Nurse Practitioners Offer Prescription for Medicaid

Group says broader role would curb costs; Florida Medical Association has different diagnosis
By: Kenric Ward | Posted: November 24, 2010 4:05 AM
Nurse Practitioner
Florida's nurse practitioners say they could save the state $1 billion and create new jobs if they were allowed to practice as they do elsewhere.

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:

“The average physician's office creates 19 jobs -- and ensures patient safety. If we want to maximize impact, create jobs and increase access to care, the state of Florida should consider investing in graduate medical education and creating more residency slots so that we can keep physicians in the state.

"This is a much better solution to meet Florida’s access to care needs. Allowing unqualified nurses to play doctor and putting patient safety at risk is not in the best interest of our citizens.”

Bruce Reuben, president and CEO of the Florida Hospital Association, sees both sides of the debate, but concludes, "The reality is, we don't have enough doctors."

"Can we utilize nurses who are trained health-care professionals to extend access to primary care? When 48 other states are doing it, it's something Florida will have to consider," he said.


Contact Kenric Ward at or (772) 801-5341.

Comments (65)

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Kristina Carmichael
5:25PM NOV 18TH 2012
After Goggling for articles looking for professional norms regarding post graduation training expectations by physicians or ARNPs for new grads, this article came up. I am a new ARNP-C in Orlando Florida. I was an RN for the last 18 years, mostly in a step down cardiac unit. I have recently left a job as a new ARNP after seven weeks of employment with a specialty group (Pulmonary), secondary to inadequate resources by employer to train me.

According to my previous employer, my job performance and efforts were above average such as dependability, effort, professionalism and attitude. They told me that they could see how hard I had tried but they did not have the resources to spend on getting me prepared to work independently. In addition, I purchased and read books suggested, studied on my time off to catch-up with professional expectations in specialty, and worked 12-14 hours a day. Most nights, I would be the last to leave in order to complete the days work. I often was the one setting the office alarm. Although this article touches on some aspects of my original search, I was wondering if I could pose some questions that may not only be relevant to my situation, but for others as well.

1. My question regards training expectations by employer/ARNP. If we are expected to step into this advanced role as ARNP's, what is the industry standard for training new ARNPs either in Florida or nationally by physicians or ARNPs, since there are limited (about 10 nationally) residency programs available to new nurses?

2.Of the 12,000 ARNP members in Florida, what is the success rate of new ARNPs that come out of school in finding a job as ARNPs that last for more than a couple of weeks or years? Is what happened to me common?

3.Are there plans for ARNP Residency Programs for someone like me in Central Florida, or on a national level? And is this something that Florida ARNPs support?

4.Any advice on how to survive Novice ARNP to Intermediate ARNP?

5. Am I expecting too much from an employer, if say, I need 3 months to acclimate to their professional environment?

6. In the interviewing process, is it ok to ask for training or expected time frames for competencies?

I attended the AANP National Conference this summer, in Orlando and it appears that Residency Programs are poorly supported or encouraged by ARNPs. Why is this not encouraged? I am all for increasing the scope of practice for ARNPs in Florida, but if individuals like myself just getting out of school lack an adequate support system either through ARNPs or physicians in the State of Florida, willing to train, where does that leave the profession in the future? Not sure, if anyone is able to answer my questions but I would be very grateful for some advice or guidance in this area.

Sincerely, Kristina
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9:32AM OCT 17TH 2011
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2:25PM OCT 13TH 2011
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Pam Winans
10:25AM DEC 1ST 2010
It appears Timothy J. Stapleton, executive vice president of FMA, has the same old tired story to say nurse practitioners would not provide the care that a physician would provide. The truth is the FMA wants to keep the nurse practitioners under the direction of a physician so the physician can continue to make money off of the nurse practitioner's care. A physician working in the Emergency Room with a nurse practitioner has to sign their charts. The physician may not have seen the patient the nurse practitioner is working with, but the physician has to sign their charts. Therefore, let's be realistic, the physician uses the nurse practitioner to make money.

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!
10:50AM NOV 28TH 2010
"This is a much better solution to meet Florida’s access to care needs. Allowing unqualified nurses to play doctor and putting patient safety at risk is not in the best interest of our citizens.”

