Although Florida, as well as other states in the USA, suffers from shortages of primary care physicians, acute physicians, and other healthcare providers, there are still barriers for foreign-trained physicians to be employed in hospitals and clinics in the state (Pande, 2014; Peterson, Pandya, & Leblang, 2014). Currently, International Medical Graduates (IMGs) need to participate in a prolonged and complex licensure process in order to prove their qualification. However, Pande (2014) also noted that “it is unfair to require fully trained IMGs to undergo repetitive training and internships when they are already fully qualified physicians and have often been practicing for years in their home country” (p. 267). As this problem is still urgent in Florida, it is important to focus on possible policy initiatives realized or discussed in this context. In 2016, Representative Daphne Campbell with the support of Senator Travis Hutson filed the bill that is known as House Bill 1277: Licensure of Foreign-Trained Physicians (HB 1277) to propose changes in the licensure procedure for IMGs coming to Florida (The Florida Senate, 2017). The purpose of this paper is to discuss and analyze the data related to HB 1277 as a healthcare policy-priority issue for Florida and conclude regarding its importance for nursing.
Key Points of the Healthcare Policy: Literature Review
The purpose of this review of sources on the problem of licensing IMGs in the United States and HB 1277 is to discuss all key points related to this healthcare policy-priority issue and analyze its aspects in detail. Furthermore, a review of the literature on the topic is important to find arguments in order to support the necessity of re-opening HB 1277 for the analysis and discussion by the Health Quality Subcommittee and the Health and Human Services Committee (The Florida Senate, 2017). In spite of the fact that HB 1277 died in one of the committees, its importance for addressing the healthcare provider shortage in Florida is considerable.
Issue Overview
The public health policy issue that should be analyzed in this paper is the impossibility to address shortages of healthcare providers in Florida with the focus on reducing barriers for IMGs to receiving licenses with the help of the required legislation. Thus, in 2016, House Bill 1277: Licensure of Foreign-Trained Physicians was proposed for the further discussion and adoption, but it was not supported (The Florida Senate, 2017). As a result, currently, a complex licensure procedure for IMGs prevents them from working in healthcare facilities in Florida. This issue is of particular importance for all healthcare providers, including physicians and nurses, because staff shortages in healthcare facilities in Florida can lead to decreasing the quality of care and increasing fatigue levels for the personnel (Kahn & Rubenfeld, 2015; Pande, 2014). As a result, rates of medical errors can also increase, and patients’ satisfaction tends to decrease along with the quality of the provided care (Emeka, 2015; Kahn & Rubenfeld, 2015; Peterson et al., 2014). This problem directly influences nurses who also suffer from the lack of physicians because of the necessity to perform additional general duties.
Those foreign-trained physicians who move to the United States face the challenge of completing a complex licensure procedure that can last months and years before proving their qualification. Thus, IMGs usually become involved in courses and different professional programs to be accredited according to the state laws (Pande, 2014; Rabben, 2013). There are also situations when foreign-trained healthcare professionals participate in programs and complete tests to become a nurse practitioner (Pande, 2014). However, this process is also prolonged and complex. In order to address shortages in healthcare facilities referring to the US-educated professionals, authorities promote a range of courses for not only foreign-trained physicians but also for the citizens of the United States who need to improve their skills and increase qualifications (Kahn & Rubenfeld, 2015; Peterson et al., 2014). Still, the problem is that these processes are extremely expensive and time-consuming in their nature. Therefore, the problem of staff shortages in healthcare facilities in Florida remains to be unresolved.
Policy History
House Bill 1277: Licensure of Foreign-Trained Physicians was filed by Representative Campbell on January 8, 2016. The purpose of this bill was to improve the legislation regarding the licensure procedure for foreign-trained physicians to address possible obstacles to receiving licenses and make health care highly accessible in Florida (The Florida Senate, 2017). The policy was proposed to address the issue of the lack of healthcare professionals in the state in spite of a large number of IMGs who regularly move to Florida (Pande, 2014; Rabben, 2013). Before proposing HB 1277, foreign-trained physicians followed the procedure of receiving training in Florida in order to be further licensed and get the needed accreditation. The policy that is currently followed in the state is presented in the 2016 Florida Statutes. According to Chapter 458, a foreign-trained physician should address a list of certain criteria and complete the United States Medical Licensing Examination in order to receive a license and be accredited to practice in Florida (The Florida Senate, 2017; Scott & Philip, 2016).
