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A Florida legislative committee has investigated whether naturopathic licensure is useful and whether the scope of naturopathic practice should be expanded. In January 2004, the committee concluded that an expanded scope might be harmful and that naturopathic licensing is not cost-effective. Here is the full report.


Sunrise Report on Proposed Licensure
of Naturopathic Physicians

Interim Project Report

Committee on Health Care
Florida House of Representatives
January 2004

Representative Frank Farkas, D.C., Chair
Representative Ed Homan, M.D., Vice Chair


Staff Contact Information:
 
Committee on Health Care
210 House Office Building
402 S. Monroe Street
Tallahassee, FL 32399-1300
(850) 487-3771
 
 
Tom Hamby, Policy Coordinator
Lucretia Shaw Collins, Staff Director
Glenn Mitchell, Ph.D., Sr. Legislative Analyst

Table of Contents

INTRODUCTION: PROPOSED LICENSURE OF NATUROPATHIC PHYSICIANS

EXECUTIVE SUMMARY

BACKGROUND: LICENSURE IN FLORIDA AND OTHER JURiSDICTIONS

Regulation of Health Care Professions in Florida
Department of Health, Medical Quality Assurance
Professional Licensing Boards and Councils
Naturopathic Physicians
History of Naturopathic Medicine
Three Types of Naturopathic Practice
Increasing Popularity of Complementary and Alternative Medicine
Existing Licensure of Naturopathic Practice in Florida
Recent Legislation and Initiatives
Legislation Relating to Complementary and Alternative Health Care
Recent Initiatives to License Naturopathic Physicians in Florida
Statutory Criteria to Establish Licensure
Documentation Provided to Support Licensure in Florida
Reasons Given for Licensure
Proposed Legislation to Establish Licensure in Florida
Licensure of Naturopathic Physicians in Other States
Scope of Practice of Naturopathic Physicians in Other States
Alternatives to Licensure
Types of Regulation
Administration of Regulation
Trends in Regulation of Health Professions in Other Countries
Consolidation of Practice Acts in Canada
Standardization of Critical Professions in Europe
Wide Variation in Regulation of Complementary and Alternative Medicine
Roles of Traditional and Alternative Practices in Other Regions
 
FINDINGS: LICENSURE ISSUES IN FLORIDA
 
The Small Number of Naturopathic Physicians
A Broad Scope of Practice that Overlaps Related Professions
Current Scope of Practice of Licensed Naturopathy in Florida
Proposed Expanded Scope of Practice of Naturopathic Physicians
Overlap with Other Licensed Health Professions
Overlap with Traditional, Complementary and Alternative Practices
Unclear Risk of Harm to the Public
No Documented Risk of Serious Harm in Florida from Not Licensing
Naturopathic Physicians with an Expanded Scope
Potential Risk from Licensing Naturopathic Physicians
Recognized Skills -- Education and Training
Educational Requirements
National Accreditation Organization
Naturopathic Medical Colleges
Licensure Examination
Professional Associations
Cost Impacts of Licensure
High Costs of Licensure and Oversight Board
Reimbursement of Naturopathic Medicine
 
CONCLUSIONS
     
    Components of Proposed Legislation
    Conditions that Support Criteria for Licensure
    Conditions that Do Not Support Criteria for Licensure
    Recommendations

INTRODUCTION: PROPOSED LICENSURE OF NATUROPATHIC PHYSICIANS

This report presents findings of an interim project by staff of the Committee on Health Care of the Florida House of Representatives to determine whether practitioners of naturopathic medicine should be licensed in Florida.

Section 11.62(2), F.S., of the Sunrise Act relating to regulation of an unregulated profession or occupation establishes the following intent of the Legislature:

(a) That no profession or occupation be subject to regulation by the state unless the regulation is necessary to protect the public health, safety, or welfare from significant and discernible harm or damage and that the police power of the state be exercised only to the extent necessary for that purpose; and
(b) That no profession or occupation be regulated by the state in a manner that unnecessarily restricts entry into the practice of the profession or occupation or adversely affects the availability of the professional or occupational services to the public.

The project followed established procedures for a Sunrise Review for professional regulation as established in s. 11.62, F.S., which requires the Legislature to consider the following factors in determining whether an unregulated profession or occupation should be regulated:

(a) Whether the unregulated practice of the profession or occupation will substantially harm or endanger the public health, safety, or welfare, and whether the potential for harm is recognizable and not remote;
(b) Whether the practice of the profession or occupation requires specialized skill or training, and whether that skill or training is readily measurable or quantifiable so that examination or training requirements would reasonably assure initial and continuing professional or occupational ability;
(c) Whether the regulation will have an unreasonable effect on job creation or job retention in the state or will place unreasonable restrictions on the ability of individuals who seek to practice or who are practicing a given profession or occupation to find employment;
(d) Whether the public is or can be effectively protected by other means; and
(e) Whether the overall cost-effectiveness and economic impact of the proposed regulation, including the indirect costs to consumers, will be favorable.

Naturopathic practitioners were first licensed in Florida in 1927. In 1957, the Legislature abolished the licensing authority for naturopathic medicine. Only those naturopathic practitioners licensed at that time could continue to be licensed and no new licenses were issued (s. 462.023, F.S.). Currently, only seven practitioners have active licenses. The licensees are regulated by the Division of Medical Quality Assurance of the Department of Health.

In 2002, the Florida Association of Naturopathic Physicians submitted documentation to legislative staff in support of reestablishing licensure. The information was submitted in response to a Sunrise questionnaire designed to solicit documentation regarding the need to regulate the profession. The information provided by the association indicated interest in expanding the scope of practice of naturopathic physicians to include activities presently outside the scope of these practitioners. Documentation submitted by the association along with information provided by the Department of Health's Division of Medical Quality Assurance was used to determine whether the state of Florida should reestablish licensure of naturopathic physicians. Staff also performed a literature search, contacted professional associations, and reviewed other states' statutes and practices in other countries.

EXECUTIVE SUMMARY

This report presents findings of an interim project by staff of the Committee on Health Care of the House of Representatives to determine whether practitioners of naturopathic medicine should be licensed in Florida. The project followed established procedures for a Sunrise Review for professional licensure as established in s. 11.62(3), F.S., which requires legislation proposing regulation to be reviewed based on evidence that shows:

  • Substantial risk of harm to the public if there is no regulation;
  • The skills required by the profession are specialized and readily measurable;
  • Regulation will not have an unreasonable effect on job creation or job
    retention;
  • The public can not be adequately protected by other means; and
  • The overall cost effectiveness and economic impact of the proposed regulation is favorable.

Naturopathic physicians

According to the Florida Naturopathic Physician Association (FNPA), naturopathic practice distinguishes itself from other health care practitioners by its holistic approach, not the specific treatments it uses. Therapy is directed at the whole person and at the underlying cause of illness, such as the patient's lifestyle, diet, and emotional state.

Naturopathic physicians are trained in nutrition (diet and nutritional supplements), health-risk assessment, homeopathy, botanical medicine, counseling, and naturopathic physical medicine (such as therapeutic ultrasound, diathermy, hydrotherapy, and naturopathic manipulative therapy).

According to the FNPA, naturopathic childbirth (with specialty training), minor office procedures (superficial skin wound repair, etc.), and naturally derived prescription drugs and their synthetic analogs (antibiotics, hormones, etc.) are also part of naturopathic training and practice, but training does not include general surgery, surgical repair of fractures, or chemotherapy.\

Three different groups of practitioners use naturopathic techniques:
  • "Naturopathic physicians," who are licensed in 12 states to practice a limited form of primary care;
  • "Traditional naturopaths," who practice non-invasive traditional and alternative healing and are not licensed; and
  • "Licensed health professionals," such as medical doctors and nurses, who incorporate some naturopathic techniques in their practice.

Increasing popularity of complementary and alternative health care

The use of what is called complementary, alternative and traditional or "folk" medicine has been increasing in the last 20 years. In much of the developing world it is the only source of health care. In the developed world, the tremendous growth in non-communicable diseases has led consumers to look for alternatives to modern medicine which are seen as gentler and more natural means to manage chronic diseases.

History of Naturopathy in Florida

Naturopathic practitioners were first licensed in Florida in 1927. In 1957, the Legislature abolished the licensing authority for naturopathy. Only those naturopathic practitioners licensed at that time could continue to be licensed and no new licenses have been issued (s. 462.023, F.S.). Currently, only seven naturopathic practitioners have active licenses. These licensees are regulated by the Division of Medical Quality Assurance of the Department of Health.

Estimated number to be licensed in Florida

One estimate of how many naturopathic physicians might be licensed in Florida if the state reestablished licensure is based on the percentage of the U.S. population living in Florida. Florida population represents 5.7% of the national total. If the total number of 1,076 licensed naturopathic physicians in U.S. practiced equally among the states, an estimated 5.7% might expect to be
,licensed in Florida. At this ratio, 61 of the 1,076 licensed naturopathic physicians nationwide might be expected to be licensed in Florida within the first several years.

Sunrise Review of proposed licensure

In the last two legislative sessions, naturopathic physicians have sought to reestablish licensure in Florida. In 2002, the Florida Association of Naturopathic Physicians submitted information to legislative staff in response to a Sunrise Review questionnaire designed for the purpose of determining the need to regulate a profession.

Documentation provided to the legislative committee

The association did not complete a Sunrise questionnaire that answers specific questions regarding the need to regulate the profession. Documentation provided by the association included:

  • 340 letters and petition signatures from students and a number of naturopathic physicians in other states, and from Florida consumers supporting licensure;
  • Descriptions of the five colleges and universities offering Doctor of Naturopathy degrees in the U.S.;
  • Background information on Naturopathy that explains the medical education and scope of practice of naturopaths; and
  • Reasons for licensure that include protection of the public, cost effectiveness and insurance coverage.

Reasons given for licensure

According to the Florida Naturopathic Physician Association (FNPA), licensure is needed to allow for:

  • Improved consumer access to health care -- consumers desire access to safe and cost effective natural treatment options provided by specifically trained physician-level professionals.
  • Naturopathic physicians to practice as trained--without licensure, new naturopathic physicians are unable to practice to the full extent of their training.
  • Insurance coverage -- some insurance companies cover some naturopathic services, but new practitioners can not be reimbursed because they are unable to become licensed as naturopathic physicians.
  • Training of naturopathic physicians in Florida -- the new Florida College of Integrative Medicine in Orlando is able to train naturopathic physicians, but they can not practice in Florida unless they are already licensed as medical or osteopathic physicians.
  • Increased cost effectiveness of health care -- the profession considers naturopathic treatment to be a cost effective alternative to conventional medicine because it emphasizes prevention, patient participation, and technologically simpler treatments.