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!
ARNP Emily
9:49AM NOV 28TH 2010
Fla ARNPs are forced to share their income with MDs. That is the reason we are so restricted. I received 43% of medicare reimbursement and 57% went to the MD. I was a Hospitalist and shared the patient load with him. When he did not answer the phone in the middle of the night, the service called me. I was not reimbursed for ON CALL. I supervised medical students and residents as part of the practice but was not paid for this. Fl MDs are using ARNPs for profit and do not want the laws changed. Look at the malpractice costs and statistics. ARNPs are often more qualified than foreign MDs, esp in Fl. Foreign MD graduate are unable to pass boards and are faxed thru 1 year of nursing school to become RNs. I do not understand why the PAs in Fl are required to have less education but are allowed to practice in Fl without onsite MD supervision. Major changes are needed in Fl but will not happen as long as the MDs control our income and can hire less educated PAs for the same $$.
Shelley Butler
1:24AM NOV 30TH 2010
I agree with the comments about PAs having less education than nurses and nurse practitioners. They practice right out of school without any medical/patient experience. RNs that become ARNPs most often have YEARS of experience, and usually critical care experience. I can speak this to be true for myself as a critical care RN. Most of the critical nurses are more educated and experienced than any PA or medical intern that I have ever worked with. Medical school rotations are only the last two years of school, the same as the ARNP's last two years. I again can speak this from experience as I was married to a physician throughout all of his schooling and residencies.

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.
Laurie Grissman
7:11PM NOV 29TH 2010
I agree with you. If MD's feel that NP's are incompetent, why is it that they all hire us. And I do not know one MD who has a NP who is directly supervised by the NP. I can't tell you how many times I was left in my practce to run the entire office, while the MD's were at the hospital or out of town. When it is convenient, we are competent. When it comes to money...we are not. The bottom line is that if NP's were independent, MD's would not be able to make as much money off of us. It's a disgrace. And when one physician can come up with EVIDENCE BASE research that indicates that we are incompetent, then I will allow for these pathetic accusations. I own my own practice, and I shelled out $45,000 this year to have my "collaborating" MD sign all the orders and medications I couldn't sign for. Yet, he has never laid aneye on any of my patients. What is wrong with this state?????
Dottie Cook, MS ARNP
5:03PM NOV 27TH 2010
After reading and commenting on this issue with the non-physician, I took it back to my office and discussed it with my physicians (non-members) and my patients, all they can say is we as ARNPs should continue to the great care we do and consider the source. I do have to agree with one comment regarding our organziations. I have watched especially here in Florida their lack of presence. I do not belong anymore to any of these organizations as thier lack of support of nurse practitioners is very visible. I have been a strong advocate for a national organization that deals with just ARNPs and do not include RN's as our plight is much different.
Sheryl Wilson
9:06AM NOV 27TH 2010
It is a shame that the FMA acts like a spoiled child. Hey FMA let some else play in the sandbox! For the FMA it may be a money issue, but for us it is a patient issue. Remember when you put patients first!? or do you?? Most physicians I knew do not belong to the FMA and don't like how they are represented by the FMA. We as ARNP's need to get the message out to our physician colleague; write to the FMA let them know your views are not the same as the FMA.
Cindy Drew ARNP
3:50PM NOV 26TH 2010
As a practicing ARNP for over 22 years, I have to say I have never worked with a Physician who considered me usafe. I do not believe the FMA speaks for the majority of physicians. My patients and the many nurses I work with as well as the physicians I have worked with consider the Florida restrictions on NP practice to be outdated and not good for the patient (the most important part of the whole story). That is why I have given our local legislators pages of signatures on a statements of support (signed by Physicians, nurses and most importantly patients).
Dottie Cook, MS ARNP
12:03PM NOV 25TH 2010
I would first like to ask, how many members of the good old boys club known as FMA have ARNPS in their offices? And those with ARNPs when they (physicians) go on vacation and leave them in their office to continue generating revenue? Why is the State of Florida the worse for controlled substances, well it is not because ARNPs prescribe them it is the good old boys of teh FMA and then pain management who employ ARNPs turn around and have to correct the mess that they made. I have been an ARNP for 17 years and have worked in other states, and I have never seen such idiotic actions. How many of these FMA members see patients with Medicaid, Healtease, or self pay etc? If they did we would not have the issues in this state for available healthcare. This good old boys club also prohibits (which means nothing to me) that once I obtain my doctorate degree that I may not use Doctor. Well I do not need their permission, they are nothing to me. My license is through the nursing board and I follow the nursing model not the medical model. I have patients who have transferred to me as their physician in a previous practice did not listen, stood at the door to get out and was always on their cell phone. Good going MD's. I have the highest respect for phsycians, but all must prove that they also can give quality care, just having a MD behind their name does provide assurance of that care which means like myself I must prove everyday with each patient that the care I provide is the best to my abililty according to evidence based medicine.

