HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/CS/HB 1145 Foreign-licensed Physicians
SPONSOR(S): Health & Human Services Committee, Healthcare Regulation Subcommittee, Snyder and
others
TIED BILLS: IDEN./SIM. BILLS: SB 956
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Healthcare Regulation Subcommittee 14 Y, 1 N, As CS Curry McElroy
2) Health & Human Services Committee 16 Y, 1 N, As CS Curry Calamas
SUMMARY ANALYSIS
The U.S. has a health care provider shortage. This shortage is predicted to continue into the foreseeable future
and will likely worsen with the aging and growth of the U.S. population. Florida is not immune to the national
problem and is also experiencing a health care provider shortage. Although Florida is the third most populous
state in the nation, and has a disproportionately aging population, it ranks 25th in physician to population ratio.
Chapter 458, F.S., provides for licensure and regulation of the practice of allopathic medicine by the Florida
Board of Medicine (BOM) within the Department of Health (DOH). The chapter imposes requirements for
licensure, including education and residency requirements.
Foreign-trained applicants must meet the same requirements as U.S.-trained applicants related to completion
of post-secondary education and obtaining a passing score on licensure examinations. Foreign-trained
applicants must also complete an approved residency. The BOM limits the approved residencies to those
accredited by the Accreditation Council for Graduate Medical Education, College of Family Physicians of
Canada or the Royal College of Physicians and Surgeons of Canada. These entities only accredit U.S. and
Canadian medical residencies. A foreign-trained physician who did not complete a U.S. or Canadian residency
is thus required to complete an additional residency irrespective of how long they have practiced medicine and
whether they completed a residency in another country.
CS/CS/HB 1145 creates an alternative to the approved residency requirement for graduates of a foreign
medical school. Specifically, a foreign-trained applicant may obtain a license to practice medicine in Florida
without completing an approved residency program if the applicant:
Holds an active, unencumbered license to practice medicine in a foreign country;
Has actively practiced medicine in the 4 years preceding the date in which the foreign graduate
submitted an application to obtain licensure;
Has completed a residency or substantially similar postgraduate medical training in a country
recognized by his or her licensing jurisdiction or has practiced medicine in his or her licensing
jurisdiction for at least 5 years; and
Has an offer for full-time employment as a physician for a health care provider that operates in
Florida and maintains employment with the employer, or with another Florida health care provider,
for 2 consecutive years after licensure.
The foreign-trained applicant must still meet all other statutory requirements for licensure.
The bill has no fiscal impact on state or local government.
The bill provides an effective date of July 1, 2023.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
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FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Present Situation
Health Care Professional Shortage
The U.S. has a health care provider shortage. For example, as of January 1, 2023, the U.S.
Department of Health and Human Services has designated 8,294 Primary Care Health Professional
Shortage Areas (HPSAs) (requiring 17,065 additional primary care physicians to eliminate the
shortage), 7,313 Dental HPSAs (requiring 11,909 additional dentists to eliminate the shortage), and
6,599 Mental Health HPSAs (requiring 7,957 additional psychiatrists to eliminate the shortage).1
This shortage is predicted to continue into the foreseeable future and will likely worsen with the aging
and growth of the U.S. population2 and the expanded access to health care under the Affordable Care
Act.3 Aging populations create a disproportionately higher health care demand due to seniors having a
higher per capita consumption of health care services than younger populations. 4 Additionally, as more
individuals qualify for health care benefits, there will necessarily be a greater demand for more health
care professionals to provide these services.
Florida is not immune to the national problem and is experiencing a health care provider shortage itself.
This is evidenced by the fact that for just primary care, dental care and mental health there are 819
federally designated HPSAs within the state.5 It would take 1,745 primary care, 1,305 dental care, and
535 mental health practitioners to eliminate these shortage areas. 6
Physician Workforce Data
The Association of American Medical Colleges Center for Workforce Studies estimates that the U.S.
will face a physician shortage of between 37,800 and 124,000 across all specialties by 2034. 7 The
projected shortfall for primary care physicians ranges from 17,800 to 48,000 physicians and for non-
primary care specialties ranges from 21,000 and 77,100 by 2034. 8
In 2020, there were 286.5 physicians actively practicing per 100,000 population in the U.S., ranging
from a high of 466 in Massachusetts to a low of 196.1 in Idaho. 9 The states with the highest number of
physicians per 100,000 population are concentrated in the northeastern states. 10 Regarding primary
care physicians, there were 94.4 per 100,000 population. 11
1 U.S. Department of Health and Human Services, Health Resources and Services Administration, Designated Health Professional
Shortage Area Statistics, First Quarter of Fiscal Year 2023 Designated HPSA Quarterly Summary , (December 31, 2023),
https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport (last visited March 27, 2023).