Licensure of naturopathic physicians in twelve states and other countries Naturopathy practice acts currently exist in twelve states: Alaska; Arizona; California; Connecticut; Hawaii; Maine; Montana; New Hampshire; Oregon; Utah; Vermont; and Washington. In some jurisdictions, the scope of practice for naturopathy includes alternative modalities such as acupuncture, biofeedback, homeopathy, hypnotherapy or massage. A few statutes permit naturopaths to perform minor surgery and naturopathic or natural childbirth. In general, the practice acts allow naturopaths to utilize an extensive array of therapies and procedures. In several states, licensees must have a special certificate to practice natural childbirth, acupuncture, or to dispense natural substances or devices. In 2002, Kansas voted to register naturopaths. The state did not sanction licensing or any practice of medicine outside of botanical treatments.

California passed legislation in September, 2003, establishing licensure of naturopathic doctors. The California Medical Association opposed the legislation because it would allow naturopathic doctors to be primary care providers, including calling themselves physicians, prescribing medications, performing minor surgical procedures, and delivering babies. The medical association succeeded in getting restrictions that naturopathic doctors may not call themselves physicians and that require physician oversight for prescribing medications and childbirth assistance. Language on minor surgery was limited to treating minor abrasions and superficial treatments, such as removing warts. The legislation leaves the terms "naturopath" and "naturopathy" in the public domain so that graduates of naturopathic vocational programs or correspondence courses can describe their practice. It does not prevent or restrict the practices or activities of any other practitioner, consultant, or individual; nor does it restrict or prevent individuals engaged in the sale of vitamins, nutritional supplements, herbs or homeopathic remedies.

In other countries, there is no uniform approach to regulation of complementary and alternative medical practices, including naturopathy. In Europe, where there is a strong emphasis on self-regulation, countries are moving very cautiously. In general, there is more freedom for complementary and alternative practitioners to practice in "common law" countries, such as Ireland and Britain, than in countries with a "civil law" tradition, such as France and Spain, where only medical doctors may practice certain complementary and alternative therapies.

Three types of regulation

The three primary forms of regulation used to grant individuals the right or privilege to perform certain activities are licensure, certification and registration. Although these terms are often used interchangeably, the literature on professional regulation makes the following distinctions:

  • Licensure is the most restrictive mechanism and entails the creation of a monopoly on the regulated activity of a profession through enactment of profession-specific Practice Acts. Licensed practitioners gain an exclusive right to deliver services, and the profession enjoys protection of its title.
  • Certification is less restrictive than licensure. It is achieved through the use of title protection acts that give a designated "recognition" to individuals who meet qualifications set by a regulatory agency. Non-certified individuals may still offer services, but they are prohibited from using the term "certified" or the designated title. Certification is also used in the context of licensure, as in the American Medical Association's scheme of specialty boards which certify physicians specializing in different practice areas. In this context, certification denotes that a licensed practitioner has met certain professional standards.
  • Registration is the least restrictive regulatory mechanism and is achieved through registration requirement acts. Registration requires an individual to file his or her name and address with a designated agency. Unlike licensure, registration does not require complex or onerous pre-entry screening requirements, nor is a registration regime exclusionary. It does little more than provide a roster of practitioners.

Conclusions

Components of proposed legislation

Draft legislation proposed by the Florida Naturopathic Physician Association to reestablish licensure with an expanded scope as naturopathic physicians amends ch. 462, F.S., to include provisions that:

  • Establish a seven-member Board of Naturopathic Medicine appointed by the Governor and approved by the Senate, with five naturopathic physicians and two non-health care practitioners;
  • Transfer responsibility for rulemaking and discipline from the Department of Health to the Board;
  • Establish new education requirements for licensure that include graduation from a four year training program that meets several possible accreditation or certification standards;
  • Establish new examination requirements for licensure that include several possible approved national examinations as well as examinations given by
    other states;
  • Grandfather in currently licensed naturopathic physicians;
  • Rename the profession from Doctor of Naturopathy to Doctor of Naturopathic Medicine;
  • Allow for minor surgery; and
  • Provide exemptions to the naturopathic physician scope of practice to provide for the continued practice of supplement retailers, religious freedoms and family remedies.

Conditions that Support criteria for licensure

The review found that proponents have provided evidence that naturopathic medicine meets statutory standards of s. 11.62(3), F.S., of the Sunrise Act in terms of:

Whether the practice of the profession or occupation requires specialized skill or training, and whether that skill or training is readily measurable or quantifiable so that examination or training requirements would reasonably assure initial and continuing professional or occupational ability. (s. 11.62(3)(b), F.S.) The review found the profession of naturopathic physician has specialized skills and training as evidenced by:

Recognized and accredited training programs for naturopathic physicians; and

A recognized national examination for licensure that assesses specialized, measurable skills.

Conditions that Do Not Support criteria for licensure

The review found that proponents have not provided evidence that naturopathic medicine meets statutory standards of s. 11.62(3), F.S., of the Sunrise Act, and that there is evidence to the contrary, in terms of:

Whether the unregulated practice of the profession or occupation will substantially harm or endanger the public health, safety, or welfare, and whether the potential for harm is recognizable and not remote. (s. 11.62(3)(a), F.S.) The review found there is:

  • No documented evidence of substantial risk from not licensing naturopathic physicians in Florida; and
  • Potential risk from licensing naturopathic physicians to allow them to provide a broad range of primary care services.

Whether the regulation will have an unreasonable effect on job creation or job retention in the state or will place unreasonable restrictions on the ability of individuals who seek to practice or who are practicing a given profession or occupation to find employment. (s 11.62(3)(c), F.S.) The review found that:

  • The proposed scope of practice of naturopathic physicians is very broad;
  • The scope of practice overlaps with related health professionals that are already licensed, including medical doctors, osteopathic physicians, chiropractic physicians, acupuncturists, massage therapists, and midwives; and
  • Persons who currently practice traditional and alternative health practices including, traditional naturopathy, through non-invasive counseling and guidance, would not be able to practice if naturopathic medicine is licensed.

Whether the public is or can be effectively protected by other means. (s. 11.62(3)(d), F.S.) The review found that:

  • The public can currently receive naturopathic modes of treatment from licensed allopathic and other physicians, and from other licensed heath professionals; and
  • The state currently permits many non-invasive, traditional, and alternative health practices as practiced by traditional naturopathy without state regulation.

Whether the overall cost-effectiveness and economic impact of the proposed regulation, including the indirect costs to consumers, will be favorable. (s. 11.62(3)(e), F.S.) The review found that:

  • The small number of naturopathic physicians would have difficulty meeting the high costs per licensed practitioner of administering licensure.
  • It is estimated that the licensure and biennial renewal fee would range from $686 to $718 per licensee.

Recommendations

Section 11.62(6), F.S., requires that when making a recommendation concerning proposed legislation providing for new regulation of a profession, a legislative committee shall determine:

(a) Whether the regulation is justified based on the Sunrise Review criteria, the information submitted by proponents of the regulation, and the information provided by the department under ss. 11.62(3)-(5), F.S.;
(b) The least restrictive and most cost-effective regulatory scheme that will adequately protect the public; and
(c) The technical sufficiency of the proposed legislation, including its consistency with the regulation of other professions and occupations under existing law.

The conclusions of the report are that while there is evidence for support of licensure based on the existence of accredited training programs and licensure exams:

  • The proponents of regulation did not provide evidence that there is substantial harm or that the public is endangered from the unregulated practice of the profession;
  • The department and other sources indicate there is a risk of harm to the public from licensing naturopathic physicians with an expanded scope of practice;
  • Licensure of naturopathic physicians would negatively impact practitioners of traditional and alternative health healing techniques that currently do not have to be licensed; and
  • The broad scope of practice of naturopathic physicians will overlap and compete with related licensed health professionals, including chiropractic physicians, acupuncturists, massage therapists, and midwives.

The conclusions of the report are also that licensure of naturopathic physicians with an expanded scope of practice would not be cost effective because:

  • The small number who would be licensed would have difficulty meeting requirements to fund the cost of administering licensure and support for a board;
  • Licensure of naturopathic physicians would negatively impact the non-invasive practice of traditional naturopathy and other health practices such as aromatherapy, therapeutic touch, and nutritional supplements, through counseling and guidance, which is not required to be licensed under Florida Statutes; and
  • Current statutes already provide cost-effective protection of the public by allowing continued practice of naturopathic modes of treatment by licensed medical doctors and osteopathic physicians, and other licensed health practitioners (s. 456.41, F.S.).

Final draft legislation was not available at the time of this report to conclude whether it is consistent with the regulation of other professions.

BACKGROUND: LICENSURE IN FLORIDA AND OTHER JURISDICTIONS

Regulation of Health Care Professions in Florida

Regulation of professions is mandated by the Legislature only for the preservation of the health, safety, and welfare of the public. The criteria for regulation of health professions is set forth in various sections of chapter 456, F.S. Health care professions are regulated by separate Practice Acts in Florida Statutes. These acts establish the profession's scope of practice, grounds for disciplinary actions, and other licensure functions.

Prior to the 1970s, occupational regulation in Florida was administered through several autonomous, independent boards appointed by the Governor. In the late 1970s, all occupational regulation was centralized in Florida's Department of Professional Regulation. When the Agency for Health Care Administration was established in 1992, it took over regulation of health professions. The regulation of health professions was then transferred to the new Department of Health when it was created as a separate department in 1995. Disciplinary enforcement functions were transferred to DOH from AHCA several years later.

Department of Health, Medical Quality Assurance

The Department of Health's Medical Quality Assurance Program (MQA) regulates health care practitioners to ensure they meet the standards of their profession. Practitioners must demonstrate they meet the standards of their profession through testing, licensing, credentialing and continuing education requirements. Currently, the MQA program supports licensure and disciplinary activities for 37 professions and 6 facilities, and works with 22 boards and 6 councils. In total, MQA regulates more than 750,000 health care practitioners and facilities. (MQA Annual Report 2001-2002.)

