Florida Senate - 2015 COMMITTEE AMENDMENT
Bill No. CS for CS for SB 614
Ì395678dÎ395678
LEGISLATIVE ACTION
Senate . House
Comm: RCS .
04/20/2015 .
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The Committee on Rules (Soto) recommended the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Subsection (7) of section 110.12315, Florida
6 Statutes, is amended to read:
7 110.12315 Prescription drug program.—The state employees’
8 prescription drug program is established. This program shall be
9 administered by the Department of Management Services, according
10 to the terms and conditions of the plan as established by the
11 relevant provisions of the annual General Appropriations Act and
12 implementing legislation, subject to the following conditions:
13 (7) The department shall establish the reimbursement
14 schedule for prescription pharmaceuticals dispensed under the
15 program. Reimbursement rates for a prescription pharmaceutical
16 must be based on the cost of the generic equivalent drug if a
17 generic equivalent exists, unless the physician, advanced
18 registered nurse practitioner, or physician assistant
19 prescribing the pharmaceutical clearly states on the
20 prescription that the brand name drug is medically necessary or
21 that the drug product is included on the formulary of drug
22 products that may not be interchanged as provided in chapter
23 465, in which case reimbursement must be based on the cost of
24 the brand name drug as specified in the reimbursement schedule
25 adopted by the department.
26 Section 2. Paragraph (c) of subsection (1) of section
27 310.071, Florida Statutes, is amended, and subsection (3) of
28 that section is republished, to read:
29 310.071 Deputy pilot certification.—
30 (1) In addition to meeting other requirements specified in
31 this chapter, each applicant for certification as a deputy pilot
32 must:
33 (c) Be in good physical and mental health, as evidenced by
34 documentary proof of having satisfactorily passed a complete
35 physical examination administered by a licensed physician within
36 the preceding 6 months. The board shall adopt rules to establish
37 requirements for passing the physical examination, which rules
38 shall establish minimum standards for the physical or mental
39 capabilities necessary to carry out the professional duties of a
40 certificated deputy pilot. Such standards shall include zero
41 tolerance for any controlled substance regulated under chapter
42 893 unless that individual is under the care of a physician,
43 advanced registered nurse practitioner, or physician assistant
44 and that controlled substance was prescribed by that physician,
45 advanced registered nurse practitioner, or physician assistant.
46 To maintain eligibility as a certificated deputy pilot, each
47 certificated deputy pilot must annually provide documentary
48 proof of having satisfactorily passed a complete physical
49 examination administered by a licensed physician. The physician
50 must know the minimum standards and certify that the
51 certificateholder satisfactorily meets the standards. The
52 standards for certificateholders shall include a drug test.
53 (3) The initial certificate issued to a deputy pilot shall
54 be valid for a period of 12 months, and at the end of this
55 period, the certificate shall automatically expire and shall not
56 be renewed. During this period, the board shall thoroughly
57 evaluate the deputy pilot’s performance for suitability to
58 continue training and shall make appropriate recommendations to
59 the department. Upon receipt of a favorable recommendation by
60 the board, the department shall issue a certificate to the
61 deputy pilot, which shall be valid for a period of 2 years. The
62 certificate may be renewed only two times, except in the case of
63 a fully licensed pilot who is cross-licensed as a deputy pilot
64 in another port, and provided the deputy pilot meets the
65 requirements specified for pilots in paragraph (1)(c).
66 Section 3. Subsection (3) of section 310.073, Florida
67 Statutes, is amended to read:
68 310.073 State pilot licensing.—In addition to meeting other
69 requirements specified in this chapter, each applicant for
70 license as a state pilot must:
71 (3) Be in good physical and mental health, as evidenced by
72 documentary proof of having satisfactorily passed a complete
73 physical examination administered by a licensed physician within
74 the preceding 6 months. The board shall adopt rules to establish
75 requirements for passing the physical examination, which rules
76 shall establish minimum standards for the physical or mental
77 capabilities necessary to carry out the professional duties of a
78 licensed state pilot. Such standards shall include zero
79 tolerance for any controlled substance regulated under chapter
80 893 unless that individual is under the care of a physician,
81 advanced registered nurse practitioner, or physician assistant
82 and that controlled substance was prescribed by that physician,
83 advanced registered nurse practitioner, or physician assistant.
84 To maintain eligibility as a licensed state pilot, each licensed
85 state pilot must annually provide documentary proof of having
86 satisfactorily passed a complete physical examination
87 administered by a licensed physician. The physician must know
88 the minimum standards and certify that the licensee
89 satisfactorily meets the standards. The standards for licensees
90 shall include a drug test.
91 Section 4. Paragraph (b) of subsection (3) of section
92 310.081, Florida Statutes, is amended to read:
93 310.081 Department to examine and license state pilots and
94 certificate deputy pilots; vacancies.—
95 (3) Pilots shall hold their licenses or certificates
96 pursuant to the requirements of this chapter so long as they:
97 (b) Are in good physical and mental health as evidenced by
98 documentary proof of having satisfactorily passed a physical
99 examination administered by a licensed physician or physician
100 assistant within each calendar year. The board shall adopt rules
101 to establish requirements for passing the physical examination,
102 which rules shall establish minimum standards for the physical
103 or mental capabilities necessary to carry out the professional
104 duties of a licensed state pilot or a certificated deputy pilot.
105 Such standards shall include zero tolerance for any controlled
106 substance regulated under chapter 893 unless that individual is
107 under the care of a physician, advanced registered nurse
108 practitioner, or physician assistant and that controlled
109 substance was prescribed by that physician, advanced registered
110 nurse practitioner, or physician assistant. To maintain
111 eligibility as a certificated deputy pilot or licensed state
112 pilot, each certificated deputy pilot or licensed state pilot
113 must annually provide documentary proof of having satisfactorily
114 passed a complete physical examination administered by a
115 licensed physician. The physician must know the minimum
116 standards and certify that the certificateholder or licensee
117 satisfactorily meets the standards. The standards for
118 certificateholders and for licensees shall include a drug test.
119
120 Upon resignation or in the case of disability permanently
121 affecting a pilot’s ability to serve, the state license or
122 certificate issued under this chapter shall be revoked by the
123 department.
124 Section 5. Section 383.336, Florida Statutes, is repealed.
125 Section 6. Section 395.1051, Florida Statutes, is amended
126 to read:
127 395.1051 Duty to notify patients and physicians.—
128 (1) An appropriately trained person designated by each
129 licensed facility shall inform each patient, or an individual
130 identified pursuant to s. 765.401(1), in person about adverse
131 incidents that result in serious harm to the patient.
