Diagnosis for 7.19.23: 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.

— Medicaid unwinding —

Florida health care officials anticipated that about 900,000 people would be disenrolled from the Medicaid program by the end of June as the state stepped back from the public health emergency caused by the COVID-19 pandemic and returned its safety net program to normal operations.

But Medicaid Director Tom Wallace told the Social Services Estimating Conference members Wednesday morning that 640,000 people have been removed from the Medicaid program in the 12 weeks since the state started the unwinding process.

Over the same span, 134,000 people have enrolled in the Medicaid program, Wallace said, noting that the Medicaid rolls have been reduced by roughly 500,000.

According to Wallace, about 7,000 more people are enrolling in Medicaid during the unwinding than during the pandemic.

The spike in enrollment could result from the Department of Children and Families “doing (a) massive amount of outreach to stakeholders, working with our managed care plans and putting out (a) massive amount of outreach on this,” Wallace said. “This is what (the Centers for Medicare and Medicaid Services) wants to have done. CMS is doing outreach, too,” he said.

Wallace acknowledged that some of the “joiners” aren’t necessarily “new” enrollees and that some of them were removed from the Medicaid program during the redetermination process and later re-enrolled. People who lose coverage have 90 days to reapply.

Amy Baker, director of the Office of Economic and Demographic Research, pressed Wallace about the joiners and how many were removed during redetermination for procedural reasons.

“You are going to match them at some point, right?” Baker asked. “That’s probably an important thing to ferret out because it’s an oddness. You would think that they were being disenrolled because they really weren’t eligible for the program. And if they are trying to get back in, they are going to have a hard time.”

Wallace downplayed Baker’s concerns, saying before the pandemic and subsequent unwinding, as many as 30% of Medicaid enrollees would be disenrolled from the program for failing to submit the necessary paperwork to continue their coverage.

“This is happening now like it’s happening previously as well,” he said.

I welcome your feedback, questions and especially your tips. You can email me at [email protected] or call me at 850-251-2317.

— Financial woes? —

The higher-than-expected enrollment means there could be more people in the safety net program in the fiscal year 2023-24 budget than lawmakers expected and budgeted for.

“We are over the budget by 245,000 people,” Wallace said.

Wallace attributed the increase in enrollment to the state and federal government’s outreach efforts during the unwinding period, which Baker acknowledged could be a factor.

“Perhaps that’s shifted the (Medicaid) takeup rate,” Baker said.

But she also said there could be other issues in play.

“That’s an economic issue,” she said, adding that the cost of food and housing have skyrocketed. “Inflation tends to hurt lower-income people far more than anybody else. So, with elevated inflation … they may really be struggling more than anybody else in this society. So, we may see ‘joiners’ that are joining because they are in distress.”

Because Medicaid is countercyclical, enrollment spikes when the economy worsens. During the public health emergency, Congress agreed to increase the amount of federal funds for state Medicaid programs by 6.2%.

Those additional federal funds will stop flowing into Florida’s coffers at the end of December, halfway through the FY 2023-24 budget.

— Put on notice —

Florida regulators are pushing ahead with implementing a new law that affects pharmacy benefits managers and plans.

On Wednesday, the Office of Insurance Regulation (OIR) notified managers about the recent changes and the start of the rule-making process related to the law that was one of Gov. Ron DeSantis’ top priorities in the 2023 Legislative Session. The memo goes over many of the key provisions in the new law.

Part of the new law places new registration requirements on pharmacy benefit managers and OIR instructions tell PBMs they must apply for a valid certificate of authority or risk getting fined $10,000 per day starting on Jan. 1.

OIR has also told PBMs about some of the new transparency requirements now in place and tells them they must file statements on their financial condition, changes in ownership interests and a report on the total number of appeals and denials by pharmacies and pharmacists regarding PBM decisions dealing with a drug’s maximum allowable cost and reimbursements. This report is required to be filed every 90 days.

The OIR notice also points out that PBMs will be subject to biennial exams starting in January 2025 and that regulators must regularly report any new law violations to the Governor and the Legislature.

— His state, his rules —

Forget the lazy days of Summer.

As DeSantis campaigns for President, his administration is quickly moving ahead to ensure his priority policies are carried out.

Eight health-care-related emergency rules were recently issued addressing some of DeSantis’ top priorities.

The Board of Medicine and Osteopathic Medicine published emergency rules regarding the standard of transgender care for some minors and the informed consent forms for adults seeking gender-affirming and gender-conforming care.

