CAP-PAC Blog

You know what scares me in my job as a nurse practitioner?  You’d probably think it is a missed diagnosis, a treatment failure, or a drug-drug interaction.  You’d probably think malpractice liability and obscure diagnoses with unusual presenting symptoms would keep me up at night.  Oh, these things are stressful, certainly, but they don’t scare me.What really frightens me is the number of middle-aged, middle-income adults I examine; find an acute or chronic illness in, and who then inform me that they are unable to afford the care they need.  There is a steady parade of people in these circumstances.  What scares me is that there are more of them and that there are ever-higher wage-earners now falling into the “don’t bother with the prescription unless I can afford it” category of patient.Every day on my job I meet patients who need something expensive and make do with something else.  The first line therapy for diabetes is inexpensive, but the recommended second-line oral medications for diabetes are over $100 per month, each.  So that patient gets last decade’s technology.  It is treatment, but not the best practice.  Arthritis sufferers cannot afford maintenance medications. Asthmatics cannot afford an inhaled steroid.  Heart attack survivors cannot afford the currently recommended regimen of drugs to prevent another heart attack.  Seizure patients can’t afford new antiepileptic medications, and instead must take 25 year-old medications with serious side-effects.What am I doing with so many patients like the ones I describe?  I am an occupational health nurse practitioner clearing people for new jobs.  I find newly discovered diseases several times per day, and almost never does the perspective new-hire have a primary care provider.  They have no job, no money, no health insurance, no access to indigent care in the county where I practice.  All they have is…..me.  And my empathy.  And my conscience.  And my band-aid-dispensing solutions to a gaping social problem in our country.  It’s a grave situation (pun intended).  I am the nurse practitioner performing employment physicals who must change his hat to primary care provider several times each day because the need is so compelling, and the system is so broken.Yet, willing as I am, the system itself conspires against me.  I am restricted by really stupid Florida laws in my professional practice.  I could do so much more if the handcuffs which prevent me from doing my job were removed.  Being in the exam room, with the door closed, facing a person who has been unemployed for a year, and watching his or her smile of pride at a new job dissolve into tears as they learn they have a chronic illness which makes him or her unable to start the job, and no way to care for themselves, is what scares me.  It scares me that my expertise, empathy, and conscience are all they’ve got, but the cracks keep widening.  It scares me that there is no social-engineered solution, and I am completely left to devise my own. 

Health care consumers face a severe shortage of primary care providers who can care for people of all ages, but particularly those with multiple chronic conditions^. Florida has about 3 million people living in health professional shortage areas. In some Florida counties no physicians will accept Medicaid and the only Medicaid providers are Advanced Practice Registered Nurses.

Florida is on the American Medical Association’s list of states where patients may have trouble accessing a primary care physician. Forty percent of internists do not take new Medicaid patients.

Leading health care economists have studied the evidence and recommend a proven cost-effective and immediate solution to the primary care shortage problem is utilization of Advanced Practice Registered Nurses (APRNs) who are allowed to practice at their full scope of certification and educational training.

APRNs are Registered Nurses who have advanced their education through graduate studies in primary care, acute hospital care, maternity care, anesthesia care and system wide population care. To practice in Florida they must receive national certification and have a minimum of a Masters degree.

The safety, quality of care and level of patient satisfaction of APRNs have been well documented in multiple research studies and found to be comparable to that of physicians.^[1]

Many studies have shown that when states utilize APRNs to their full capacity, the state insurance organizations save money.  Utilizing Nurse Practitioners as primary care providers in Tennessee was shown to decrease Medicaid costs by over 20 percent.

In Florida several legislative restrictions prevent APRNs from practicing to their full scope. This causes many Medicaid patients to be denied necessary care.

The national standard is to allow APRNs to practice at their full capacity and realize tremendous cost savings as a result/

In order to increase care and save costs, Florida should change the laws that restrict APRNs from practicing at full scope.

[1] American Academy of  Nurse Practitioners. Quality of Nurse Practitioner Practice. Washington D.C. 2007

Letter to Editor in rebuttal of Florida Medical Association Comments from article titled: Looking to Write Controlled Prescriptions, Nurse Practitioners Seek to Engage Mike Haridopolos on August 4, 2010.

It is estimated that by granting Nurse Practitioners, Nurse Midwives and Nurse Anesthetists the same prescriptive privileges as 48 states and the district of Columbia, Florida could save billions in dollars every year. Studies in other states have shown a reduction to state Medicaid budgets of twenty percent or greater when Nurse Practitioners are allowed to practice at their full abilities.

