Legislative Issues-2010 Update for Nurse Practitioners 2010

Legislative Issues-2010 Update for Nurse Practitioners

2010 Leadership • M. Christopher Saslo DNS ARNP BC President • Jean Aertker, DNP, ARNP, FNP-BC, COHN-S, FAANP Treasurer, Past President • Francis Rankin Sahebzamani , DNP ARNP FAANP 2 nd Vice President-Legislative Affairs • Janet Du. Bois, DNP, ARNP-BC, FAANP 1 st Vice President-Conference • Doreen Cassarino, MSN ARNP-BC Secretary AANP Florida State Representative • Marifrances Gullo, MSN, ARNP-BC PAC Chair • Armando Riera, MSN ARNP-BC Membership Chair

Background on the issue / Current Situation • Presently forty percent of Floridians have inadequate access to basic health care. • Everyday it is estimated that hundreds of uninsured and Medicaid/Medicare patients must go to emergency rooms. This is complicated further if their primary care provider is an APRN, to get medications for their diagnosis of anxiety, attention deficit disorder medication refills, cough medication with codeine, diarrhea medication, and pain medicine.

National NP Legislative Agenda • To Protect the Scope of Practice for NPs • Assure Parity Language in All Bills to Include APNs • Removal of Statutory Collaboration to be Regulated by BON • To Educate NPs on Legislative Issues • To Educate Others About the Vital Role of NPs for Florida Nurse Practitioner Network 4

Florida Legislative Agenda • Maximize health care access to Floridians • Provide comprehensive health care including all prescriptive authority • Become recognized primary care providers on most insurance panels • Identify practice barriers and set legislative efforts to remove.

Historical Problems • Piecemeal approach to statutes and rules • Lack of strong statewide unity amongst NPs • NPs move out of Florida due to practice restrictions • No statewide NP legislative training after graduation • Restricted sharing ability to promote best NP practices – NPs are the Best Kept Secret! • Lack of formal procedure for performing and documenting NP practice needs assessment • Lack of individual expertise in legislative issues Florida Nurse Practitioner Network 6

1982: Florida begins graduating Masters Prepared Nurse Practitioners as entry Level preparation. By 1995 Florida adopts this as a regulation. 1965, Advanced Practice Nursing concept introduced, University of Colorado Pediatric Nurse Practitioners, Loretta Ford & Dr. Henry Silver 1979, Advanced Registered Nurse Practitioners, with title protection for A. R. N. P. , was added to the Florida Nurse Practice Act. However, FMA begins assault early on to reduce any threat to Physician practice. 1993: approximat ely 2500 Nurse Practitioner s hold licenses in Florida 1988: rules implementing the Joint Committee s decision to authorize ARNPs to prescribe noncontrolled drugs were in place and ARNPs throughout the state began to prescribe legend drugs under a protocol agreement. 1997: 4500 Nurse Practitioners licensed to practice in Florida 1994: Florida APNs begin seeking prescriptive authority for controlled substances. Florida Nurse Practitioner Network 2009: 15 years of seeking controlled substances remain unsuccessful 11, 2021 Nurse practitioners licensed 7

In your neighborhood • Florida boasts second highest population of APNs in the U. S. (11, 221 NPs, 14, 028 total APN) – Broward County: 1066 Nurse Practitioners – Dade County: 907 Nurse Practitioners – Palm Beach County: 674 Nurse Practitioners (*active, unrestricted, excludes CRNA and CNMs, data from MQA database, August, 2009) Florida Nurse Practitioner Network 8

Florida State Legislation Effects of 2005 Legislation • Handicapped Park (HB 63 Rep David Simmons from Altamonte Springs), Fire School and Gun Permits (Rep Don Brown from De. Funiak Springs) Florida Nurse Practitioner Network 9

Florida State Legislation Effects of HOUSE BILL 699 that passed in 2006: Orchestrated by the Dermatologists for control of Med Spas: NPs will need Dermatologist/Plastic Surgeon as collaborating physician now Dermatology: NPs in Derm as primary practice will need Dermatologist as collaborating Physician Does not apply to NPs in designated “rural” health settings or university run/sponsored clinics. Site limitations: Physicians limited to five “off-site” clinics supervision- aimed at Retail Clinics Dermatologists no more than three (reduced to one site by 2008) Physician ‘On Site’ postings: NPs must post physician ‘on site’ hours. NP Identification: Must inform patients of their designation either in writing or name tag Florida Nurse Practitioner Network 10