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.
Vicki Spitzer MSN ARNP CS
9:39AM NOV 25TH 2010
Who ever this Lane guy is, we must not be distracted by his silly comments. The bottom line is ARNP's in Fl and Alabama are just as competent as ARNP's in all other states and there is no data ANYWHERE to substantiate their bold face lies. They are bullies and we must keep it sweet and simple and stop dancing with the distractions.
Vicki Spitzer MSN ARNP CS
9:35AM NOV 25TH 2010
Stapleton replies with the same old signature party line that has been drummed into the FMA spokes persons. Having a very close inside connection I know this to be true. Come on now we are not "nurses" we are ADVANCED PRACTICE NURSES as has been stated over and over again. Where is the AMA? What makes ARNP's in Florida (and Alabama) less competent than all other ARNP's in the country? Stapleton knows there is NO DATA ANYWHERE IN THE WORLD TO SUPPORT HIS RUTHLESS CLAIMS. This is one profession bullying another with fear and greed as their sole motives.
Jeffrey P. Hazzard
8:42PM NOV 24TH 2010
Timothy J. Stapleton isn't fooling anyone. Stapleton is the executive vice president of the Florida Medical Association. His outrageous aspersions against "nurses," as quoted in the November 24, 2010 Sunshine State News, were predictable and clearly agenda-biased.

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.
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.
Donna Lester
12:26PM NOV 29TH 2010
Well said Jeff. Healthcare is broken and I think this is part of the fix to bring Florida out of the dark ages and stop being at the bottom of the list for best care in the US. Wake up Floridians and help us give you the care you do deserve. Write your politicians and become active, it is the only way to fight for yourselves and your future. I don't want you to have to wait long hours in an office or take 4 weeks to see someone for an ear ache.
1:17PM NOV 26TH 2010
Mr. Hazzard, as a student for Advanced Practice Nurse I applaud your letter and thank you ever so kindly for taking the time to voice your very kind and heart felt true opinion. Thank you!
8:10PM NOV 24TH 2010
My, my, my - such a vitriolic discussion! I fear for Mr. Stapleton’s and (I presume Mr.) Lane’s physical and mental health. Such angry and vengeful attitudes put them at risk for a host of acute and chronic diseases. Poor fellows.

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?
Jeff Zumarraga
4:50PM NOV 24TH 2010
Are you kidding me? The FMA has the audacity to say that nurse practitioners are unsafe. Yes, I am a Family Nurse Practitioner (board certified), and I am one week from completing another graduate degree as a Psychiatric Nurse Practitioner. It's a bit ironic that physicians will hire NPs and "dump" huge patient loads on them, and then turn around and say that we are unsafe. We as NPs started out as bachelors prepared nurses in the trenches of ERs, ICUs, and medical/surgical units. I recall a catching multiple unsafe orders written by physicians while working in the ICU. Upon calling them to clarify their orders, I would get many thanks for preventing potential total mishaps.

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!
M. Funk
4:07PM NOV 24TH 2010
There is one glaring hole in the logic of this argument. If all ARNPs in Florida are currently working full time, seeing patients all day long already, then how is having independent practice privileges going to increase patient access? Also, independent NPs in other states have asked to be compensated equal to physicians, so where will the cost savings be? Finally, if the NPs are working full time now, the staff that supports them won't be created anew, it will just be transferred with no net increase in jobs.
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!
7:16PM NOV 24TH 2010
I am a doctorally prepared nurse practitioner. I have over 20 years of full time clinical practice experience as a nurse practitioner in primary care and a total of nearly 30 years of experience as a RN. This year I decided to teach full time (I teach both undergraduate and graduate nursing students including nurse practitioner students). Since I am not employed by a medical clinic/institution or a physician I am no longer able to practice clinically because I do not have a “supervising physician” to sign my Protocol Agreement (or a Collaborative Agreement). However, if I am willing to pay a physician to sign my Protocol Agreement I will be able to practice. Am I any less competent or less safe now than I was a few months ago when I was employed by a physician who signed my protocol agreement? It is very frustrating to have these types of practice restrictions. I know there is so much I can offer, especially to help the under-served populations, if these types of restrictions are removed.

