Diagnosis for 9.14.22: Checking the pulse of Florida health care news and policy

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It's time again to check the pulse — of Florida's health care policy and politics.

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


Florida is the third least vaccinated state in the nation, a new WalletHub analysis shows.

To determine the overall rankings, WalletHub analyzed 17 weighted metrics across three main categories: children and teenage immunization rates, adult immunization rates and uptake disparities/influencing factors. The analysis ranks the performance in each of the three areas to find the overall ranking.

Florida ranked second to last in adult immunization. Only Mississippi had lower rates. Metrics in that category include the share of adults with tetanus vaccines, shingle vaccines and flu vaccines, as well as the share of adults considered “increased risk” who are vaccinated against the flu.

Only four states had lower children and teenage immunization rates than Florida: Wyoming, Alaska, Mississippi and Oklahoma. The metrics in that category include the rate of children vaccinated against four strains of meningococcal bacteria that cause meningitis and blood poisoning, the number of vaccinations required for entrance into kindergarten, whether minors can access vaccines without parental consent, completion of the human papilloma vaccine series, and share of children under three who have completed the seven-vaccine series.

Unwelcome news about Florida and vaccines.

Vaccines protect people from diseases before coming into contact with them by training the body’s immune system to create antibodies. When exposed to the germ that causes the condition in the future, a vaccinated person’s immune system can quickly destroy it.

Data was collected from the U.S. Census Bureau, the Centers for Disease Control and Prevention, the Health Resources and Services Administration and the Commonwealth Fund, ProCon.org and IBTimes.

Meanwhile, Florida ranked 18th in the uptake disparities/influencing factors category. The metrics in that category include, among other things, the number of people living in primary care health professional shortage areas, the percent of people without insurance and change in the childhood immunization uptake between 2015 and 2020.

The WalletHub analysis did not look at vaccination rates for COVID-19.


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— A not-so-rosy outlook

Gov. Ron DeSantis and Republican legislative leaders have discussed the state’s record budget surpluses. But there’s one clear trouble spot state economists and budget staff flagged — the state’s health insurance program for state workers and universities.

Last week the Legislative Budget Commission officially signed off on a new three-year financial outlook for the state. The top-line numbers are truly impressive, with a projected general revenue budget surplus of $13.5 billion in the 2023-24 fiscal year to $15.5 billion in the 2025-26 fiscal year.

When economists draw up the outlook, they look at the incoming revenues and expect to spend them on key areas such as education and health care. The three-year forecast tapped three critical needs areas that will drive spending in the years ahead: increased public-school enrollment, Medicaid enrollment, and increased benefits for state employees.

Florida’s budget leaves health care trouble spots. Image via AP.

That last item was projected to cost the state $931 million over three years, more than three times higher than the current state Medicaid cost projection. That increased cost is driven primarily by a projected deficit in the State Employees Health Insurance Trust Fund, which is used to pay for the $3.2 billion program that provides health insurance benefits to approximately 350,000 state and university employees, retirees and their families.

The fact that there’s a looming deficit in the program was first projected over the Summer by economists. But now, it’s considered one of the more significant budget quandaries the Governor and Legislature will confront during the 2023 session.

For years now, lawmakers have generally resisted raising the cost of employee health insurance premiums and have instead increased the amount of money coming from general revenue to respond to rising costs.

However, the Department of Management Services is supposed to contract for a comprehensive cost containment analysis due in January. The question is whether that will be a prelude to serious changes next year given the size of the projected trust fund deficit or if legislators will instead opt to use the large surplus to fill the gap.

— Another fast track? —

Are members of Florida’s medical boards fast-tracking proposals to create a Florida-specific standard for the treatment of gender dysphoria?

The boards are considering developing state-specific standards for treating gender dysphoria at the behest of state Surgeon General Joseph Ladapo. The DeSantis administration has already amended state Medicaid regulations to ban providers from reimbursing for treating gender dysphoria, regardless of the patient’s age.

Joseph Ladapo is calling for changes in the way Florida doctors treat gender dysphoria.