Professions Regulated by the Division of Quality Medical Assurance of the Department of Health

Acupuncture, Athletic Trainers, Certified Nursing Assistants, Chiropractic Physicians, Clinical Laboratory Personnel, Clinical Social Workers/Counselors, Dentists and Dental Hygienists, Dietetics/Nutrition Counselors, Electrolysis, Hearing Aid Specialists, Marriage and Family Therapists, Massage Therapists, Master-Social Work, Medical Physicists, Mental Health Counselors, Midwifery, Naturopaths

Professional Licensing Boards and Councils

Most health care practitioners in Florida are governed by professional licensing boards or councils that are independent entities assigned to the Department of Health for administrative support purposes.

Regulatory responsibilities of boards and councils include:

  • Setting licensing requirements for the profession;
  • Establishing standards of professional practice;
  • Verifying applicant credentials (credentialing);
  • Issuing and renewing members' licenses;
  • Curtailing unlicensed activity; and
  • For professions without a national examination--preparing and administering licensing examinations.

Naturopathic Physicians

According to the American Naturopathic Physician Association, the majority of naturopathic physicians are in private practice, either alone or in group practice with other naturopaths or other professionals such as chiropractors and osteopaths. According to the Florida Naturopathic Physician Association, naturopathic practice is distinguished from other health care practices by its holistic approach not its specific treatments. Naturopathy endeavors to cure disease by harnessing the body's own natural healing powers. Naturopathic physicians believe that health results from the harmonious functioning of all parts of a person. Therapy is directed at the whole person and at the underlying cause of illness, such as the patient's lifestyle, diet, and emotional state.

Naturopathic physicians are trained in nutrition (diet and nutritional supplements), health-risk assessment, homeopathy, botanical medicine, counseling, and naturopathic physical medicine (such as therapeutic ultrasound, diathermy, hydrotherapy, and naturopathic manipulative therapy). Naturopathic childbirth (with specialty training), minor office procedures (superficial skin wound repair, etc.), and naturally derived prescription drugs and their synthetic analogs (antibiotics, hormones, etc.) are also part of naturopathic training and practice. According to the Florida Naturopathic Physician Association, naturopathic physicians are not trained in general surgery, surgical repair of fractures or chemotherapy.

History of Naturopathic Medicine

Naturopathic medicine grew out of the natural cure healing systems of the 18th and 19th centuries that included fresh air, positive thinking, diet, and water treatments. Many of the therapies used in natural medicine have a long history of use in Europe, Asia and the United States. At one time, conventional medicine and naturopathy were similar in their use of medicinal plants, diet therapies and hydrotherapy treatments to help heal the sick.

Naturopathy evolved in the late nineteenth century through the work of Dr. Benjamin Lust, a German physician who came to the United States in 1892 to spread the practice of hydrotherapy, the use of water cures to treat illness. The practice grew to include all natural methods of healing, including the use of botanical medicines, homeopathy, nutritional therapy, and manipulative therapies. In 1895, Dr. John Scheel of New York City coined the term "naturopathy" to describe a method of health care that includes an evolving system of natural therapies. (Profile of a Profession: Naturopathic Practice, Dower and O'Neil, University of California-S.F., Center for the Health Professions, 2001).

As the health care industry developed and became regulated, the practice of naturopathic medicine almost ceased. Beginning in the 1970s, there has been increasing interest in holistic and alternative health care that has brought about a resurgence of naturopathy. Currently, five schools nationally train naturopathic physicians, including the Florida College of Integrative Medicine in Orlando.

Three Types of Naturopathic Practice

There are three different groups of practitioners that use naturopathic techniques: "naturopathic physicians;" "traditional naturopaths;" and "licensed health professionals," such as medical doctors and nurses, who incorporate some naturopathic techniques in their practice.

The term "naturopathic physician" is largely reserved for those who have gone to a 4-year naturopathic physician program currently offered by five colleges. There are also educational programs for "traditional naturopaths" that offer "ND" or Naturopathic Doctor degrees. Some members of both groups call themselves naturopathic "doctors." According to a review by the naturopathic profession by the state of California (Profile of a Profession: Naturopathic Practice, University of California, Center for the Health Professions, 2001), in states that license naturopathic physicians, the titles "naturopathic physician," "naturopathic doctor," and even "naturopath" may be protected by statute for use only by those who have completed the 4-year naturopathic physician programs. Elsewhere, traditional naturopaths may call themselves naturopaths, traditional naturopaths, naturopathic practitioners, or naturopathic consultants.

  • Naturopathic Physicians -- Naturopathic physicians as a group have focused much of their energy on making the process for training and entry into the profession more formal. The group has worked to: standardize entry into the profession as they define it; improve evidence-based research; and seek formal recognition by state accreditation bodies. The five schools that have formal four year programs support this approach.
  • Traditional Naturopaths -- Traditional naturopaths maintain a strict definition of natural healing, and do not incorporate surgical, non-natural pharmaceutical or obstetrical care into their practice. They often focus their practice on only a number of the various modalities that comprise naturopathic healing. They have a much more varied set of pathways for entry into practice. Training ranges from self instruction and apprenticeship to formal courses of study. Traditional naturopaths place great value on the independence and responsiveness allowed by such flexibility.
  • Licensed Health Professionals Practicing Naturopathic Techniques -- A third group that practices naturopathic techniques are licensed practitioners of medicine, dentistry, and nursing who have added some holistic or naturopathic modalities to their practice. According to the California review, the level of preparation of these practitioners varies widely, with most practitioners acquiring knowledge of naturopathic techniques in settings that are less formal than extended courses of study. According to the review, members of this group represent several different licensed allopathic professions, and do not have one voice on naturopathy issues. They tend to value independence and practice freedom with regards to naturopathy, but within the structured framework that their licenses provide.

Some states, including Texas, have initiated practice guidelines for physicians practicing alternative and complementary medicine (Texas Administrative Code title 22, part 9, 200.1-200.3). Florida passed legislation in 2001 (ch. 2001-116, L.O.F.) that created s. 456.41, F.S., which allows licensed health care practitioners to provide complementary and alternative health care treatment that may include naturopathic techniques.

Increasing Popularity of Complementary and Alternative Medicine

Naturopathy is a health care practice that falls within what is called integrative, complementary, alternative, and traditional or "folk" medicine. Such practices include an immense variety of natural medicines, spiritual therapies, manual techniques and exercises that are used to maintain well-being, and to treat, diagnose or prevent illness in different parts of the world.

According to the World Health Organization, the use of traditional medicine in an extensive range of diseases has been increasing in the last 20 years, in both developing and developed countries. In much of the developing world, it is the only source of health care and is used to provide comfort to those with conditions such as AIDS. In the developed world, the tremendous growth in non-communicable diseases has caused consumers to look for alternatives to modern medicine that are seen as gentler and more natural means to manage chronic diseases.

In the U.S., the National Institutes of Health recently established the National Center for Complementary and Alternative Medicine (NCCAM) to provide research support to the diverse practices and products that make up complementary and alternative medicine. NCCAM identifies naturopathy as an alternative medical system that evolved with its own system of theory and practice apart from the conventional medical approach used in the U.S. NCCAM provides the following definitions of complementary and alternative medicine in the U.S:

  • Complementary medicine is made up of health care practices that are used together with conventional medicine-for example, using aromatherapy to help lessen a patient's discomfort following surgery.
  • Alternative medicine is used in place of conventional medicine-for example, the use of a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor.

According to NCCAM, while some scientific evidence exists regarding some complementary and alternative therapies, for the most part, there are key questions that are yet to be answered through well-designed scientific studies. Such questions include whether the therapies are safe and work for the diseases or medical conditions for which they are used.

Existing Licensure of Naturopathic Practice in Florida

Naturopaths were first licensed in Florida beginning in 1927 under the Naturopathy Practice Act, currently ch. 462, F.S. (ch. 12286, L.O.F., 1927). In 1957, after court decisions construed that the act authorized naturopaths to prescribe and administer drugs, including narcotics, the Legislature stopped licensure of naturopaths and limited their practice (ch. 57-1239, L.O.F. 1957). The Governor, in his message to the Legislature, recommended outright abolition of the practice of naturopathy in Florida. The Governor pointed out that at the time, only six other states recognized the profession, and no schools offered courses conforming to requirements of Florida statutes.

Rather than abolish the profession completely, the Legislature abolished the State Board of Naturopathic Examiners and transferred oversight of the profession to the State Board of Health. The Legislature also repealed sections of the act that provided for the examination and licensing of any new applicants to practice naturopathy. It specifically prohibited licensed naturopaths from prescribing or administering any drug or medicine "included within materia medica or listed in the United States pharmacopoeia." Following court challenges, the authority to license naturopaths was abolished in 1959 and only licensees who were licensed at that time were allowed to continue their practice.

The current practice act includes a wide variety of healing techniques but prohibits surgery and the practice of "materia medica," a term that includes prescription of drugs. The act does not protect the titles "naturopathic physician" and "naturopathic doctor" by requiring that these titles can only be used by state licensed practitioners. -

Currently, no one can obtain a license as a naturopath in Florida, unless they are one of the remaining people who currently hold a license. According to the Department of Health, only seven naturopaths continue to have active licenses in Florida. If anyone else claims to be a licensed naturopath, they can be prosecuted for unlicensed activity. (s. 462.023, F.S.)

Recent Legislation and Initiatives

Legislation Relating to Complementary and Alternative Health Care

In 2001, the Legislature passed SB 1324 (ch. 2001-116, L.O.F.) that created s. 456.41, F.S., to authorize already licensed health care practitioners to provide complementary or alternative health care treatment as an option to conventional treatment. The law provides that health care practitioners utilizing complementary or alternative treatment methods are subject to the same requirements, provisions, and liabilities associated with conventional treatment methods. The law explicitly requires documentation of informed consent by the patient. In addition, it specifies that it does not modify or change the scope of practice of any Florida health care practice acts. Finally, the legislation revised the Florida Patient's Bill of Rights and Responsibilities to include the right to access complementary or alternative health care treatments. The law does not specify which procedures are included in the definition of complementary and alternative health care treatment.

In 2003, HB 1301 was introduced and referred to committee, but was not considered. The legislation, known as the "Consumer Health Freedom Act" to allow persons to provide certain complementary and alternative health care services that do not pose a risk of harm even if they are not licensed health care practitioners. The bill provided that such practice would not be considered unlicensed practice of a health care profession. The bill excluded certain practices, including, surgery, x-rays and legend drugs, and required disclosure and consent. The bill died in committee.

