Expanding the Role of ARNPs and PAs in Increasingly Competition
The following article was published in Miami Medicine, Dade County Medical Association's monthly magazine.
As if physicians do not have enough changes to deal with, the 2016 Florida Legislature has determined that Advanced Registered Nurse Practitioners ("ARNPs")and Physician Assistants ("PAs") should have expanded prescription authorization. The Barbara Lumpkin Prescribing Act (the "Act"), HB 423, ends a lengthy battle by ARNPs, PAs and their supporters to grant these healthcare professionals full prescribing privileges and responsibilities, thereby enabling them to treat patients within the full scope of their training and licensure. In adopting HB 423, the Legislature has joined most states in recognizing that these healthcare practitioners should be authorized to practice to the fullest extent of their training. While this change in the scope of these healthcare practitioners' practice may appear to represent a fundamental change in the way medicine is practices in Florida, a careful review of the Act suggests that it will be beneficial to the physicians who retain ARNPs or PAs and their patients.
Florida's duly licensed ARNP's and PAs have been seeking authority to prescribe Schedule II, Schedule III, and Schedule IV drugs ("Controlled Substances") for several years. They argued, among other things, that authorization to prescribe and dispense Controlled Substances (i) is within the scope of their training; (ii) makes full use of their skills; and (iii) increases patient access, particularly in rural and medically underserved areas of the State, where ARNPs and PAs may comprise most of the primary care providers in the area. Opponents expressed concern that permitting ARNPs and PAs to prescribe and dispense these Controlled Substances could endanger the public and lead to an increase in the inappropriate use of these drugs.
Prior to the passage of the HB 423, Florida's prescribing statutes prevented these healthcare professionals from taking advantage of the full scope of their licenses. Indeed, Florida may have been the last state where ARNPs and PAs did not have the authority to prescribe and dispense all of the classes of Controlled Substances. Effective July 1, 2016, that will no longer be the case; ARNPs and PAs will be authorized to order and dispense Controlled Substances in Florida.
The Act subjects ARNPs and PAs to the same restrictions applicable in the case of a physician who prescribes and dispenses Controlled Substances. As with physicians, the standard of practice an ARNP or PA will need to demonstrate before prescribing a Controlled Substance includes, among other things: (i) A complete medical history and physical examination of a patient before beginning any treatment that involves Controlled Substances, and (ii) documentation in the patient's medical record. In addition that patient will have to be seen at regular intervals. Consequently, it would seem to be prudent for ARNPs, PAs and their collaborating/supervising physicians to review these standards of care. They also should be familiar with any other relevant restrictions and requirements including, but certainly not limited to, those relating to the storage of and accounting for Controlled Substances. Like physicians, ARNPs and PAs will need to be licensed by their licensing agencies in order to dispense Controlled Substances.
Perhaps sharing the concern of physicians that expanding the authorization to prescribe and dispense Controlled Substances may increase the opportunity for inappropriate dispensing of these drugs, the Act includes an exception for pain clinics. In this place of service "[o]nly a physician licensed under [chapter 458 or chapter 459, Florida Statutes] may dispense medication or prescribe a controlled substance … on the premises of a registered pain-management clinic." 458.3265(2)(b) and 459.0137(2)(b), Florida Statutes.
The Act makes clear that both ARNPs and PAs will be obligated to continue practicing under the framework of an established supervisory protocol. Thus, the role of the collaborating/supervising physician will become more important as he or she will bear some risk for the inappropriate prescriptions written by their collaborating ARNPs and PAs.
Clarifying the role of ARNPs and PAs in prescribing controlled substances is likely to have a significant impact on the delivery of healthcare in Florida. Particularly for ARNPs and PAs who practice in rural areas, where a physician may not be readily available, this authorization is likely to make it easier for them to provide appropriate and timely treatment to patients. In urban areas ARNPs and PAs are likely to take over even more of the "routine" care they already are providing in many physicians' practices and other healthcare organizations.
Enactment of the Barbara Lumpkin Prescribing Act is likely to rise at least as many new questions as those resolved by this legislation. However, time, the adoption of new regulations, Board of Medicine/Osteopathic Medicine and Board of Nursing Declaratory Statements and disciplinary actions, and court decisions will address and eventually resolve many of these questions. In the meantime, physicians, ARNPs, PAs, other healthcare professionals and providers, and healthcare entrepreneurs who want to retain the services of ARNPs or PAs will be well served to work with experienced health law counsel in understanding how these changes will impact their practices and businesses.