The administration wants the medical boards to adopt state-specific regulations to make it a practice violation for doctors to treat gender dysphoria in people under 18.

The Florida Boards of Medicine and Osteopathic Medicine have scheduled a joint rules committee meeting Oct. 6 in Tampa. That’s one day before the entire Board of Medicine meeting and less than a week after a Sept. 30 meeting of the joint rules committee in Tallahassee. The four-hour Tallahassee public meeting will include a combination of public testimony and “presentations from subject matter experts,” according to the public notice. It’s unclear what experts the medical boards will hear from because the state hasn’t published details.

An agenda for the Oct. 6 joint rules committee meeting in Tampa also had not been posted at press time. According to the notice, the meeting will start around 4 p.m. The notice does, however, caution the meeting can be canceled before Oct. 6.

A closer look

Just how common is it for Medicaid to reimburse for gender-affirming care?

Agency for Health Care Administration data shows not very.

AHCA data provided to Florida Politics shows the number of adults and children receiving gender-affirming care and the care Medicaid reimbursed for the fiscal year (FY) 2017-18 through FY 2021-2022.

Medicaid does not provide any benefits to children without parental consent. Children are defined as beneficiaries under 21 years of age, meaning the children category could include information on 18,19 or 20-year-old beneficiaries.

Gender care, while relatively rare, remains a hot-button issue for Florida.

Data show that 12 children and 13 adults underwent surgical procedures in FY 21-22 that Medicaid reimbursed. The most common procedure for both groups was a simple mastectomy, with three children and six adults undergoing the process sometime between July 1, 2021, and June 30, 2022.

Medicaid covered the removal of the testis for two children and two adults and the amputation of a penis for one adult and one child. The safety net program for the poor, elderly and disabled also paid for the surgical construction of two artificial vaginas, one for a child and one for an adult.

Doctors performed 15 gender-affirming surgical procedures on 12 children, in addition to 19 on adults in FY 21-22.

AHCA supplied data that show 1,775 prescriptions for 15 minutes of behavioral therapy services were written for 233 children. Far fewer adults received prescriptions for 15 minutes of behavioral therapy services than children, with 320 prescriptions written for 33 adults in FY 21-22.

However, data show the number of children and adults receiving treatment has increased in recent years. For instance, in FY 2017-2018, 1,024 prescriptions for 15 minutes of behavioral therapy services were written for 143 children. Thirty-three adults received 320 prescriptions for the therapy services in the same year.

The data also show the number of children and adults receiving prescriptions for estrogen and testosterone increased in FY 21-22 from previous years. In 2021, 391 prescriptions for estrogen were written for 151 children compared to 185 prescriptions for 72 children in FY 17-18.

In FY 21-22, 233 adults received 688 estrogen prescriptions. By contrast, 148 adults received 392 estrogen prescriptions in FY 17-18.

More adults received written estrogen prescriptions than children, a data review shows. But the same is not valid for testosterone.

In FY 21-22, 346 children were given 925 prescriptions for testosterone. By contrast, 143 adults were written 373 prescriptions during the same period. Again, it’s an increase from FY 17-18 when 130 children were written 330 prescriptions for testosterone and 63 adults were written 174 prescriptions for testosterone.

Puberty blockers are only given to children. AHCA data show that 180 prescriptions for puberty blockers were written for 55 children in FY 21-22. That’s an increase from FY 17-18 when 15 beneficiaries had written 55 prescriptions.

Bad form at Broward Health?

A North Broward Hospital District Commissioner does not have to recuse himself from voting on whether the Ft. Lauderdale hospital system, better known as Broward Health, should contract for a new electronic health system database, according to a Florida Commission on Ethics advisory opinion.

But before voting Friday to accept the advisory opinion, Commission members made clear they didn’t think it was good form for Broward Health Commissioner Ray Berry to threaten to sue the hospital district if it didn’t switch electronic health vendors.

Ray Berry threatens to sue if Broward Health doesn’t update its systems.

Florida Commission on Ethics member Jim Waldman, who is from Ft. Lauderdale, agreed with the recommendation but said he was uncomfortable with Berry’s threatened litigation and that the district has agreed to rebid the services.