The Florida Medical Association recently made several statements that were blatantly false regarding Nurse Practitioners.  Their claim that Nurse Practitioners are not educated in their graduate programs to prescribe controlled medications is untrue and appears to be an attempt to scare the public.

Nurse Practitioners, Nurse Midwives and Nurses Anesthetists education occurs in graduate educational programs. They study pharmacology and pharmacotherapeutics including the indications, possible interactions, management and monitoring for prescribing all legal medications both those that are controlled and non-controlled. They must undergo rigorous certification examinations that test their ability to manage the medical care of their patients.

Nurse Practitioners, Nurse Midwives and Nurse Anesthetists have been shown in numerous research studies to provide the same safe, high quality cost effective health care to their patients as physicians, including the prescription of controlled medications.

Clearly the Florida Medical Association is not making evidenced based statements and we encourage them to read the numerous studies showing Nurse Practitioners are safe prescribers of all medications, including controlled substances.

Florida has a shortage of primary care physicians. Three million Floridians have inadequate access to basic health care. Twenty-one percent of Floridians are uninsured, and eight million Floridians are medically disenfranchised. Millions of Floridians need access to quality care. Medical schools simply cannot produce enough primary care physicians to provide the care needs of our state.

Advanced Practice Registered Nurses (APRNs) can meet the needs of our medically underserved and disenfranchised Floridians, and expand the health care delivery capability of the state without added costs. In Florida, there are 14,000 APRNs in the state and they are titled Advanced Registered Nurse Practitioners (ARNPs).

ARNPs are registered nurses who have Masters and Doctoral degrees and have passed   registered nurse exams and national specialty advanced practice certification examinations. Depending on their specialty certification they administer and manage anesthesia, manage pregnancies and deliver babies, provide and direct inpatient acute care, manage psychiatric care and provide primary health care.

Numerous studies show that ARNPs deliver high quality cost effective care equal to that of physicians.

Unlike most states, Florida law has several significant barriers which prevent full utilization of ARNPs. As a result, ARNPs cannot practice to the full extent of their education, training and experience, and Floridians cannot receive the full benefit, in terms of more timely access to health care and lower cost, and improved quality of care.

These restrictions place heavy burdens on certain populations of patients, especially those who receive Medicaid, Medicare, live in rural areas, or are uninsured. They force citizens to travel far distances to locate a physician or go to an emergency room for care when a locally available APRN could easily provide that care. Often resulting in a doubling or tripling in the cost of care.

Removing the restrictions that prevent APRNs from practicing to their full extent requires no additional dollars be added to our state budget and will have immediate impact on decreasing emergency room visits and increasing access to healthcare.

July 21, 2010 FNA hosted an ARNP think tank to discuss bills for up coming session and begin a conversation on strategy.

In attendance were representatives from CAP-PAC, Florida Association of Nurse Anesthetists (FANA), Florida Chapter of American College of  Nurse Midwives (FCACNM), Florida Nurse Practitioner Network (FNPN) and Florida Nurses Association (FNA)

Controlled substance prescribing was discussed and FNPN President suggested that the bill not be filed and instead efforts should focus on trying to elect supportive legislators into office. CAP-PAC’s Susan Lynch strongly opposed this based on the survey data CAP-PAC had received that controlled substance prescribing was one of the main obstacles to ARNPs in providing high quality cost effective care.

Lobbyist for FNA, Bob Levy concurred on the basis that the bill would loose momentum and it was important to keep the issue in the fore front.

CAP-PAC president Stan Whittaker had received a suggestion for a physician colleague that we need to get the door opened and perhaps introducing a bill that restricted opiod prescribing may work. It was decided that a version of the bill that placed some limits on certain types of prescribing would be introduced.  

This has been a successful strategy in other states and will immediately increase access to care for many, but not all, of ARNP patients in Florida.

Other bills that will be introduced will be:

Baker Act bill allowing ARNPs to involuntarily commit a patient who is a danger to self or others.

Death Certificate Bill allowing ARNPS to sign death certificates.

In Hospital controlled substance bill. This bill will address the recent problem of hospital pharmacists not accepting post op pain orders form CRNAs and post delivery pain orders form CNMs.  that has risen  in some hospitals.

Although originally planned to be able to discuss bills of importance and strategy, time ran out to delve into strategy planning.

Since strategy is key to success in our endeavors, CAP-PAC suggested that we reconvene at a near future time to discuss strategy planning. Although one member was unhappy with this because of the great commitment of time needed to attend, the majority were in agreement.

Welcome to the CAP-PAC blog. Our focus is on access to health care for all Floridans through grassroots advocacy efforts.