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Rob Bradley’s fairness doctrine

Senate Appropriations Chair Rob Bradley is undertaking something seen too rarely in the Legislative process: He is actually trying to clean up and improve Florida’s health care financing policy.

Bradley, an Orange Park Republican, intends to do this by finally eliminating “auto-payments,” a payment scheme that Gov. Rick Scott described in 2015 as arbitrary, inconsistent and bearing no relationship to improving access or quality of care.

This is not the first attempt to deconstruct the auto-payment policy.

Last year, the House acted to eliminate the policy for all but a small number of public hospitals that qualify as “safety net” providers.

The House accomplished this through a formula that requires hospitals receiving auto-payment money to have a Medicaid caseload of 25 percent or more. Then they added a complicated set of additional conditions designed to direct as much funding as possible to 11 large, government-funded hospitals.

The result was that out of 28 facilities that qualified for a piece of the $318 million in auto-payment funding, 92 percent – or roughly $292 million – went to those 11 facilities.

The argument those hospitals are making now is that they treat the highest percentage of Medicaid patients. What they don’t want you know is the state already recognizes their high Medicaid caseloads through other channels.

Those same 11 hospitals received $400 million of Low Income Pool funding. They got $163 million in Medicaid Disproportionate Share payments as well.

That’s a whopping $563 million in tax dollars already.

Many hospitals in rural Florida also treat high numbers of Medicaid and charity care patients, but the LIP formula has been manipulated to direct the money to public hospitals, so those rural hospitals now get little to nothing from LIP or the Disproportionate Share program.

Overall, these large, government-funded hospitals are doing very well.

Based on 2016 data, they had an average total margin of nearly 10 percent. That compares favorably with HCA at 9.6 percent or Tenet at 6.6 percent, two for-profit hospital corporations with their own Medicaid and charity care obligations.

About 1 in 6 patients served at an HCA hospital were covered by Medicaid and the company provided $122 million in charity care services. Tenet had a Medicaid percentage of 23.5 percent and provided $33 million in charity care.

Bradley is providing much-needed leadership by attempting to end payment formulas disconnected from any incentives for efficiency or quality of care.

His approach requires a smaller total cut in Medicaid payments to all hospitals compared to last year, specifically improves Medicaid payments for freestanding children’s hospitals and provides a special allocation to fund UF Health Jacksonville, one of those 11 hospitals that truly does need additional help.

Let’s hope this common-sense approach is embraced by both the House and Senate.

House, Senate start negotiations on tighter budget

House and Senate leaders Tuesday night kicked off formal negotiations on a new state budget — but face hundreds of millions of dollars in unexpected costs and less tax revenue than originally thought.

Leaders held an initial conference committee meeting after announcing earlier in the day they had reached agreement on “allocations,” which are big-picture numbers for the various parts of the budget such as education, health care and criminal justice. House and Senate negotiators will use those numbers as they hammer out details of each budget area in the coming days.

The House and Senate have a week to finish the budget if the Legislative Session is going to end as scheduled March 9. A legally required 72-hour “cooling off” period means the budget will have to be done March 6. House Appropriations Chairman Carlos Trujillo, a Miami Republican, expressed confidence the Session will finish on time.

While numerous details still need to be worked out, Senate Appropriations Chairman Rob Bradley, a Fleming Island Republican, said, in part, that lawmakers plan to provide $80 million in tax cuts and will fund an expansion of the Bright Futures scholarship program, a priority of Senate President Joe Negron, a Stuart Republican.

Also, the agreement means that $543.6 million in more funding will be available in the health and human services section of the budget, which includes five agencies. Bradley, however, stressed that policy differences between the House and Senate still need to be negotiated on issues including how the state will reimburse hospitals and nursing homes in the Medicaid program.

Both chambers on Feb. 8 passed budget plans for the fiscal year that starts July 1, with the Senate proposing to spend $87.3 billion and the House proposing to spend $87.2 billion. While the overall numbers were similar, the House and Senate disagreed on myriad details.

But in announcing the allocations Tuesday, Bradley said lawmakers are grappling with unexpected costs and a lower estimate of corporate tax revenue than when the House and Senate approved their budget proposals.

The biggest change stems from lawmakers’ plans to spend at least $400 million in response to the mass shooting Feb. 14 at Marjory Stoneman Douglas High School in Parkland that left 17 people dead. The House and Senate are quickly moving forward with bills that include taking steps to boost school safety and mental-health services.