Recent Initiatives to License Naturopathic Physicians in Florida

In 2002, legislation sponsored by the Florida Association of Naturopathic Medicine (FANM) was introduced to establish a Board of Naturopathic Medicine and expand the current scope of practice in ch. 462, F.S., to include prescription drugs and surgery (SB 2444 and HB 1829). The proposed legislation would have established that licensed naturopathic physicians would have the same rights as other physicians in hospitals and other facilities. The bill would also eliminate restrictions against soliciting patients, advertising and prescribing or dispensing certain growth hormones. The legislation died in committee.

In 2003, legislation was introduced by a different organization, the Florida Naturopathic Physicians Association (FNPA), to restore licensure for naturopathic physicians in Florida (SB 2014 and HB 1615). The legislation would have also created a Board of Naturopathic Medicine. It provided guidelines for probable cause panels and disciplinary decisions and revised the maximum amount of biennial license fee. The legislation died in committee.

Draft legislation has been proposed for the 2004 Legislative session that addresses some of the scope-of-practice issues that were raised concerning previous proposed legislation. The initial draft of the proposed legislation provided by representatives of the FNPA specifically excludes major surgery and "materia medica," the term relating to prescribing drugs. The proposed legislation also specifically excludes acupuncture from the scope of practice of naturopathy, as it is already licensed in Florida under ch. 457, F.S.

Statutory Criteria to Establish Licensure

In determining whether to regulate a profession or occupation, Section 11.62(3), F.S., of the Sunrise Act, requires the Legislature to consider the following factors:

    (a) Whether the unregulated practice of the profession or occupation will substantially harm or endanger the public health, safety, or welfare, and whether the potential for harm is recognizable and not remote;
    (b) Whether the practice of the profession or occupation requires specialized skill or training, and whether that skill or training is readily measurable or quantifiable so that examination or training requirements would reasonably assure initial and continuing professional or occupational ability;
    (c) Whether the regulation will have an unreasonable effect on job creation or job retention in the state or will place unreasonable restrictions on the ability of individuals who seek to practice or who are practicing a given profession or occupation to find employment;
    (d) Whether the public is or can be effectively protected by other means; and
    (e) Whether the overall cost-effectiveness and economic impact of the proposed regulation, including the indirect costs to consumers, will be favorable.

Florida statutes also require that professional regulation be self funded (ss. 456.025(1) and (3), F.S.).

Information Required from Proponents

Section 11.62(4), F.S., of the Sunrise Act, requires proponents of regulation of a profession which is not already expressly subject to state regulation, to provide information to the department, upon request, that includes:

  • The number of individuals who would be subject to the regulation;
  • The nature and extent of the harm to the public caused by the unregulated practice of the profession;
  • Voluntary efforts made by members of the profession to protect the public and a statement of why these efforts are not adequate to protect the public;
  • An explanation of the reasons why other types of less restrictive regulation would not effectively protect the public;
  • The cost, availability, and appropriateness of training and examination requirements; and
  • The cost of regulation, including the indirect cost to consumers, and the method proposed to finance the regulation.

Information Required from the Department

Section 11.62(5), F.S., requires the department to provide the Legislature with
information concerning the effect of proposed legislation to regulate a new profession, to include:

  • Department resources necessary to implement and enforce the proposed regulation;
  • The technical sufficiency of the proposal for regulation, including its consistency with the regulation of other professions under existing law;and
  • If applicable, any alternatives to the proposed regulation which may result
  • in a less restrictive or more cost-effective regulatory scheme.

Documentation Provided to Support Licensure in Florida

In 2002, the Florida Naturopathic Physician Association submitted information to legislative staff in response to a Sunrise questionnaire designed for the purpose of gathering information pursuant to s. 11.62(4), F.S., to aid the Legislature in its determination of the need for regulation of a profession and to aid in analyzing proposed legislation.

The Florida Naturopathic Physician Association did not submit a completed Sunrise questionnaire that would have provided specific information regarding the need for licensure. The packet of information that was provided by the association to document the need for licensure included:

  • 340 letters and petition signatures from students and a number of naturopathic physicians in other states and from Florida consumers supporting licensure. (All except a few were form letters);
  • Descriptions of the five colleges and universities offering Doctor of Naturopathy degrees in the U.S.;
  • Background information on Naturopathy that explains the medical education and scope of practice of naturopaths; and Reasons for licensure that include protection of the public, cost
    effectiveness and insurance coverage.

Of the documented support for licensure of naturopathic physicians, 21 letters were from naturopathic doctors in other states, 15 of whom indicated they were interested in practicing in Florida. A total of 260 students supported licensure in Florida, including 131 students at the Florida College of Integrative Medicine in Orlando and 34 graduate students in Florida interested in seeking education in naturopathic medicine.

Fifty-nine health care consumers filled out form letters indicating their support for naturopathic medicine in Florida.

Reasons Given for Licensure

According to the Florida Naturopathic Physician Association (FNPA), licensure is needed to allow for:

  • Improved consumer access to health care: Consumers desire access to safe and cost effective, natural treatment options provided by specifically trained physician-level professionals.
  • Naturopathic physicians to practice as trained: Without licensure, new naturopathic physicians are unable to practice to the full extent of their training.
  • Insurance coverage: Some insurance companies cover naturopathic services, but new practitioners in Florida are not covered because they can not be licensed as naturopathic physicians.
  • Training of naturopathic physicians in Florida: The Florida College of Integrative Medicine in Orlando is able to train naturopathic physicians, but these naturopathic physicians can not practice in Florida unless they are already licensed as medical doctors or osteopathic physicians.
  • Increased cost effectiveness of health care: National and state naturopathic physician associations argue that because naturopathic medicine emphasizes prevention, patient participation, and technologically simpler treatments, it is a cost effective alternative to conventional medicine.

According to the profession, naturopathic treatment:

  • Reduces or eliminates the need for prescription or non-prescription medications;
  • Reduces the need for surgery, medical interventions, procedures, and services; and
  • Increases patients' ability to give self-care.

The FNPA argues that lack of licensure increases health care costs to consumers because they must seek additional or duplicate services that could otherwise be provided by their naturopathic physician.

Proposed Legislation to Establish Licensure in Florida

The Florida Naturopathic Physician Association (FNPA) has proposed legislation to establish licensure of naturopathic physicians in Florida. The proposed legislation:

  • Establishes a Board of Naturopathic Medicine;
  • Transfers responsibility for rulemaking and discipline from the Department of Health to the Board;
  • Renames the profession from "Doctor of Naturopathy" to "Doctor of Naturopathic Medicine;"
  • Allows for minor surgery; and
  • Establishes new education and examination requirements for licensure.

FNAP states that it does not seek legislation that would:

  • Prevent any other licensed practitioner or citizen from using the therapeutic modalities that are within the scope of naturopathic practice;
  • Require insurance companies to cover naturopathic services; or
  • Prevent anyone from selling vitamins, minerals or homeopathic medicines, as provided by other state laws.

Licensure of Naturopathic Physicians in Other States

Naturopathy practice acts currently exist in twelve states: Alaska; Arizona; California; Connecticut; Hawaii; Maine; Montana; New Hampshire; Oregon; Utah; Vermont; and Washington. (See table below.) According to a Colorado Sunrise Review (Sunrise Review of Naturopathic Physicians, Colorado Office of Policy and Research, 1998), in states that do not have naturopathy practice acts, the use of naturopathy may be considered to be the practice of medicine for which a medical license is required. In some jurisdictions, the scope of practice for naturopathy includes alternative modalities such as acupuncture, biofeedback, homeopathy, hypnotherapy or massage. A few states permit naturopaths to perform minor surgery and natural childbirth. In general, the practice acts allow naturopaths to utilize an extensive array of therapies and procedures.

Of the twelve states with naturopathy practice acts, seven states have established independent boards to regulate this profession. (In Arizona and Oregon, the boards are autonomous and self regulate naturopaths without state agency regulation.) Three states regulate naturopathy at the department level with assistance from advisory committees. In two states, boards of alternative health care regulate naturopathic physicians. All the practice acts authorize naturopaths through licensure. In several states, licensees must have a special certificate to practice natural childbirth, acupuncture, or dispense natural substances or devices.

In 2002, Kansas approved registration of naturopaths, but did not sanction licensing or any practice of medicine outside of botanical treatments.

In September, 2003, California passed legislation establishing licensure of naturopathic doctors (NDs). The law establishes naturopathic medicine as a distinct system of primary health care practiced by naturopathic doctors. The California Medical Association opposed the legislation because it originally would have allowed naturopathic doctors to be primary care providers, including, calling themselves physicians, prescribing medications, performing minor surgical procedures, and delivering babies. The final bill requires that naturopathic doctors may not call themselves physicians and requires physician oversight for prescribing medications and childbirth assistance. NDs must meet the same criteria as certified nurse midwives to deliver babies. Language on minor surgery was limited to treating minor abrasions and superficial treatments, such as removing warts.

The California law leaves the terms "naturopath" and "naturopathy" in the public domain so that graduates of naturopathic vocational programs or correspondence courses can describe their practice. It does not prevent or restrict the practices or activities of any other practitioner, consultant, or individual, nor does it restrict or prevent individuals engaged in the sale of vitamins, nutritional supplements, herbs or homeopathic remedies from continuing to do so.

(Table summarizing naturopathic practice laws in other states)

Scope of Practice of Naturopathic Physicians in Other States

Practice acts in each state define what licensed members of a profession may and may not do in the provision of health care. Although some professions, such as allopathic physicians, are governed by similar scope of practice laws in all states, other professions, including naturopathic physicians, must adhere to a different set of laws and regulations in each state that licenses them.

The following table, prepared for the California review of the profession, presents information on the legal scope of practice of naturopathic physicians. Naturopathic physicians are allowed to prescribe drugs in some states, but the range of drugs is limited in Maine, New Hampshire, and Vermont. In Maine and Montana, naturopathic physicians are allowed to order x-rays for patients, but not perform the procedure themselves.

