians wrote the prescriptions for controlled substance medication. They discuss the deaths caused by these prescriptions but failed to acknowledge physicians are the responsible party.
Let's bring Florida in line with the other 48 states that allow nurse practitioners to be independent health care providers. Mr. Stapleton wants support of the medical schools in Florida for future physicians, but failed to discuss the fact most physicians today will go into a specialty to make more money. The majority of new physicians do not go into primary care.
It is time to change Florida law so the nurse practitioner can provide the much needed primary care in Florida!
Play doctor?? I am unclear about this statement. I take pride in using my nursing assessment skills to look at a patient holistically, then using the principles of creating a list of differential diagnoses within my scope, I develop a sound plan. I don't have to PLAY doctor. I practice medicine and nursing within my scope of practice and education. They call it PRACTICE because physicians don't have all the answers either.
Thankfully, There are no "toys" in my office, only a group of caring doctors and other mid level providers who genuinely want to help people that would be without if we weren't there.
I invite any of the FMA members to come and work with me one weekend.
But,,,,, don't bring any toys!
The AMA likes and supports PAs because they have the CONTROL over them through the AMA governences, and they are more dependent on the physicians in their scope of practice. I would love to see the law suit proportions of physicians vs ARNPs. Are they really concerned about patient SAFETY??? The MDs complain that if the ARNPs can write scripts for narcotics that we would have a drug problem in Florida. HELLO..the top 25 physicians that write the most narcotics are in Florida. I did grad school research on this topic. We are one of the few states without a drug monitoring system, because physicians are profitting from these pain clinics. The overdose statistics in Florida are horrendous. Is THIS SAFE??
My husband (physician) and I both think the AMA protests are about money, control/power. Hmmmm..Could it be the God complex that a lot of physicians have perhaps.
Why are they so concerned about safety when they allow one of their own ( a physicians assitant) to practice after being arrested? This group of people are not something special, in fact I would like to know how many medical doctors are members, I know I work for a company that few do belong.
The FMA needs to reexamince their purpose in life is not to belittle nurses (though they did it for years) instead of providing each and every citizen in the Florida affordable, timely and qulaity health care.
Nurse practitioners (NOT "NURSES," as Stapleton refers to nurse practitioners, even though he certainly knows the difference) don't want to practice medicine. They have something better -- integrated advanced practice nursing. The advanced nursing discipline treats the patient as a combined social, biologic, and spiritual individual and seeks to restore the ill to a state of health and then to achieve optimal wellness by health promotion. Many of the things nurse practitioners do are familiar to patients (testing, diagnosis, prescribing medications and treatment), but there is more. Nurse practitioners take the time to ask what other factors in a patient's life might keep him from getting well and staying well. Physicians are taught to steer the patient ship, nurse practitioners are taught to leave the patient at the helm but to provide expert navigation. There is a difference.
Mr. Stapleton, this is no game! Nurse practitioners are not "playing doctor." Nurse practitioners are serious and highly educated, rigorously licensed, and certified by specialty through nationally validated and administered exams. To suggest that advanced practice nurses (certified nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, and clinical nurse specialists) are a danger to Floridians is a boldface lie, AND I THINK YOU KNOW IT!!
I wrote this response letter to let those bent on disparaging advanced practice nurses that it will take someting better than simply telling the citizens of Florida, "be afraid." We already are afraid. We are afraid that there is no access to the health care we need and that we can't afford the health care that a monopoly controls. We also are afraid that physician groups will continue to put their own turf protection ahead of the public interest. I also wrote this letter to tell organized medical groups that they aren't fooling anybody any more. Stomping of feet and name-calling is quite unbecoming.
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When a solution is working so well in 48 other states and SAVES BILLIONS, it is obscene that any physician group would oppose it in our state. Bruce Reuben, president and CEO of the Florida Hospital Association even said in the article the time has come to join the rest of the nation. What I'm hearing organized physician groups say to us all, essentially, is "We don't care if you Floridians get health care or not, we just care that we control all health care and that no other professional is allowed to provide any health care for less money than we're willing to accept to provide it ourselves." SHAME ON THEM!!! And shame on the politicians that do their bidding, too! Those politicians have blood on their hands.