2 The U.S. population is expected to increase by 79 million people by 2060, and average of 1.8 million people each year between 2017
and 2060. See U.S. Census Bureau, Demographic Turning Points for the U.S.; Population Projections for 2017 to 2060 (February
2020), available at https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25 -1144.pdf (last visited March 27,
2023).
3 Association of American Medical Colleges, The Complexities of Physician Supply and Demand: Projections from 2019 to 2034, (June
2021), available at https://www.aamc.org/media/54681/download (last visited March 27, 2023).
4 Id.
5 Supra note Error! Bookmark not defined..
6 Id. The population aged 65 and older is expected to grow 42.4% between 2019 to 2034. This grow is primarily du e to a 74% growth in
size of those aged 75 and older.
7 Supra note 3.
8 Id.
9 These totals include allopathic and osteopathic doctors.
10 Association of American Medical Colleges, 2021 State Physician Workforce Data Book, January 2022, pg. 10, available at:
https://store.aamc.org/downloadable/download/sample/sample_id/506/ (last visited on March 27, 2023).
11 Id.
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Florida had 273.9 physicians actively providing direct patient care per 100,000 population in 2020.
Although Florida is the third most populous state in the nation, 12 it ranks as having the 25th highest
physician to population ratio.13 In 2020, Florida had a ratio of 81.5 primary care physicians providing
direct patient care per 100,000 population, ranking Florida 30th compared to other states.14
Licensure of Physicians in Florida
Chapter 458, F.S., provides for the licensure and regulation of the practice of allopathic medicine by the
Florida Board of Medicine within the Department of Health (DOH). The chapter imposes requirements
for licensure examination and licensure by endorsement. 15
Licensure by Examination – U.S.-Trained Applicant
An individual seeking to be licensed by examination as a physician must meet the following
requirements:16
Complete 2 years of post-secondary education which includes, at a minimum, courses in fields
such as anatomy, biology, and chemistry prior to entering medical school;
Graduate from an allopathic medical school recognized and approved by an accrediting agency
recognized by the U.S. Office of Education or recognized by an appropriate governmental body
of a U.S. territorial jurisdiction;
Completed at least one year of approved residency training; and
Obtain a passing score on:
o The United States Medical Licensing Examination (USMLE);
o A combination of the USMLE, the examination of the Federation of State Medical Boards
of the United States, Inc. (FLEX), or the examination of the National Board of Medical
Examiners up to the year 2000; or
o The Special Purpose Examination of the Federation of State Medical Boards of the
United States (SPEX), if the applicant was licensed on the basis of a state board
examination, is currently licensed in at least one other jurisdiction of the United States or
Canada, and has practiced for a period of at least 10 years.
Licensure by Examination – Foreign-Trained Applicant
Foreign-trained applicants must meet the same requirements as U.S.-trained applicants related to
completion of post-secondary education and obtaining a passing score on the USMLE, FLEX or SPEX,
as applicable. Applicants who graduated from an allopathic foreign medical school registered with the
World Health Organization and certified pursuant to statute as meeting the standards required to
accredit U.S. medical schools, are required to have completed at least one year of an approved
residency training.17 Applicants who graduated from an allopathic foreign medical school that has not
been certified pursuant to statute must have:
12 As of July 1, 2022, the U.S. Census Bureau estimated Florida to have 22,244,823 residents, behind California (39,029,342) and
Texas (30,029,572). U.S. Census Bureau, U.S. Annual Estimates of Resident Population for the United States, Regions, States, District
of Columb ia and Puerto Rico: April 1, 2020 to July 1, 2022: available at: https://www.census.gov/data/tables/time-series/demo/
popest/2020s-state-total.html (last visited on March 27, 2023).
13
Supra note 10, at pg. 13.
14 Association of American Medical Colleges, 2019-2020 Florida Physician Workforce Profile, available at https://www.aamc.org/
media/58161/download (last visited March 27, 2023).
15 An individual who holds an active license to practice medicine in another jurisdiction may seek licensure by
endorsement to practice medicine in Florida in lieu of examination. The applicant must meet the same requirements for
licensure by examination. To qualify for licensure by endorsement, the applicant must also submit evidence of the
licensed active practice of medicine in another jurisdiction for at least 2 of the preceding 4 years, or evidence of
successful completion of either a board-approved postgraduate training program within 2 years preceding filing of an
application or a board-approved clinical competency examination within the year preceding the filing of an application for
licensure. S. 458.313(1)(c), F.S.