“The tragedy in Parkland changed everything,” Bradley said.

Bradley said leaders have agreed to spend $400 million and that additional money could come through the state’s school-funding formula.

“That is something that we do because you cannot put a price, obviously, on the safety of our children,” he said.

Bradley said, however, that will affect other parts of the budget, which lawmakers are required to balance each year.

“When you take $400 million and put it towards necessary efforts, that creates challenges in other areas of the budget, and we’re up to that challenge, and we will meet those challenges,” he said.

To help pay for the issues stemming from the school shooting, Bradley said lawmakers will take $200 million out of a reserve fund known as the “working capital fund” and will take money from trust funds that are normally earmarked for other purposes such as affordable housing. Also, the budget likely will include a reduced number of projects requested by lawmakers.

“We’re going to be lean on projects this year,” he said. “It’s necessary.”

The budget also will be tighter than originally thought because of a revised estimate last week of the state’s corporate income-tax revenue. Analysts said the state is expected now to bring in $167 million less in corporate taxes than estimated earlier.

Also, Bradley said lawmakers are faced with paying $100 million more in Medicaid expenses than what had been anticipated.

“These are bills that need to be paid. This is not a discretionary choice,” Bradley said. “These are bills that health providers have incurred pursuant to our obligations under law to provide these services to individuals. And so these are bills we will pay, because we pay our bills.”

Senate pitches health care alternative for veterans

A state Senate proposal would authorize Florida to begin negotiations with the federal government to see if the state could offer managed health-care programs to veterans and their families as an alternative to the health system provided by the federal Veterans Administration.

The Senate could vote on the proposal (SB 440) as soon as Wednesday.

Sponsor Rene Garcia, a Hialeah Republican, agreed Tuesday to add an amendment to make clear the proposal is not designed to expand Medicaid for veterans in Florida. Instead, he said the proposal would authorize discussions with the federal government to discuss opening access to the Medicaid managed-care infrastructure of health plans and physicians.

The bill would authorize the state Department of Veterans’ Affairs, the Agency for Health Care Administration and the Department of Children and Families to jointly negotiate with federal agencies to seek approval for a waiver, a state-plan amendment, or other approval for federal funding for the “Florida Veterans Care” program.

The amendment was intended to provide comfort to House members who thought the proposal was an attempt to expand Medicaid, Garcia said.

House Speaker Richard Corcoran, a Land O’ Lakes Republican, has been steadfast in his opposition to expanding Medicaid.

The federal Veterans Administration system serves more than 1.5 million Floridians, which is the third highest population of veterans in the country. Over half of the state’s veterans are age 65 and older, according to a staff analysis of the bill.

Garcia made a plea to members of the Florida House of Representatives and Corcoran to “not stand in the way” of negotiations.

“Our veterans deserve better,” Garcia said. “Enough with using our veterans as political pawns. The time is now to ensure that we take care of our veterans.”

House committees have not heard the House version of the bill (HB 403).

Lawmakers seek more money for opioid epidemic

Two Democratic senators are pushing to increase by $25 million the amount of funding the Senate has committed to addressing the state’s opioid problems in the upcoming year.

Sen. Kevin Rader praised Senate leaders for proposing to spend $100 million on mental-health services and school-safety programs in the wake of the Marjory Stoneman Douglas High School shooting last week that left 17 people dead. But he said they also need to put more money into a plan to curb the opioid epidemic.

“It looks like we are finding a lot of mental health funding, and that’s great. And I absolutely, completely support it and it’s much needed,” said Rader, a Delray Beach Democrat whose district includes Parkland, where Marjory Stoneman Douglas High is located. “I hope in the next two weeks …. we can really put the money into the opioid funding to take an enormous bite out of this apple and really help Floridians who need it.”

Rader’s remarks came as the Legislature enters the last two weeks of the annual Legislative Session and prepares to go into budget negotiations. The Senate is earmarking about $53 million for a variety of programs for opioid treatment, outpatient care and case management, medically assisted treatment, and naloxone for emergency responders.

Senate President Joe Negron, a Stuart Republican, said Thursday he has spent “a long time talking” with Rader and Sen. Darryl Rouson, a St. Petersburg Democrat, about the opioid epidemic, and he thinks the Legislature ultimately will increase funding from the current levels.

