Diagnosis for 3.29.23: 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.

— Up for grabs? —

Could a high-profile post in shaping health care policy in Florida come open sooner than expected?

Palm Bay Republican Rep. Randy Fine is Chair of the House Health & Human Services Committee and the main sponsor of a controversial bill that would ban physicians from providing puberty-blocking hormones or gender-affirming surgeries.

Fine took on this new role after spending time leading budget panels on higher education and PreK-12 under the previous two House Speakers. In 2022, he led a charge to attempt to penalize school districts that adopted mask mandates despite opposition from Gov. Ron DeSantis.

Fine is term-limited and had already begun running for a seat in the Florida Senate. But he revealed this week that DeSantis approached him about seeking the presidency of Florida Atlantic University. FAU’s former President — John Kelly — stepped down at the end of last year and the university has begun to slowly ramp up the search for a permanent replacement.

Fine, who holds an MBA from Harvard, has told multiple media outlets that he is considering applying for the job.

If Fine decides to go for the position it would not affect any of the work that he’s doing during the current Session that runs until May 5. But it could put him on a timeline to leave the House before the 2024 Session — and leave a top spot vacant heading into an election-year Session. Stay tuned.

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— Power, pharmacists and PBMs —

There’s an axiom in Tallahassee: what DeSantis wants; he gets.

On the health care front this year that means regulation of pharmacy benefit managers (PBMs).

But it’s been an interesting path to get to this moment and reflects what happens when someone with clout jumps into a long-running battle in the halls of the Capitol.

DeSantis initially pushed a Canadian drug importation program to help lower prescription drug costs, but the federal government has not signed off on the plan despite the Governor’s persistent criticism over the delays.

But with a potential presidential run looming, DeSantis in January announced his plans to rein in PBMs to control costs.

Independent and community pharmacists have been traveling to Tallahassee for years to share their experiences with PBMs and how the so-called “middlemen” have blocked them from treating patients and, if left unchecked, will run them out of business.

In 2018, the Legislature passed a bill that prevented clawbacks, gave pharmacists the right to challenge PBM audits and for the first time required PBMs to “register” with the state. But the measure’s impact was diminished by some technical issues. For instance, while PBMs were required to register with the Office of Insurance Regulation the state didn’t have the authority to sanction or fine PBMs who didn’t pay the $5 registration fee.

The audit protections in the bill also proved to be ineffective because the authority was placed with the Board of Pharmacy. While the pharmacy board has authority over pharmacists, it has no authority over PBMs.

Former Rep. Jackie Toledo filed a bill in 2021 that would have fixed those problems and would have gone further by prohibiting PBMs from charging pharmacists to participate in networks and requiring PBMs to update pricing information.

In order to get the bill (HB 1155) out of committee, though, Toledo agreed to rewrite the measure and strip most of the “substance” from it. That move was criticized at the time by Tallahassee lobbyist Barney Bishop, whose recent actions relative to a Tallahassee charter school and whether the statue of David should be seen by sixth graders have made headlines worldwide.

“This bill has been neutered so much it doesn’t even have a gender,” Bishop, who represents Small Business Pharmacies Aligned for Reform, said at the time. “PBMs, to me, act like the Chinese Communist Party. Everything is in secret. Everything is secret.”

But even after eliminating the “substance” of the bill it still didn’t make it across the finish line. Ultimately the “neutered” bill passed the House unanimously but died in the Senate.

— Devil in the deets —

With DeSantis on board, this year’s legislation will most likely punch through — much to the delight of pharmacists.

House and Senate health care panels this week discussed their respective PBM proposals, HB 1509 and SB 1550. Both committees did tag on lengthy amendments filed just hours before they were poised to meet. While not identical, the bills are now close.

One difference is a provision in the House bill that requires PBMs to freeze their formularies, or the list of drugs that policyholders can access without jumping through hoops, such as prior authorization or step therapy.

While the initial House bill would have required the formularies to be frozen for a year, the latest version requires a 60-day freeze. There is no requirement for PBMs to freeze their formularies in the Senate bill.

One highlight from the committee action this week came after House Healthcare Regulation Committee Chair Chuck Clemons heard at times heart-wrenching testimony from patients.

Clemons (who voted for Toledo’s watered-down bills in 2021 and 2022, when it ultimately passed) opined: “It’s a wonder that we have the organization of government that we do, because, in a level of government that’s less than ours, some of these folks would be running from pitchforks — because they steal. They’re stealing from sick people. And all I can say is, ‘You better get good with your maker, because you may rot in hell for some of these things that have happened in the past.’”

