Healthcare Law, Access Issues At Center of Scope-of-Practice Fights

Mar 1, 2013

The nation’s healthcare system is changing. In the next few years, under the federal healthcare law, the Affordable Care Act, more people will gain access to health insurance. But that doesn’t necessarily mean they will gain access to healthcare. And that’s what’s driving many of fights between different healthcare professionals over the kinds of services they can offer.

“The problem is, simply having the insurance card doesn’t mean that you can find the appropriate provider in your geographic area...who is willing or available to take you on as a patient," says Marshall Kapp, Director of the Center for Innovative Collaboration in Medicine and Law at Florida State University's College of Medicine.

It takes years to educate and train a doctor. And while the state has done things like open new medical schools and increase the number of residency positions so students can be trained—they’re still far away from becoming actual workers. Meanwhile, more Floridians are expected to gain insurance under the federal affordable care act—and they’re going to be looking for services now, not later.

“We may see longer waiting times. We may see more government intervention intended to change the distribution of physicians. Frankly, one of the ways we’ve dealt with this is immigration—using foreign physicians and other professionals, certainly in long-term care," Kapp said.

But that’s not a long-term solution. The growth in demand at a faster rate than changes in supply has many states looking for more efficient ways to address provider shortages. And other healthcare groups are stepping forward with a solution that, in Florida, is highly controversial. And that is essentially expanding scopes-of-practice. Take the example of Florida nurses:

“We think there are other qualified practitioners who can help with this workload and nurse practitioners are one such group," says Alisa Snow, a lobbyist or the Florida Nurses Association.

Right now, some nurses with advanced training can treat patients and prescribe basic medicines like antibiotics under the direction of a doctor. But the nurses say they can do more. They want to be able to have patients directly referred to them by health plans, and they want to be able to prescribe medications that have controlled substance, like painkillers, and cough medications with Codine. Snow says nurses can provide basic primary care and help fill gaps left by a shortage of physicians in that area:

“The biggest opportunity we have is for nurses, in particular, Nurse Practitioners, is to step up and play a role in primary healthcare needs in our state. So we’re looking for opportunities to make that happen.”   

Groups like the National Governor’s Association, have called on states to reexamine their scope-of-practice laws and Florida TaxWatch, a state government watchdog, has done its own studies too.  The group says letting groups like the nurses expand their scope of practice can allow more people access to care and a cheaper cost:

“The areas that ARNP’s and nurse anesthetists are able to provide those services, studies show they provide the same quality of care, so we would receive lower cost but no harm in quality," said Robert Weissert, TaxWatch's Vice President of Research.

Under the Affordable Care Act people will gain greater access to insurance by purchasing subsidized plans on an exchange, or if they’re low- income, though an expansion of the Medicaid program if Florida lawmakers approve. Medicaid reimburses nurses at cheaper rates than doctors, and so do many insurance plans.  But nurses aren’t the only group looking to get additional authority. Florida optometrists—the people who do things like eye exams and prescribe glasses, want to be able to prescribe controlled substances, something done by opthalmologists. Last year, the optometrists came close—but a bill giving them that power failed in the legislature. And while optometrists can provide the additional services in the majority of other states, physician groups and others are opposed to letting them do it here. One reason, says former Republican state senator Durell Peaden, is that optometrists, and nurses are not doctors:

“When I came to the legislature, the optometrists wanted to do laser surgery," he said.

"And some folks just aren’t trained to do that level of care. And it’s hard to give them that responsibility with just passing a statute. Just because the state of Florida in statute says you’re qualified without training, doesn’t mean you are qualitfied.”   

Peaden, who is a retired doctor, says there’s no doubt that workforce demands will only increase in the next few years, but he disagrees with letting physician groups practice outside their traditional area and wold rather see the state fund more residency slots to train future doctors, and provide an easier path to medical school for military veterans. The Florida Academy of Family Physicians is also against letting other providers expand their scope of practice. Peaden says he believes the battles are largely about money. And the federal affordable care act through the Medicaid expansion, is expected to bring billions of dollars into the state.  The Florida Nurse Association’ lobbyist Alisa Snow says Peaden is an extent. But she sees things differently.

“I think there’s a concern about a loss of money to certain practitioners who have cornered the market on patient care.”  

The Florida Renal Coalition, which deals with people who have kidney disease and renal failure, wants its providers to be able to offer vaccinations. And with more people demanding access to healthcare services once they get insurance, observers say there’s more than enough money, and patients, to go around.

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