132 Notification of outcomes of care that result in harm to the
133 patient under this section does shall not constitute an
134 acknowledgment or admission of liability and may not, nor can it
135 be introduced as evidence.
136 (2) A hospital shall notify each obstetrical physician who
137 has privileges at the hospital at least 90 days before the
138 hospital closes its obstetrical department or ceases to provide
139 obstetrical services.
140 Section 7. Subsection (7) of section 456.072, Florida
141 Statutes, is amended to read:
142 456.072 Grounds for discipline; penalties; enforcement.—
143 (7) Notwithstanding subsection (2), upon a finding that a
144 physician has prescribed or dispensed a controlled substance, or
145 caused a controlled substance to be prescribed or dispensed, in
146 a manner that violates the standard of practice set forth in s.
147 458.331(1)(q) or (t), s. 459.015(1)(t) or (x), s. 461.013(1)(o)
148 or (s), or s. 466.028(1)(p) or (x), or that an advanced
149 registered nurse practitioner has prescribed or dispensed a
150 controlled substance, or caused a controlled substance to be
151 prescribed or dispensed in a manner that violates the standard
152 of practice set forth in s. 464.018(1)(n) or s. 464.018(1)(p)6.,
153 the physician or advanced registered nurse practitioner shall be
154 suspended for a period of not less than 6 months and pay a fine
155 of not less than $10,000 per count. Repeated violations shall
156 result in increased penalties.
157 Section 8. Subsections (2) and (3) of section 456.44,
158 Florida Statutes, are amended to read:
159 456.44 Controlled substance prescribing.—
160 (2) REGISTRATION.—Effective January 1, 2012, A physician
161 licensed under chapter 458, chapter 459, chapter 461, or chapter
162 466, a physician assistant licensed under chapter 458 or chapter
163 459, or an advanced registered nurse practitioner certified
164 under part I of chapter 464 who prescribes any controlled
165 substance, listed in Schedule II, Schedule III, or Schedule IV
166 as defined in s. 893.03, for the treatment of chronic
167 nonmalignant pain, must:
168 (a) Designate himself or herself as a controlled substance
169 prescribing practitioner on his or her the physician’s
170 practitioner profile.
171 (b) Comply with the requirements of this section and
172 applicable board rules.
173 (3) STANDARDS OF PRACTICE.—The standards of practice in
174 this section do not supersede the level of care, skill, and
175 treatment recognized in general law related to health care
176 licensure.
177 (a) A complete medical history and a physical examination
178 must be conducted before beginning any treatment and must be
179 documented in the medical record. The exact components of the
180 physical examination shall be left to the judgment of the
181 registrant clinician who is expected to perform a physical
182 examination proportionate to the diagnosis that justifies a
183 treatment. The medical record must, at a minimum, document the
184 nature and intensity of the pain, current and past treatments
185 for pain, underlying or coexisting diseases or conditions, the
186 effect of the pain on physical and psychological function, a
187 review of previous medical records, previous diagnostic studies,
188 and history of alcohol and substance abuse. The medical record
189 shall also document the presence of one or more recognized
190 medical indications for the use of a controlled substance. Each
191 registrant must develop a written plan for assessing each
192 patient’s risk of aberrant drug-related behavior, which may
193 include patient drug testing. Registrants must assess each
194 patient’s risk for aberrant drug-related behavior and monitor
195 that risk on an ongoing basis in accordance with the plan.
196 (b) Each registrant must develop a written individualized
197 treatment plan for each patient. The treatment plan shall state
198 objectives that will be used to determine treatment success,
199 such as pain relief and improved physical and psychosocial
200 function, and shall indicate if any further diagnostic
201 evaluations or other treatments are planned. After treatment
202 begins, the registrant physician shall adjust drug therapy to
203 the individual medical needs of each patient. Other treatment
204 modalities, including a rehabilitation program, shall be
205 considered depending on the etiology of the pain and the extent
206 to which the pain is associated with physical and psychosocial
207 impairment. The interdisciplinary nature of the treatment plan
208 shall be documented.
209 (c) The registrant physician shall discuss the risks and
210 benefits of the use of controlled substances, including the
211 risks of abuse and addiction, as well as physical dependence and
212 its consequences, with the patient, persons designated by the
213 patient, or the patient’s surrogate or guardian if the patient
214 is incompetent. The registrant physician shall use a written
215 controlled substance agreement between the registrant physician
216 and the patient outlining the patient’s responsibilities,
217 including, but not limited to:
218 1. Number and frequency of controlled substance
219 prescriptions and refills.
220 2. Patient compliance and reasons for which drug therapy
221 may be discontinued, such as a violation of the agreement.
222 3. An agreement that controlled substances for the
223 treatment of chronic nonmalignant pain shall be prescribed by a
224 single treating registrant physician unless otherwise authorized
225 by the treating registrant physician and documented in the
226 medical record.
227 (d) The patient shall be seen by the registrant physician
228 at regular intervals, not to exceed 3 months, to assess the
229 efficacy of treatment, ensure that controlled substance therapy
230 remains indicated, evaluate the patient’s progress toward
231 treatment objectives, consider adverse drug effects, and review
232 the etiology of the pain. Continuation or modification of
233 therapy shall depend on the registrant’s physician’s evaluation
234 of the patient’s progress. If treatment goals are not being
235 achieved, despite medication adjustments, the registrant
236 physician shall reevaluate the appropriateness of continued
237 treatment. The registrant physician shall monitor patient
238 compliance in medication usage, related treatment plans,
239 controlled substance agreements, and indications of substance
240 abuse or diversion at a minimum of 3-month intervals.
241 (e) The registrant physician shall refer the patient as
242 necessary for additional evaluation and treatment in order to
243 achieve treatment objectives. Special attention shall be given
244 to those patients who are at risk for misusing their medications
245 and those whose living arrangements pose a risk for medication
246 misuse or diversion. The management of pain in patients with a
247 history of substance abuse or with a comorbid psychiatric
248 disorder requires extra care, monitoring, and documentation and
249 requires consultation with or referral to an addiction medicine
250 specialist or psychiatrist.