AMA Focuses on Restricting NPs 2008 House of Delegates to AMA: Resolution 13, "Physician Employment by a Physician Extender, " called for the AMA to define ethical boundaries applicable to supervising or collaborating physicians who are employed by NPs. Resolution 214, "Doctor of Nursing Practice, " would have required physician supervision for NPs who earn the doctorate of nursing practice degree. Resolution 303, "Protection of the Titles 'Doctor, ' 'Resident' and 'Residency, '" would have limited the use of these terms to physicians, dentists and podiatrists. Resolution 716, "AMA Model Agreement with Advanced Practice Nurse Clinicians, Nurse Practitioners and/or Clinical Nurse Specialists, " recommended that collaborative agreements address the "quality of care, continuity of care, and scope of practice" provided by NPs. Florida Nurse Practitioner Network 11

2008 • Two APRN Bills introduced: • Clinical Lab Bill: This bill passed and now labs have to accept specimens ordered by APNs. • Controlled Substance Authority : did not get read, did not move out of committee even though it had a favorable senate report. For 15 years it has failed.

Bills of impact filed 2009 • • Clinical Laboratories Bill - HB 53/ SB 408 Sponsored by Senator Mike Fasano and Representative Luis Garcia. This bill mandates that clinical laboratories accept specimens from ARNPs. Labs are already required to accept specimens from most other licensed health care providers, and ARNPs have been permitted to order lab tests since 1996. Was signed into law by Governor Crist. ARNP Controlled Substance (CS) Prescribing - SB 426 Sponsored by Senator Mike Bennett and Representative Juan Carlos Zapata. Unfortunately this bill was not passed and in fact was not even on the agenda in the committees despite the Senate Staff Report that was supportive on ARNP prescribing of controlled substances. One argument against the CS prescribing bills over the past years is that FL is the leader in illegal CS access on the streets. To combat this, a Controlled Substance Tracking Bill was introduced by Senator Dave Aronberg and was signed into law by Governor Crist. This will eliminate one of the arguments against our CS bill for 2010. Florida Nurse Practitioner Network 13

Efforts to impact patient Care • For 16 consecutive years, APRNs have sought legislation that would enable them to prescribe to the full scope of their education and training. • Each year, the Florida Medical Association has successfully blocked any legislation that would permit this type of prescribing.

Changing the landscape of legislation • As a result of constant battles with legislators and weak support from individual nursing organizations, the Coalition for Advanced Practice Nurses was formed in 2007. – Partners included Florida Nurses Association, Florida Nurse Practitioner Network, Florida Assoc. of Nurse Anesthetists, the Florida Chapter of Nurse Midwives and educators from around the state

Preparing the future • As a result of efforts, a “White Paper” was developed that outlined the plan to impact the accessibility of adequate health care by Advanced Practice Nurses (APNs) to allow them to practice as their education prepared them. • In addition to the development of a white paper, lobbyists were successful in convincing the Senate that an interim study analysis on the feasibility of APRNs prescribing should be done.

Interim Report 2009 -117 In October of 2008, the Florida Senate published a study on the issue of APRNs and the authorization of prescription of controlled substances. This study concluded that, like forty-eight other states, Florida should change this outdated law and grant the authority to prescribe controlled substances to APRNs.

Data from Interim Report 2009 -117 supports the following findings: “Giving APRNs the authority to prescribe controlled substances will enhance the ability of APRNs to manage their patients’ care and reduce delays and costs for patients in obtaining needed medications” (p. 10).

Data from Interim Report 2009 -117 supports the following findings: • “Advanced Practice Nurses do not appear to be any more susceptible to diversion or inappropriate prescribing than any other prescribing practitioners. ”

Data from Interim Report 2009 -117 supports the following findings: • The current certification requirements appear to sufficiently protect the public to give qualified APRNs the authority to prescribe controlled substances.

Data from Interim Report 2009 -117 supports the following findings: “Senate professional staff recommends that the Legislature consider extending authority to Florida-licensed APRNs who have attained certification in a nursing specialty from a nationally recognized certifying entity to prescribe controlled substances under protocols and within the scope of practice for their specialty. ”(p. 10)

Opponents of giving APRNs the authority to prescribe controlled substances argue that: • “APRNs do not have the adequate training to make the appropriate diagnosis and suggest proper treatment options relative to controlled substances. (p. 1)” Interim Report 2009 -117 points out that “In addition to nursing, an APN may perform medical acts of diagnosis, treatment and prescription. ” (p. 1)

Opponents of giving APRNs the authority to prescribe controlled substances also argue that: • That increasing the number of persons prescribing controlled substances will lead to further opportunities for abuse of prescription drugs and diversion of prescription drugs from legal distribution systems. • Interim Report 2009 -117 concluded that APRNs are no more likely to be subject to diversion or improper prescribing than any other type of prescribing healthcare provider. Senate Interim Report, 2009 -117

Opponents of giving APRNs the authority to prescribe controlled substances argue that: There is no indication that patients who need controlled substances have problems getting these drugs. • As the Interim Report 2009 -117 points out, many rural areas do not have adequate number of physician providers. – “ People living in these areas must find or drive long hours to reach a physician to get certain types of care that can be provided and prescribed by the APRNs who already live and work there, if legislative barriers were removed”. Senate Interim Report, 2009 -117