— Shrewd move —

Tucked into the end of the PBM bills is language that the proposals are not meant to conflict with any federal law.

That is followed by a severability clause which essentially ensures that if a ruling invalidates a portion of the bill the remainder will remain intact. It’s a shrewd move because the provision in the bill that requires drug rebates to be given to the insured at the point of purchase also impacts Medicare Part D plans.

While the provision would ideally put discounts into the hands of seniors — remember, DeSantis announced his PBM plan in The Villages — it’s worth noting that the federal government, not the state, regulates Medicare Part D plans.

Moreover, the Inflation Reduction Act championed by the Biden administration and passed by Congress last year capped the cost of insulin at $35, allowed Medicare for the first time ever to negotiate lower prescription drug costs for seniors, and required prescription drug companies to pay rebates to Medicare if they raise their prices faster than inflation.

If Florida lawmakers don’t carve Medicare Part D plans out from the rebate requirements, the law is ripe for a challenge in federal court. If challenged, DeSantis can still claim a victory saying that he fought for the rights of seniors.

— A strange mandate —

The Legislature could pass a new type of health insurance “mandate” this year.

Insurance mandates usually require HMO and insurance companies to include certain services in their health insurance policies. But the House is advancing a bill this Session that prohibits insurance companies and managed care plans from including in their policies coverage for gender-affirming and gender-conforming health care.

The bill, sponsored by Fine and Rep. Ralph Massullo, codifies into law — and expands upon — some of the administrative actions taken by the DeSantis administration.

The Board of Medicine and the Board of Osteopathic Medicine passed rules that prohibit Florida licensed physicians from providing gender-affirming care to minors but made exceptions for those currently receiving the care.

The House bill (HB 1421) goes further and bans all health care practitioners (think physician assistants and advanced nurses) from providing gender clinical interventions to minors. And, unlike the medical board rules, the legislation does not provide a safe harbor to minors currently in treatment. Instead, it allows physicians to provide the services through Dec. 31, 2023.

The DeSantis administration amended its Medicaid rules to ban the safety net program from reimbursing the services to enrollees of all ages, not just minors. The measure codifies the Medicaid ban into law but goes further to ban HMOs and insurance companies from covering the services in any of their “commercial” policies sold to small employers or large group employers.

The commercial insurance ban is not included in the Senate counterpart, SB 254, filed by Sen. Clay Yarbrough. If passed, it would be the first anti-mandate mandate in Florida’s insurance codes.

— ‘Amblyopia Awareness Month’ —

The Senate recently OK’d a resolution designating August as “Amblyopia Awareness Month.”

Amblyopia, more commonly referred to as “lazy eye,” is the most common cause of permanent vision loss in children. It is caused by several eye disorders, and it affects an estimated one in 20 children.

Amblyopia is preventable if caught and treated early, so the Florida Society of Ophthalmology and the For Eye Care Foundation have made raising awareness a priority. FSO and FECF’s awareness effort was given a boost by Lantana Democratic Sen. Lori Berman, who sponsored the resolution (SR 1724).

Since many forms of amblyopia are difficult to detect and can only be identified through proper screening techniques, it is imperative they receive screenings in early childhood.

However, a recent report from the American Academy of Ophthalmology shows that even though half of the childhood blindness in the U.S. is preventable, fewer than one in five preschool children are screened for vision problems, even though screenings are covered service by many health insurance plans and health maintenance organizations.

“Vision screenings early and often are one of the best tools parents and guardians have against vision issues like amblyopia, which can be caught and treated if found early enough,” said FSO President Joseph T. Nezgoda, a medical doctor and Fellowship Trained Retina Specialist at The Retina Macula Institute.

“No child should have to suffer permanent vision loss that could have been prevented if only there was more education and awareness of the importance of vision screenings, particularly screenings done before age 5. The Florida Society of Ophthalmology thanks Sen. Lori Berman for helping to keep our children safe and well, and for championing early vision screenings for all children.”

— RULES —

— The Board of Osteopathic Medicine proposes amending Rule 64B15-14.015 to update reporting forms for physicians who perform abortions other than in a medical facility. More here.

— The Board of Medicine proposes amending Rule 64B15-14.015 to update reporting forms for physicians who perform abortions other than in a medical facility. More here.

— The Board of Psychology proposes amending Rule 64B19-11.005 to update supervised experience requirements. More here.

— The Board of Dentistry proposes amending Rule 64B5-12.01 to allow providers to obtain the two mandated continuing education hours in controlled substance prescribing by attending courses approved by the Board of Medicine. More here.