251 (f) A registrant physician registered under this section
252 must maintain accurate, current, and complete records that are
253 accessible and readily available for review and comply with the
254 requirements of this section, the applicable practice act, and
255 applicable board rules. The medical records must include, but
256 are not limited to:
257 1. The complete medical history and a physical examination,
258 including history of drug abuse or dependence.
259 2. Diagnostic, therapeutic, and laboratory results.
260 3. Evaluations and consultations.
261 4. Treatment objectives.
262 5. Discussion of risks and benefits.
263 6. Treatments.
264 7. Medications, including date, type, dosage, and quantity
265 prescribed.
266 8. Instructions and agreements.
267 9. Periodic reviews.
268 10. Results of any drug testing.
269 11. A photocopy of the patient’s government-issued photo
270 identification.
271 12. If a written prescription for a controlled substance is
272 given to the patient, a duplicate of the prescription.
273 13. The registrant’s physician’s full name presented in a
274 legible manner.
275 (g) Patients with signs or symptoms of substance abuse
276 shall be immediately referred to a board-certified pain
277 management physician, an addiction medicine specialist, or a
278 mental health addiction facility as it pertains to drug abuse or
279 addiction unless the registrant is a physician who is board
280 certified or board-eligible in pain management. Throughout the
281 period of time before receiving the consultant’s report, a
282 prescribing registrant physician shall clearly and completely
283 document medical justification for continued treatment with
284 controlled substances and those steps taken to ensure medically
285 appropriate use of controlled substances by the patient. Upon
286 receipt of the consultant’s written report, the prescribing
287 registrant physician shall incorporate the consultant’s
288 recommendations for continuing, modifying, or discontinuing
289 controlled substance therapy. The resulting changes in treatment
290 shall be specifically documented in the patient’s medical
291 record. Evidence or behavioral indications of diversion shall be
292 followed by discontinuation of controlled substance therapy, and
293 the patient shall be discharged, and all results of testing and
294 actions taken by the registrant physician shall be documented in
295 the patient’s medical record.
296 (h) Upon receipt from the Board of Nursing of the name of a
297 physician or dentist who has an established protocol with an
298 advanced registered nurse practitioner whose prescribing of
299 controlled substances may constitute grounds for disciplinary
300 action pursuant to s. 464.018(1)(n) or s. 464.018(1)(p)6., the
301 Board of Medicine, the Board of Osteopathic Medicine, or the
302 Board of Dentistry, as appropriate, shall investigate the
303 occurrences upon which the report was based and determine if
304 action by the board against the physician or dentist is
305 warranted. In addition, the respective board shall determine
306 whether the actions of the advanced registered nurse
307 practitioner violate medical standards for controlled substance
308 prescribing, and forward those finding to the Board of Nursing.
309
310 This subsection does not apply to a board-eligible or board
311 certified anesthesiologist, physiatrist, rheumatologist, or
312 neurologist, or to a board-certified physician who has surgical
313 privileges at a hospital or ambulatory surgery center and
314 primarily provides surgical services. This subsection does not
315 apply to a board-eligible or board-certified medical specialist
316 who has also completed a fellowship in pain medicine approved by
317 the Accreditation Council for Graduate Medical Education or the
318 American Osteopathic Association, or who is board eligible or
319 board certified in pain medicine by the American Board of Pain
320 Medicine, the American Board of Interventional Pain Physicians,
321 the American Association of Physician Specialists, or a board
322 approved by the American Board of Medical Specialties or the
323 American Osteopathic Association and performs interventional
324 pain procedures of the type routinely billed using surgical
325 codes. This subsection does not apply to a registrant, advanced
326 registered nurse practitioner, or physician assistant who
327 prescribes medically necessary controlled substances for a
328 patient during an inpatient stay in a hospital licensed under
329 chapter 395.
330 Section 9. Section 458.326, Florida Statutes, is amended to
331 read:
332 458.326 Intractable pain; authorized treatment;
333 interventional pain medicine; unauthorized practice.—
334 (1)(a) For the purposes of this subsection section, the
335 term “intractable pain” means pain for which, in the generally
336 accepted course of medical practice, the cause cannot be removed
337 and otherwise treated.
338 (b)(2) Intractable pain must be diagnosed by a physician
339 licensed under this chapter and qualified by experience to
340 render such diagnosis.
341 (c)(3) Notwithstanding any other provision of law, a
342 physician may prescribe or administer any controlled substance
343 under Schedules II-V, as provided for in s. 893.03, to a person
344 for the treatment of intractable pain, provided the physician
345 does so in accordance with that level of care, skill, and
346 treatment recognized by a reasonably prudent physician under
347 similar conditions and circumstances.
348 (d)(4) Nothing in this section shall be construed to
349 condone, authorize, or approve mercy killing or euthanasia, and
350 no treatment authorized by this section may be used for such
351 purpose.
352 (2)(a) For the purposes of this subsection, the term
353 “interventional pain medicine” means the practice of medicine
354 devoted to the diagnosis and treatment of pain-related
355 disorders, principally with the application of interventional
356 techniques in managing chronic, intractable pain, independently
357 or in conjunction with other treatment modalities. These
358 techniques include minimally invasive procedures, including
359 percutaneous precision needle placement, with placement of drugs
360 in targeted areas or destruction of targeted nerves, and some
361 surgical techniques such as laser or endoscopic discectomy,
362 cement stabilization of spine fractures, intrathecal infusion
363 pumps, and spinal cord stimulators, for the diagnosis and
364 management of chronic, intractable pain.
365 (b) A person may not practice interventional pain medicine
366 or offer to practice interventional pain medicine, unless such
367 acts are performed within facilities licensed under chapter 395
368 or are performed by or under the direct supervision of a
369 physician licensed under this chapter or an osteopathic
370 physician licensed under chapter 459.
371 Section 10. Paragraph (b) of subsection (2) of section
372 458.3265, Florida Statutes, is amended to read:
373 458.3265 Pain-management clinics.—
374 (2) PHYSICIAN RESPONSIBILITIES.—These responsibilities
375 apply to any physician who provides professional services in a
376 pain-management clinic that is required to be registered in
377 subsection (1).
378 (b) A person may not dispense any medication on the
379 premises of a registered pain-management clinic unless he or she
380 is a physician licensed under this chapter or chapter 459. A
381 person may not prescribe any controlled substance regulated
382 under chapter 893 on the premises of a registered pain
383 management clinic unless he or she is a physician licensed under
384 this chapter or chapter 459.