Equality Florida and LGBTQ+ advocates have criticized the proposed forms.

“As expected, these forms are misleading, do not reflect the medical consensus supporting gender-affirming care, and likely violate the Boards’ legal authority. They are rooted in creating barriers to care, not patient well-being,” Equality Florida’s Jon Harris Mauer wrote in an email.

“These barriers include requirements like quarterly suicide risk assessment, annual X-rays, bone density scans and mental health assessment. For adults, the Legislature only directed the Boards to adopt forms that ‘informed the patient of the nature and risks’ of care. The Boards exceeded this direction and imposed substantive requirements like psychological and social evaluation by a Florida licensed board-certified psychiatrist or psychologist every two years.”

There are three informed consent forms for minors: one for feminizing hormones, one for masculinizing hormones and one for puberty blockers.

There also are three separate informed consent forms for transgender adults: one form for masculinizing hormones, one form for feminizing hormones and one form for gender-conforming care.

Meanwhile, AHCA and the Department of Health jointly worked on a quartet of new emergency rules to implement a new law that bans doctors’ offices and hospitals from requiring all visitors, patients or employees to wear masks. Facilities requiring masks or facial coverings must develop policies consistent with the rules by Aug. 1.

—Snapshot —

There were 223 “final actions” taken against Medicaid managed care plans by state regulators in the fiscal year that ended June 30.

According to AHCA, those actions resulted in the state levying $2.36 million in liquidated damages or sanctions against the contracted managed care plans between July 1, 2022, and June 30, 2023.

There were six more final actions against the plans in the fiscal year 2022-23 than in the previous fiscal year, but the damages and sanctions levied in 2021-22 totaled $30.91 million.

The state has taken 896 final actions against managed care plans, resulting in $42.68 million in assessments since the contracts took effect.

The most final actions (32) were taken against Sunshine Health Plan, which has the largest Medicaid enrollment in the state, followed by Humana Medical Plan with 25. Perhaps not surprisingly, Sunshine also led the state in liquidated damages and sanctions at $533,100.

Most final actions resulted in liquidated damages. Only three final actions resulted in sanctions levied against the plans.

And just two health plans have been sanctioned: Florida Community Care and Sunshine Health. The former, which successfully lobbied to test managed care for people served by the Medicaid IBudget Waiver on a pilot basis, was hit with a $2,500 fine, according to the agency’s website.

Sunshine Health was sanctioned twice and hit with $9.09 million in fines. One of the fines was associated with a merger with WellCare.

The current round of Medicaid managed care contracts expires Dec. 31, 2023.

Earlier this year, AHCA issued an invitation to negotiate (ITN) its Statewide Medicaid Managed Care Program. It’s the third time it is procuring the program. AHCA revealed this week that winning contracts are expected to be worth over $150 billion.

— RULES —

—The Board of Osteopathic Medicine issued Emergency Rule 64B15ER23-10 regarding mandatory standardized informed consent forms for transgender care for adults. More here.

—The Board of Osteopathic Medicine issued Emergency Rule 64B15ER23-9 regarding the standards of practice for treating transgender youth. More here.

—The Board of Medicine issued Emergency Rule 64B8ER23-8 regarding mandatory standardized informed consent forms for prescriptions or procedures for transgender adults. More here.

—The Board of Medicine issued Emergency Rule 64B8ER23-7 regarding the standards of practice for treating transgender minors. More here.

—AHCA published Emergency Rule 59AER23-1, establishing facial covering requirements for health care practitioners and providers. More here.

—AHCA published Emergency Rule 59AER23-2, establishing facial covering requirements for health care practitioners and providers. More here.

—AHCA withdrew its proposed rule on Medicaid policies for early intervention services. Rule 59G-4.085. More here.

—The Division of Medical Quality Assurance has amended proposed Rule 64B-9.001 regarding biennial licensure to reflect comments made by the Joint Administrative Procedures Committee. More here.

—The Board of Chiropractic Medicine proposes amending Rule 64B2-13.007 regarding continuing education requirements for newly licensed providers. More here.

—The Board of Chiropractic Medicine proposes amending Rule 64B2-13.004 regarding continuing education requirements during the initial licensure period. More here.

—The Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling proposes amending Rule 4B4-2.0025 to mandate supervision logs for supervisors. More here.

—The Board of Acupuncture proposes amending Rule 64B1-4.0011 to clarify existing requirements for licensure by endorsement. More here.