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.
M. Funk
4:05PM NOV 24TH 2010
There is one glaring hole in the logic of this argument. If all ARNPs in Florida are currently working full time, seeing patients all day long already, then how is having independent practice privileges going to increase patient access? Also, independent NPs in other states have asked to be compensated equal to physicians, so where will the cost savings be? Finally, if the NPs are working full time now, the staff that supports them won't be created anew, it will just be transferred with no net increase in jobs.
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!
Lee Moss, NP
12:56AM NOV 29TH 2010
Mr. Funk, The increase in access will come from the large number of Nurse Practitioners who might stay in Florida after completeing their education but now leave because of the restrictve envionment they are forced to work in. Please don't be so paternal in your effort to protect NPs from the realities of owning a practice. There are NP owned practices in "independent" states that hire Physicians to work for them. Lastly, you believe that Physicians are the highest trained members of the team. Please present the evidence that physicians have better patient outcomes than NPs in "independent" states or that Florida patients better outcomes than patients in NP "independent" states.
Jonathan Hazzard
3:54PM NOV 24TH 2010
Since 48 other states allow nurse practitioners the freedom to practice, and the statistics show positive results in those states, it seems like just a matter of time before Florida will be forced to follow suit.

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.
Florida NP
1:10PM DEC 3RD 2010
Well said.
Patricia A. Perry
2:59PM NOV 24TH 2010
Why is it that doctors and specifically, the FMA, always groups nurse practitioners with all nurses? There are basically three levels of registered nurses..the 2-year Associate Degree RN, the 4-year Baccalaureatte Degree RN, and the 6-7 year Masters or Doctoral Degree Advanced prepared RN. Of course, it would be inappropriate for a 2 - year AD prepared nurse to perform the level of judgement and services of an ARNP. You wouldn't find any such hospital or office nurse willing to do that. Why does the FMA continue to ignore studies which support the safety and performance of higher educationally prepared nurse professionals? Sounds like they purposely want to mislead their readers and constituents or they just don't do their homework before making comments like that.
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.
Leann Davidson
1:53PM NOV 24TH 2010
As a nurse practitioner working in hospital administration, it is obvious everyday, just by looking at the patients who visit emergency rooms, that Florida needs more primary care providers. Allowing nurse practitioners to practice to the full extent of their capabilities will lessen the burden, not only in emergency departments, but also on other specialists who are seeing primary care patients in addition to their regular patient load. Nurse practitioners are not asking to be treated as doctors, we are simply asking the legislature to extend the Florida NP scope of practice to coincide with our education in order to assist the needs of our communities.
12:50PM NOV 24TH 2010
Mr. Stapleton is wrong assuming that he can just pass along his opinion that is not backed in evidence. There are over 40 years of heavily weighted evidence conferring equivocal or higher quality of care delivered by nurse practitioners when compared to physicians. Mr. Stapleton needs to know this does not have to be about "turf wars" but rather about patient centered care. The abundant research and evidence suggests nurse practitioners are quality care providers, cost effective and receive high ratings in patient satisfaction and are already practicing to the full scope of their education in many states. I believe if given the opportunity nurse practitioners from Florida and many other states, along with renowned economists, and members of the Institute of Medicine, would love to have an intelligent dialogue with Mr. Stapleton on this matter. Mr. Stapleton also does not mention that physicians do not want this role anymore as evidenced by the lack of filling available primary care slots in medical schools. Residents are not choosing this line of work and this seems to be a more pressing issue and one for the medical associations to investigate.
1:10PM NOV 24TH 2010
Read my earlier comment below. You are the one that needs to bring forward the "facts" of these claims. Research studies merely assess patient satisfaction interviews, NOT patient outcomes. The IOM is under heat for their misleading report, and I wouldn't be surprised to see them adjust if not retract their opinion within the next 12 months.