385 Section 11. Paragraph (b) of subsection (2) of section
386 459.0137, Florida Statutes, is amended to read:
387 459.0137 Pain-management clinics.—
388 (2) PHYSICIAN RESPONSIBILITIES.—These responsibilities
389 apply to any osteopathic physician who provides professional
390 services in a pain-management clinic that is required to be
391 registered in subsection (1).
392 (b) A person may not dispense any medication on the
393 premises of a registered pain-management clinic unless he or she
394 is a physician licensed under this chapter or chapter 458. A
395 person may not prescribe any controlled substance regulated
396 under chapter 893 on the premises of a registered pain
397 management clinic unless he or she is a physician licensed under
398 this chapter or chapter 458.
399 Section 12. Paragraph (e) of subsection (4) of section
400 458.347, Florida Statutes, is amended, and paragraph (c) of
401 subsection (9) of that section is republished, to read:
402 458.347 Physician assistants.—
403 (4) PERFORMANCE OF PHYSICIAN ASSISTANTS.—
404 (e) A supervisory physician may delegate to a fully
405 licensed physician assistant the authority to prescribe or
406 dispense any medication used in the supervisory physician’s
407 practice unless such medication is listed on the formulary
408 created pursuant to paragraph (f). A fully licensed physician
409 assistant may only prescribe or dispense such medication under
410 the following circumstances:
411 1. A physician assistant must clearly identify to the
412 patient that he or she is a physician assistant. Furthermore,
413 the physician assistant must inform the patient that the patient
414 has the right to see the physician prior to any prescription
415 being prescribed or dispensed by the physician assistant.
416 2. The supervisory physician must notify the department of
417 his or her intent to delegate, on a department-approved form,
418 before delegating such authority and notify the department of
419 any change in prescriptive privileges of the physician
420 assistant. Authority to dispense may be delegated only by a
421 supervising physician who is registered as a dispensing
422 practitioner in compliance with s. 465.0276.
423 3. The physician assistant must file with the department a
424 signed affidavit that he or she has completed a minimum of 10
425 continuing medical education hours in the specialty practice in
426 which the physician assistant has prescriptive privileges with
427 each licensure renewal application. Three of the 10 hours must
428 consist of a continuing education course on the safe and
429 effective prescription of controlled substance medications,
430 which shall be offered by a statewide professional association
431 of physicians in this state accredited to provide educational
432 activities designated for the American Medical Association
433 Physician’s Recognition Award Category I Credit.
434 4. The department may issue a prescriber number to the
435 physician assistant granting authority for the prescribing of
436 medicinal drugs authorized within this paragraph upon completion
437 of the foregoing requirements. The physician assistant shall not
438 be required to independently register pursuant to s. 465.0276.
439 5. The prescription must be written in a form that complies
440 with chapter 499 and must contain, in addition to the
441 supervisory physician’s name, address, and telephone number, the
442 physician assistant’s prescriber number. Unless it is a drug or
443 drug sample dispensed by the physician assistant, the
444 prescription must be filled in a pharmacy permitted under
445 chapter 465 and must be dispensed in that pharmacy by a
446 pharmacist licensed under chapter 465. The appearance of the
447 prescriber number creates a presumption that the physician
448 assistant is authorized to prescribe the medicinal drug and the
449 prescription is valid.
450 6. The physician assistant must note the prescription or
451 dispensing of medication in the appropriate medical record.
452 (9) COUNCIL ON PHYSICIAN ASSISTANTS.—The Council on
453 Physician Assistants is created within the department.
454 (c) The council shall:
455 1. Recommend to the department the licensure of physician
456 assistants.
457 2. Develop all rules regulating the use of physician
458 assistants by physicians under this chapter and chapter 459,
459 except for rules relating to the formulary developed under
460 paragraph (4)(f). The council shall also develop rules to ensure
461 that the continuity of supervision is maintained in each
462 practice setting. The boards shall consider adopting a proposed
463 rule developed by the council at the regularly scheduled meeting
464 immediately following the submission of the proposed rule by the
465 council. A proposed rule submitted by the council may not be
466 adopted by either board unless both boards have accepted and
467 approved the identical language contained in the proposed rule.
468 The language of all proposed rules submitted by the council must
469 be approved by both boards pursuant to each respective board’s
470 guidelines and standards regarding the adoption of proposed
471 rules. If either board rejects the council’s proposed rule, that
472 board must specify its objection to the council with
473 particularity and include any recommendations it may have for
474 the modification of the proposed rule.
475 3. Make recommendations to the boards regarding all matters
476 relating to physician assistants.
477 4. Address concerns and problems of practicing physician
478 assistants in order to improve safety in the clinical practices
479 of licensed physician assistants.
480 Section 13. Effective January 1, 2016, paragraph (f) of
481 subsection (4) of section 458.347, Florida Statutes, is amended
482 to read:
483 458.347 Physician assistants.—
484 (4) PERFORMANCE OF PHYSICIAN ASSISTANTS.—
485 (f)1. The council shall establish a formulary of medicinal
486 drugs that a fully licensed physician assistant having
487 prescribing authority under this section or s. 459.022 may not
488 prescribe. The formulary must include controlled substances as
489 defined in chapter 893, general anesthetics, and radiographic
490 contrast materials, and must limit the prescription of Schedule
491 II controlled substances as defined in s. 893.03 to a 7-day
492 supply. The formulary must also restrict the prescribing of
493 controlled substances that are psychotropic medications,
494 including antihypnotics, antipsychotics, antidepressants,
495 anxiety agents, sedatives, psychomotor stimulants, and mood
496 stabilizers for children under the age of 18.
497 2. In establishing the formulary, the council shall consult
498 with a pharmacist licensed under chapter 465, but not licensed
499 under this chapter or chapter 459, who shall be selected by the
500 State Surgeon General.
501 3. Only the council shall add to, delete from, or modify
502 the formulary. Any person who requests an addition, deletion, or
503 modification of a medicinal drug listed on such formulary has
504 the burden of proof to show cause why such addition, deletion,
505 or modification should be made.
506 4. The boards shall adopt the formulary required by this
507 paragraph, and each addition, deletion, or modification to the
508 formulary, by rule. Notwithstanding any provision of chapter 120
509 to the contrary, the formulary rule shall be effective 60 days
510 after the date it is filed with the Secretary of State. Upon
511 adoption of the formulary, the department shall mail a copy of
512 such formulary to each fully licensed physician assistant having
513 prescribing authority under this section or s. 459.022, and to
514 each pharmacy licensed by the state. The boards shall establish,
515 by rule, a fee not to exceed $200 to fund the provisions of this
516 paragraph and paragraph (e).