After receiving the support of Senator Hutson, Representative Campbell formulated the key aspects of the policy to resolve the issue of the shortage of physicians in Florida. Representative Campbell created an alternative licensure procedure for IMGs while accentuating the necessity of demonstrating competencies that are required for a position and the necessity of having 10 years of experience in a foreign country along with an active physician license (The Florida Senate, 2017). In the situation when a candidate has passed the examination equivalent to the United States Medical Licensing Examination conducted in Florida, the licensure procedure for this person becomes less complicated (The Florida Senate, 2017). These important ideas were reflected in the text of the bill to demonstrate how the overall procedure could be changed successfully.
It is important to note that, after being accepted on January 8, 2016, HB 1277 was referred to the Health Quality Subcommittee on January 15, 2016. Furthermore, on January 26, 2016, the bill was presented to the members of the Health Care Appropriations Subcommittee, and after being discussed and supported, it was referred to the Health and Human Services Committee on February 2, 2016, where it died on March 11, 2016 (The Florida Senate, 2017). In spite of receiving the support in the Health Quality Subcommittee and the Health Care Appropriations Subcommittee, HB 1277 was not accepted as appropriate to be taken into action. Therefore, current active steps are required to draw the public’s and policymakers’ attention to this issue.
Beneficiaries and Outcomes
If HB 1277 is accepted as a state policy, the healthcare industry in Florida and communities will benefit significantly. The reason is that HB 1277 is oriented to making the licensure procedure less complex, and more IMGs will start working in healthcare facilities in Florida without additional barriers to their practice (The Florida Senate, 2017). As a result, while attracting foreign-trained physicians to work in rural and remote territories of Florida, it is possible to address the needs of populations who have the limited access to care and medical services (Kahn & Rubenfeld, 2015; Pande, 2014; Rabben, 2013). As a result, the problem of staff shortages in rural and remote territories will be resolved. Furthermore, it is important to pay attention to the fact that a high percentage of students who participate in the Family Nurse Practitioner program and other similar programs to receive the qualification in nursing are IMGs, and changes in the licensure procedure can attract more high-qualified but foreign-trained specialists to the work in healthcare facilities in Florida (Emeka, 2015; Pande, 2014; Peterson et al., 2014). From this perspective, benefits of revising the discussed policy are obvious.
Therefore, stakeholders promote the idea of re-opening HB 1277 or accepting other similar policy like Senate Bill 1546: Licensure of Foreign-Trained Physicians (SB 1546) that was formulated and filed by Senator Rene Garcia on March 2, 2017. SB 1546 was oriented to revising the licensure requirements for IMGs, but the bill died on May 5, 2017 (The Florida Senate, 2017). From this point, much attention should be paid to discussing positive outcomes of these initiatives for citizens of Florida in order to contribute to passing the policy oriented to revising the procedure of licensing for foreign-trained physicians in order to address the staff shortage in hospitals and clinics of the state.
Benefits of re-opening and passing HB 1277 in Florida are numerous, and experts in the field focus on analyzing potential positive outcomes of this process (The Florida Senate, 2017; Pande, 2014). According to different researchers, changes in procedures of licensing foreign-trained physicians can result in overcoming the shortage problem, increasing the number of high-qualified specialists who work in healthcare facilities, and addressing staff shortages in rural and remote territories (Emeka, 2015; Pande, 2014). In addition, benefits are also associated with improving the quality of provided care, increasing health outcomes for populations in communities, and improving the quality of care for older individuals (Pande, 2014; Peterson et al., 2014; Rabben, 2013). Thus, a range of positive outcomes can be observed for such beneficiaries as citizens of Florida, and IMGs, including physicians and nurses, will also become beneficiaries of this policy adoption.
The evaluation of possible options for resolving the issue of staff shortages in healthcare facilities in Florida indicates that it is possible to concentrate on re-opening HB 1277 or SB 1546 to adopt changes in the licensing procedure for foreign-trained physicians. It is also possible to file another bill, in which an alternative procedure for licensing IMGs will be formulated in a way to revise the current procedure and make it appropriate and efficient, but probable threats will be taken into account to make the formulation attractive to House Representatives and members of the committees (The Florida Senate, 2017). From this perspective, more action is required in order to promote the idea of the bill among policymakers.