Scope of Practice for Licensed Naturopathic Physicians, 2000*
  AK AZ CT HI ME MT NH OR UT VT WA
Prescribe drugs no yes no no limited yes limited yes yes limited yes
Minor Surgery no yes yes no yes yes no yes yes no limited
Hydrotherapy yes yes yes yes yes yes yes yes yes yes yes
Colonic Irrigation yes yes yes yes yes yes yes yes yes yes yes
Naturopathic manipulation yes yes yes yes yes yes yes yes yes yes yes
Physiotherapy yes yes yes yes yes yes yes yes yes yes yes
Electrotherapy yes yes yes yes yes yes yes yes yes yes yes
X-ray yes yes yes yes can order can order yes yes yes yes yes
Venipuncture yes yes yes yes yes yes yes yes yes yes yes
Obstetrics no yes yes yes no yes with certificate yes with certificate yes with certificate yes not specified yes with certificate
Gynecology yes yes yes yes yes yes yes yes yes yes yes
Botanical medicine yes yes yes yes yes yes yes yes yes yes yes
Acupuncture no yes no no yes yes yes no no no no
Nutrition yes yes yes yes yes yes yes yes yes yes yes
Homeopathy yes yes yes yes yes yes yes yes yes yes yes

*Does not include California, where licensure was just established in statute in September, 2003, and has not yet been implemented.

Source: Dower and O'Neil, Profile of a Profession: Naturopathic Practice, University of California-SF, Center for the Health Professions, September 2001, From American Association of Naturopathic Physicians, Alliance for State Licensing, 2001.

Alternatives to Licensure

Types of Regulation

There are three primary forms of regulation used to grant individuals the right or privilege to perform certain activities: licensure; certification; and registration. (See, Ontario Regulatory Advisory Council, Report on Regulating, De-Regulating and Changing Scopes of Practice in the Health Professions, April, 2003.)

  • Licensure is the most restrictive mechanism and entails the creation of a monopoly on the regulated activity of a profession through enactment of profession-specific Practice Acts. Licensed practitioners gain an exclusive right to deliver services, and the profession enjoys protection of its title. Certification is less restrictive than licensure. It is achieved through the use of title protection acts that give a designated "recognition" to individuals who meet qualifications set by a regulatory agency. Non-certified individuals may still offer services, but they are prohibited from using the term "certified" or using the designated title.
    Certification is also used in the context of licensure as in the American Medical Association's scheme of specialty boards which certify physicians specializing in different practice areas. In this context, certification denotes that a licensed practitioner has met certain professional standards.
  • Registration is the least restrictive regulatory mechanism and is achieved through registration requirement acts. Registration requires an individual to file his or her name and address with a designated agency. Unlike licensure, registration does not require complex or onerous pre-entry screening requirements, nor is a registration regime exclusionary. It does little more than provide a roster of practitioners.

Administration of Regulation

The actual regulation of a profession is carried out through administrative structures and laws that establish the regulatory framework for the profession.

How regulation is achieved reflects the legislature's delegation of its regulatory authority to another body to carry out the regulation. According to the Canadian review, the three main institutional frameworks identified in the literature for regulatory administration are: direct government control; partial self-regulation; and self-regulation.

  • Direct Government Control: Under direct control, the state is responsible for all aspects of regulation and administration, including setting requirements for entry to practice, professional standards, investigation of complaints, and discipline. Direct control can occur with or without the assistance of an advisory board. For example, in New York state, the majority of health care professions are licensed and regulated by the Board of Regents (a citizen body) or the Office of the Professions of the Department of Education, with a few regulated by the Department of Health. According to the Canadian review, direct government control is the least used institutional framework for regulation.
  • Partial Self-Regulation: The majority of states, including Florida, California, Connecticut, Alaska and Montana, utilize some form of partial self-regulation. The profession is self-governing in the sense of governing its membership (or it may be governed by a dominant related profession), but many regulatory functions are undertaken by a state agency. Such functions include administrative support, investigation of complaints and adjudication of discipline matters.
  • Self-Regulation or Self-Administration: In a number of states, including Alabama, Iowa, New Hampshire, and South Dakota, health professions are self-governing. With self-regulation, the governing body, whether a Council, Board, or College, is responsible for all decisions both administrative and profession-specific, including clinical, ethical, investigative and disciplinary. A majority of the governing body's members are members of the profession who may either be appointed by the governor or elected from the membership.
    In a broader sense, "self-regulation" means that a member's professional conduct is judged by a jury of their peers, regardless of the bureaucratic form of administration. The hallmark of self-regulation is peer review in clinical review and disciplinary proceedings.

Trends in Regulation of Health Professions in Other Countries

Review of regulatory frameworks in various countries points to several trends in the approaches being taken to deal with the changing and often conflictive relations among health care professions.

Consolidation of Practice Acts in Canada

Canadian provinces have been involved in a long process of consolidating their health care practice acts. Separate acts governing physicians, optometrists, dentists, podiatrists, chiropractors, registered nurses and naturopaths have been repealed and replaced by a uniform Health Professions Act. Individual professions are regulated through administrative rules that focus on quality assurance and improved practice standards.

In British Columbia for example, prior to the repeal of separate practice acts in 1999, the scopes of practice of the regulated health professions were framed in exclusive and restrictive terms. The right to provide health services within the scope of practice of a particular profession was restricted to persons who met the requirements of the regulatory body of that profession.

With the passage of a new Health Professions Act in British Columbia, the scope of practice statement for each health profession is no longer exclusive. Aspects of the scope of practice of each health profession may overlap, or be shared, with those of other health professions. Now the only restrictive element of a profession's scope of practice is any reserved act within its scope that presents a significant risk of harm. Reserved acts that represent significant risk of harm include invasive acts, prescribing drugs, managing labor or delivery of a baby, and prescribing or fitting devices for vision, hearing, or dental conditions.

Standardization of Critical Professions in Europe

In the European Community, the delivery of health care services is the domain of member states. The European Union (EU) is currently working on common standards for recognition of professional qualifications that will enable professionals to have greater mobility and consumers to have easier access to skilled care among member states.

The framework being used will establish EU standards for critical professions that involve public risk, while allowing member states to regulate other professions. The professions currently proposed for EU regulation include: medical doctors; nurses responsible for general practice; dentists; veterinary surgeons; midwives; pharmacists; and architects. (Commission of the European Communities, Proposal for a Directive of the European Parliament and of the Council on the Recognition of Professional Qualifications, July, 2003.)

Wide Variation in Regulation of Complementary and Alternative Medicine

Regulation of complementary and alternative medicine is not being addressed by the European Union, and varies according to member states. According to a survey of regulation in member states (Report on the Regulation of Practitioners of Complementary and Alternative Medicine in Ireland, by the Institute of Public Administration, 2002), there is no uniform approach to regulation of complementary and alternative medical practices, and countries are moving very cautiously in this area. The report found no example of a system of statutory registration for such therapies.

The report found a strong emphasis on self-regulation in Europe. It found that generally there is more freedom for complementary and alternative practitioners to practice in "common law" countries, such as Ireland and Britain, than in countries with a "civil law" tradition, such as France and Spain, where only medical doctors may practice certain complementary and alternative therapies.

In the United Kingdom, the "common law" legal system has allowed a "free market" situation to exist where anyone can practice complementary and alternative medicine as long as they do not falsely call themselves a doctor or treat specified conditions that are reserved for licensed practitioners.

In many countries, there is special recognition for particular therapies that are seen as particularly "advanced" or in a good position to benefit from regulation, such as chiropractic or osteopathy in Britain, chiropractic and naprapathy (the treatment of locomotor disorders) in Sweden, and homeopathy, acupuncture, osteopathy and chiropractic in Belgium. Homeopathy and acupuncture are recognized in the French system but may be practiced only by medical doctors. France has recently considered the regulation of osteopathy and chiropractic. In Spain, only fully qualified medical doctors may provide medical treatments, whether alternative or not.

Roles of Traditional and Alternative Practices in Other Regions

The variety of roles of alternative health practices is even wider when considering health care systems throughout the world. The World Health Organization (WHO) has established a strategy for 2002-2005 to improve understanding and use of traditional medicine. The WHO Traditional Medicine Team distinguishes three types of health care systems based on the degree to which traditional or alternative medicine is officially recognized as part of health care:

  • Integrative systems: where traditional medicine is officially recognized and incorporated into all areas of health care provision (health care delivery, education, training, regulation and insurance). For example, China, Republic of Korea and Vietnam have integrative systems.
  • Inclusive systems: where traditional medicine is recognized, but is not completely integrated into all aspects of health care. This is typical of countries such as the United States, Canada, United Kingdom, Norway, Germany and Australia, and also Nigeria, India, Ghana, Indonesia, Sri Lanka, Japan and the United Arab Emirates.
  • Tolerant systems: where the national health care system is totally based on allopathic medicine, but where some traditional health practices are tolerated by law, as is the case in Italy.

FINDINGS: LICENSURE ISSUES IN FLORIDA

The Small Number of Naturopathic Physicians

Naturopathy has a small number of professionals compared to other related health care professions. According to the American Association of Naturopathic Physicians, the number of licensed naturopathic physicians in the U.S. is 1,076. This compares to the estimated 64,100 active chiropractic physicians and 44,731 osteopathic physicians in the U.S. in 2000, according to federal Department of Health and Human Services' Health Workforce Personnel Factbook.

According to 2000 figures obtained from state licensing boards for the California review of naturopathic licensure, approximately 1,313 naturopathic physicians were licensed in the U.S. (Profile of a Profession: Naturopathic Practice, University of California, Center for the Health Professions, September 2001). The larger number from the California report includes practicing physicians as well as those persons who may not be actively practicing, practicing in another state, or retired.

In Florida, with new licensure closed in 1959, currently there are only 7 active licensed naturopathic physicians, compared to 43,567 medical doctors, and 4,356 chiropractic physicians.

Number of Licensed Naturopathic Physicians, 2000
State Number
Alaska 21
Arizona 127
Connecticut 106*
Florida 7**
Hawaii 63
Maine 10
Montana 41
New Hampshire 19
Oregon 410
Utah 19
Vermont 63
Wahington 427
TOTAL 1313

*Connecticut's total includes 68 in-state naturopaths and 38 out-of-state.
**The California study reports 56 licensed practitioners in Florida, but this included non-active licensees at the time.

Source: Profile of a Profession: Naturopathic Practice, Dower and O'Neil, University of California, S.F., Center for the Health Professions, September 2001

Active Licensed Health Care Practitioners in Florida
Selected Professions 2001-2002
Registered Nurses 177,225
Medical Doctors 43,567
Massage Therapists 20,031
Chiropractic Physicians 4,356
Osteopathic Physicians 3,943
Podiatric Physicians 1,523
Licensed Acupuncturists 1,202
Naturopathic Physicians 7

Source: Department of Health,
Medical Quality Assurance Annual Report, 2001-2002

One estimate of how many naturopathic physicians might be licensed in Florida if the state reestablished licensure is based on the percentage of the U.S. population living in Florida. Florida population represents 5.7% of the national total. If the total number of 1,076 licensed naturopathic physicians in the U.S. practiced equally among the states, an estimated 5.7% might expect to be licensed in Florida. At this ratio, 61 of the 1,076 licensed naturopathic physicians nationwide might be expected to be licensed in Florida within the first several years.