517 Section 14. Subsection (2) of section 464.003, Florida
518 Statutes, is amended to read:
519 464.003 Definitions.—As used in this part, the term:
520 (2) “Advanced or specialized nursing practice” means, in
521 addition to the practice of professional nursing, the
522 performance of advanced-level nursing acts approved by the board
523 which, by virtue of postbasic specialized education, training,
524 and experience, are appropriately performed by an advanced
525 registered nurse practitioner. Within the context of advanced or
526 specialized nursing practice, the advanced registered nurse
527 practitioner may perform acts of nursing diagnosis and nursing
528 treatment of alterations of the health status. The advanced
529 registered nurse practitioner may also perform acts of medical
530 diagnosis and treatment, prescription, and operation as
531 authorized within the framework of an established supervisory
532 protocol which are identified and approved by a joint committee
533 composed of three members appointed by the Board of Nursing, two
534 of whom must be advanced registered nurse practitioners; three
535 members appointed by the Board of Medicine, two of whom must
536 have had work experience with advanced registered nurse
537 practitioners; and the State Surgeon General or the State
538 Surgeon General’s designee. Each committee member appointed by a
539 board shall be appointed to a term of 4 years unless a shorter
540 term is required to establish or maintain staggered terms. The
541 Board of Nursing shall adopt rules authorizing the performance
542 of any such acts approved by the joint committee. Unless
543 otherwise specified by the joint committee, such acts must be
544 performed under the general supervision of a practitioner
545 licensed under chapter 458, chapter 459, or chapter 466 within
546 the framework of standing protocols which identify the medical
547 acts to be performed and the conditions for their performance.
548 The department may, by rule, require that a copy of the protocol
549 be filed with the department along with the notice required by
550 s. 458.348.
551 Section 15. Subsection (6) is added to section 464.012,
552 Florida Statutes, to read:
553 464.012 Certification of advanced registered nurse
554 practitioners; fees; controlled substance prescribing.—
555 (6)(a) The board shall establish a committee to recommend a
556 formulary of controlled substances that an advanced registered
557 nurse practitioner may not prescribe or may prescribe only for
558 specific uses or for limited quantities. The committee must
559 consist of three advanced registered nurse practitioners
560 licensed under s. 464.012, recommended by the Board of Nursing;
561 three physicians licensed under chapter 458 or chapter 459 who
562 have had work experience with advanced registered nurse
563 practitioners, recommended by the Board of Medicine; and a
564 pharmacist licensed under chapter 465 who holds a Doctor of
565 Pharmacy degree, recommended by the Board of Pharmacy. The
566 committee may recommend an evidence-based formulary applicable
567 to all advanced registered nurse practitioners, which is limited
568 by specially certification or to approved uses of controlled
569 substances, or subject to other similar restrictions the
570 committee finds are necessary to protect the health, safety, and
571 welfare of the public. The formulary must restrict the
572 prescribing of controlled substance psychotropic medications,
573 including antihypnotics, antipsychotics, antidepressants,
574 anxiety agents, sedatives, psychomotor stimulants, and mood
575 stabilizers for children under the age of 18 to psychiatric
576 nurses as defined in s. 394.455. The formulary must also limit
577 the prescribing of Schedule II controlled substances as defined
578 in s. 893.03 to a 7-day supply, except that such restriction
579 does not apply to controlled substances that are psychiatric
580 medications prescribed by psychiatric nurses as defined in
581 394.455.
582 (b) The board shall adopt by rule the recommended formulary
583 and recommended additions or deletions to the formulary which it
584 finds are supported by evidence-based clinical findings
585 presented by the Board of Medicine, the Board of Osteopathic
586 Medicine, or the Board of Dentistry.
587 (c) The formulary required under this subsection does not
588 apply to a controlled substance order that is dispensed for
589 administration including orders for medication authorized in
590 subparagraph (4)(a)3. or subparagraph (4)(a)4.
591 (d) The board shall adopt the committee’s initial
592 recommendation no later January 1, 2016.
593 Section 16. Effective January 1, 2016, subsection (3) of
594 section 464.012, Florida Statutes, is amended to read:
595 464.012 Certification of advanced registered nurse
596 practitioners; fees; controlled substance prescribing.—
597 (3) An advanced registered nurse practitioner shall perform
598 those functions authorized in this section within the framework
599 of an established protocol that is filed with the board upon
600 biennial license renewal and within 30 days after entering into
601 a supervisory relationship with a physician or changes to the
602 protocol. The board shall review the protocol to ensure
603 compliance with applicable regulatory standards for protocols.
604 The board shall refer to the department licensees submitting
605 protocols that are not compliant with the regulatory standards
606 for protocols. A practitioner currently licensed under chapter
607 458, chapter 459, or chapter 466 shall maintain supervision for
608 directing the specific course of medical treatment. Within the
609 established framework, an advanced registered nurse practitioner
610 may:
611 (a) Prescribe, dispense, administer, or order any drug;
612 however, an advanced registered nurse practitioner may only
613 prescribe or dispense a controlled substance as defined in s.
614 893.03 if the advanced registered nurse practitioner has
615 graduated from a program leading to a master’s degree in a
616 clinical nursing specialty area with training in specialized
617 practitioner skills. Monitor and alter drug therapies.
618 (b) Initiate appropriate therapies for certain conditions.
619 (c) Perform additional functions as may be determined by
620 rule in accordance with s. 464.003(2).
621 (d) Order diagnostic tests and physical and occupational
622 therapy.
623 Section 17. Subsection (3) of section 464.013, Florida
624 Statutes, is amended to read:
625 464.013 Renewal of license or certificate.—
626 (3) The board shall by rule prescribe up to 30 hours of
627 continuing education biennially as a condition for renewal of a
628 license or certificate.
