The paper examines the Bill CS/CS/SB 614 filed by State Senator Denise Grimsley that allows the advanced registered nurse practitioners (ARNPs) to prescribe and dispense controlled substances for patients in ambulatory surgical centers, hospitals or mobile surgical facilities in the State of Florida. It is suggested that the bill should be passed by the senate of Florida State. Such controlled substances are to be prescribed under existing supervisory standards for physician assistants (PAs) and protocols for ARNPs. The bill mandates the ARNPs and PAs to prescribe and dispense controlled substances in compliance with similar dispensing and prescribing obligations for physicians. However, the state of Florida, unlike other states, does not permit ARNPs or PAs to prescribe controlled substances.
The organization I represent is the Florida Association of Nurse Practitioners (FLANP). It is an organization that is comprised of pro-active health care advocates and nurse practitioners working towards improving access to health care for the citizens of Florida. The policy bill CS/CS/SB 614 fronted by State Senator Denise Grimsley authorizes PAs and ARNPs to prescribe controlled substances under the existing supervisory standards for PAs and protocols for ARNPs except in pain-management clinics. It implies that PAs and ARNPs are obligated by the policy to work in a similar manner as physicians in this context. The paper provides an in-depth analysis of this policy from the point of view of a representative of a professional association, the FLANP.
Grimsley’s bill was introduced in response to many incidents emerging after wrongful prescription of drugs. This bill aims at expanding the number of people who could prescribe drugs classified as brand drugs. The changes proposed by this bill reflect the present practices that advanced registered nurses have with regard to prescribing drugs classified as prescription drugs. It is worth noting that the State of Florida, unlike other US states, does not allow ARNPs to prescribe controlled substances. Additionally, Florida is among the two states in the US that do not allow PAs to prescribe controlled substances. This legislation would allow Florida’s ARNPs to prescribe controlled substances, just like advance nurses in other states do. In Florida, ARNPs have been prescribing medications with the exception of scheduled drugs since 1987. They were authorized to prescribe medications via a collaborative practice agreement with a physician. Moreover, they could only prescribe medications used within their scope of practice and included in the agreement.
Evidence-Based Guidelines Published on the Policy
ARNPs have the capacity to manage common medical problems such as prescription of a controlled substance as stipulated in a guideline that was adopted by Goudreau and Smolenski. In the guideline, they may monitor, initiate, order or alter drug therapies as a nursing function in line with their scope of practice, training and knowledge and provided that they are authorized by the supervising physician. According to Goudreau and Smolenski, the prescribing authority of the ARNPs must work within a well defined protocol that spells out the prescription guidelines. The guidelines define controlled substances as chemicals or drugs such as illegal drugs and prescription medication that are outlawed or strictly regulated due to their potential risk of addiction or abuse. Such controlled substances include drugs classified as stimulants, narcotics, hallucinogens, depressants and cannabis, and guidelines do not mandate the involved physician who prescribes them.
The Drug Enforcement Administration (DEA) has the mandate of regulating controlled substances, and a health practitioner is therefore mandated to register with and acquire a registration number from DEA to prescribe controlled substances. A DEA registrant is required to comply with applicable state laws for prescribing controlled substances. If state law does not authorize practitioners to prescribe controlled substances, then the DEA will not issue a DEA registration number as in the case of Florida.
Key Policy Events
The policy has had several challenges for two decades in an attempt to persuade state lawyers to remove prescription barriers put for the ARNPs. There have been previous legislative acts, the notable one being the Tallahassee regular sessions, which did not make it through either house of the legislature. According to Curry, this bill was viewed as divisive and putting a barrier between nurses and doctors who ought to be working collaboratively. Additionally, this bill was discarded as the federal government considered nurse practitioners as those posing a risk for addiction or abuse, thus denying them the chance to obtain a DEA license to prescribe a controlled substance medication. Other issues that precede this legislation include:
- A bill opposing the Medicaid’s increased funding by the federal to insure hundreds of thousands through eliminating or loosening regulations;
- Lobbying from the Florida Medical Association opposed to expansion of nurse practitioner prescribing powers;
- Support from the National Governors Association and Florida Tax Watch for the expansion of prescribing authority as a means of promoting access to healthcare in the wake of doctor’s shortage;
- The Patient Protection and Affordable Care Act and the new Medicaid managed care models allowed to ARNPS through their education and experience to step in and fill the gap created by the shortage in the number of physicians.