A Broad Scope of Practice that Overlaps Related Professions

Current Scope of Practice of Licensed Naturopathy in Florida

The current scope of practice of naturopathy in Florida Statutes contains a wide range of treatment modes that overlap with the scope of practice of other licensed health professionals in the state.

Section 462.01 (1), F.S., defines naturopathy in the following terms:

(1) "Natureopathy" and "Naturopathy" shall be construed as synonymous terms and mean the use and practice of psychological, mechanical, and material health sciences to aid in purifying, cleansing, and normalizing human tissues for the preservation or restoration of health, according to the fundamental principles of anatomy, physiology, and applied psychology, as may be required. Naturopathic practice employs, among other agencies, phytotherapy [use of plants], dietetics, psychotherapy, suggestotherapy, hydrotherapy, zone therapy, biochemistry, external applications, electrotherapy, mechanotherapy, mechanical and electrical appliances, hygiene, first aid, sanitation, and heliotherapy; provided, however, that nothing in this chapter shall be held or construed to authorize any naturopathic physician licensed hereunder to practice materia medica or surgery or chiropractic medicine, nor shall the provisions of this law in any manner apply to or affect the practice of osteopathic medicine, chiropractic medicine, Christian Science, or any other treatment authorized and provided for by law for the cure or prevention of disease and ailments.

The professional titles of "naturopathic physician" and "naturopathic doctor" are not established by Florida Statutes.

The use of archaic terms for procedures that provide a broad and unclear scope of the profession reflect the fact that licensure of naturopathic doctors has been frozen since 1959 and the practice act has not been updated to reflect changes in health care.

Proposed Expanded Scope of Practice of Naturopathic Physicians

The Florida Naturopathic Physician Association proposes to replace the current practice act for naturopathy with an expanded scope of practice for naturopathic physicians. According to the MNP, naturopathic practice includes the following diagnostic and treatment modalities:

  • Primary Care: Naturopathic physicians consider themselves to be general practitioners trained as specialists in natural medicine. Naturopathic physicians perform physical examinations, laboratory testing, gynecological exams, nutritional and dietary assessments, metabolic analysis, and allergy testing. They may order x-ray, ultrasounds, other imaging procedures and other diagnostic tests.
  • Clinical Nutrition: Naturopathic physicians may use specific individual diets, fasting, and nutritional supplements with their patients to treat many medical conditions.
  • Botanical Medicine: Naturopathic physicians use plant substances for their healing effects and nutritional value.
  • Homeopathic Medicine: Naturopathic physicians use homeopathic medicines which are very small doses of natural substances that are believed to stimulate the body's self-healing. Based on the principle that "like cures like," the patient receives tiny dosages of natural substances that in larger dosages would cause the same symptoms as the ailment.
  • Physical Medicine: Naturopathic medicine includes methods of therapeutic manipulation for muscles and bones. Naturopathic physicians also employ therapeutic exercise, massage, hydrotherapy, gentle electrical therapies, ultrasound, and heat and cold. While naturopathic medicine includes spinal manipulation, naturopathic physicians differ from chiropractors in that naturopathic practice includes a broader range of therapies.
  • Oriental Medicine: Naturopathic physicians are trained in the fundamentals of oriental medicine and diagnosis. They use acupuncture, acupressure and Chinese herbal medicine to promote healing.
  • Lifestyle Counseling and Stress Management: Naturopathic physicians are trained in counseling, nutritional balancing, stress management, hypnotherapy and biofeedback. They also attend to environmental and lifestyle factors that affect their patient's health.
  • Natural Childbirth: Naturopathic physicians, with additional specialty training, provide natural childbirth care in an out-of-hospital setting. They provide prenatal and postnatal care.
  • Minor Surgery: As primary care physicians, naturopathic physicians perform in-office minor surgery including repair of superficial wounds and removal of foreign bodies, warts, and cysts with local anesthesia.

Overlap with Other Licensed Health Professions

The scope of practice of naturopathic physicians described by the American Association of Naturopathic Physicians (AANP), and the Florida Naturopathic Physician Association (FNPA) includes a broad range of practices that are already established as part of the scope of practice of other health care professions licensed in Florida, including osteopathic medicine, chiropractic medicine, acupuncture, massage and midwifery.

The most inclusive scope of health care practice is reserved for the practice of medicine. Other health care professions have been established as separate from the medical practice reserved for medical doctors, by establishing a more narrow scope of practice limited to treatment of a specific part of the body and using specific treatment modalities.

  • Medical Practice -- Section 458.305(3), F.S., defines the "practice of medicine" as "the diagnosis, treatment, operation, or prescription for any human disease, pain, injury, deformity, or other physical or mental condition.
    The statutes establish the term "physician" to mean "a person who is licensed to practice medicine in this state."

The Florida Medical Association (FMA) has stated in a memo to committee staff dated October 28,2003, that the legislation filed in 2003 (SB 2014 and HB 1615) would have allowed unqualified persons to practice several health care professions, including medicine. According to the FMA, the bill would have allowed a person who attends a school of naturopathy to diagnose, treat, operate and prescribe for disease, pain, injury or other physical or mental condition, and this is the definition of the practice of medicine.

The scope of practice of each of the other health professions that may be impacted by the proposed scope of practice of naturopathic physicians is as follows:

  • Osteopathic Medicine -- Section 459.003(3), F.S., defines the "practice of osteopathic medicine" as "the diagnosis, treatment, operation, or prescription for any human disease, pain, injury, deformity, or other physical or mental condition, which practice is based in part upon educational standards and requirements which emphasize the importance of the musculoskeletal structure and manipulative therapy in the maintenance and restoration of health."
  • Chiropractic Medicine -- Section 460A03(9)(a), F.S., defines the "practice of chiropractic medicine" as "a noncombative principle and practice consisting of the science, philosophy, and art of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education. No person other than a licensed chiropractic physician may render chiropractic services, chiropractic adjustments, or chiropractic manipulations."
  • Acupuncture -- Section 457.102(1), F.S., defines "acupuncture" as "a form of primary health care, based on traditional Chinese medical concepts and modern oriental medical techniques, that employs acupuncture diagnosis and treatment, as well as adjunctive therapies and diagnostic techniques, for the promotion, maintenance, and restoration of health and the prevention of disease. Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi Gong, oriental massage, herbal therapy, dietary guidelines, and other adjunctive therapies, as defined by board rule."
  • Massage -- Section 480.033(3), F.S., defines "massage" as "the manipulation of the soft tissues of the human body with the hand, foot, arm, or elbow, whether or not such manipulation is aided by hydrotherapy, including colonic irrigation, or thermal therapy; any electrical or mechanical device; or the application to the human body of a chemical or herbal preparation."
  • Midwifery -- Section 467.003(8), F.S., defines "midwifery" as "the practice of supervising the conduct of a normal labor and childbirth, with the informed consent of the parent; the practice of advising the parents as to the progress of the childbirth; and the practice of rendering prenatal and postpartal care."

The initial draft of legislation proposed for the 2004 session by the Florida Naturopathic Physicians Association addresses some of these scope-of-practice issues by excluding major surgery and "materia medica," a term relating to prescribing drugs, and by proposing to specifically exclude acupuncture, which is already licensed in Florida.

Overlap with Traditional, Complementary and Alternative Practices

The Coalition for Natural Health (CNH), which represents individuals who practice natural therapies but not as physicians, has stated in a memo to committee staff dated November 19, 2003, that it is also opposed to Florida licensure of naturopathic physicians. The coalition states that it represents traditional "naturopaths" who use natural therapies and modalities through education and counseling. The coalition is opposed to licensure of "naturopathic physicians" who want to be able to practice as primary care physicians. The coalition is concerned that licensure of naturopathic physicians would make it illegal for anyone else to provide traditional and natural therapies.

Unclear Risk of Harm to the Public

No Documented Risk of Serious Harm in Florida from Not Licensing Naturopathic Physicians with an Expanded Scope

In support of licensure, the Florida Naturopathic Physician Association provided only two actual cases of serious harm, both of which occurred in other states.

  • One case occurred in North Carolina in 1999, when a person calling himself a naturopathic doctor persuaded the mother of an 8 year old, insulin-dependent diabetic girl to discontinue insulin injections and to instead treat her with herbs. The girl died soon afterwards.
  • In the other case, a man died in Van Nuys, California in October, 2002, after receiving a fatal injection from a woman calling herself a naturopath.

Many of the practices proposed to be licensed under naturopathic physicians are practiced with limited risk by practitioners who are not required to be licensed, such as traditional naturopaths, aromatherapists and Reiki masters. In addition some of the practices for which some risk has been identified are licensed under existing practitioners in Florida including: acupuncturists and midwives.

Despite at least 246 traditional naturopaths practicing in Florida who are not required to be licensed under Florida Statutes, neither the Florida Naturopathic Physician Association nor the Department of Health provided evidence of harm from their practice. Traditional naturopaths practice many of the natural healing modalities included in the proposed scope of practice of naturopathic physicians including: exercise; diet therapy; herbs; reflexology; herbology; electricity; massage; manual manipulation; magnetism; color therapy; sound therapy; nutritional supplementation; homeopathy; iridology; and kinesiology. The number of traditional naturopaths is based on reports from the American Naturopathic Medical Association and the American Naturopathic Medical Certification and Accreditation Board (ANMCAB) which offers private sector (non-governmental) certification in naturopathy. They reported there were 3,679 certified. naturopaths in the U.S. in January, 2001, although actual number of practicing traditional naturopaths is estimated to be greater because traditional naturopaths are not required to be certified.

According to the California report (Profile of a Profession: Naturopathic Practice, University of California, S.F., Center for the Health Professions, September 2001), on the continuum of potential risk of harm to patients, traditional naturopathy falls close to the safe end of the spectrum. Because "the goal is to optimize the body's self-healing ability, rather than to address symptoms of disease, such as infection, there is no occasion in which a naturopath would ever diagnose or treat a disease, perform any invasive procedure, perform surgery, or prescribe drugs or pharmaceuticals." (Coalition for Natural Health, 2000).

