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Across the country, there is an impending shortage of health care providers. The problem might be especially pronounced in a state like Florida with nearly 20% of the population more than 65 years old. In fact, Florida already has fewer than 86 primary care physicians per 100,000 residents compared to the national average of 92 physicians.
As Florida’s population ages, so too will its doctors. More than one-third of active physicians in the Sunshine State are over the age of 60 and will begin to retire in the coming years. Expanding the role of non-physician health care providers through occupational licensing and scope of practice reform offers one solution to the growing shortage.
Licensure of non-physician health care workers might seem like a reasonable form of regulation in the interest of public safety, but the variation in licensing requirements across states indicates that there is room for reform. Depending on state policies, they are capable of practicing autonomously and serve particularly important roles in rural areas where access to medical care is often limited. However, regulations in Florida restrict the autonomy and range of services these practitioners can provide.
Dentists typically lead a team of oral care providers including dental assistants and dental hygienists. There are about 51 dentists for every 100,000 Floridians, compared to the national average of 61 dentists. Increasing the autonomy of non-dentist team members could help expand access directly through independent practice and indirectly by freeing dentists to focus on the most complex procedures.
Dental hygienists are licensed at the state level and are trained through accredited dental hygiene programs. In Florida, dental hygienists have direct access, which means they are permitted to perform some procedures without the physical presence, prior examination or authorization of a dentist. However, dental hygienists in Florida do not have prescriptive authority while Oregon, New Mexico, Colorado and Maine allow dental hygienists to prescribe certain fluoride treatments.
Dental therapists, a relatively new category of dental care providers, could further reduce the strain on dentists. They are mid-level dental practitioners capable of performing several services previously reserved for dentists. Beginning with Alaska in 2005, 12 states have recognized dental therapists through licensing reform with at least eight others, including Florida, considering similar reforms. Multiple studies suggest that dental therapists could contribute to reduced wait and travel times for patients, cost savings, increased productivity and improved patient satisfaction.
Nurse practitioners are registered nurses who undergo additional education and training though graduate level programs. A report from the Office of Technology Assessment indicated that NPs could perform a substantial proportion of tasks normally provided by primary care physicians and “as much as 75% of the well-person care for both adults and children.” However, state-level regulations limit the autonomy of NPs by restricting their practice authority and prescriptive authority.
According to the American Association of Nurse Practitioners, Florida is among the 12 most restrictive states. NPs in Florida must have a career-long supervision agreement with a physician that outlines the services they are allowed to provide and procedures for consultation with the physician. Moreover, Florida law only permits NPs to prescribe certain controlled substances in limited quantities under the supervision of a physician. About half of states offer NPs greater independence and prescriptive authority than Florida.
Proponents of full practice authority for APRNs include the National Academies of Medicine and AARP. Research suggests that less restrictive scope of practice laws improve health care access without posing risks to public safety. For example, a study published in the Journal of Law and Economics found that more restrictive scope of practice policies resulted in 3-16% higher costs for well-child visits with no difference in quality or safety.
Like NPs, physician assistants are required to participate in approved graduate-level programs to receive licensure from state boards. PA programs are modeled after traditional medical school curriculums and prepare PAs to perform many of the same functions as physicians. By definition, PAs work under the supervision of physicians, but their degree of autonomy varies widely across states depending on supervision requirements, prescriptive authority and scope of practice laws.
In Florida and 21 other states, supervision requirements are determined by state licensing boards or law. The remaining 28 states offer more flexibility by allowing physicians and PAs to determine supervision conditions at the practice level. Florida also limits the number of PAs that can work under the supervision of an individual physician. Fourteen other states place no limit on the number of PAs a physician can supervise.
Allowing more flexibility for PAs could increase access to care and reduce costs. A study from the Mercatus Center found that less restrictive scope of practice laws for PAs reduced the cost of outpatient services to Medicaid recipients by 11.8-14.4%.
As Florida’s population continues to age, adequate access to medical care will be increasingly difficult to achieve without expanding the role of non-physician health care providers. Dental hygienists, dental therapists, NPs and PAs are capable of performing many of the same procedures as dentists and physicians, but state-level regulation prevents them from practicing the full extent of their education and training. Occupational licensing and scope of practice reform would expand access to health care and lower costs by allowing physicians and dentists to use their time most efficiently.
Torio Nastasi is a policy analyst at Reason Foundation, and Sal Nuzzo is a vice president at the James Madison Institute.
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