629 (a) A nurse who is certified by a health care specialty
630 program accredited by the National Commission for Certifying
631 Agencies or the Accreditation Board for Specialty Nursing
632 Certification is exempt from continuing education requirements.
633 The criteria for programs must shall be approved by the board.
634 (b) Notwithstanding the exemption in paragraph (a), as part
635 of the maximum 30 hours of continuing education hours required
636 under this subsection, advanced registered nurse practitioners
637 certified under s. 464.012 must complete at least 3 hours of
638 continuing education on the safe and effective prescription of
639 controlled substances. Such continuing education courses must be
640 offered by a statewide professional association of physicians in
641 this state accredited to provide educational activities
642 designated for the American Medical Association Physician’s
643 Recognition Award Category 1 Credit, the American Nurses
644 Credentialing Center, or the American Association of Nurse
645 Practitioners and may be offered in a distance-learning format.
646 Section 18. Paragraph (p) is added to subsection (1) of
647 section 464.018, Florida Statutes, subsection (2) of that
648 section is republished, and subsection (5) of that section is
649 amended, to read:
650 464.018 Disciplinary actions.—
651 (1) The following acts constitute grounds for denial of a
652 license or disciplinary action, as specified in s. 456.072(2):
653 (p) For an advanced registered nurse practitioner:
654 1. Presigning blank prescription forms.
655 2. Prescribing for office use any medicinal drug appearing
656 on Schedule II in chapter 893.
657 3. Prescribing, ordering, dispensing, administering,
658 supplying, selling, or giving a drug that is an amphetamine or a
659 sympathomimetic amine drug, or a compound designated pursuant to
660 chapter 893 as a Schedule II controlled substance, to or for any
661 person except for:
662 a. The treatment of narcolepsy; hyperkinesis; behavioral
663 syndrome in children characterized by the developmentally
664 inappropriate symptoms of moderate to severe distractibility,
665 short attention span, hyperactivity, emotional lability, and
666 impulsivity; or drug-induced brain dysfunction.
667 b. The differential diagnostic psychiatric evaluation of
668 depression or the treatment of depression shown to be refractory
669 to other therapeutic modalities.
670 c. The clinical investigation of the effects of such drugs
671 or compounds when an investigative protocol is submitted to,
672 reviewed by, and approved by the department before such
673 investigation is begun.
674 4. Prescribing, ordering, dispensing, administering,
675 supplying, selling, or giving growth hormones, testosterone or
676 its analogs, human chorionic gonadotropin (HCG), or other
677 hormones for the purpose of muscle building or to enhance
678 athletic performance. As used in this subparagraph, the term
679 “muscle building” does not include the treatment of injured
680 muscle. A prescription written for the drug products listed in
681 this paragraph may be dispensed by a pharmacist with the
682 presumption that the prescription is for legitimate medical use.
683 5. Promoting or advertising on any prescription form a
684 community pharmacy unless the form also states: “This
685 prescription may be filled at any pharmacy of your choice.”
686 6. Prescribing, dispensing, administering, mixing, or
687 otherwise preparing a legend drug, including a controlled
688 substance, other than in the course of his or her professional
689 practice. For the purposes of this subparagraph, it is legally
690 presumed that prescribing, dispensing, administering, mixing, or
691 otherwise preparing legend drugs, including all controlled
692 substances, inappropriately or in excessive or inappropriate
693 quantities is not in the best interest of the patient and is not
694 in the course of the advanced registered nurse practitioner’s
695 professional practice, without regard to his or her intent.
696 7. Prescribing, dispensing, or administering a medicinal
697 drug appearing on any schedule set forth in chapter 893 to
698 himself or herself, except a drug prescribed, dispensed, or
699 administered to the advanced registered nurse practitioner by
700 another practitioner authorized to prescribe, dispense, or
701 administer medicinal drugs.
702 8. Prescribing, ordering, dispensing, administering,
703 supplying, selling, or giving amygdalin (laetrile) to any
704 person.
705 9. Dispensing a controlled substance listed on Schedule II
706 or Schedule III in chapter 893 in violation of s. 465.0276.
707 10. Promoting or advertising through any communication
708 medium the use, sale, or dispensing of a controlled substance
709 appearing on any schedule in chapter 893.
710 (2) The board may enter an order denying licensure or
711 imposing any of the penalties in s. 456.072(2) against any
712 applicant for licensure or licensee who is found guilty of
713 violating any provision of subsection (1) of this section or who
714 is found guilty of violating any provision of s. 456.072(1).
715 (5) The board shall by rule establish guidelines for the
716 disposition of disciplinary cases involving specific types of
717 violations. Such guidelines may include minimum and maximum
718 fines, periods of supervision or probation, or conditions of
719 probation or reissuance of a license. In disciplinary cases
720 involving an alleged violation of s. 464.018(1)(n) or s.
721 464.018(1)(p)6. by an advanced registered nurse practitioner
722 which also involves the ordering, prescribing, administering, or
723 dispensing of a controlled substance, the board shall notify the
724 Board of Medicine, the Board of Osteopathic Medicine, or the
725 Board of Dentistry of the existence of the disciplinary case and
726 shall forward all materials to the respective board for review
727 pursuant to s. 456.44(3)(h). The Board of Nursing shall review
728 and may consider the findings of the Board of Medicine, the
729 Board of Osteopathic Medicine, or the Board of Dentistry
730 rendered pursuant to s. 456.44(3)(h) prior to its disposition of
731 the disciplinary case.
732 Section 19. Subsection (21) of section 893.02, Florida
733 Statutes, is amended to read:
734 893.02 Definitions.—The following words and phrases as used
735 in this chapter shall have the following meanings, unless the
736 context otherwise requires:
737 (21) “Practitioner” means a physician licensed under
738 pursuant to chapter 458, a dentist licensed under pursuant to
739 chapter 466, a veterinarian licensed under pursuant to chapter
740 474, an osteopathic physician licensed under pursuant to chapter
741 459, an advanced registered nurse practitioner certified under
742 chapter 464, a naturopath licensed under pursuant to chapter
743 462, a certified optometrist licensed under pursuant to chapter
744 463, or a podiatric physician licensed under pursuant to chapter
745 461, or a physician assistant licensed under chapter 458 or
746 chapter 459, provided such practitioner holds a valid federal
747 controlled substance registry number.
748 Section 20. Paragraph (n) of subsection (1) of section
749 948.03, Florida Statutes, is amended to read:
750 948.03 Terms and conditions of probation.—
751 (1) The court shall determine the terms and conditions of
752 probation. Conditions specified in this section do not require
753 oral pronouncement at the time of sentencing and may be
754 considered standard conditions of probation. These conditions
755 may include among them the following, that the probationer or
756 offender in community control shall:
757 (n) Be prohibited from using intoxicants to excess or
758 possessing any drugs or narcotics unless prescribed by a
759 physician, advanced registered nurse practitioner, or physician
760 assistant. The probationer or community controllee may shall not
761 knowingly visit places where intoxicants, drugs, or other
762 dangerous substances are unlawfully sold, dispensed, or used.