According to the California report, the approach of traditional naturopathy minimizes potential risk of harm to the public. Most of the modalities and therapies employed by traditional naturopaths pose little to no harm because naturopaths are not licensed to dispense regulated products, naturopaths limit their work to promoting health and wellness through education, and they specialize in detoxification, gentle natural therapies, and lifestyle changes. At the same time, even unregulated substances, such as herbs, may pose some risk of harm.

According to the Florida Department of Health, because currently licensed naturopaths in Florida are not allowed to perform minor surgery or prescribe pharmaceutical drugs, the current risk to the public is low. The department reports no recent prosecutions of unlicensed naturopathic practice. According to the department, the absence of unlicensed activity reflects the availability of naturopathic treatment modalities provided by many licensed health care practitioners, and current statute (s. 456.41, F.S.) provides that patients may choose to be treated by complementary and alternative modalities.

Potential Risk from Licensing Naturopathic Physicians

As the review by the California Center for Health Professions points out, while many of the modalities and therapies employed by naturopathic physicians, such as nutrition guidance and some herbal therapies, pose little to no harm to the individual, some modalities such as minor surgery and prescription of some pharmaceutical drugs, are less inherently safe. While naturopathic medicine may emphasize the use of natural, non-toxic therapies, the inclusion of some invasive techniques raises the potential for risk of harm. (Profile of a Profession: Naturopathic Practice, University of California, S.F., Center for the Health Professions, September 2001 ).

In a memo to committee staff dated October 28,2003, the Florida Department of Health determined that the proposed licensure of naturopathic physicians would likely increase the risk of harm to the public compared to current practice (this assessment was based on review of an early draft of proposed legislation). The current practice act prohibits licensees from doing any type of surgery. According to the department, this greatly limits the type of patient encounters that could result in patient harm. The proposed bill would only prohibit "major surgery." This would allow licensees to practice "minor surgery," which is undefined in the bill, and would increase the potential risk to patients.

The Department of Health points out that currently, licensed naturopaths in Florida are not practicing any type of medicine---they are practicing naturopathy. A consumer does not see the term "medicine" in the naturopathy practice act, as they would with a licensee practicing medicine, osteopathic medicine, chiropractic medicine, or podiatric medicine.

The proposed bill would specifically add the terms "Naturopathic Medicine, Naturopathic Physician and Doctor of Naturopathic Medicine" to statutes. According to the department, this would be a significant change in how a consumer currently perceives naturopathy. The department has determined that this would increase the risk that a patient would go to a naturopathic medical practitioner expecting to receive full medical care, when the practitioner has more limited training and expertise than that required of a Medical Doctor or Doctor of Osteopathy to practice medicine.

The Florida Medical Association has also expressed concerns for the "safety of patients and the general public" from the proposed licensure of naturopathic physicians. According the association, "the proposed scope of practice is essentially the practice of medicine."

Recognized Skills -- Education and Training

In recent years, naturopathic physicians have improved the educational standards of their profession through nationally accredited four year programs, standardized licensure examinations, and support of professional associations. The profession is still in the process of development. The training programs for naturopathic physicians do not include residency programs after graduation, such as those required of Medical Doctors and Osteopathic Physicians, which provide rigorous, supervised, hands on training. Some of the colleges providing four year programs are not yet fully accredited.

Educational Requirements

The Council on Naturopathic Medical Education (CNME) has accredited or recognized five, four-year, graduate-level, naturopathic medical education programs leading to the Doctor of Naturopathic Medicine (N.M.D.) or Doctor of Naturopathy (N.D.) degree in the U.S.

Accreditation standards for naturopathic physician education established by CNME include a minimum of three years of undergraduate premedical study from an accredited college or university as a prerequisite for entry to a naturopathic medical school.

An accredited naturopathic medical college program is a four-year curriculum. The first two years of study focus on standard medical sciences (e.g., anatomy, physiology, pathology, biochemistry, immunology, embryology and related areas). Specialty courses are required in pediatrics, obstetrics, cardiology, dermatology, neurology, urology, and other clinical sciences.

The second two years focus on clinical skills and a range of natural therapeutics. Training in naturopathic therapeutics includes botanical medicine, homeopathy, natural childbirth, acupuncture, hydrotherapy, naturopathic manipulative therapy and therapeutic nutrition. In addition to these natural therapies the second two years of training includes physical diagnosis, laboratory and x-ray diagnosis, and pharmacology. The four years training includes a clinical internship that consists of 1500 hours of treating patients under the supervision of licensed naturopathic and conventional medical physicians.

National Accreditation Organization

The Council on Naturopathic Medical Education (CNME) is recognized by the U.S. Department of Education as an accrediting agency for naturopathic graduate education programs under Sections 114 and 496 of the Higher Education Act of 1965. The Act requires federal recognition of accrediting organizations in order for the programs they accredit to be eligible for participation in federal educational loan programs and receive federal grants.

CNME lost its federal recognition, January 16, 2001, because the National Advisory Committee on Institutional Quality and Integrity of the U.S. Secretary of Education found that CNME had not responded appropriately to violations of its standards at Southwest College of Naturopathic Medicine and Health Sciences in Tempe, Arizona. The college had gone through an administrative upheaval that nearly led to its closure in 1997 and 1998. The committee concluded that CNME had failed to issue a timely order to show cause why Southwest should not have its candidacy for accreditation ended.

On September 10,2003, CNME regained its recognition by the U.S. Department of Education. CNME was given initial recognition for two years as an accrediting agency for graduate-level, four-year naturopathic medical education programs leading to the Doctor of Naturopathic Medicine (N.M.D.) or Doctor of Naturopathy (N.D.).

Naturopathic Medical Colleges

The following descriptions of approved educational programs were taken from school brochures and Internet sites (see Sunrise Review of Naturopathic Physicians, Colorado Office of Policy and Research, 1998).

  • Bastyr University (Seattle, WA) -- Bastyr University was founded in 1978 to train naturopathic physicians. Degree programs have been added in nutrition, acupuncture, oriental medicine and psychology. Bastyr is accredited by the Council on Naturopathic Medical Education (CNME), and also the Commission on Colleges of the Northwest Association of Schools and Colleges. The National Institutes of Health, Office of Alternative Medicine has funded an AIDS Research Center at Bastyr to study the use of alternative and complementary therapies for the treatment of HIV/AIDS.
  • Florida College of Integrative Medicine (Orlando, FL) -- The Florida College of Integrative Medicine was established in 1990 as the National College of Oriental Medicine with a single program in Acupuncture, Herbology and Oriental Medicine. The current College of Integrative Medicine includes Western biomedical sciences, technologies and clinical practices to support integration of naturopathic medicine within the overall health care delivery system.
    On May 14, 2003, the Council on Naturopathic Medical Education (CNME) accepted the Florida College of Integrative Medicine's application for candidacy for accreditation of its naturopathy program. Candidacy status indicates the college or program satisfies the eligibility requirements, complies with the standards to the degree expected for its stage of development, and has demonstrated the potential for achieving accreditation within five years of having obtained candidacy.
    The college's Master of Science in Oriental Medicine Degree Program is accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). A special Doctor of Naturopathic Medicine program for licensed MDs, Doctors of Osteopathy and Doctors of Chiropractic, has been approved by the Florida Commission for Independent Education.
  • National College of Naturopathic Medicine (Portland, OR) -- The National College of Naturopathic Medicine was founded in 1956. It is the oldest naturopathic medical school in North America. Of the total 4,824 hours of instruction, 1,974 is clinical training.
  • Southwest College of Naturopathic Medicine and Health Sciences (Tempe, AZ) -- The Doctor of Naturopathic Medicine program at Southwest College of Naturopathic Medicine and Health Sciences began in 1993. Southwest College is approved by an autonomous Arizona Naturopathic Physicians Board of Medical Examiners and by the Arizona Board for Private Post-secondary Education.
  • University of Bridgeport College of Naturopathic Medicine (Bridgeport, CT) -- The University of Bridgeport, College of Naturopathic Medicine was granted candidacy status by the Council on Naturopathic Medical Education in 2001.

Florida Medical Association's Concerns Regarding Training

According to the Florida Medical Association (FMA), the prerequisites for becoming a naturopath do not adequately prepare a person to perform the acts that the proposed scope of practice would allow. In a memo to committee staff dated October 28, 2003, the FMA expressed concern that neither the proposed legislation from 2003, nor the naturopathic schools, requires a bachelor's degree as a prerequisite to naturopathic training. According to the FMA, a person who does not have a bachelor's degree would be allowed to perform the same acts as a medical doctor, including among other things, perform surgery, prescribe controlled substances and perform psychotherapy.

In contrast, the FMA points out that a medical doctor receives the following training:

  • A Bachelor's degree in science;
  • Two years of medical school consisting primarily of classroom study;
  • Two years of medical school consisting of clinical work; and an additional
  • Three-year labor intensive residency program consisting of hands-on clinical practice.

In addition, the FMA points out that many physicians complete a fellowship lasting two to four years that consists of more clinical, hands-on practice. A physician receives a minimum of six years of classroom study and five years of clinical practice before he or she becomes licensed as a physician in Florida.

Licensure Examination

The Naturopathic Physicians Licensing Examination (NPLEX) is the standard examination used by all licensing jurisdictions for Naturopathic physicians in the U.S. For the purposes of a Sunrise Review of the naturopathic physicians' request for licensure in Colorado (1998), the testing expert of the Colorado Department of Regulatory Agencies, Division of Registrations, reviewed the development, scoring, and security of the NPLEX examination and concluded that the NPLEX satisfies standards for credentialing tests.

The NPLEX includes 5 basic science exams (anatomy, physiology, pathology, biochemistry, microbiology and immunology) that are taken after the first 2 years of training. The clinical science examinations are taken following graduation after the 4th year of school. These clinical exams include: clinical and physical diagnosis, laboratory diagnosis and diagnostic imaging, botanical medicine, pharmacology, nutrition, physical medicine, homeopathy, minor surgery, psychology and lifestyle counseling, and emergency medicine. Individual jurisdictions may give additional examinations in jurisprudence and acupuncture.

NPLEX was formed in 1985 to establish licensing standards that could be accepted across jurisdictions. Initial development of the examination was done by the National Assessment Institute, which set standards for test development, administration, item review, and scoring. NPLEX has contracted with other organizations (including Columbia Assessment Services and the Washington State Department of Health) to provide exam production and scoring services.

