More than half of states have passed laws allowing nurse practitioners to obtain a license to practice without physician supervision, often based on the notion that doing so will expand patients’ access to primary care.
Florida is one of those states. Its House Bill 607, passed in March 2020, allows nurse practitioners who have completed at least 3,000 clinical practice hours within the previous five years to practice without physician supervision, with one important stipulation—that they do it within primary care. But new research shows that primary care is getting short shrift from nurse practitioners in the Sunshine State.
For a study published in February in the journal Family Practice, researchers examined the practice patterns of autonomous nurse practitioners—those practicing independently, without physician supervision—in Florida. They found that more than half of those reached were practicing in settings outside of primary care. A large number were practicing in medical spas, but others had branched out into other in-demand specialties, even cardiology.
“The reasoning behind the bill is that NPs are supposed to be able to manage low-risk, straightforward conditions,” said Rebekah Bernard, MD, the study’s lead author and a family physician in private practice at Gulf Coast Direct Primary Care, in Fort Myers, Florida.
“I'm a primary care doctor, and I understand how hard it is to do good, high-quality primary care,” Dr. Bernard said. “It was very frustrating when our legislators decided to enact primary care unsupervised practice for nurse practitioners under the guise of, ‘There’s a primary care shortage; they will fill the gap.’ So we now have a huge number of NPs, but my phone is still ringing off the hook from people looking for a primary care doctor.”
Learn more with the AMA about what sets apart physicians and nonphysicians.
It started with an observation
Dr. Bernard saw a gaping need for research on the subject.
“As I have eyes that can see, I’ve noticed all these med spas,” Dr. Bernard said, given that the industry has grown sixfold since 2010. But she and her colleagues were interested to study the matter more rigorously to "see if we can validate that what I'm seeing with my eyes is true.’”
Between November 2024 and February 2025, she and her colleagues conducted a randomized sample of autonomous nurse practitioners across Florida using a database obtained from the Florida Department of Health. Of the almost 12,000 autonomous nurse practitioners listed, they randomly sampled 464 from across the state, ultimately reaching 328 autonomous nurse practitioner practices.
“We simply called and asked, ‘I'm seeking a doctor for primary care—do you offer primary care?’ and then coded the responses,” Dr. Bernard said.
They found that 59% of the nurse practitioners they reached we're not practicing primary care at all.
Only 128 were in primary care settings, and six were working in nonclinical roles. The remaining 194 autonomous nurse practitioners were working clinically in settings outside primary care.
For the nurse practitioners outside primary care, the five most common settings were:
- Cosmetic and nonstandard medical/surgical practices—53.
- Psychiatry/addiction medicine—53.
- Emergency/urgent care—20.
- Inpatient medicine—13.
- Cardiology—9.
Find out how the AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.
What needs to change—and what doesn’t
“Our study provides strong evidence that many autonomous NPs in Florida have established specialty practices and other services not within the legal scope of practice of Florida law,” the authors wrote. “Stricter enforcement of NP practice within the scope of training and legislation is needed.”
Looking at the issue more broadly, nationwide data from the American Association of Nurse Practitioners shows that 89% of NPs are trained and certified in primary care, yet multiple workforce studies show that only one-quarter to one-third practice in primary care.
In addition, an AMA survey unveiled at the 2026 AMA State Advocacy Summit found that one in three NPs and PAs switch specialties at least once in their careers, and they often do so without any formal advance training in the new specialty. The AANP’s own data published in 2024 shows that, while NPs can earn optional certifications in various specialties, 92.8% of NPs lack any at all.
"Why aren't NPs going into primary care? Well, it's the same reason everybody's struggling with primary care,” Dr. Bernard said. “It's because of payment issues and overhead costs, and it goes back to the AMA's goal of payment reform. You’re not going to solve problems with payment by coming up with shortcuts, like hiring lesser-trained people.”
According to an AMA issue brief on nurse practitioners' views of physician-led care (PDF), 95% reported practicing on a physician-led team, and 88% said they are satisfied, with over half stating they are very satisfied. Physician assistants (PAs) felt much the same (PDF).
Both groups of nonphysician providers cited collaboration on complex cases, mentorship, liability protection and patient safety as significant benefits.
“In my research for my books, what I discovered is that there's so much great data showing that when physicians and nurse practitioners and physician assistants work together in teams, patients can get fantastic care,” said Dr. Bernard, who has written two books on scope of practice and has a third on the way. “There are no studies that I’ve found that show what care looks like when you remove physicians from the care team.”
Through its Advocacy Resource Center, the AMA works directly with national, state and specialty medical societies to enact state laws and regulations that protect patients and support physicians—and fight back against those that do not.