When did the act of caring for people become SO dangerous? When did helping people stay healthy become the sole domain of physicians? Nurses have been nursing since the beginning of time. Nurse practitioners (not ALL nurses, Mr. Stapleton, please try to keep up) have been BOTH nursing AND doctoring for more than 40 years. I’ve yet to read a single study anywhere that showed NPs are harming patients’ - all the studies I’ve read have shown patients benefit from NP care.
I would appreciate (the presumably Mr.) Lane citing just one single study that supports his position that NP care is substandard and unsafe. While I understand that sometimes a good offense is the best defense, I find (the presumably Mr.) Lane’s comments to be not only offensive but they in no way defend of his loquaciously and audaciously expressed point of view.
W.H. Auden said it best: “Health is a subject about which medicine has nothing to say.”
NPs practice “health care” – something we could use more of in Florida, across America and around the world. It is past time to take the handcuffs off NPs here in Florida and let them do what they do without impediments and layers of restriction in their practice and prescriptive authority. Physicians won’t lose a single patient in need their advanced skills and training in “sick care”. But imagine if patients are allowed to receive “health care” from NPs. They might be able to learn how to prevent or control chronic diseases themselves. Maybe they could lower health care costs and decrease hospitalizations by teaching patients how to take better care of themselves, how to take their medications properly, how to eat a proper diet and exercise to reduce health risks. Patients need a lot of teaching if they are to learn how to prevent and manage chronic conditions themselves. Lifestyle diseases such as diabetes, heart disease and lung disease require lifestyle change right along with medications and medical surveillance. Rather than waiting until it’s too late and physicians’ advanced care is required, shouldn’t we take a chance on NPs practicing prevention and see if we can improve health rather than only treating illness?
NPs are minimally masters prepared and many with doctorates. We DO NOT practice beyond our scope of practice. We are highly educated. Regarding the comment about going to medical school to practice medicine, our curriculums are highly rigorous; and we DO practice safely. I can't think of more thorough clinicians than nurse practitioners because we not only assess our patients, but we TEACH them about being proactive about their health. In addition, we SPEND TIME with them to hear their frustrations. I am well aware of the physician's role. My father and sister are practicing physicians. If I wanted to go to medical school I would have, but the path that the good Lord has chosen for me is one in which makes me very proud. I am proud to say that I am a nurse first, but I am also a NURSE PRACTITIONER. I love taking care of my patients.
If the FMA wants to look into unsafe medical practices, they should just look in the mirror. To the physicians, we don't want your jobs. Nurse practitioners are intelligent, competent, and highly skilled clinicians. Only 2 states (Alabama and Florida) will not allow us minimal prescriptive privileges of schedued medicines. What does this say about our state? NPs are successful and SAFE in 48 states, but not in Florida...absolutely preposterous. God bless the sick, the needy, and the weary. We, NPs, are here for you!
There is no question that NPs provide quality care but in today's healthcare environment, the team approach, supervised by the highest trained team member, the doctor, is the model that provides the best quality patient care.
The days of the independent provider are numbered, anyway, so this argument will soon be mute. ACOs and other group models will be the new reality.
And, for those few NPs who do choose to become independent, be careful what you wish for. When the reality of running a small business hit you, your medical liability insurance, law suits, etc. hit you, you may wish for the good old days of having a good supervising physician!
What I would like to see is for the Florida Medical Association to produce evidence (research studies, literature) to support their defamatory statements that nurse practitioners are unsafe practitioners. Let us examine FMA’s motivations/motives for making these false statements that are contrary to the Institute of Medicine’s most recent report on the Future of Nursing. This report was chaired by former Department of Health and Human Services Secretary Donna Shalala and endorsed by Dr. Harvey Fineberg, the President of the Institute of Medicine. This report recommended that nurses including nurse practitioners be allowed to practice to the full extent of their education and training; and nurses should be full partners with physicians and other health professionals in redesigning health care in the United States. Allowing Advanced Registered Nurse Practitioners (ARNPs) to practice to the full scope of their educational training and including ARNPs as primary care providers in the Medicaid and healthcare legislations, will lead to improved access to healthcare and to reduce healthcare costs in Florida.