Rader is working closely with Rouson, who has drafted a plan that directs funding to a number of different areas. They include spending $2 million on an additional seven “bridge programs” between hospital emergency departments and community-based opioid programs, spending $2.9 million for evidence-based prevention and launching a statewide media campaign, similar to the state’s effective anti-smoking campaign.

The four-page draft obtained by The News Service of Florida contains handwritten notes with numbers by each of the ideas. The proposal marked No 1 is a request to increase funding to managing entities, which have contracts with the state to coordinate care regionally, by $3.1 million to provide housing options for people who suffer from both mental health and addiction issues and are frequently jailed or require emergency room services.

The proposal does not include additional funding beyond what already is targeted for medication-assisted treatment programs. Negron though, indicated that he would direct additional dollars toward medication-assisted treatment.

“I want to make sure the prevention is directly related to tangible items that we can measure rather than just diffuse dissemination of information, which I don’t think is effective,” Negron said.

Gov. Rick Scott in May 2017 declared a state of emergency due to the opioid crisis, fueled by an increasing number of deaths associated with the drugs. A state report shows that in 2016, Florida had 952 heroin deaths, 1,390 fentanyl-related deaths, 723 oxycodone-caused deaths and 245 hydrocodone-related deaths.

To try to address the issues, the House and Senate are considering bills (HB 21 and SB 8) that would limit physicians’ abilities to prescribe opioids. Also, the state Medicaid program announced last week that it is limiting prescriptions for narcotics to a maximum seven-day supply, unless a physician determines it is medically necessary to increase the prescription.

During a discussion in a Senate committee, Rader reminded Senate Health and Human Services Appropriations Chairwoman Anitere Flores, a Miami Republican, that she acknowledged earlier the Senate hasn’t gone far enough in its recommendations for the upcoming year.

“You said, and I didn’t put words in your mouth, that this is ‘woefully underfunded and needed hundreds of millions of dollars of help as well,’ “ Rader said to Flores during a Wednesday meeting. “We just can’t keep the eye off the ball.”

Chris King releases post-Parkland proposal to address mental illness, ban guns

Declaring that Republican leadership in Tallahassee has “transformed Florida into a petri dish of experimentation for the NRA” and “utterly failed to address public health and mental health care,” Democratic gubernatorial candidate Chris King said Friday he would fight the gun lobby, veto their bills, and seek to expand coverage and ban assault weapons.

The pledges are not new to King or to Democrats in general, though King, a Winter Park businessman, offered them as his call to action following the horrific mass murder at Marjory Stoneman Douglas High School on Wednesday. He also urged support for House Bill 219 and Senate Bill 196, two bills to ban assault weapons, sponsored by state Rep. Carlos Guillermo Smith and state Sen. Linda Stewart, both Orlando Democrats.

“The next governor must have the courage to stand up and say that we will not allow weapons designed for the killing fields to be sold in our state,” King said in a statement that also was included in a video message posted to his campaign’s Facebook page.

Specifically, King vowed that he would oppose and veto bills he said make Florida “less safe,” such as a provision to Senate Bill  740 that would expand concealed weapons permits availability; expand mental health coverage availability by expanding Medicaid and the Affordable Care Act in Florida; and push to ban assault weapons.

“The shooter at Marjory Stoneman Douglas High School chose an AR-15 semi-automatic assault weapon. These types of weapons have been used again and again in mass shootings across the country: Aurora, Newtown, San Bernardino, Orlando, Sutherland Springs, Las Vegas, and now Parkland,” King said “These shootings should be reason enough that weapons designed for war should not be in our neighborhoods. One individual with a weapon like this can do unspeakable damage in a matter of seconds and no cavalry of well-armed law enforcement or good samaritans can move quickly enough to stop it.”

King, who attended Thursday’s vigil in Parkland, specifically criticized Republican gubernatorial candidate and Agriculture Commissioner Adam Putnam for supporting the concealed weapons provision in SB 740, and indirectly criticized him by declaring that “Florida’s leaders call themselves ‘proud NRA sellouts.'”

“We have seen how effective the NRA and the gun lobby are in moments like these,” King said. “The gun lobby muddies the waters and delays any discussion on guns until the news vans and camera crews have gone home and most Americans have moved on. But we are stronger. We owe it to the victims and to our children to draw a line in the sand. We can’t just talk about guns, we must put our best ideas forward. We must not stop until we achieve change that will make us all safer. This is how we honor the victims of such unspeakable tragedies — with action.”