“I don’t think any of us should be in a position as a Commissioner that we threaten, ‘If you don’t do this, I’m going to sue you,'” Waldman said.

Don Gaetz, also a member of the Florida Commission on Ethics, agreed.

“When that kind of threat is made it’s in the environment, it’s in the air. It can’t be unsaid, and it can’t be explained away by saying ‘I was just being hyperbolic.’” Gaetz said.

Berry is the CEO of Health Business Solutions, a company that helps hospitals with health care revenue cycle management, the process that hospitals use to track revenue. He asked the Commission on Ethics for an advisory opinion in late June after Cerner, the current EHR database vendor made allegations that Berry’s firsthand experiences were a conflict of interest that could lead to the company potentially losing its contract after the health system voted to solicit bids for new EHR databases.

The decision to solicit a new contract comes after Berry’s father-in-law died at a Broward Health hospital in 2019. Berry explained in the letter seeking an advisory opinion that his father-in-law suffered from multiple myeloma and that he was initially treated at a hospital run by Memorial Healthcare System, also known as the South Broward Hospital District, but was transferred to one run by Broward Health. He contends his father-in-law died in part from an inability of the two health care providers to exchange electronic health care records.

Berry said in the letter he made a promise not to sue the district over his father-in-law’s death if “proper procedures were implemented” and that “something like this never happens again,” although attorneys for Broward Health acknowledge nothing was ever put in writing.

“I was distraught after my father-in-law’s death, both because a wonderful man was lost, but also because in my opinion, the district, where I serve as commissioner, was partly responsible,” Berry wrote in the letter to the Commission.

Berry later said the remarks were hyperbolic.

But Cerner raised questions about Berry’s role and whether his involvement had “tainted” the process and cited many times Berry had raised questions about Cerner.

In mid-May, an attorney with the Kutak Rock law firm sent a lengthy letter to Broward Health’s general counsel contending Berry had used his public position on the board “to secure a special privilege and benefit for himself and his family.”

It said that Berry was using his “personal situation” to “influence the situation” of the Broward Health board.

“Commissioner Berry’s unwillingness to recuse himself, and the failure of the board to demand his recusal, has created a serious litigation threat and any decision made at this point would likely be set aside by a court,” reads the letter signed by attorney Diane Carter.

Staff for the Florida Commission on Ethics reviewed the situation and said Berry has no financial or contractual relationship with any of the electronic health database vendors and therefore he has no conflict of interest. Staff also noted in the advisory opinion that Berry’s comments assuring the district he wouldn’t sue so long as it could ensure its EHR databases could transmit information to other hospitals was unenforceable and therefore was not a conflict.

Advisory opinions are meant to guide public officials on code of ethics compliance and don’t apply to past behavior, Commission on Ethics General Counsel Steven Zuilkowski said.

“The fact remains that is past conduct. There isn’t anything that we can do to advise him on a going-forward basis on what to do and what not to do. He is potentially, as is any individual with their past conduct, open to a complaint. But as far as the posture we are in right now there really isn’t anything for us to do with that statement,” Zuilkowski said.


The Board of Opticianry proposes changes to Rule 64B12-16.003 on apprenticeships. More here.

The Board of Respiratory Care proposes amending Rule 64B32-4.001 to allow a fee holiday. More here.

The Department of Health proposes amending Rule 64B21-500.002 to update the application form for licensure by endorsement as a school psychologist. More here.

The Board of Occupational Therapy proposes amending Rule 64B11-4.001 to allow didactic training to be conducted either in-person or from interactive, real-time courses. More here.

— ETC —

— Seven Florida-certified nurse anesthetists have been designated with the title of Fellow of the AANA, a recognized hallmark of leadership and outstanding achievements in the profession. They belong to a class of 52 CRNAs who were awarded the designation in 2022.

“We recognize these exceptional Florida CRNAs as leaders who have demonstrated a depth of expertise that is critical to shaping the future of anesthesia care,” said Lorraine Jordan, Chief Advocacy Officer of AANA and CEO of the AANA Foundation. “Earning this distinction signifies a commitment of excellence and dedication to making impactful changes for our profession.”