Financial Impact
Although HB 1277 can cost thousands of dollars in order to be realized because of the necessity of modifying the procedure of licensing foreign-trained physicians and eliminating certain payments and fees that will be not required in the future, the potential financial impact of this bill on health care in Florida is considerable. The reason is that HB 1277 will make the process of licensing for IMGs more time- and cost-efficient, and this regulatory process will become less complicated (The Florida Senate, 2017; Pande, 2014). Furthermore, the increased number of physicians in healthcare facilities will lead to decreasing costs that are associated with covering gaps caused by staff shortages (Peterson et al., 2014; Rabben, 2013). Moreover, a potential financial benefit of adopting HB 1277 is the improvement of community members’ health and reductions in associated healthcare costs or expenses.
Still, the discussion and adoption of this bill can take several months or even years because of the necessity of analyzing the efficiency of changing the procedure and developing specific steps for modifying this regulatory process from the perspective of legislation. Furthermore, the budget of Florida can have no enough resources to adopt this policy within the shortest period of time because of dependence of the budget on taxes and fees associated with the participation of foreign-trained physicians in the procedure of receiving a license. As a result, the financial aspect of the policy adoption requires its further discussion in order to prove the feasibility of the policy from a financial perspective. However, while discussing the benefits of the policy from a long-term perspective, it is possible to become aware of its important role in improving the public health and decreasing costs associated with the provision of healthcare services for different populations (Pande, 2014; Peterson et al., 2014; Rabben, 2013). The reason is that foreign-trained physicians can be attracted to the work in rural territories where the lack of medical professionals is observed. Thus, it is possible to note that a financial impact of the policy adoption can be viewed as positive.
Support System
Currently, HB 1277 is discussed as a bill that failed to be adopted by the House of Representatives. In spite of the fact that the bill of 2016 was developed by Representative Campbell and supported by Senator Hutson, it was not promoted by the Health and Human Services Committee. In 2017, Senator Garcia made an attempt to re-open the bill and promoted SB 1546 that was also oriented to resolving the issue of licensing foreign-trained physicians and revising the procedure and licensure requirements. Therefore, it is possible to note that, at the state and local levels, the issue of licensing IMGs is of great importance because of staff shortages in healthcare facilities in Florida, and policymakers are interested in addressing this problem (The Florida Legislature Office of Economic and Demographic Research, 2013; The Florida Senate, 2017). The issue needs to be addressed at the state level, but the experience of promoting the bills in 2016 and 2017 demonstrates that there are still barriers for persons interested in simplifying the procedure of proving qualifications for foreign-trained physicians.
Although there are no active steps currently taken to re-open HB 1277, it is possible to assume that the House Health Quality Subcommittee is still interested in finding the solution to the issues of physician shortages and decreased quality of care. Furthermore, Representative Campbell, Senator Hutson, and Senator Garcia are also focused on resolving the problem with the licensure procedure that prevents from employing foreign-trained specialists and addressing the lack of healthcare professionals in Florida. The Political Action Committee of the Florida Medical Association and the Florida Association of Nurse Practitioners also support the necessity of modifying the procedure of examining IMGs and providing a license to them while following a shortened process (The Florida Legislature Office of Economic and Demographic Research, 2013; Scott & Philip, 2016). The current situation regarding physician shortages in hospitals and clinics of Florida is monitored by the Florida Department of Health and the Florida Legislature Office of Economic and Demographic Research. The data collected by these organizations are important to provide support for activating the discussion of HB 1277 or the similar bill in the committees of the House of Representatives.
Empirical Evidence: Statistics
In order to support the importance of the discussed issue and the need for the policy to address the problem of staff shortages in health care, it is necessary to focus on analyzing and providing the critique of the existing evidence related to the issue and associated statistics. According to Scott and Philip (2016) and the data of the Florida Department of Health, physician shortages in healthcare facilities of the state are connected with the fact that more than 60% of practicing physicians in Florida are aged 50 years and even older. Thus, an average age of a healthcare professional working in a hospital in Florida is 54 years. In addition, more than 13% of physicians plan to cease their career and retire within the next five years (Scott & Philip, 2016). As a result, in spite of a current shortage of professionals in the sphere, there is a potential for the further negative development of this tendency because more than a half of healthcare professionals are aged over than 50 years.