— LOBBYISTS —

Jason Allison, Foley & Lardner: iLab

Laura Boehmer, Seth McKeel, Mike Moore, The Southern Group: Employer Direct Healthcare

Kevin Comerer, Rubin Turnbull & Associates: Association of Dental Support Organizations

Cynthia Henderson, Cynergy Consulting: CIOX Health, Epic Pharmacies, INDIVIOR

Eric Johnson: AvMed

Joshua Keepes: URAC

Aimee Lyon, Karl Rasmussen, Metz Husband & Daughton: GoodRx

Frank Mayernick, Tracy Mayernick, Rob Johnson, The Mayernick Group: Senior Friendship Centers

Stephen Smith: GetInsured

Frank Terraferma: National Council of State Boards of Nursing

— ETC —

— The U.S. Food and Drug Administration approved Narcan, a 4 mg naloxone hydrochloride nasal spray for over-the-counter, nonprescription use — the first naloxone product approved for use without a prescription. Naloxone rapidly reverses the effects of opioid overdose and is the standard treatment for opioid overdose. The approval action paves the way for the lifesaving medication to be sold directly to consumers in places such as drugstores, convenience stores, grocery stores and gas stations, as well as online.

— Florida Medicaid officials will begin disenrolling people from the state’s Medicaid program on April 1. The DeSantis administration says it’s time to return the state’s safety net program for the poor elderly and disabled back to its pre-pandemic operations. Florida will focus its efforts initially on removing 900,000 residents who no longer qualify for the program, either because they aged out, left the state, or earn too much to qualify and have not been tapping into the health care benefits. The focus will then turn to disenrolling ineligible beneficiaries who have been receiving care but no longer qualify for Medicaid. The state will next begin Medicaid eligibility redetermination efforts for another 850,000 recipients who haven’t provided the state with ongoing pertinent financial information during the pandemic, according to the rewinding document posted on the Department of Children and Families website.

—Mayo Clinic Jacksonville is one of 13 institutions around the country to receive new federal funding to help identify the next generation of precision medicine biomarkers and potential therapeutic targets for Alzheimer’s disease and related dementias in multiethnic populations.

— ROSTER —

— Former Rep. MaryLynn Magar, who was the House’s chief health care budget writer for two years, was appointed to the State Board of Education.

— Oscar J. Horton has been named to the Tampa General Hospital to its Board of Directors. Horton is the Chair and CEO of Horton Holdings, which owns and oversees the operations of Sun State International and Sun State Real Estate.

— Ashley Vertuno, the CEO of HCA Florida JFK North Hospital in Palm Beach, has been named to Modern Healthcare’s list of the Top 25 Emerging Leaders for 2023.

— Joe Johnson was named president and CEO of AdventHealth Carrollwood in Tampa. Johnson previously held that post but left in 2018 to lead AdventHealth Ocala’s transition into AdventHealth.

—Erika Skula was named president and CEO of AdventHealth Ocala in Marion County.

— DeSantis reappointed Tampa General Hospital Director of Pharmacy Maja Gift to the Florida Board of Pharmacy. Her appointment is subject to confirmation by the Florida Senate.

— ICYMI —

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

Five-year plan: To reduce the number of unintended pregnancies and increase the time between having kids, the state is asking the federal government to extend its Medicaid Family Planning waiver for another five years. Before the AHCA can submit its waiver request to the Centers for Medicare & Medicaid Services for approval it is required to receive public input. AHCA has scheduled public meetings in Tallahassee on April 10 and April 18. It is also accepting written comments on the proposed waiver until April 26. The program serves teenagers and women between the ages of 14 and 55 who have a family income at or below 191% of the federal poverty level. Program eligibility is for a two-year period, but the state will re-determine enrollees’ income eligibility annually.

‘Specific role’: A bill that would define who uses what bathroom is advancing in the House — a bill with a similar intent to the one that landed North Carolina on a boycott list in 2017. The House bill defines “female” and “male” according to the “specific reproductive role of each.” The “female” is defined as “producing eggs” and the “male” as “producing sperm.” Republican Rep. Rachel Saunders Plakon of Lake Mary introduced the bill. It passed largely along party lines.

Mega millions: The Senate plans to establish trust funds in multiple budget silos using a $200 million settlement with opioid manufacturers. The projects include a $67.5 million fund within the Department of Children and Families to provide services associated with opioids. Outside the health silo, Senators also plan to direct $25.7 million through the criminal justice system.