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.
Dottie Cook, MS ARNP
12:26PM NOV 25TH 2010
OMG, lower status who the bleep do you think you are not a physician. So (Mr) Lane. Thursday afternoon, physician is not in office, patient comes in to see me yes the lower status of healthcare, and she thinks she should not be there. After talking with patient, examining her I insist she go to the hospital she refuses, I continue to discuss the issues and that I thought she had a pumonoary embolus and ensured her I would direct admit her this after one hour in my office, she agreed. OH but you would not know what that assessment would be would you???? She was admitted and was found to have bilateral (oops that means both sides) pulmonary embolus. Would have been dead in less than 12 hours and if driving her car more people could have died. My physicians allow me to care for their patients when they are out of the office, and I do a good no great job. I have my own patient population and oh I care for healthease patients.

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.
1:21AM NOV 25TH 2010
FYI, my independence does not come as a DNP but rather in the State of NH, nurse practitioners have autonomous practice rights. We are not required to have supervision or oversight by a physician. I have owned my own practice for 9+ years caring for approximately 7,000 patients (along with three other family NP's). I advertised the first year in practice and since have accepted patients from referral sources from many surrounding physicians that are not threatened. These physicians repeatedly comment on the quality of care our patients receive and as a matter of fact, I serve as a primary care provider for several physicians, dentists, lawyers and their families. Your comment that we need more outcome studies is right on, but that does not mean there are not any out there as there certainly are. Are you insinuating that all physician outcome studies show "good" outcomes? I would redirect you back to the available literature to review how well we are doing in this country in overall health targets. I believe it has not been all that great, correct me if I am wrong. Look to see how well we are doing caring for patients with diabetes or hypertension to name a few. Target cholesterol levels and blood pressures are poor at best. Obviously, this is not all the physicians fault as there are many variables, but the bottom line is if we had teams of qualified people caring/educating patients on preventative care or active in disease management, we all win, individually and society. These teams should be directed by the most qualified health care provider, not a certain discipline. None of us should practice in silos anymore as that model does not work. We need to join forces, respect each other’s strengths and work together for the sake of patient centered care. Let this be about patient care and not about medicine or nursing. We both have tremendous value and proven worth and there are plenty of patients to go around. Let the patients choose which model of care best fits their needs.
2:12PM NOV 24TH 2010
It seems to me that patient satisfaction is directly related to outcome, not many would be satisfied with a bad outcome. Instead of trying to be devisive, you should seek to embrace what will eventually become the norm.
2:38PM NOV 24TH 2010
Sorry, but that is incorrect... satisfaction is measured by surveys. Patient outcomes are measured by concrete data on treatment response, mortality/morbidity, etc. Asking a patient who just saw an NP if they feel like their care was equal, greater or less than the care of a physician does not equal patient outcomes. If it did, then astrologists, southern minister healers, and fortune tellers would have all of us beat in such studies.
S Lynch
1:57PM NOV 24TH 2010
Studies on quality of care delivered by Advanced Practice Registered Nurses abound. And these studies are not satisfaction surveys. They are evidenced based studies that measure the outcomes of patients when cared for by a nurse practitioner as compared to a physician.

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!
2:04PM NOV 24TH 2010
Really?? The only data you have is a 2000 article by Mary Mudinger, who happens to be one of the founders of the NP profession. Perhaps we need to review some facts about Mary Mudinger, which I have taken the liberty of copy and paste from a UK site (

“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.
S Lynch
10:52PM NOV 25TH 2010
So you are calling into question the Journal of the AMA . They published a follow up study as well on this reasearch.