Proponents of giving APRNs the authority to prescribe controlled substances argue that: Giving to APRNs authority will increase access to needed health care services in areas of the state where there are underserved populations and shortages of physicians • Improve the quality of patient care. • Minimize unnecessary utilization of health care resources • Improve patient outcomes • Improve patient satisfaction Senate Interim Report, 2009 -117

Additional efforts • In 2009, the Coalition for Advanced Practice Nurses enlisted the services of a media company and developed a video that emphasized the impact of caring for our Floridians and having a positive impact on health care by using APRNs effectively (www. fnpn. org). • In January of 2009, the Coalition met with the Lt. Governor to outline their strategic plan to address these shortcomings.

Proponents of giving APRNs the authority to prescribe controlled substances argue that: APRNs have the education to safely and effectively prescribe controlled substances and that the evidence from the 48 states where APNs currently prescribe controlled substances supports this claim.

Recommendations for consideration • Controlled Substances/Prescription Monitoring Bill, taking into effect on July 1, 2009. Will help in monitoring those prescribing controlled substances. • Empanelling of APRNs by insurance companies will increase accessibility of health care and further acknowledge the safety and cost effective care of APRNs. • Meeting with Florida Blue Cross & Blue Shield to discuss empanelling of ARNPs as Primary Providers

Keeping your finger on the pulse • Being constantly on guard related to practice issues can often be a daunting task. Even with paid professionals, legislation has a way of sneaking in…. – Senate Bill 1986, now section 456. 0635, Florida Statutes (2009), was passed during the 2009 Florida legislative session. This law became effective July 1, 2009 and affects any licensee that was licensed on July 1, 2009 and licensee renewals. Florida Nurse Practitioner Network 29

• 456. 0635 Medicaid fraud; disqualification for license, certificate, or registration. -- • (1) Medicaid fraud in the practice of a health care profession is prohibited. • (2) Each board within the jurisdiction of the department, or the department if there is no board, shall refuse to admit a candidate to any examination and refuse to issue or renew a license, certificate, or registration to any applicant if the candidate or applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant, has been: • (a) Convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, chapter 893, 21 U. S. C. ss. 801 -970, or 42 U. S. C. ss. 1395 -1396, unless the sentence and any subsequent period of probation for such conviction or pleas ended more than 15 years prior to the date of the application; Florida Nurse Practitioner Network 30

• (b) Terminated for cause from the Florida Medicaid program pursuant to s. 409. 913, unless the applicant has been in good standing with the Florida Medicaid program for the most recent 5 years; • (c) Terminated for cause, pursuant to the appeals procedures established by the state or Federal Government, from any other state Medicaid program or the federal Medicare program, unless the applicant has been in good standing with a state Medicaid program or the federal Medicare program for the most recent 5 years and the termination occurred at least 20 years prior to the date of the application. • (3) Licensed health care practitioners shall report allegations of Medicaid fraud to the department, regardless of the practice setting in which the alleged Medicaid fraud occurred. • (4) The acceptance by a licensing authority of a candidate's relinquishment of a license which is offered in response to or anticipation of the filing of administrative charges alleging Medicaid fraud or similar charges Florida Nurse Practitioner Network 31 constitutes the permanent revocation of the license.

Upcoming Legislative & Insurance Efforts • March on Tallahassee scheduled for March 2010! • Meeting was very positive with Florida Blue Cross/Shield to discuss empanelling NPs as PCPs Florida Nurse Practitioner Network 32

2010 Legislation • ARNPs- SB 188/ HB 677 by Senator Mike Bennett and Representative Juan Carlos Zapata. The bill has now been filed in both the House and Senate, the next challenge is to get it placed on the agenda of the committees to which it has been referred. Representative Nick Thompson, Chair of Health Policy Regulation Committee is hesitant to have this bill heard. Florida Nurse Practitioner Network 33

16 years of: • Studies that show we are safe providers. • False rumors by the FMA and targeted actions to prevent this bill’s passage. • Being ignored by state legislators

Are you Happy? • Do you feel that you are able to provide the best most complete care to your patients? • Do you like having to get approval to order controlled substances? • Do you like your orders being refused by hospitals without co signatures on them?

• Is it fun to not be able to order medical equipment for your patients? • Do you look forward to telling patients families that you cannot sign the death certificate and their loved one will need an autopsy? • Is it comforting to know that because you cannot Baker Act a patient they will be unable to access care?