There is no question that NPs provide quality care but in today's healthcare environment, the team approach, supervised by the highest trained team member, the doctor, is the model that provides the best quality patient care.
The days of the independent provider are numbered, anyway, so this argument will soon be mute. ACOs and other group models will be the new reality.
And, for those few NPs who do choose to become independent, be careful what you wish for. When the reality of running a small business hit you, your medical liability insurance, law suits, etc. hit you, you may wish for the good old days of having a good supervising physician!
It is blatantly obvious in this article that Timothy Stapleton, speaking for the FMA, is intentionally disparaging NPs, especially in his refusal to distinguish between nurses and nurse practitioners in his choice of language. Florida's Doctors must really feel threatened.
I'm sure that daily practice as a physician in direct patient care requires a healthy dose of compassion for the less fortunate. It's a shame that quality doesn't translate into the professional conduct of the FMA.
The American Academy of Nurse Practitioners and other reputable national groups have so much information on the safety and quality of care with cost savings that can be reviewed by all. Florida's own Senate issued a report on the safety of ARNPs in prescribing controlled substance prescriptions and recommended that barriers to practice be lifted. Every legislator and healthcare provider needs to be educated and ready to change a healthcare delivery system which is gunked up with old rules and stuff which obviously have stopped working to meet the healthcare needs of all citizens, rich or poor.
BTW, physicians are veering away from primary care because insurance companies and most of all government (M'Care, M'Caid) have continued to dwindle away reimbursement levels. Physicians graduate with loans exceeding $200,000 and cannot possibly hope to survive on the average $90-$120K that many of them are pulling in after their overhead is covered. As a DNP, should you get all this independence you seek, it won't belong before you too feel that sting and your graduates begin veering toward specialty medicine. You don't think the insurance companies will eventually try to pay you LESS based on your lower status in the healthcare world? And when they do, will you expect new NP students to actually stay in primary care? If you do, then you will be surprised at the ultimate truth.
The problem with primary care physician recruitment and shortages isn't the medical students... it is the lack of respect the healthcare industry has for the physician profession. FYI, I am not a physician. But I have spent years studying the healthcare market as well as this issue and happen to know what I am talking about. The days of a doctor being able to hang up a shingle and open a practice are over thanks to what the managed care industry and our government has done to medicine. As a result, we will ultimately see the watering down of healthcare in America and by the time everyone realizes it, it will be too late to fix.
My student loans are just as high, after completion of my doctorate and I will be called Dr. no matter you people say because I am directed by the nursing board not you oops not you because you can not even be a collaborative physician. FYI Doctor is a title, not a degree, that would physician, DO, ARNP, etc.
I am from up north and I remember for years we use to encourage people not to attend universities here. We would just laugh at the how far behind you are, well you are just proof that we were right. You continue to prove the North superior in thinking and actions. What an impressive group of "Good Old Boys". Oh but you are nothing in health care.
Repeatedly the evidence shows that the outcomes are equivalent. On the other hand, no studies exists to show a lack of safety or quality when care is given by Advanced Practice Registered Nurses. For reference to one of these studies you can look at the Journal of the American Medical Association (JAMA) by Mudinger et al, 2000.
Advanced Practice Registered Nurses and Physician Assistants are also the back bone of the military’s medical care program both in the VA and overseas.
If we are to practice evidenced based medicine, then we need to look at the evidence. And the evidence is clear; Advanced Practice Registered Nurses deliver high quality safe care at reduced costs.
Five percent of physicians in Florida accept Medicaid. Patients here suffer everyday because they cannot find a provider to give that care. I would highly recommend that all physicians practice according to the evidence and would work to remove barriers to that care.
Patients are suffering!
“Mary Mundinger, who recently resigned from her position as dean at Columbia School of Nursing where the doctoral program for nurses began, has arguably been the most aggressive advocate for replacing physicians with nurses.
There is more to the story. Over the years, there have been a number of conflicts of interest. Mundinger is entwined with corporate interests in the healthcare industry. She is on the Board of Directors of UnitedHealth Group, Welch Allyn, Gentiva Health Systems (nationwide provider of home health and nursing services), and Cell Therapeutics.