In all, there are just 116 CRNAs who have been designated as a Fellow of the AANA.

“I am so proud of my incredible colleagues who are now members of a very select group of CRNAs in the country who have received the AANA’s national recognition,” said William L. Self, president of the Florida Association of Nurse Anesthesiology. “These CRNAs strive for excellence in all clinical and educational settings, as well as their service on the front lines, while continuing to serve the residents of our state with their unwavering commitment and care. I join the 5,400 nurse anesthesiology professionals of our association in congratulating them on this prestigious accomplishment.”

William Self is honoring seven CRNAs recognized as fellows.

The seven Florida CRNAs earning the designation are Michelle Canale, USF Nurse Anesthesiology program director; Debra Diaz, adjunct faculty, Barry University; Gerard T. Hogan, Mayo Clinic; Rebecca Lee, Barry University Nurse Anesthesiology program director; L. Alan Todd, associate professor/sr. associate dean of academic affairs, University of South Florida College of Nursing; Jorge Valdes, chair/associate professor, Department of Nurse Anesthesiology, Florida International University; and Randolf R. Harvey, chief of anesthesia, Florida Eye Clinic Ambulatory Surgery Center.

— AHCA received an additional two letters of intent from providers that may be interested in offering hospice care in Hernando County. Regency Hospice of Northwest Florida, Inc. and VITAS Healthcare Corporation of Florida submitted letters of intent notifying the state of their interest in sending applications for the Sept. 28 hospice batching cycle. More here.


Registrations and withdrawals — Week of Sept. 6-13

Melany Cordell registered to represent Elevance Health, and its affiliate

Jeffrey Kottkamp registered to lobby for Small Business Pharmacies Aligned for Reform, Inc.


Jason Weida was named AHCA Chief of Staff. He replaces Cody Farrill who has taken a position in the Governor’s Office as Deputy Chief of Staff for Communications & Legislative Affairs. Brock Juarez has been named Deputy Chief of Staff for Communications and External Affairs.

Samantha Ferrin was named top lobbyist for Simply Healthcare, an affiliate of Elevance Health.

Congrats to Samantha Ferrin on her new leadership role at Simply Healthcare.

Jose Castillo was named acting vice chair of the Florida board of nursing. He is a past FANA president.


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

Suicide prevention month should be yearlong focus instead: September’s Suicide Prevention Awareness Month helps bring needed attention to the mental health crisis in the state, but Patricia Babcock sees some inherent shortfalls with the campaign.

Nikki Fried blasts Ron DeSantis’ latest MMJ restrictions: Agriculture Commissioner Fried is speaking out against new caps on medical marijuana allotments imposed by the DeSantis administration. The emergency rule sets up daily limits for each individual route in categories ranging from edibles and topicals to vapes and concentrates, but for many patients, the aggregate cap is the real impact.

For some patients, the new restrictions subvert doctors’ recommendations and restrict them from buying their medicine until they are below the rolling cap, which at least in theory could be a boon for the black market.

Blast cap: Nikki Fried takes aim at the state’s new marijuana limits. Image via AP.

Food programs for pregnant women, infants, children and elderly get $1B boost: Members of the Legislative Budget Commission (LBC) agreed to the increased funding when they met Friday in Tallahassee. The DeSantis administration also supported the increase in federal spending, budget documents show. The increased spending — which came from federal dollars — was approved without fanfare or debate

Lawmakers agreed to spend another $270 million on refugee services: Florida legislators agreed to spend to $270 million to provide services to immigrants, including money that would be used to help 51,000 refugees who have resettled in the state obtain health assessments and immunizations. The DeSantis administration has asked the Legislative Budget Commission to approve the spending, with most of the funding coming from the federal government.