Pay bump: In an attempt to beef up the number of physicians willing to treat workers’ compensation patients, a House subcommittee gave the green light to a bill that will increase — for the first time in 20 years — reimbursement rates for expert medical witnesses who testify in workers’ comp cases.

On the fast track: A bill that would ban abortion after the sixth week of pregnancy cleared the Florida Senate’s Fiscal Policy committee, largely along party lines. That was the measure’s final committee of reference, positioning it for a fast track to the Senate floor. It could be on Thursday’s Special Order calendar and may get a vote the same day.

— FOR YOUR RADAR —

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

—“Florida’s newest doctors choose primary care and psychiatry, shun emergency medicine” via Cindy Krischer Goodman of the South Florida Sun-Sentinel — Florida’s newest batch of medical school graduates want to become internists, psychiatrists and other higher-paying specialties. What few want to become are emergency medicine doctors, one of the most needed jobs in Florida. Nationally, in this year’s match day on March 17, when medical school graduates are assigned to hospitals that will train them, 555 positions in emergency medicine went unfilled, more than double the 219 unfilled positions last year. Florida’s 10 medical schools graduated 795 future doctors who matched and will begin their residencies in the summer and fall.

—“Health care ‘equity’ was a Florida priority until the DeSantis administration erased it” via Kirby Wilson and Lawrence Mower of the Miami Herald/Tampa Bay Times — In 2017, when Florida Department of Health officials crafted their once-every-five-years list of state health goals, they published what was then a noncontroversial top priority: improving health equity. The state sought to home in on “avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” When the state reconvened in 2022 to release its new set of state health goals, its Governor and Surgeon General had changed. So had its priorities. No longer was equity the plan’s top priority area — or a listed priority at all.

—“22,435 Floridians with disabilities remain on yearslong waitlist for services” via Scott Maxwell of the Orlando Sentinel — Thousands and thousands of children with disabilities who have been waiting for years. Not for school vouchers, but for access to basic services like respite care, physical therapy and medical equipment. That waiting list for Medicaid waivers has more than 22,000 families on it. Nearly half the families have been waiting for more than a decade. Some children die before getting served. Years ago, Florida had no waitlist. Every qualified family got served.

—“How Florida uses a little-known law to punish abortion clinics” via Arek Sarkissian of POLITICO — Florida regulators over the last year punished more than a dozen abortion providers for violating a nearly decade-old law that requires pregnant patients wait 24 hours before getting the procedure. Florida legislators approved the law in 2015, but it remained in limbo after the American Civil Liberties Union challenged it. After a judge upheld the law in April, Florida’s abortion regulator, the Agency for Health Care Administration, almost immediately began issuing fines.

—“A mystery: 16,000 previously uncounted COVID-19 cases added to Florida’s total” via Chris Persaud of The Palm Beach Post — The CDC said this week that it had added about 16,000 previously uncounted COVID-19 cases over the past four months to its Florida total. At the same time, the state’s new case count increased slightly this week while hospitalizations have sunk to pre-Winter surge levels. The CDC added 15,993 COVID-19 cases to its Florida sum that had not been previously reported between November and March, the federal agency reported Thursday. Representatives for the CDC and the Florida Department of Health did not explain Friday why those infections have gone uncounted for months.

— PENCIL IT IN —

Thursday

Rep. Fabian Basabe’s birthday.

8 a.m. — The House Health & Human Services Committee will consider legislation (HB 7) instituting a six-week abortion ban. Room 17, House Office Building.

8 a.m. — The House Ways & Means Committee will consider a bill (HB 29) that would provide a sales tax exemption for diapers and incontinence products. Room 404, House Office Building.

8:30 a.m. — The Senate Rules Committee meets will consider legislation (SB 1674) that would make it a second-degree misdemeanor for a person to enter a bathroom that does not align with their biological sex. Room 412, Knott Building.

11 a.m. — The House holds a floor Session. House Chambers.

1:30 p.m. — The Senate will consider numerous bills during a floor Session, including a measure (SB 300) that would create a six-week abortion ban. Senate Chambers.

6:15 p.m. — The Senate Special Order Calendar Group Room 401, Senate Office Building.

Friday

Rep. Dana Trabulsy’s Birthday.

11:30 a.m. — The House holds a floor Session. House Chambers.

Monday

10 a.m. — The Senate holds a floor Session. Senate Chambers.

10:30 a.m. — The House Healthcare Regulation Subcommittee meets. Room 102, House Office Building.

Tuesday

4:30 p.m. — The Senate holds a floor Session. Senate Chambers.

Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson.