Diagnosis for 8.1.22: Checking the pulse of Florida health care news and policy

Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.

— Medicaid expansion excluded from budget deal —

The surprising legislative budget deal that Senate Majority Leader Chuck Schumer and Sen. Joe Manchin announced last week in Washington D.C. has ramifications for Florida, including what’s not included in the proposed “Inflation Reduction Act.”

The measure deals with taxes and climate, but it also allows Medicare to negotiate on prescription drug prices, and it would continue Affordable Care Act subsidies through 2025.

But the proposal does not address Medicaid expansion which has been a major goal of Democrats from the 12 states that have not expanded Medicaid eligibility that was allowed under Obamacare.

House Democrats, including those from Florida, had been hopeful that a final budget reconciliation deal would create a workaround in non-expansion states. Florida’s Republican-controlled Legislature has rejected calls for expansion over the past 12 years.

Several members of Congress last Thursday wrote about their disappointment that the deal did not address Medicaid expansion and called on Schumer to add a provision to the legislation. The House passed a comprehensive bill that dealt with expansion last year.

“Millions of Americans have never received any benefit from the Affordable Care Act in states that failed to expand Medicaid due to sustained Republican opposition,” states the letter signed by 50 House members. “This has had devastating consequences for health equity, maternal mortality and substance use disorder, among many other public health crises.”

The letter adds “in your further work to move this legislation forward, it is essential that relief be provided for our most economically disadvantaged neighbors who have been stuck in the coverage gap for over a decade. We cannot afford to go home without something to help out those who have been left out and left behind for so long.”

Ten Florida Democrats, including Reps. Charlie Crist and Val Demings, both of whom are running for higher office, signed the letter. Crist, who is running for Governor, has made Medicaid expansion a part of his campaign platform and has vowed to veto any state budget that does not include expansion.

Medicaid expansion allowed states to expand coverage to uninsured childless adults with incomes up to 138% of the federal poverty level.

Florida Republicans, however, resisted calls for expansion, citing everything from fears of having the federal government reduce future payments to contending Medicaid is a broken program.

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— Happy 57th birthday —

The health care programs that provide nearly 140 million Americans access to health care are 57 years old.

Department of Health and Human Services Secretary Xavier Becerra and Centers for Medicare and Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure released the following statement: “On the 57th anniversary of Medicare and Medicaid, we celebrate the peace of mind that these critical programs are working to make it easier for people to navigate their health care options under each program.”

Among other things, the Biden administration has championed the extension of postpartum coverage to a full year after pregnancy for Medicaid parents and made care more accessible for the millions of seniors and people with disabilities by increasing funding for Medicaid home- and community-based services. Florida, unwilling to expand Medicaid under Obamacare, agreed to tap into the added postpartum benefits and $2.1 million in increased funds for home and community-based services.

Medicaid is the largest public health insurance program, covering more than 24% of the U.S. population. The latest state data show that more than 5.3 million Florida residents were enrolled in Medicaid as of June 30. Enrollment in the safety net program in Florida has never been higher and has been driven by the COVID-19 pandemic and the public health emergency issued following the spread of the virus in 2020. So long as the public health emergency stays in effect, Congress has agreed to increase the federal Medicaid payments by 6.2%. But the increased money means that the state cannot remove anyone from Medicaid, which the state and federal governments jointly administer.

Nationwide, Medicaid enrollment increased by 26.5% between February 2020 and before the COVID-19 pandemic to about 74 million people in March 2022. Medicaid supplies health care to the poor, elderly and disabled.

The program paid for 42.1% of all births in 2019.

There are another 64 million people enrolled in Medicare, which is administered solely by the federal government, and supplies health care coverage to people who are disabled or who are aged 65 and older regardless of income.

“Over the last 57 years, Medicare and Medicaid have connected people to lifesaving health coverage at critical moments in their lives,” Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure said in a statement. “And while there is much to celebrate, we continue to be laser-focused on ensuring that the promise of these programs remains protected, more robust, and stronger than ever for generations to come. Happy 57th Birthday, Medicare, and Medicaid.”

— Changes for autism providers —

The Agency for Health Care Administration has changed how it pays for Medicaid applied behavior analysis services for children with autism.

AHCA says that the changes, part of an overhaul of how the state provides ABA services to children, are budget neutral but providers say otherwise.

The changes mean providers will use Current Procedural Terminology, or CPT, codes to bill their services, a move the Florida Association of Behavioral Analysis (FABA) providers support.

Developed by the American Medical Association, the standardized codes give health insurers, Medicare, Medicaid, and other payers the ability to track health care use, identify services for payment, and gather statistical health care information about populations.

But providers say that the CPT codes they are being told to use don’t perfectly align with the codes issued by the AMA. Specifically, the state won’t allow ABA providers to use “modifiers” for ongoing treatment services to differentiate who is working with the client.

Like other health care services, there is a team of providers working with the client, from a Board-Certified Behavior Analyst, which is a graduate-level certification in behavior analysis, to a registered behavior technician which is a paraprofessional certification in behavior analysis with 40 hours of training.

The higher the level of education and skill the higher the reimbursement.

By eliminating the modifier in the CPT code for the provision of ongoing treatment services the state is reimbursing providers at the RBT rate which is 36% less than the BCBA rate.

“The lack of a … modifier conflicts with recommendations from the AMA that state services provided by a professional behavior analyst rather than an RBT should be reported with an appropriate modifier and reimbursed at a rate that is appropriate for the professional-level provider,” the FABA wrote in a letter to AHCA.

It’s not the only concern FABA raises in its letter to the state.

AHCA, which administers the Medicaid program, adopted the CPTs for ABA services supplied outside of the Medicaid managed care setting, as part of the state’s efforts to ferret fraud and abuse out of the system.

AHCA announced in 2018 that the costs of applied behavior analysis therapy to the state more than doubled from 2016 to 2018. The agency put the blame on unqualified providers rendering unnecessary services. The actual amount of fraud was never released by the state, however.

“FABA is very concerned that the fee schedule is not “budget neutral,’ “the letter states.

AHCA has said in public meetings the modifier was dropped because the state doesn’t want to reimburse ABA services provided and not the qualifications of the provider. But in its letter, the association notes that there are modifiers for other ABA CPT service categories.

“Our providers have informed us if modifiers are not added … many children with serious challenging behavior will lose services from their current providers,” the letter notes.

— Patient safety surveys —

It’s been more than two years since the Legislature directed AHCA to collect, compile and publish patient safety culture survey data from Florida ambulatory surgical centers and hospitals.

The state holds a meeting Aug. 3 on the proposed surveys the providers should use, as well as the rules to make it all happen.

At the behest of House Speaker Chris Sprowls, lawmakers in 2020 passed HB 763, requiring hospitals and ambulatory surgical centers (ASCs) to conduct anonymous patient safety culture surveys of facility staff.

The law requires surveys to be conducted biennially and the data submitted to the state. AHCA must publish the survey results for each hospital and ASC, in aggregate and by composite measure. For hospitals, AHCA must also publish the survey results by unit work areas.

While the law requires hospitals and ASCs to use the federal hospital or ASC Survey on Patient Safety Culture, it also directs the state to customize the surveys to include questions that will generate data on the likelihood of a respondent seeking care at the surveying facility, both in general and for hospitals, within the respondent’s specific unit or department.

The bill also requires AHCA to customize the hospital survey to allow staff to identify whether they work in the pediatric cardiology patient care unit and a pediatric cardiology surgical services unit.

A draft of the proposed hospital survey is here.

A draft of the proposed ASC patient safety culture survey is here.

Drafts of the hospital and ASC survey tools and a copy of the agenda are here.

Participants can attend the meeting at the agency’s Tallahassee headquarters or call 888-585-9008; participant code, 998518088.

— Democrats’ platforms —

In their pitch to top Democratic voters, the two leading Democrats in the Aug. 23 Gubernatorial Primary have focused on critical issues such as affordable housing, gun rights and abortion.

But Crist and Nikki Fried have not spent a lot of time lately talking about health care issues outside of abortion rights as the primary moves ever closer. During their one and only debate, the two Democrats sparred over Crist’s record on abortion rights as Fried tried to repeatedly raise questions about his stance, given that he once used to be a Republican.

Crist earlier this year rolled out an action plan for seniors where he pledged to expand Medicaid eligibility as allowed under Obamacare and he vowed to veto any state budget that did not include expansion. He threw his support behind a plan to import prescription drugs from Canada, a plan already approved by Gov. Ron DeSantis and is still awaiting an OK from the Biden administration, and he said that the state government would help with insulin pricing as well as create an independent prescription drug affordability board that would review drug prices and require manufacturers to justify what they were charging.

Crist also said he wants Medicaid to pay for home renovations like wheelchair ramps, wider doorways, and no-step bathing and he has promised to do spot checks of nursing homes. He also wants to provide paid sick days to those who care for seniors.

Fried has also come out in favor of Medicaid expansion, calling it a “No. 1 priority” earlier this year and she has said she would veto budgets if not more was done to assist those on waiting lists for “IBudget” services that provide Medicaid help to those with intellectual and developmental disabilities.

Fried’s health care platform also calls for expanding development and retention programs for doctors and nurses, expanding telehealth in rural areas, and providing tax incentives to minority access providers and those who operate free and charitable medical clinics.

— ROSTER —

— Michael Okun, M.D., executive director of the Norman Fixel Institute for Neurological Diseases at UF Health and chair of UF neurology., co-led a 42-member multinational panel that believes there is a “crisis” when it comes to the accessibility of deep brain stimulation for people with obsessive-compulsive disorder who don’t respond to traditional treatment. The group penned an article that was published in Nature Medicine. The experts argued that, while effective in most well-selected patients with severe cases, deep brain stimulation is underutilized for treatment-refractory OCD.

— The National Cancer Institute has awarded nearly $1 million to Florida State University Center for Translational Behavioral Science Director Sylvie Naar to develop a course that teaches rigorous and replicable new methods for early-stage behavioral intervention for cancer prevention and treatment.

— Carolyn Johnson has been promoted to vice president of Government Affairs at the Florida Chamber.

— ETC —

August is designated as a month for awareness of cataracts; national immunization; psoriasis; and spinal muscular atrophy.

Aug. 1-6 also marks World Breastfeeding Week. The World Alliance for Breastfeeding Action (WABA) is a global network of individuals and organizations dedicated to breastfeeding. The Florida Health Department says it’s working “to promote breastfeeding as a vital health activity and encourages breastfeeding-friendly hospitals, child care facilities, workplaces, and communities.”

— ICYMI —

In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.

— ‘Growth recession’ looming? State Medicaid officials have anticipated hundreds of thousands of people can be disenrolled from the health care safety net health care program for the poor, disabled and elderly when the COVID-19 public health emergency expires. But the state’s top economist warned Florida may not be able to disenroll as many people as quickly as previously thought due to a potential “growth recession.”

— Negative natural growth: The Office of Economic and Demographic Research projects the state’s population to grow by 352,301 in 2022, to 22,251,246 people, or 3,795 more than the December estimate. That’s a 1.61% growth rate. But while the state is still expected to grow over the next five years, the rate is expected to decline. In 2023, economists predict a 1.47% increase, which is projected to slow to 1.16% by 2027. Part of the reason for the slower growth is the state’s negative natural growth rate. The state had 7,540 more deaths than births in the 2020 fiscal year, the first time Florida had a negative natural growth rate since at least 1950.

— Pistol packing youth? A new federal report, based on youth surveys taken from across the country, including Florida, found that 1 in 15 boys and 1 in 50 girls reported carrying a gun in the last 12 months for non-recreational purposes. Researchers also found that gun carrying was more prevalent among those who experienced violence, suicidal ideation or attempts, or substance use.

— Abortions, guns and trans care: Some describe it as a showdown for the “heart and soul” of the state’s largest medical society. Members of the Florida Medical Association (FMA) House of Delegates will vote this weekend on a number of resolutions that could not only pit members of the association against each other but put the FMA on a crash course with legislative leaders and Gov. Ron DeSantis. Documents obtained by Florida Politics show members of the FMA’s House of Delegates will be asked to weigh in on issues ranging from abortion to constitutional carry to providing gender-affirming health care to patients.

— Good move: Florida will begin adding gun storage safety tips when it mails concealed weapons licenses to its residents, Agriculture Commissioner Fried said. Her department will encourage people to keep their guns locked, unloaded and stored in a separate place than ammunition, among other tips. The goal is to prevent accidental shootings and to keep guns out of the hands of children, said Fried, a gun owner herself.

— FOR YOUR RADAR —

Aside from coverage by Florida Politics, these stories are worthy of your time.

—”Conservatives skeptical of coronavirus vaccines battle to lead a hospital” via Tim Craig of The Washington Post — The Sarasota candidates, at least three of whom are skeptical of coronavirus vaccine mandates, are rallying behind the theme of “medical freedom.” The term is increasingly used by the conservative movement nationwide and hits a belief that patients aren’t given enough control over their medical care. Proponents point to vaccine mandates and difficulty accessing unproven coronavirus treatments like Ivermectin that were touted by politicians but rejected by physicians. “All 4 of us are devoted Christians, conservatives and patriots who deserve to make the [Sarasota Memorial Hospital] system stronger, more accountable with greater transparency,” one of the candidates, Joseph S. Chirillo, a retired physician, wrote in a social media post.

—”A look inside Florida’s hospitals as the newest COVID-19 wave sweeps through the state” via Cindy Krischer Goodwin of the South Florida Sun-Sentinel — At West Boca Medical Center, Dr. Cory Harlow sees patients coming into the emergency department with many of the same symptoms they complained of during the early days of COVID-19 in Florida: pneumonia, high fever and shortness of breath. Although Harlow no longer has to rush patients into intensive care and put them on a ventilator, he does admit them to a regular room in an area dedicated again for COVID patients. “COVID hospitalizations were trending down and then with this strain, they took a left turn,” he said.

—”Florida Department of Health suspends Pensacola abortion clinic doctor calling him ‘a great public danger’” via Jennie McKeon of WUWF — A doctor at the American Family Planning clinic in Pensacola has had his license suspended by the Florida Department of Health after investigators have accused him of being a “great public danger.” Dr. Christopher Saputa, a Tarpon Springs-based doctor, is accused of failing to provide emergency care to three patients who nearly died waiting for help after abortion procedures. In the complaint, an American Family Planning nurse even noted Saputa should have initiated emergency transport sooner than he did in at least one case.

—”Florida hospital ignored years of complaints about surgeon, patients and families allege” via Elizabeth Chuck of NBC News — An orthopedic surgeon in Florida caused “hundreds of devastating injuries” while his hospital ignored complaints from patients for years after he started displaying signs of a progressive neurological disorder, according to court documents. Between 2016 and 2020, patients noticed Dr. Richard David Heekin slurring his words and a “difficulty with balance, inability to concentrate, angry outbursts, erratic behavior, gait disturbances and impaired judgment and mood,” according to court documents. Among his alleged errors made during surgeries were bone fractures, ruptured tendons and severed nerves. The resulting complications were significant, with many patients requiring revision surgeries, and at least one complication cost a patient her life, according to the civil complaints.

—”Man accused of selling bleach as COVID cure extradited to U.S.“ via The Associated Press — A man accused of selling a toxic industrial bleach as a coronavirus cure through his Florida-based church has been returned to the United States after being arrested in Colombia. Mark Grenon, 64, made his initial court appearance Thursday in Miami federal court following his recent extradition, according to court records. Grenon and his three adult sons were indicted last year on one count each of conspiracy to commit fraud and two counts each of criminal contempt. Grenon is the archbishop of the Genesis II Church of Health and Healing, based in Bradenton, Florida.

— PENCIL IT IN —

Tuesday

2 p.m. Revenue Estimating Conference tobacco tax and surcharge, tobacco settlement. Room 117 of the Knott Building.

6:30 p.m. AARP Florida and Spectrum Bay News 9 host a Community Conversation with Congressional Candidates” at St. Petersburg College, Seminole Campus, Digitorium.

Wednesday

10 a.m. Agency for Health Care Administration holds a workshop hearing on draft language and forms to be incorporated into the rule on patient safety surveys — 59A-35.115 2727 Mahan Drive, Tallahassee.

Thursday

Happy Birthday Rep. Andrew Learned

8 a.m. The Board of Medicine credentials committee meets at Marriott Fort Lauderdale Airport, 166 North Compass Way, Dania Beach.

8:30 a.m. The Board of Nursing meets at DoubleTree by Hilton Hotel Miami Airport & Convention Center, 711 NW 72nd Ave, Miami.

9 a.m. The Social Services Estimating Conference on Federal Medical Assistance Percentage or FMAP. meets .117 Knott Building Tallahassee.

9:15 a.m. The Social Services Estimating Conference on KidCare expenditures meets. Room 117 of the Knott Building.

1 p.m. The Boards of Medicine and Osteopathic Medicine hold a joint surgical care/quality assurance committee workshop on office surgery rules — Marriott Fort Lauderdale Airport, 166 North Compass Way, Dania Beach.

4 p.m. The Board of Medicine rules and legislative committees meet. Marriott Fort Lauderdale Airport, 166 North Compass Way, Dania Beach.

Friday

Happy Birthday Sen. Ed Hooper

Happy Birthday Rep. Tyler Sirois

8 a.m. The Board of Medicine meets Marriott Fort Lauderdale Airport, 166 North Compass Way, Dania Beach. Agenda here.

8:30 a.m. The Board of Nursing meets at DoubleTree by Hilton Hotel Miami Airport & Convention Center, 711 NW 72nd Ave, Miami.

9 a.m. The Board of Nursing Home Administrators holds a telephone conference call — Meeting link here.