Props to Senate for ending enhanced payments to hand-picked hospitals

For the last couple of years, budget talks have seemed to put House leadership in the driver’s seat on instituting new reforms, with the Senate reacting defensively. So it was a breath of fresh air to see the two chambers heading in the same direction, toward positive change on funding for charity care provided by hospitals across Florida.

The two sides aren’t taking identical approaches to the budget question of how government reimburses hospitals for providing essential services to the poor, such as Medicaid and charity care. But they’re also not lined up facing each other, with guns raised awaiting the order to fire. With a pot of almost $400 million at stake — not exactly nickels and dimes — any progress toward finding common ground is something to celebrate.

It had looked like the House was planning to continue the practice of providing “enhanced payments” to a few hand-picked hospitals, while the Senate’s plan makes that money available to all Florida hospitals. But in the last few days, there has been some movement in the House toward the more balanced approach of divvying up the funds based on the amount of Medicaid and charity care the hospitals actually provide, adding objectivity and accountability to the process.

This totally makes sense — if you provide the service, you get reimbursed accordingly.

The status quo model of subjectively selecting hospitals for huge boosts in state funding — the so-called “enhanced payments” — has excluded hundreds of hospitals that provide the same essential services to low-income patients.

That system may have once helped to support struggling charitable hospitals, but that’s not the reality anymore. The most likely recipients — designated as nonprofits, mind you — made a combined $1.4 billion in profits in 2016. They also receive more than $1 billion in unrestricted state and local tax revenue and federal subsidies. These hospital systems are run like for-profit corporate behemoths, but then they cry poor in order to collect taxpayer dollars.

While the formal House plan doesn’t currently include this shift from enhanced payments to a more broad-based approach, I am hopeful after reading that Rep. Jason Brodeur (a Sanford Republican), chair of the Health Care Appropriations Subcommittee, says he is open to the change and likes the idea of having the money more closely follow the patients.

Florida provides less Medicaid funding per capita than almost any other state in the nation, so it’s important that we allocate every dollar smartly in order to make the biggest impact statewide.

The Senate plan would send this money to benefit the most low-income patients across the entire state. I trust that the House will make the change in its budget as well.

Medicaid expansion could save state $500M, lawmaker says

A Democratic push to expand affordable health care coverage in Florida has a unique selling point: it could save the state more than $500 million.

At a news conference on Thursday, Rep. Lori Berman, a Lantana Democrat, said a resolution she’s sponsoring to expand Medicaid coverage would significantly cut costs from other health spending areas supported by the state.

“If Florida were to expand Medicaid, the net — that’s net savings — would be nearly half a billion dollars,” Berman said. “Medicaid expansion would increase funds for mental health and substance abuse, a true crisis in our state.”

Berman’s claim is supported by analysis from the Florida Policy Institute, or FPI. According to FPI, the net savings — calculated through estimated budgetary savings and estimated increases in general revenue — total $501,950,000. The figure was calculated using FY 2016-17 Medicaid spending in Florida as a benchmark.

FPI said enhanced federal matching funds would account for around $364 million in savings. The other savings bulk would come through substituting Medicaid funds for General Revenue spends on mental health and substance abuse, hospital costs for prisoners, and uncompensated care. In those areas, FPI says Medicaid would account for $364.6 million in savings.

Those two savings figures total roughly $747.75 million. According to FPI, subtracting the state’s $250 million cost to expand Medicaid results in the $500 million net savings figure.

Berman’s resolution, HJR 911, has a companion in Miami Democratic Sen. Annette Taddeo’s SJR 1136.

The legislation, if passed, would result in a proposed constitutional amendment requiring voter approval in November. Berman and Taddeo are hopeful the Legislature will allow the issue to be decided by voters. Medicaid expansion has been an issue for years in Florida but has failed to progress through the Legislature.

“It is so disappointing to continue to see the Florida Legislature play politics with this issue when all we’re asking for is a basic principle of our democracy: Let the voters decide,” Taddeo said.

The Affordable Care Act first mandated the expansion of Medicaid to all states, but a 2012 case in the U.S. Supreme Court ruled participation optional.

Nineteen states, including Florida, have opted not to expand Medicaid. Medicaid expansion under the Affordable Care Act would provide coverage to families with incomes up to 138 percent of the Federal Poverty Line. According to FPI, expanded Medicaid coverage would extend to individuals making $16,643 yearly and families of four making $33,948 yearly.