Medicaid trans ban challenged as state medical boards announce public meeting: As two Florida medical boards announced plans to start developing Florida-specific guidelines that doctors providing gender-affirming care must follow, state Medicaid officials were sued in federal court for a rule that bans Medicaid from reimbursing costs for any of the care. The Florida Board of Medicine and the Florida Osteopathic Board of Medicine, whose members are appointed by DeSantis, announced Wednesday they would hold a joint public meeting in Tallahassee on Sept. 30.


In addition to Florida Politics coverage, these stories are worth your time:

—“Orlando abortion clinic faces $193K fine for allegedly violating Florida law, fears bankruptcy” via Caroline Catherman of the Orlando Sentinel: The Center of Orlando for Women is fighting a $193,000 fine from the Florida Agency for Health Care Administration after the Orlando abortion clinic was found to have reportedly performed abortions without following a law that requires a 24-hour waiting period. The law, passed in 2015, was tied up in court until April 25, when a Leon County circuit judge upheld it. It requires people seeking abortions to come in person to a clinic to receive information, then to make an additional appointment at least 24 hours later to undergo the procedure.

An Orlando women’s clinic is fined under the state’s new abortion ban.

—“It’s been legal for six years, and medical marijuana business is booming in Florida” via Lamaur Stancil of The Palm Beach Post: With less than six years of legality, the medical marijuana industry in Florida has exploded with hundreds of dispensaries across the Sunshine State, not to mention increased support businesses such as referral doctors, pot growers and accessory products. Palm Beach County has nearly three dozen medical marijuana treatment centers for the full range of products. But residents can buy products with lower THC amounts without a medical marijuana card at other locations, some of which offer appointments with doctors who can recommend a patient get a card.

—“Brazilian butt lift ban for doctor following death at Coral Gables cosmetic surgery center” via David J. Neal of the Miami Herald: For the second time in the last five years, the death of a Brazilian butt lift patient at Coral Gables’ Seduction Cosmetic Surgery has led to the doctor being banned from performing such procedures. Dr. John Sampson, whose seventh illegal surgery patient died June 16June 16, 2021, keeps his medical license. Sampson’s punishment from the Florida Board of Medicine was handed down Friday. Additionally, he was fined $20,000, charged $5,626 for investigation and prosecution costs, ordered to perform five hours of continuing medical education in medical records keeping, must present a one-hour lecture on liposuction and gluteal fat grafting (BBL surgeries are a form of each) and can’t be the Designated Physician at any office surgery center.

—“Vaccines, mask mandates seemed to limit COVID-19 spread at Orlando medical conference, study suggests” via Caroline Catherman of the Orlando Sentinel: Even during COVID-19 surges, medical conferences may safely continue if attendees are willing to take precautions, new survey results suggest. The survey, published Wednesday in JAMA Network Open, compares COVID-19 positivity rates in people who attended the Academic Surgical Congress in Orlando Feb. 1-3 this year in person at the Hilton Orlando Lake Buena Vista versus virtually.

—“Hospitals divert primary care patients to health center ‘look alikes’ to boost finances” via Phil Galewitz of Kaiser Health News: Lee Health, a hospital system based in Fort Myers, Florida, converted more than two dozen of its outpatient clinics to look-alike status starting in 2014. Bob Johns, senior vice president for Lee Community Healthcare, is the lone full-time executive of the look-alike. Other personnel are still employed by the hospital system. The higher Medicaid funding has helped pay for four new adult family practice clinics and a pediatric mental health clinic, Johns said. A mobile health clinic that goes to underserved areas is also partly funded through enhanced Medicaid reimbursements. Johns said the look-alike clinic gets about $120 for a Medicaid primary care office visit, nearly double the payment clinics received when Lee Health owned them.



Happy birthday, to Gov. Ron DeSantis

Happy birthday to Gov. Ron DeSantis. Image via AP.


Happy birthday to Rep. Mike Caruso

10 a.m. The State Consumer Health Information and Policy Advisory Council (SCHIP Advisory Council) meets. Register for the webinar here. Agenda here

Christine Jordan Sexton

Tallahassee-based health care reporter who focuses on health care policy and the politics behind it. Medicaid, health insurance, workers’ compensation, and business and professional regulation are just a few of the things that keep me busy.


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