In spite of the fact that the number of practicing and licensed physicians in Florida increased in comparison to the period of 2008-2009 from about 38,000 persons to more than 45,700, “the population of Florida grew from 18.7 million to 19.8 million, an increase of 5.9%” (Scott & Philip, 2016, p. 1). In addition, the population of Florida will grow in the future because of migration processes and “most of Florida’s population growth through 2030 will be from net migration (90.0%)” (The Florida Legislature Office of Economic and Demographic Research, 2013, p. 1). Moreover, it is forecasted that the population of Florida will grow to more than 23,500,000 people by 2030 in comparison to about 18,800,000 people in 2010 (The Florida Legislature Office of Economic and Demographic Research, 2013). The number of older people will also increase, and by 2030, this number will potentially grow by more than 100% (Scott & Philip, 2016). As a result, more qualified healthcare professionals, including primary care physicians, will be required, but extreme shortages of physicians are expected (Peterson et al., 2014; Rabben, 2013). However, the current situation in the state does not allow for resolving this issue without attracting foreign-trained specialists.
The problem of the lack of physicians in healthcare facilities of Florida is observed today with the focus on the number of patients served by each professional. More than 66% of healthcare providers, including primary care physicians, work with about one hundred persons per week, and about 33% of physicians work with about 50-100 patients during a week (Scott & Philip, 2016). These data are also supported by other researchers who note that physician shortages in the United States can lead to significant increases in flows of patients served by only one specialist. As a result, primary care physicians have tough schedules that influence the quality of the provided services (Pande, 2014; Peterson et al., 2014). Moreover, the problem still remains urgent for persons who live in rural regions because of the limited access to healthcare services. From this point, foreign-trained physicians are viewed as resources to address “some – but by no means all – of the gaps in underserved areas” because currently about 25% of IMGs practice in the United States (Rabben, 2013, p. 4). The increase in the number of IMGs in Florida is important to cover even more gaps in the field, and recent studies in the area of healthcare and nursing support this idea.
It is possible to note that the authors of recent studies and articles on the problem of licensing IMGs in the United States are inclined to positively discuss the role of foreign-trained physicians to address shortages in the country. As a result, they support the idea of changing licensure procedures (Pande, 2014; Peterson et al., 2014). Thus, “licensure rules do not govern migrants’ entry into country but they dictate the ease with which migrants can enter the labor market for their specialized skills” (Peterson et al., 2014, p. 51). This focus on modifying policies regarding providing licenses to physicians is extremely important for Florida where the shortage of healthcare providers is extremely high. This situation is also typical for other states in the country because tough regulations regarding licensure will lead to shortages of more than 90,000 physicians, and changed regulations will not address the problem completely, leading to shortages of more than 60,000 physicians (Peterson et al., 2014). Therefore, researchers agree that more complex procedures are required to address such shortages, and changes in regulations or policies are the first step.
From this point, it is possible to state that the reviewed evidence indicates that foreign-trained physicians face a lot of challenges at different stages of their employment in the United States. Today, “it is harder for IMGs to find residency positions (52 per cent IMGs vs. 89 per cent US-trained)” (Pande, 2014, p. 271). This tendency is observed in spite of the lack of qualified specialists in many areas of the country and because of the complex regulations related to the procedure of receiving a license. As a result, the evidence of the problem supports the idea that the whole country and Florida experience the same challenges and barriers, and new policies in order to regulate the licensure procedure for IMGs are required to be adopted in Florida.
Impact and Importance: The Nurse Practitioner Role
In spite of the fact that HB 1277 is directly related to the issue of the physician shortage in the United States, and Florida in particular, this problem also influences the role of nurses and nurse practitioners in healthcare facilities. The problem is that shortages of physicians also lead to decreases in the number of nurses in hospitals and intensive care units. The lack of specialists in some regions of the country often results in closing certain departments or units, affecting the nurse staff (Pande, 2014; Peterson et al., 2014). The lack of specialists in some healthcare facilities is usually a reason for making physicians work with more patients per week because of the larger demand for services and increased flows of patients (Emeka, 2015; Pande, 2014; Peterson et al., 2014; Rabben, 2013). One more negative effect of the physician shortage on nurses is the re-distribution of roles and job responsibilities.
As a result, it is possible to state that the pressure on nurses also increases because they need to cover certain gaps in services and address more patients who require assistance. In addition, many physicians need to change their qualifications while being trained in foreign countries, and this aspect also affects nursing (Emeka, 2015; Kahn & Rubenfeld, 2015; Pande, 2014; Peterson et al., 2014). From this perspective, the problem associated with the shortage of physicians can be viewed as complex, and it also has a significant impact on nurses.