16 S. 458.311(1), F.S.
17 Id.
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An active, valid certificate issued by the Educational Commission for Foreign Medical Graduates
(ECFMG);18
Passed the ECFMG’s examination; and
Completed an approved residency or fellowship of at least 2 years in one specialty area.
Residency Programs
A residency, also called graduate medical education, is a training program that medical students and
international medical school graduates must complete at a postgraduate hospital. The duration of the
program varies in length from three to eight years depending on the specialty.19 While in a residency
program, residents train in a specialty or core program (e.g., general surgery, pediatrics, or internal
medicine). The residency placement occurs during the final year of medical school. Residents are
matched to a program based on certain criteria including resident preference for a particular specialty,
aptitude based on medical school grades and performance in rotations, and available residency
positions or slots.20
In Florida an approved one-year residency consists of a course of study and training in a single
program for a period of at least 12 months by a medical school graduate (resident). 21 The hospital and
the program in which the resident is participating must be accredited for the training and teaching of
physicians by the Accreditation Council for Graduate Medical Education (ACGME), College of Family
Physicians of Canada (CFPC) or the Royal College of Physicians and Surgeons of Canada (RCPSC)
and the resident must be assigned an allocated position or slot 22 approved by the ACGME, CFPC or
RCPSC.23
Similarly, an approved two-year residency in one specialty area consists of two progressive years in a
course of study and training as long as each year is accepted by the American Board of Medical
Specialties in that specialty for at least twenty-four months by a medical school graduate. The hospital
and the program in which the resident is participating must meet the same accreditation and slot
assignment requirements as an approved one-year residency.24
As noted above, foreign-trained applicants are required to complete a 1-year or 2-year approved
residency to become licensed in Florida. The BOM limits the approved residencies to those accredited
by the ACGME, CFPC and the RCPSC. These entities only accredit U.S. and Canadian medical
residencies. Thus, a foreign-trained physician who did not complete a U.S. or Canadian residency is
required to complete an additional residency irrespective of how long they may have practiced medicine
and whether they previously completed a residency in another country.
Effect of the Bill
18
A graduate of a foreign medical school does not need to present an ECFMG certification or pass its exam if the graduate recei ved his
or bachelor’s degree from an accredited U.S. college or university, studied at a medical school recognized by the World Healt h
Organization, and has completed all but the internship or social service requirements, has passed parts I and II of the N ational Board
Medical Examiners licensing examination or the ECFMG equivalent examination. Section 458.311, F.S.
19 USMLE Courses, Residency & Match, at https://www.usmle-courses.eu/residency-match/ (last visited March 24, 2023).
20
OPPGA, Florida’s Graduate Medical Education System, Report No. 14.08, February 2014 at https://www.floridahealth.gov/provider-
and-partner-resources/community-health-workers/HealthResourcesandAccess/physician-workforce-development-and-
recruitment/additional-council-resources/OPPAGAGMERepor14-08February2014.pdf (last visited March 24, 2023).
21 64B8-4.004 F.A.C.
22 A residency position or slot refers to federally supported residency training slots. These slots are typically funded through Medicare
Graduate Medical Education Payments, which cover Medicare’s share of the costs of a hospital’s approved medical residenc y program.
These costs include direct costs of operating a residency program, such as resident stipends, supervisory physician salaries, and
administrative costs. In fiscal year 2020, Medicare paid $16.2 billion for medical residency training. See Congress ional Research
Service, Medicare Graduate Medical Education Payments: An Overview., September 29, 2022 at https://crsreports.congress.gov
/product/pdf/IF/IF10960#:~:text=Medicare%20GME%20payments%20cover%20Medicare's,physician%20salaries%2C%20and%20adm
inistrative%20costs . (last visited March 24, 2023) and Id. note 13.
23 Rule 64B8-4.004, F.A.C.
24 Id.
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The bill creates an alternative to the approved residency licensure requirement for graduates of a
foreign medical school. Specifically, a foreign-trained applicant may obtain a license to practice
medicine in Florida without completing an approved residency program if the applicant:
Holds an active, unencumbered license to practice medicine in a foreign country;
Has actively practiced medicine in the 4 years preceding the date in which the foreign graduate
submitted an application to obtain licensure;
Has completed a residency or substantially similar postgraduate medical training in a country
recognized by his or her licensing jurisdiction or has practiced medicine in his or her licensing
jurisdiction for at least 5 years; and
Has an offer for full-time employment as a physician for a health care provider that operates in