763 Section 21. Paragraph (a) of subsection (1) and subsection
764 (2) of section 458.348, Florida Statutes, are amended to read:
765 458.348 Formal supervisory relationships, standing orders,
766 and established protocols; notice; standards.—
767 (1) NOTICE.—
768 (a) When a physician enters into a formal supervisory
769 relationship or standing orders with an emergency medical
770 technician or paramedic licensed pursuant to s. 401.27, which
771 relationship or orders contemplate the performance of medical
772 acts, or when a physician enters into an established protocol
773 with an advanced registered nurse practitioner, which protocol
774 contemplates the performance of medical acts identified and
775 approved by the joint committee pursuant to s. 464.003(2) or
776 acts set forth in s. 464.012(3) and (4), the physician shall
777 submit notice to the board. The notice shall contain a statement
778 in substantially the following form:
779
780 I, ...(name and professional license number of
781 physician)..., of ...(address of physician)... have hereby
782 entered into a formal supervisory relationship, standing orders,
783 or an established protocol with ...(number of persons)...
784 emergency medical technician(s), ...(number of persons)...
785 paramedic(s), or ...(number of persons)... advanced registered
786 nurse practitioner(s).
787
788 (2) ESTABLISHMENT OF STANDARDS BY JOINT COMMITTEE.—The
789 joint committee created under s. 464.003(2) shall determine
790 minimum standards for the content of established protocols
791 pursuant to which an advanced registered nurse practitioner may
792 perform medical acts identified and approved by the joint
793 committee pursuant to s. 464.003(2) or acts set forth in s.
794 464.012(3) and (4) and shall determine minimum standards for
795 supervision of such acts by the physician, unless the joint
796 committee determines that any act set forth in s. 464.012(3) or
797 (4) is not a medical act. Such standards shall be based on risk
798 to the patient and acceptable standards of medical care and
799 shall take into account the special problems of medically
800 underserved areas. The standards developed by the joint
801 committee shall be adopted as rules by the Board of Nursing and
802 the Board of Medicine for purposes of carrying out their
803 responsibilities pursuant to part I of chapter 464 and this
804 chapter, respectively, but neither board shall have disciplinary
805 powers over the licensees of the other board.
806 Section 22. Paragraph (a) of subsection (1) of section
807 459.025, Florida Statutes, is amended to read:
808 459.025 Formal supervisory relationships, standing orders,
809 and established protocols; notice; standards.—
810 (1) NOTICE.—
811 (a) When an osteopathic physician enters into a formal
812 supervisory relationship or standing orders with an emergency
813 medical technician or paramedic licensed pursuant to s. 401.27,
814 which relationship or orders contemplate the performance of
815 medical acts, or when an osteopathic physician enters into an
816 established protocol with an advanced registered nurse
817 practitioner, which protocol contemplates the performance of
818 medical acts identified and approved by the joint committee
819 pursuant to s. 464.003(2) or acts set forth in s. 464.012(3) and
820 (4), the osteopathic physician shall submit notice to the board.
821 The notice must contain a statement in substantially the
822 following form:
823
824 I, ...(name and professional license number of osteopathic
825 physician)..., of ...(address of osteopathic physician)... have
826 hereby entered into a formal supervisory relationship, standing
827 orders, or an established protocol with ...(number of
828 persons)... emergency medical technician(s), ...(number of
829 persons)... paramedic(s), or ...(number of persons)... advanced
830 registered nurse practitioner(s).
831 Section 23. Subsection (10) of s. 458.331, paragraph (g) of
832 subsection (7) of s. 458.347, subsection (10) of s. 459.015,
833 paragraph (f) of subsection (7) of s. 459.022, and paragraph (b)
834 of subsection (5) of s. 465.0158, Florida Statutes, are
835 reenacted for the purpose of incorporating the amendment made by
836 this act to s. 456.072, Florida Statutes, in references thereto.
837 Section 24. Paragraph (mm) of subsection (1) of s. 456.072
838 and s. 466.02751, Florida Statutes, are reenacted for the
839 purpose of incorporating the amendment made by this act to s.
840 456.44, Florida Statutes, in references thereto.
841 Section 25. Section 458.303, paragraph (b) of subsection
842 (7) of s. 458.3475, paragraph (e) of subsection (4) and
843 paragraph (c) of subsection (9) of s. 459.022, and paragraph (b)
844 of subsection (7) of s. 459.023, Florida Statutes, are reenacted
845 for the purpose of incorporating the amendment made by this act
846 to s. 458.347, Florida Statutes, in references thereto.
847 Section 26. Paragraph (c) of subsection (3) of s. 464.012,
848 Florida Statutes, is reenacted for the purpose of incorporating
849 the amendment made by this act to s. 464.003, Florida Statutes,
850 in a reference thereto.
851 Section 27. Paragraph (a) of subsection (1) of s. 456.041,
852 subsections (1) and (2) of s. 458.348, and subsection (1) of s.
853 459.025, Florida Statutes, are reenacted for the purpose of
854 incorporating the amendment made by this act to s. 464.012,
855 Florida Statutes, in references thereto.
856 Section 28. Subsection (7) of s. 464.0205, Florida
857 Statutes, is reenacted for the purpose of incorporating the
858 amendment made by this act to s. 464.013, Florida Statutes, in a
859 reference thereto.
860 Section 29. Subsection (11) of s. 320.0848, subsection (2)
861 of s. 464.008, subsection (5) of s. 464.009, and paragraph (b)
862 of subsection (1), subsection (3), and paragraph (b) of
863 subsection (4) of s. 464.0205, Florida Statutes, are reenacted
864 for the purpose of incorporating the amendment made by this act
865 to s. 464.018, Florida Statutes, in references thereto.
866 Section 30. Section 775.051, Florida Statutes, is reenacted
867 for the purpose of incorporating the amendment made by this act
868 to s. 893.02, Florida Statutes, in a reference thereto.
869 Section 31. Paragraph (a) of subsection (3) of s. 944.17,
870 subsection (8) of s. 948.001, and paragraph (e) of subsection
871 (1) of s. 948.101, Florida Statutes, are reenacted for the
872 purpose of incorporating the amendment made by this act to s.
