By: Jeff Cohen
The issue of scope of practice is front and center in Florida right now with the expansion of what nurse practitioners (and nurse midwives) are legally permitted to do. The newly enacted 464.0123 allows for qualified APRNs (there is specific criteria) to practice independent of a supervising physician in the following areas of medicine–primary care, family medicine, general pediatrics, and general internal medicine.
Even more, assuming they meet the membership criteria for admission to a healthcare facility medical staff, they may admit patients, manage patient care, and discharge patients. One of the only preserved connections with a physician established by the law is if the APRN practices at a healthcare facility, a transfer agreement including a physician is required. Additionally, the new law establishes a Council On Advanced Practice Registered Nurse Autonomous Practice, two members of which are appointed by the Board of Medicine and an additional two appointed by the Board of Osteopathic Medicine.
While a “game changer” in Florida, the new law extends to APRNs many of the same restrictions applicable to physicians for many years, including state self-referral restrictions (the “Florida Patient Self-Referral Act of 1992”), adverse incident reporting, fee splitting prohibitions and professional liability insurance requirements, none of which were directly applicable to APRNs before the new law.
The law distinguishes between APRNs that engage in autonomous practice and those that do not, pinning very particular clinical requirements and responsibilities to those who elect to practice autonomously. They are not all bound by the specific provisions applicable to autonomously practicing APRNs. Finally, the new law is clear that neither commercial insurance, self-insurance nor HMOs may require a patient to treat with an autonomously practicing APRN.
Whether physicians view the expanded scope of practice to be positive or negative, they should expect and plan as if it is here to stay. And they should expect that there will be continued attempts to expand the scope of autonomous practice. The issue of “scope creep” has existed for years and will not go away. We’ve seen tremendous change in the area of relationships between ophthalmologists and optometrists (e.g. co management) and others.
The question physicians have to begin to ask is how it can be good for them and for their patients. Will patients come to demand an APRN (as some do with nurse midwives)? How can working with an APRN improve access, ensure quality and be cost effective? While relationships between physicians and APRNs are common, the challenges for both physicians and APRNs will be how to transition relationships with APRNs who want to practice autonomously into a platform that meets the needs of the medical practice, the APRN and patients. For the enterprising (or just curious) physician, this is an interesting time! PCPs, FPs, GPs and internists would be best served to lead here.
Here’s what I mean: the specialties where autonomous practice are open happen to involve lower reimbursement by payers and high staffing requirements. From a business perspective, these are not “easy” practices. Moreover, any physician in practice for years will attest to the trials and tribulations (and the expensive learning curve) of these businesses. Issues like HR, billing and collecting, practice administration and regulation are especially challenging and will likely be even more challenging to APRNs who likely will not receive the same level of reimbursement from payers that physicians do. In short, it’s isn’t easy!
All of this can mean that physicians already in practice with an existing patient base might have an existing platform for the APRN, might have an APRN who should be considered for partnership or as an independent business partner in a stand-alone practice. It’s a guessing game at this point as to whether this new niche will take flight. But it’s better to be at the table!
The issue of “scope creep” is not a new issue. And as training and degree programs expand for healthcare professionals, the social issues of access to care and affordability continue to dominate public discussion, scope creep will continue. Physicians have to decide whether these changes are opportunities and whether they can use the changes to stabilize cost and quality in a profitable business model.