—The Division of Disease Control published Emergency Rule 64DER23-5 to provide definitions related to the standards for the appropriate use of facial coverings by health care practitioners and health care providers. More here.

—The Division of Disease Control published Emergency Rule 64DER23-6 to provide standards for the appropriate use of facial coverings by health care practitioners and health care providers. More here.

—The Board of Pharmacy proposes amending rule 64B16-28.750 regarding Class III Institutional Pharmacies to update incorporated form DH5032-MQA. More here.

—LOBBYISTS —

Brian Ballard, Christina Daly Brodeur, Ballard Partners: PointClickCare Technologies USA

Douglas Bell, James Daughton, Leslie Dughi, Allison Liby-Schoonover, Aimee Diaz Lyon, Andrew Palmer, Karl Rasmussen, Metz Husband & Daughton: GeneDx

Bryan Cherry, Jason Maine, PinPoint Results: North Walton Rural Hospital

Mike Haridopolos: Paydhealth

Valerie Norman-Wickboldt, Avail Strategies: Quelliv

Robert Schenck, The Legis Group: Stop Florida Blood Clots

Patrick Stone: Otsuka America Pharmaceutical

— ETC —

— The Food and Drug Administration this week approved a pediatric drug to prevent respiratory syncytial virus lower respiratory tract disease. Commonly referred to as RSV, the virus hospitalizes up to 160,000 older adults and 80,000 young children annually. AstraZeneca’s pediatric RSV drug, Beyfortus (nirsevimab-alip), was approved for children two or younger. With the approval of AstraZeneca’s drug, the U.S. will have at least three RSV drugs — one for infants and two for adults 60 and older. According to the Centers for Disease Control and Prevention, RSV kills between 6,000 and 10,000 adults 65 years and older and 100 to 300 children under five.

— Vital Pharmaceuticals (VPX) notified the state that it plans to lay off more than 400 workers in South Florida. According to the notice, the company marketed its assets through a competitive sale process, which is anticipated to be completed soon. As a result, the company will eliminate 19 employees from its Pembroke Pines location, 47 employees from its facility in Medley; and 397 people from its Weston facility.

— Seven Florida nursing homes have earned the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) 2023 Silver Achievement in Quality Award: Avante at Mount Dora, Mount Dora; Clermont Health & Rehabilitation Center in Clermont; DeBary Manor in DeBary; Gulf Coast Medical Center SNU in Fort Myers; Lakeside Oaks Care Center in Dunedin; Living Center of Safety Harbor in Safety Harbor; and The Lodge at Cypress Cove in Fort Myers. Florida now has 111 centers statewide that have earned the Silver Quality Award.

— LeadingAge Florida announced the organizations and people contributing to the aging field at its 60th Annual Convention and Exposition in Orlando this week. The winners: Sunnyside Village in Sarasota received the Distinguished Service award for its disaster relief efforts for communities and staff following Hurricane Ian; Aimee Rubinstein was bestowed the Emerging Leader award; Rocco Voglio of Westminster in St. Augustine was bestowed with the Employee of the Year award for creating new dining structures and programs that increased participation and satisfaction among the community’s residents, Rachel Blumberg of Sinai Residences in Ft. Myers was given the Executive of the Year award, Terry Rogers of Westminster Communities of Florida in Orlando was bestowed with the Innovation award for identifying and implementing innovative programs and services to better serve Westminster residents and team members, Delia Sanchez of Palermo Lakes in Miami was given the Service Coordinator of the Year award for her compassion helping seniors navigate the complexities of affordable housing programs and resources, and Flora Mummery of East Ridge at Cutler Bay was given the Volunteer of the Year award for helping residents and acting as a trusted go-between for residents and management.

— ROSTER —

— Cory Mead was named the CEO of HCA Florida Woodmont Hospital, a 271-bed acute care facility. He assumes the role on August 7.

— Carmel Barrau, M.D., has taken the helm at Dade County Medical Association. The medical society’s first Haitian American leader, Barrau, is co-founder of the Herbert Wertheim College of Medicine at Florida International University and chairs the Dean’s Advisory Council. He is also a board member of the FIU Foundation. He earned his undergraduate and medical degrees from the State University School of Medicine in Port-au-Prince, Haiti. He completed his internship and residency at the University of Miami, Jackson Memorial Hospital, and received numerous commendations throughout his career. He has been an active voice in Miami area health care for the past 30 years, serving as a leader and adviser in patient care, peer review, and medical education.