HB 1277 was oriented to providing more possibilities for foreign-trained physicians to be employed in healthcare facilities of Florida within a short period of time because of simplifying the procedure of receiving a license. As a result of attracting more foreign-trained physicians to hospitals located in Florida, it is possible to address the problem of physician shortages predicted for the next decades (Emeka, 2015; Scott & Philip, 2016). This policy is also important to reduce the potential pressure on those nurses who work with physicians or who need to share some responsibilities, as it is in case of nurse practitioners and registered nurses, in order to cover gaps in the provided care in those healthcare facilities where there is a lack of staff (Kahn & Rubenfeld, 2015; Pande, 2014). From this point, the discussed issue is important for those nurses who cooperate with US-trained and foreign-trained physicians, as well as for those nurses who work in organizations where shortages of healthcare professionals are observed (Emeka, 2015; Pande, 2014). Therefore, nurses should learn more about the potential benefits of HB 1277 for addressing staff shortages in healthcare organizations of Florida and for improving the quality of care for patients.
It is also possible to state that nurses can influence the resolution of the issue and adoption of the policy while drawing the attention of policymakers to the problem of staff shortages in healthcare organizations that directly influence the quality of the provided services. Nurses can participate in conducting studies to support the necessity of accepting HB 1277 and collecting patients’ views regarding the quality of services proposed in regions where there is a lack of physicians (Pande, 2014; Peterson et al., 2014; Rabben, 2013). Furthermore, nurse researchers can also participate in conducting statistics regarding the number of IMGs who annually move to Florida, apply for taking examinations and receiving a license, and face certain barriers on their path to proving their qualification in the United States (The Florida Legislature Office of Economic and Demographic Research, 2013). These findings need to be published and spread within the professional nurse community and discussed by healthcare authorities (Emeka, 2015; Pande, 2014). It is necessary to involve nurses in the process of drawing the public’s and policymakers’ attention to the problem while referring to potential health outcomes for community members in Florida.
Conclusion
House Bill 1277: Licensure of Foreign-Trained Physicians was filed to be reviewed by the House Committees in 2016 in order to address the problem of licensing foreign-trained physicians, but it is important to note that this bill failed to be adopted. In spite of the fact that the idea of this House Bill was also reflected in Senate Bill 1546, the problem remains unresolved because that bill also died in the Senate Committees. The main negative consequence of the impossibility to adopt the policy in order to improve the procedure of licensing foreign-trained physicians in Florida is the physician shortage observed in healthcare organizations of the state.
Recommendations to address this issue and promote the policy are associated with the necessity of organizing the public discussion of the problem and with the necessity of involving the Florida Department of Health in these debates. The shortage of physicians in Florida, especially in remote and rural territories, is a problem that requires its immediate solution because of the potential growth of the population with the focus on older people. In addition, it is also important to concentrate on nurse practitioners’ and healthcare providers’ efforts in this area. After receiving the public’s and authorities’ support, it is important to file one more bill in order to address the problem of licensing IMGs that will be based on evidence of the necessity to make the licensure procedure more efficient in order to cover current gaps in the health care system of Florida.
References
Emeka, O. C. (2015). Migration of international medical graduates: Implications for the brain-drain. Open Medicine Journal, 2(1), 17-24.
The Florida Legislature Office of Economic and Demographic Research. (2013). Demographic overview & population trends: Select committee on health care workforce innovation.
The Florida Senate. (2017). HB 1277: Licensure of foreign-trained physicians.
Kahn, J. M., & Rubenfeld, G. D. (2015). The myth of the workforce crisis: Why the United States does not need more intensivist physicians. American Journal of Respiratory and Critical Care Medicine, 191(2), 128-134.
Pande, V. (2014). A comparative study of reciprocity in international physician licensing. International Journal of Pharmaceutical and Healthcare Marketing, 8(3), 265-283.
Peterson, B. D., Pandya, S. S., & Leblang, D. (2014). Doctors with borders: Occupational licensing as an implicit barrier to high skill migration. Public Choice, 160(1-2), 45-63.
Rabben, L. (2013). Credential recognition in the United States for foreign professionals. Migration Policy Institute Research, 1(1), 1-17.
Scott, R., & Philip, C. (2016). 2016 physician workforce annual report. Web.