Marketplace health insurance in Florida currently covers families of four who earn at least $24,600 yearly. According to FPI, that creates a coverage gap for families earning an annual income of $7,380 (the ceiling for Medicaid coverage) and $24,600 (the marketplace floor). FPI estimates there are 500,000 Floridians in that gap.

Taddeo and Berman’s legislation has yet to be heard in committee.

Rick Scott administration again mishandles individuals’ personal information

The private information of nearly 1,000 individuals was mishandled by the state’s Division of Elections as it responded to a public records request last year, making it the second time in four months that a state agency has compromised the private information of Floridians.

State officials said Friday that the last four digits of the social security number of 945 individuals were sent in error to a member of the public.

The department has notified all the individuals whose confidential information was released by mistake.

While officials say there is no reason to believe their private information has been misused, they are offering those affected a year-long membership to an identity theft protection service.

Earlier this month, officials with the Agency of Health Care Administration confirmed that the medical records and personal information of up to 30,000 people enrolled in the state’s Medicaid program may have been compromised after a data breach.

The incident in that agency stemmed from a state employee opening a malicious phishing email. The data breach exposed the Social Security numbers, dates of birth, Medicaid ID numbers and private health care information of clients.

Darren Soto under fire for having urged Puerto Ricans to declare they intend to stay

U.S. Rep. Darren Soto of Orlando has come under fire for statements he made last Friday at a Puerto Rico town hall meeting in Kissimmee, when he urged evacuees to declare they intend to stay in Florida.

Soto’s comments had come during a question-and-answer period after he, Puerto Rico Gov. Ricardo Rossello, and others including Florida Gov. Rick Scott had addressed more than 500 people gathered at the Kissimmee Civic Center about issues surrounding Puerto Rico, evacuees who have fled to Florida following Hurricane Maria, and federal, state, and local assistance and recovery efforts.

Responding to a question about federal assistance, Soto noted inequities and legal quirks in the federal Medicaid and Medicare programs. He noted that when evacuees go home to the island they lose coverage, and that he and others are working on legislation to try to make benefits more seamless as people move back and forth. But that’s not the case yet, he said.

“One thing for those who recently arrived need to know is, you’re going to be asked the question, ‘Do you intend to stay?’ I urge you to say ‘yes, for now,'” Soto told the town hall. “Because otherwise you’re going to get rejected, and then you’re going to find yourself without health care. So I urge you to watch for that pitch-fall question.”

A report on WFTV-News in Orlando and posts on Facebook other social media, raised the question of whether Soto was encouraging people to make false claims about their intentions to stay in Florida or not.

In a written statement provided by his office Wednesday morning, Soto denied he made any such overture.

“I do not encourage anyone who is planning to leave our state to falsely claim otherwise. Many recently arrived Puerto Ricans have a high probability of staying in Florida. The intent of my statement was to encourage them to err on the side of caution and declare their intent to stay if they are in doubt about their future plans,” Soto said. “If they eventually leave, their Medicaid or Medicare will automatically be terminated and they will have to reapply back in Puerto Rico. Healthcare could mean the difference between life and death for eligible seniors, disabled and children evacuees, many of whom have been without healthcare for months.”

One of Soto’s Republican opponents seeking to take him on in the 2018 election, Wayne Liebnitzky of St. Cloud, said he did not think Soto said anything that would raise legal problems, but he questioned the ethics of the statement.

“There is an ethics problem here,” Liebnitzky said. “Is it a big problem? Probably not. It is an ethical problem. He shouldn’t have done it.”

Up to 30,000 state Medicaid clients warned of potential data breach

Thousands of Floridians enrolled in Florida’s Medicaid program are being notified that their medical records and personal information may have been compromised, the state’s Agency of Health Care Administration said.

The data breach occurred after a state employee opened a malicious phishing email last November. The incident may have exposed the  Social Security numbers, dates of birth, Medicaid ID numbers and private health care information of up to 30,000 Floridians, a two-month-review by the Inspector General found.

While the review is ongoing, AHCA has so far been able to confirm that the Medicaid IDs and/or Social Security numbers of approximately 1,800 clients have been potentially accessed.

In response, AHCA officials are offering those affected a free one-year membership to an identity theft protection program, even though they contend there is no reason to believe individuals’ information has been misused.

No other state systems or email accounts were targeted and AHCA is currently exploring additional security options to protect against further breaches.

For more information, including steps one may take to protect themselves from potential information, enrollees may call the Agency’s hotline at 1-844-749-8327.

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