Currently, NPLEX is forming a new organization known as the North American Board of Naturopathic Examiners (NABNE) to oversee administration of the examination. NPLEX will retain its role as the producer of the licensing board examination, while NABNE will accept and review credentials for those wanting to take the exam. NABNE will also set up testing centers in the U.S. and Canada for administration of the exams. NABNE is an examining board, not a licensing board. State jurisdictions still hold all authority for investigating the credentials of and approving candidates for licensure.

Professional Associations

The American Association of Naturopathic Physicians (AANP) was founded in 1985 to represent naturopathic physicians who are licensed or eligible for licensing as primary care providers and to further the development of the profession. According to AANP, the association's membership has grown to over 1800 members, including students, supporting, and corporate members.

Two competing organizations claim to represent the naturopathic profession in Florida: the Florida Naturopathic Physicians Association; and the Florida Association of Naturopathic Medicine.

Cost Impacts of Licensure

High Costs of Licensure and Oversight Board

Proponents of licensure have not addressed how the profession will be able to support the costs of licensure with the small number of practitioners who would be expected to be licensed in Florida. Section 456.025(3), F.S., requires that each licensed health profession ensure that license fees are adequate to cover all anticipated costs of licensure and maintain a reasonable cash balance. According to the Department of Health, the Naturopaths currently carry a deficit of $247,390 for administration of licensure. This does not include support for a board that would be established by the proposed legislation.

Costs of licensure oversight generally include such costs as reviewing applications for licensure, investigating complaints, handling discipline, and supporting board meetings, policy, and rulemaking. These costs vary by profession depending on the size of the profession and whether it has a separate board.

Based on expenditure reports for the Board of Medicine and the Board of Osteopathy for the fiscal year ending June 30, 2003, the estimated biennial renewal fee for Naturopathic Medicine would range from $686 to $718. This would be required to meet estimated annual expenses to cover the cost of licensure and support for a board of Naturopathic Medicine that are expected to be in the range of $343 to $359 per licensee each year.

These estimates are based on the total expenditures for Fiscal Year 2002-2003 for the Board of Medicine of $14,742,991 for approximately 43,000 licensed MDs, which equals approximately $343 per licensee per year. The total expenditures for the Board of Osteopathic Medicine were $1,505,862 for approximately 4,200 licensed ODs, which equals approximately $359 per licensee per year. The ratio of costs per licensee for the two professions is very similar. The Board of Osteopathic Medicine has about 1/10th the number of licensees as the Board of Medicine and approximately 1/10th the expenditures.

For a very small profession the costs per licensee could be much higher. Currently, the two smallest licensed health care professions--naturopathy with 7 active licenses and midwifery with 133--have average annual licensure costs that of $585 per practitioner per year, which do not include support for a board. These costs would require a biennial renewal fee of $1,170 per licensee to meet expenses.

An estimated 61 naturopathic physicians might be licensed in Florida in the first several years if licensure is reestablished. This estimate is based on the percentage of the U.S. population living in Florida. Florida population represents 5.7% of the national total. If the total number of 1,076 licensed naturopathic physicians in the U.S. practiced equally among the states, an estimated 5.7% might expect to be licensed in Florida. At this ratio, 61 of the 1,076 licensed naturopathic physicians nationwide might be expected to be licensed in Florida.

The Florida Medical Association (FMA) has expressed concern that the Medical Quality Assurance Trust Fund that uses licensure fees to fund the boards and Department of Health licensure functions is already not adequately funded. The FMA believes that it would not be fiscally prudent for the Trust Fund to take on another inadequately funded profession, when the fund is expected to encounter increased deficits in coming years.

Reimbursement of Naturopathic Medicine

Because of the small number of naturopathic physicians that might be expected to be licensed in Florida, there would not be a significant impact, either positive or negative, on spending for health care services. However, in states where naturopathic physicians are licensed there continue to be issues regarding reimbursement for services.

Federal reimbursement of naturopathic medicine

According to the California review, Medicare does not provide reimbursement for services rendered by naturopathic physicians. Medicaid will cover acupuncture and naturopathic medical services if the practitioner is licensed by the state where the service is provided, and the service is considered a medical necessity. (Profile of a Profession: Naturopathic Practice, University of California, S.F., Center for the Health Professions, September 2001.)

Private sector reimbursement of naturopathic medicine

According to the California review, the majority of complementary and alternative medical treatments are not reimbursed by insurance companies, although several health plans and Health Maintenance Organizations (HMOs) have begun to expand coverage and include chiropractic and acupuncture. Managed care companies that do provide such coverage typically provide it through a "rider" specifically covering the services. The rider requires a policy holder to pay for services out-of-pocket, but at a discount for services provided by practitioners who are members of the plan's credentialed network. (Profile of a Profession: Naturopathic Practice, University of California, S.F., Center for the Health Professions, September 2001.)

CONCLUSIONS

Components of Proposed Legislation

Draft legislation proposed by the Florida Naturopathic Physician Association to reestablish licensure of naturopathic physicians with an expanded scope of practice amends ch. 462, F.S., to include provisions that:

  • Establish a Board of Naturopathic Medicine of seven members appointed by the Governor and approved by the Senate, with five naturopathic physicians and two non health care practitioners;
  • Transfer responsibility for rulemaking and discipline from the Department of Health to the Board;
  • Establish new education requirements for licensure that include graduation from a four year post-graduate training program which meets several possible accreditation or certification standards;
  • Establish new examination requirements for licensure that include several possible approved national examinations as well as examinations given by other states;
  • Grandfather in currently licensed naturopathic physicians;
  • Rename the profession from Doctor of Naturopathy to Doctor of Naturopathic Medicine; .
  • Allow for minor surgery; and
  • Provide exemptions to the naturopathic physician scope of practice to provide for the continued practice of supplement retailers, religious freedoms and family remedies.

Conditions that Support Criteria for Licensure

The review found that proponents have provided evidence that naturopathic medicine meets statutory standards of s. 11.62(3), F.S., of the Sunrise Act in terms of:

Whether the practice of the profession or occupation requires specialized skill or training, and whether that skill or training is readily measurable or quantifiable so that examination or training requirements would reasonably assure initial and continuing professional or occupational ability. (s. 11.62(3)(b), F.S.) The review found the profession of naturopathic physician has specialized skills and training as evidenced by:

  • Recognized and accredited training programs for naturopathic physicians; and
  • A recognized national examination for licensure that assesses specialized, measurable skills.

Conditions that Do Not Support Criteria for Licensure

The review found that proponents have not provided evidence that naturopathic medicine meets statutory standards of s. 11.62(3), F.S., of the Sunrise Act, and that there is evidence to the contrary, in terms of:

Whether the unregulated practice of the profession or occupation will substantially harm or endanger the public health, safety, or welfare, and whether the potential for harm is recognizable and not remote. (s. 11.62(3)(a), F.S.) The review found there is:

  • No documentation of substantial risk from not licensing naturopathic physicians in Florida; and
  • Potential risk from licensing naturopathic physicians to provide primary care in broad areas.

Whether the regulation will have an unreasonable effect on job creation or job retention in the state or will place unreasonable restrictions on the ability of individuals who seek to practice or who are practicing a given profession or occupation to find employment. (s. 11.62(3)(c), F.S.) The review found that:

  • The proposed scope of practice of naturopathic physicians is very broad; . The scope of practice overlaps with related health professionals that are already licensed, including medical doctors, osteopathic physicians, chiropractic physicians, acupuncturists, massage therapists, and midwives; and
  • Persons who currently practice traditional and alternative health practices including, traditional naturopathy, through non-invasive counseling and guidance, would not be able to practice if naturopathic medicine is licensed.

Whether the public is or can be effectively protected by other means. (s. 11.62(3)(d), F.S.). The review found that:

  • The public can currently receive naturopathic modes of treatment from licensed allopathic and other physicians, and other licensed heath professionals; and
  • The state currently permits many non-invasive, traditional, and alternative health practices through counseling and guidance without state regulation, including those practiced by traditional naturopathy.

Whether the overall cost-effectiveness and economic impact of the proposed . regulation, including the indirect costs to consumers, will be favorable. (s. 11.62(3)(e), F.S.) The review found that:

  • The small number of naturopathic physicians would have difficulty meeting the high costs per licensed practitioner of administering licensure and supporting an oversight board; and
  • It is estimated that the licensure and biennial renewal fee would range from $686 to $718 per licensee.

Recommendations

Section 11.62(6), F.S., requires that when making a recommendation concerning proposed legislation providing for new regulation of a profession, a legislative committee shall determine:

    (a) Whether the regulation is justified based on the Sunrise Review criteria, the information submitted by proponents of the regulation, and the information provided by the department under ss. 11.62(3)-(5), F.S.;
    (b) The least restrictive and most cost-effective regulatory scheme that will adequately protect the public; and
    (c) The technical sufficiency of the proposed legislation, including its consistency with the regulation of other professions and occupations under existing law.

The conclusions of the report are that while there is evidence for support of licensure based on the existence of accredited training programs and licensure exams:

  • The proponents of regulation did not provide evidence that there is substantial harm or that the public is endangered from the unregulated practice of the profession;
  • The department and other sources indicate there is a risk of harm to the public from licensing naturopathic physicians with an expanded scope of practice;
  • Licensure of naturopathic physicians would negatively impact practitioners of traditional and alternative health healing techniques that currently do not have to be licensed; and
  • The broad scope of practice of naturopathic physicians will overlap and compete with related licensed health professionals, including medical doctors, osteopathic physicians, chiropractic physicians, acupuncturists, massage therapists, and midwives.

The conclusions of the report are also that licensure of naturopathic physicians with an expanded scope of practice would not be cost effective because:

  • The small number who would be licensed would have difficulty meeting requirements to fund the cost of administering licensure and support for a board;
  • Licensure of naturopathic physicians would negatively impact the non-invasive practice of traditional naturopathy and other health practices such as aromatherapy, therapeutic touch, and nutritional supplements, through counseling and guidance, which is not required to be licensed under Florida Statutes; and
  • Current statutes already provide cost-effective protection of the public by allowing continued practice of naturopathic modes of treatment by licensed medical doctors and osteopathic physicians, and other licensed health practitioners (s. 456.41, F.S.).

Final draft legislation was not available at the time of this report to conclude whether it is consistent with the regulation of other professions.

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This page was posted on March 9, 2004.