Mundinger has pushed for more power for advance practice nurses at the same time she has had a fiduciary duty to UnitedHealth Group and its stock-holders, and the similar duties to stock-holders of other companies.
Mundinger, a Director of UnitedHealth since 1997, HAS RECEIVED OVER 1 MILLION DOLLARS IN COMPENSATION FROM UNITEDHEALTH SINCE 2006 alone. As of December 2007, Mundinger held 32,000 shares of UnitedHealth stock.
How much of Mundinger’s aggressive advocacy to replace physicians with nurses is related to her duties to UnitedHealth insurance company and other healthcare corporations? Mundinger is a highly compensated director of organizations that could profit from her recommendations to replace physicians with less expensive (though not equivalently trained) nurses.
This issue is especially relevant given the U.S. Institute of Medicine’s recent report on conflicts of interest in medicine with its recommendations to remove industry influence from medical education and the development of practice guidelines.
Of concern is that Mundinger has not mentioned these important conflicts of interest in her academic articles and research reports. These reports have propelled the ‘nurse doctor’ movement. One wonders how much of Mundinger’s work reflects her professional and academic research and beliefs, and how much reflects her fiduciary responsibilities to commercial organizations.”
Perhaps you need to rely on a more reliable source for your studies. Again, I would love to see some links to some of these studies that "abound" that NP is equal or better to MD/DO in clinical outcomes.
Obviously the strict standards of JAMA were applied to this reasearch data.
I also agree that there are NPs that do not know what they do not know - - - but what they DO know is solid information from which to act and make decisions. Independent practice in isolation cannot survive regardless of the discipline. However, practicing at capacity can indeed compliment the entire system.
I also agree that there are NPs that do not know what they do not know - - - but what they DO know is solid information from which to act and make decisions. Independent practice in isolation cannot survive regardless of the discipline. However, practicing at capacity can indeed compliment the entire system.
Numerous studies done by many prestigious universities have shown that NP care is quite equivalent to MDs in the primary care setting. Perhaps, and just perhaps, one doesn't need 4 years of medical school and 3 years of residency to handle the majority of primary care issues??
The other argument that MDs have 4 years of medical school plus residency might hold some weight at the beginning of the MD and NP careers but that washes out over time. I am currently at one of Boston's largest hospitals and let me tell you the NPs are VERY experienced. Most of the MDs in an academic center see patients ONE day a week (maybe only a 1/2 day) and see on average of 12 patients a week and do research in the lab the rest of the week. Many NPs see patients FIVE days a week and see well over 100 patients a week! Who would you rather have taking care of you? Someone who sees 12 patients a week or 100?
In fact, recent misinterpretation of such studies from the American Institute of Medicine has the IOM organization facing possible litigation. The vast scope of the nurse population has power in many places and their manipulation of studies and information is further adding to the confusion of the public. And it isn't right.
Don't get me wrong. I have nothing against nurses, just something against the idea that with a few ethics courses and 660-800 hours of clinical rotations, they are the same as a doctor. Nobody can replace nurses, they are a pillar to the medical community and we couldn't survive without them. But lets stop pretending they are equal or better than doctors.
Every day yes everyday I see 28 patients and diagnose, order testing, educate intervene and provide total care. My patients opt to see me, they are educators, CEO's of companies, law enforcement parents with children who feel I have made a difference in their childs life.
I now nothing about the FMA and truthfully I could care less about you, and since you and your good old boys live with your head in the sand just stay there but do not take the residents of this state go in with you.
I don't think we should be thinking about the number of jobs a medical professional creates- after all, we have to pay those salaries in our health care bill. (And also pay them in our taxes when someone on Mediciad or Medicare sees a doctor.)
Anyway, 18 additional paychecks to support when seeing a doctor versus 2 or 3 for a nurse practitioner, and you can clearly see the savings.
As for ensuring patient safety, I don't think that's really an issue with the education and training required of them. I would feel as comfortable with a nurse practitioner as I would a doctor for not only 90% of my health care needs, but those of my elderly family on Medicare.
Florida should step it up and let them fully practice. (Along with the ability to prescribe all but the drugs that need to be closely monitored- like those addictive pain medicines.)