According to the Florida Association of Nurse Practitioners [FLANP], one million Floridians lack sufficient access to health care despite the fact that there are more than 17,700 practitioners who can aid in providing health care access. The situation is even worse in the rural areas, especially in the wake of the projected shortage of doctors. FLANP further asserts that Florida’s demand for family practice/general medicine doctors will surpass its supply by 13% by 2025. According to FLANP, this gap can be filled through expanding the authority of nurses, including giving them the authority to prescribe controlled substances. Financial data from the FLANP estimates that $339 million could be saved across Florida’s health care system provided that ARNPS and PAs were allowed to prescribe controlled substances and direct bill insurers for patient healthcare. This $339 million could be saved specifically from $44 million and $2.2 million saved from Medicaid and state employee health insurance respectively.
This bill was sponsored by Grimsley and the major stakeholders are the Florida Nurses Association, the National Governors Association and the Florida Tax Watch. The Florida Nurses Association supports this bill as it would allow ARNPs to prescribe controlled substances just like advanced practice nurses in the other states do and would relieve pressure on the few physicians available. The National Governors Association recommends this bill as it would enable more ARNPs to provide primary health care service for 16 million people anticipated to gain health insurance coverage by 2016 and for the quickly aging population. The Florida Tax Watch supports this bill as it would achieve cost savings for taxpayers and Florida business while sustaining high quality healthcare during a period of increasing demand. These views by the Florida Nurses Association, the National Governors Association and the Florida Tax Watch are strong and thus likely to influence the outcome of this bill. Their cost saving opinions, the current shortage of physicians and the anticipated increase in the aging population and those demanding health care insurance are likely to sway the outcomes of this bill.
Social, Economic, Legal and Political Factors
The Florida Medical Association is a doctors lobbying organization that has been viewed very influential, especially in the development of health policies. According to Goudreau and Smolenski, this group has opposed efforts to increase prescribing powers of nurse practitioners for years and has not changed when this bill was introduced in the legislature. However, the opinions of this lobby group may not count as the National Governors Association, the Florida Tax Watch and the FLANP support this expansion as cost saving measure and a means to promote access to healthcare in the wake of doctor shortage. The FLANP estimates that one million Floridians lack sufficient access to health care despite the presence of more than 17,700 practitioners who can aid in providing health care services. This problem can be solved by increasing the prescribing authority of ARNPs, especially, authority to prescribe controlled substances. Additionally, the demand for general medicine doctors in Florida is projected to exceed supply by 13% in 2025. Also, $339 million could be saved across Florida’s health care system provided that ARNPS and PAs were authorized to prescribe controlled substances and directly charge bills for health care insurers.
According to FLANP, the demand for primary care services in most states is straining the health care capacity, with an excess of 16 million people expected to acquire health insurance as of 2016. In Florida, there is a documented shortage of physicians, especially, at a time when the demand for primary health care is increasing. The only solution to this glaring problem is expanding the scope of practice for ARNPs and the PAs as it would not only enhance high quality medical care but also generate fiscal savings.
Policy Intervention Options
It is worth noting that the issue under discussion is the policy aimed at increasing the powers of ARNPs and PAs to prescribe controlled substances in Florida, just like it is done in other states. Relevant legislation to the current issue includes the Senate Interim Report of 2009. According to Florida Senate, this Senate Interim Report proposed that the Legislature should contemplate extending authority to Florida’s licensed ARNPs, those who have achieved certification in the nursing field. The certification has to be obtained from a credible, nationally acknowledged certifying body to prescribe controlled substances under conventions and in line with the scope of practice for their domain. This recommendation is closely related to the policy brief. The only difference is that the policy brief recommends granting full prescribing powers to ARNPs. The alternative solution to this Senate Interim Report would be to grant ARNPs full prescribing authority but with careful statutory modifications in the prescription of controlled substances, malpractice insurance and direct billing. The other alternative would be to develop a program for prescription drugs for the Florida that would enable a scheduled dispensing of controlled substances.
There has been a concern that Floridians are wary of proposals allowing untrained practitioners prescribe controlled substances and narcotics independently without the supervision of a physician. Additionally, this limitation of ARNPs and APs prescription powers in Florida has made Florida a role model for other states as the number of deaths caused by prescription overdoses has declined by 23% in 2014. However, there is no indication or evidence in any state that authorizing ARNPs to prescribe controlled substances directly augments prescription drug abuse.
The state of Florida is the only state denying nurse practitioners the chance of obtaining their DEA numbers, which would empower them to prescribe controlled substances for their patients. The Grimsley bill of 2015 was to change this by expanding the APRNs prescription powers. However, despite the limited prescription powers of APRNs, nurse practitioners used numerous strategies to prescribe medication in the primary care settings, even in the absence of legal authority. Nurse practitioners chose medication for patients and then had physicians write and sign the prescription. They also used a physician’s name to call in a prescription to a pharmacy. In addition, they used written protocols to allow nurses prescribe medications with the dosage and type determined by formulary.
Due to the challenges presented above, the policy Bill CS/CS/SB 614 filed by State Senator Denise Grimsley should be adopted by the Florida state senate and enacted as a medical policy.