873 948.03, Florida Statutes, in references thereto.
874 Section 32. Except as otherwise expressly provided in this
875 act, this act shall take effect upon becoming a law.
876
877 ================= T I T L E A M E N D M E N T ================
878 And the title is amended as follows:
879 Delete everything before the enacting clause
880 and insert:
881 A bill to be entitled
882 An act relating to drug prescription by advanced
883 registered nurse practitioners and physician
884 assistants; amending s. 110.12315, F.S.; expanding the
885 categories of persons who may prescribe brand drugs
886 under the prescription drug program when medically
887 necessary; amending ss. 310.071, 310.073, and 310.081,
888 F.S.; exempting controlled substances prescribed by an
889 advanced registered nurse practitioner or a physician
890 assistant from the disqualifications for certification
891 or licensure, and for continued certification or
892 licensure, as a deputy pilot or state pilot; repealing
893 s. 383.336, F.S., relating to provider hospitals,
894 practice parameters, and peer review boards; amending
895 s. 395.1051, F.S.; requiring a hospital to notify
896 certain obstetrical physicians within a specified
897 timeframe before the hospital closes its obstetrical
898 department or ceases to provide obstetrical services;
899 amending s. 456.072, F.S.; applying existing penalties
900 for violations relating to the prescribing or
901 dispensing of controlled substances by an advanced
902 registered nurse practitioner; amending s. 456.44,
903 F.S.; deleting an obsolete date; requiring advanced
904 registered nurse practitioners and physician
905 assistants who prescribe controlled substances for
906 certain pain to make a certain designation, comply
907 with registration requirements, and follow specified
908 standards of practice; requiring certain respective
909 entities review the information to determine whether
910 disciplinary action is appropriate; requiring the
911 respective board to forward certain findings to the
912 Board of Nursing; providing applicability; amending s.
913 458.326, F.S.; defining the term “interventional pain
914 medicine”; limiting the practice of interventional
915 pain medicine to specified circumstances; amending ss.
916 458.3265 and 459.0137, F.S.; limiting the authority to
917 prescribe a controlled substance in a pain-management
918 clinic to a physician licensed under ch. 458 or ch.
919 459, F.S.; amending s. 458.347, F.S.; revising the
920 required continuing education requirements for a
921 physician assistant; amending s. 458.347, F.S.;
922 requiring the Council of Physician Assistants to
923 create a formulary which includes the controlled
924 substances a physician assistant is authorized to
925 prescribe; amending s. 464.003, F.S.; revising the
926 definition of the term “advanced or specialized
927 nursing practice”; deleting the joint committee
928 established in the definition; amending s. 464.012,
929 F.S.; requiring the Board of Nursing to establish a
930 committee make recommendations regarding the need for
931 adoption of a formulary of controlled substances that
932 may be prescribed by an advanced registered nurse
933 practitioner; specifying the membership of the
934 committee; providing parameters for the
935 recommendations of the committee; requiring that any
936 formulary be adopted by board rule; specifying the
937 process for amending the formulary and imposing a
938 burden of proof; limiting the formulary’s application
939 in certain instances; requiring the board to adopt the
940 committee’s initial recommendations by a specified
941 date; amending s. 464.012, F.S.; authorizing an
942 advanced registered nurse practitioner to prescribe,
943 dispense, administer, or order drugs, rather than to
944 monitor and alter drug therapies; providing an
945 exception; amending s. 464.013, F.S.; revising
946 conditions for renewal of a license or certificate;
947 amending s. 464.018, F.S.; specifying acts that
948 constitute grounds for denial of a license or for
949 disciplinary action against an advanced registered
950 nurse practitioner; requiring that in certain
951 disciplinary cases, the board notify certain entities
952 and forward all materials to the respective board;
953 amending s. 893.02, F.S.; redefining the term
954 “practitioner” to include advanced registered nurse
955 practitioners and physician assistants under the
956 Florida Comprehensive Drug Abuse Prevention and
957 Control Act; amending s. 948.03, F.S.; providing that
958 possession of drugs or narcotics prescribed by an
959 advanced registered nurse practitioner or physician
960 assistant does not violate a prohibition relating to
961 the possession of drugs or narcotics during probation;
962 amending ss. 458.348 and 459.025, F.S.; conforming
963 provisions to changes made by the act; reenacting ss.
964 458.331(10), 458.347(7)(g), 459.015(10),
965 459.022(7)(f), and 465.0158(5)(b), F.S., to
966 incorporate the amendment made to s. 456.072, F.S., in
967 references thereto; reenacting ss. 456.072(1)(mm) and
968 466.02751, F.S., to incorporate the amendment made to
969 s. 456.44, F.S., in references thereto; reenacting ss.
970 458.303, 458.3475(7)(b), 459.022(4)(e) and (9)(c), and
971 459.023(7)(b), F.S., to incorporate the amendment made
972 to s. 458.347, F.S., in references thereto; reenacting
973 s. 464.012(3)(c), F.S., to incorporate the amendment
974 made to s. 464.003, F.S., in a reference thereto;
975 reenacting ss. 456.041(1)(a), 458.348(1) and (2), and
976 459.025(1), F.S., to incorporate the amendment made to
977 s. 464.012, F.S., in references thereto; reenacting s.
978 464.0205(7), F.S., to incorporate the amendment made
979 to s. 464.013, F.S., in a reference thereto;
980 reenacting ss. 320.0848(11), 464.008(2), 464.009(5),
981 and 464.0205(1)(b), (3), and (4)(b), F.S., to
982 incorporate the amendment made to s. 464.018, F.S., in
983 references thereto; reenacting s. 775.051, F.S., to
984 incorporate the amendment made to s. 893.02, F.S., in
985 a reference thereto; reenacting ss. 944.17(3)(a),
986 948.001(8), and 948.101(1)(e), F.S., to incorporate
987 the amendment made to s. 948.03, F.S., in references
988 thereto; providing effective dates.
989
990 WHEREAS, the Legislature recognizes the importance of
991 access to primary health care for citizens of Florida, most
992 especially for those who reside in the medically underserved
993 areas of the state, and
994 WHEREAS, the Legislature further recognize that there is a
995 state and national shortage of primary care providers which
996 necessitates the removal of regulatory barriers that prevent
997 advanced registered nurse practitioners and physician assistants
998 from practicing to the full extent of their education, training,
999 and certifications, NOW, THEREFORE,