What Can I Do to Help? • Like you, encourage your colleagues to joining your professional organizations • Subscribe to a legislative list serve • Stay Informed • Examine your own practice for change • Join a Political Action Committee (PAC) • Write letters, send e-mails, call your representatives- all the time! • ‘Just Do It’ Florida Nurse Practitioner Network 37

House of Representatives Criminal & Civil Justice Policy Council Civil Justice & Courts Policy Committee Public Safety & Domestic Security Policy Committee Economic Development & Community Affairs Policy Council Economic Development Policy Committee. Governmental Affairs Policy Committee. Military & Local Affairs Policy Committee. Roads, Bridges & Ports Policy Committee Education Policy Council Pre. K-12 Policy Committee State Universities & Private Colleges Policy Committee Finance & Tax Council Florida Legislative Committee on Intergovernmental Relations Full Appropriations Council on Education & Economic Development (4) Full Appropriations Council on General Government & Health Care Criminal & Civil Justice Appropriations Committee Government Operations Appropriations Committee Health Care Appropriations Committee Natural Resources Appropriations Committee General Government Policy Council Agriculture & Natural Resources Policy Committee Energy & Utilities Policy Committee Insurance, Business & Financial Affairs Policy Committee Government Accountability Act Council Health & Family Services Policy Council Elder & Family Services Policy Committee Health Care Regulation Policy Committee Health Care Services Policy Committee Joint Administrative Procedures Committee Joint Committee on Public Counsel Oversight Joint Legislative Auditing Committee Joint Legislative Budget Commission Rules & Calendar Council Joint Legislative Committee on Everglades Oversight Joint Legislative Sunset Committee Office of Reapportionment Policy Council Select Policy Council on Strategic & Economic Planning Select Committee on Seminole Indian Compact Review Select Committee on Standards of Official Conduct

Senate Policy and Steering Committees (5) Standing Committees (26) Select Committees Joint Committees (6) Other Legislative Entities Policy and Steering Committee on Commerce and Industry CPSC Policy and Steering Committee on Energy, Environment, and Land Use EPSC Policy and Steering Committee on Governmental Operations GPSC Policy and Steering Committee on Social Responsibility SPSC Policy and Steering Committee Ways&Means Agriculture AG Banking and Insurance BI Children, Families, and Elder Affairs CF Commerce CM Communications, Energy, and Public Utilities CU Community Affairs CA Criminal and Civil Justice Appropriations JA Criminal Justice CJ Education Pre-K - 12 ED Education Pre-K - 12 Appropriations EA Environmental Preservation and Conservation EP Ethics and Elections EE Finance and Tax FT General Government Appropriations GA Governmental Oversight and Accountability GO Select Committee on Florida’s Economy Florida Legislative Committee on Intergovernmental Relations LCIR Joint Administrative Procedures Committee JAPC Joint Committee on Public Counsel Oversight JCPO Joint Legislative Auditing Committee JCLA Joint Legislative Committee on Everglades Oversight JCEO Joint Legislative Sunset Committee Joint Legislative Budget Commission Health and Human Services Appropriations HA Health Regulation HR Higher Education HE Higher Education Appropriations HI Judiciary JU Military Affairs and Domestic Security MS Reapportionment RE Regulated Industries RI Rules RC Transportation TR Transportation and Economic Development Appropriations

The Big Players • Senator Jeff Atwater SENATE President ( R ) District 25 • • • Banker, Catholic, UF grad District Offices: 824 US Highway 1, #210 North Palm Beach, FL 33408 (561) 625 -5101 FAX (561) 625 -5103 Statewide: 1 -866 -757 -1902 Legislative Assistants: Laura Coburn, Megan Kossove and Cheri Vancura • Rep. Larry Cretul (R) HOUSE Speaker (2009 - 2010) District 22 (Marion Co) • Real Estate Broker • • District Office: 6911 SW Highway 200 Ocala, FL 34476 -9210 Phone: (352) 873 -6564 Legislative Assistant: Gina Evans

Committee on Health Regulation (Senate) • • Don Gaetz (R), Ft Walton Beach, CHAIR Elenor Sobel (D), Hollywod, Vice Chair Thad Altman (R), Melbourne Mike Bennett (R) Bradenton Andy Gardiner (R) Orlando (Majority Whip) Dennis Jones, DC (R) Seminole Al Lawson (D) Tallahassee

Health Care Regulation Policy Committee • • • (House) Thompson, Nicholas R. (R) Chair Van Zant, Charles E. (R) Vice Chair Porth, Ari Abraham (D) Democratic Ranking Member Bush III, James (D) • Nehr, Peter (R) Ford, Clay (R) • Proctor, William L. (R) Fresen, Erik (R) • Rehwinkel Vasilinda, Michelle (D) Horner, Mike (R) • Renuart, Ronald (R) Hudson, Matt (R) Hukill, Dorothy L. (R) • Roberson, Yolly (D)

"Passive indifference is as bad as active malice" …Barack Obama Florida Nurse Practitioner Network 43