Obviously the strict standards of JAMA were applied to this reasearch data.
12:37PM NOV 24TH 2010
Dr Stapleton hit nail on the head. The degree is that of nursing and not practice of medicine. There is a reason why physicians must go through four full years of medical school followed by three to seven years of residency and fellowship before being deemed qualified to care for patients. The problem that I have found when working with NP's is that they do not know what they dont know.... and that is just dangerous.
4:13PM NOV 25TH 2010
I wish you were kidding about NP's "not knowing what they don't know". If you would get your head out of the sand, you will find NP's and Physician Assistants practicing at some of the best hospitals in the country. I lived in the DC area for many years and let me tell you....the NP's & PA's are on the FRONT line of healthcare. They have seen it all. Hopefully someday you will be fortunate enough to realize what valuable assets they are to the health care system and stop trying to protect a "medical monopoly" for doctors.
10:55PM NOV 24TH 2010
I agree with you to a point, RDS. The degree is that of nursing and not practice of medicine. The NP degree grants rights and privileges within a scope of practice to provide patient care services that can benefit patients / families / communities / economics, etc. These NPs are not holding themselves out to be physicians. It's good for all involved to have varying levels of expertise to draw upon.
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.
10:55PM NOV 24TH 2010
I agree with you to a point, RDS. The degree is that of nursing and not practice of medicine. The NP degree grants rights and privileges within a scope of practice to provide patient care services that can benefit patients / families / communities / economics, etc. These NPs are not holding themselves out to be physicians. It's good for all involved to have varying levels of expertise to draw upon.
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.
12:25PM NOV 24TH 2010
Mr. Stapleton needs to come out of the dark ages, put to rest his phobia and ego and concern himself with the needs of the public rather than the needs of a physician's ego. He obviously has not done any research to back up his comments, which are inflammatory I might add...while you were with your nose in a book Mr. Stapleton, nurses were at the bedside, FOR YEARS....before we ever sought advanced practice we already had years of experience on you guys coming out of the chute in medical school. How do you think nurses are able to anticipate the needs of a physician...because we learn through critical thinking and vicarious observation, not by jumping at your orders like monkeys with no mind. Most advanced practice nurses also come from critical care environments where they had advanced protocols set by DOCTORS I might add, who realized they had a brain...and nurses....ALWAYS have the patient's best interest in mind..which is why not one of them would attempt to manage a patient for which they didn't have proper training- we ALL know we must defer to a physician in some instances, but the facts are simple, for routine primary healthcare, we could offer huge resolve to the thousands that can't afford it, and since we are prevention oriented, we could save the hospitals thousands by charity admissions that could have been prevented through routine monitoring, the public thousands by increases in taxes to pay for those admissions- and offer a viable working relationship that would benefit the patient by having an affordable alternative as well as a direct referral to a physician should the need present itself, but this will only happen with cooperative working relationships between physicians and advanced practice nurses. So please take your ego out of the equation and replace it with research on the benefits nurse pracitioners offer for the public at large. We don't "play doctor" anymore than you do..our education backs up our credentials as primary care providers and like it or not, we are your colleagues not your enemy.
Kevin Knoblock
12:14PM NOV 24TH 2010
The comments from Timothy Stapleton are so misinformed and misguided. One would think that all state medical associations share the same talknig points. I'm tired of hearing such nonsense as should the educated public.

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?
12:30PM NOV 24TH 2010
"Numerous studies done by many prestigious universities"... please show us these studies by prestigious universities. I will guarantee you will find none that say care is "equivalent"... these are not studies on "care" these are studies on patient perception, or interviews of patients. Such studies tend to show patients prefer NP care as equivalent or better than MD care. However, none of these "studies" happen to say how the cross section of patients interviewed was obtained and furthermore none of these studies assess OUTCOMES DATA! Being a friend to a patient and convincing them they can trust you is easy. Saving their life and keeping them healthy cannot be measured in an interview.

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.
Dottie Cook, MS ARNP
12:39PM NOV 25TH 2010
What is your issue, nurses are LPN, ADNs , BSN, MSN, and yes ARNP;s DNP. If read so much read about it. I heard a MD once say the patient coming back to the office and the ability to provide quality of care is the only measure he would need, and he gets sick of the pencil pushers trying to prove otherwise. If my patients, phsyicians feel that I am not capable they would tell me and I would find a new career after 40 years. You say education, do you know who teaches residents how to start IV;s nurses, do you know you would not because you have not practiced as a physician or nurse how to flush an Umibilical line we taught them. You are such a fool who do you think at 3 am calls a doctor who is sleeping about a patient and with our assessment skills ask the phsyician for specific orders which I have to tell you we usally ask for and they approve.

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.
7:38AM NOV 24TH 2010
“The average physician's office creates 19 jobs -- and ensures patient safety."

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.)
12:17PM NOV 24TH 2010
"the state of Florida should consider investing in graduate medical education and creating more residency slots so that we can keep physicians in the state." We already pay GME for US residents as well as non US residents. What we should do is include Nurse Practitioner as residents in GME. The answer is with increasing access to health care providers, NPs have been providing a high level of care since the 1960s and MDs have been fighting the process ever since. I would suggest you ask the MDs to show you the $$$$, as the real reason of opposing NP practice is all about $$$$, not health care.

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