— Lee Health has named Malissa Wood, M.D., vice president and chief physician executive of Lee Health Heart Institute. Her new role is effective July 10. Wood previously served as the staff physician in the cardiac ultrasound laboratory at Boston-based Mass General Hospital and was the co-director of the Carrigan Women’s Heart Health Program.

— Jose P. Garcia, M.D., a Harvard-educated and fellowship-trained cardiothoracic surgeon, has been named chief of the adult heart transplant surgery and mechanical circulatory support programs at Memorial Healthcare System. Garcia has held leadership positions at multiple institutions, including Indiana University (Methodist Hospital), Harvard University (Massachusetts General Hospital), and the University of Maryland Medical Center.

— ICYMI —

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

Pearly whites: As Florida readies for a new Medicaid dental contract, a new report shows that most young children’s visits to emergency departments (EDs) were due to issues stemming from a lack of preventive care, even though Medicaid covers the services. Medicaid covered 80.6% of emergency department visits for nontraumatic dental care for children 14 and younger in 2020, according to a report released by Massachusetts-based CareQuest Institute for Oral Health. By contrast, commercial insurance accounted for just under 10% of emergency room visits by children for nontraumatic care. The most common diagnoses for these children during their emergency department visit were abscesses, tooth decay and cavities, mouth ulcers, and chronic gingivitis. All of those conditions are largely preventable with proper oral health care.

Tick tock: Health care providers have an extra week to make the state an offer to provide managed care plans, health care networks and accountable care organizations through the statewide Medicaid Managed Care Program that serves nearly 4.5 million Floridians. The Agency for Health Care Administration released a lengthy addendum to its invitation to negotiate, bumping the deadline for vendors to reply to Sept. 22. While the vendors have an additional week to prepare their ITN responses, the anticipated date for the state to post the names of the winning vendors electronically remains the same: Dec. 11. Additionally, the state still intends to negotiate with as many as 10 health plans between October and November.

Food pyramid: DeSantis failed to answer a question from a “rising ninth grader” in South Carolina about school lunches and whether he supported Barack Obama’s “Let’s Move” program. Instead, he reaffirmed “choices” to eat junk food before denouncing the “food pyramid.” From there, the Governor pivoted to denouncing federal nutritional recommendations. “I don’t want the federal government coming down, and honestly, the federal government in the past, remember, used to do the food pyramid. They said don’t eat, don’t eat fat, eat all the carbs. No, the carbs will make you fat too. And so, they were wrong about that.” The Governor changed the subject, saying that the “CDC, NIH, FDA need to be cleaned out” because “these agencies failed during, they lied to the American people about all these different issues.”

Song and dance: As a 2024 candidate, DeSantis continues being pushed to explain where he stood half a decade ago in Congress on senior citizen entitlements. “We’ve got to make sure we preserve it for our seniors because they depend on it,” DeSantis said during a Sunday interview. DeSantis explained that while today’s older generations would be exempt from Social Security and Medicare reforms, millennials and members of younger generations would have to adjust if DeSantis were elected President. DeSantis’ position on senior citizen entitlements has been a moving target in recent months, as he has been walking back previous calls for “market forces” and privatization to replace the current programs.

Long odds: DeSantis doesn’t have faith that a six-week abortion ban will get through Congress as it did the Florida Legislature, despite vowing to be a “pro-life President” if elected. During a Sunday interview addressed a question about his support of a national equivalent to 2023’s Heartbeat Protection Act. “Look, the Congress is probably not the place you want to put your hopes and dreams if you’re supporting pro-life. And so, I think we’re going to really have a strong bottom-up approach. We’re going to be working with states and localities to be able to advance the cause of life.” This wasn’t the first time the Governor said he wouldn’t apply Florida’s commitment to the “cause of life” to the other states if President.

—FOR YOUR RADAR —

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

“Florida hospitals comply with new immigration law with advocates ‘on alert’” via Ana Goñi-Lessan of the Tallahassee Democrat — In a patchwork of ways, medical officials across Florida have started complying with the state’s new immigration law, which requires hospitals that accept Medicaid to ask admitted patients their citizenship status. The law leaves room for discretion for health care administrators and allows hospitals to determine how much detail to include after “What is your citizenship status?” Florida hospitals are offering either an actual citizenship question form, electronic or paper, or asking patients verbally during the intake process, said Justin Senior, CEO of the Safety Net Hospital Alliance of Florida. GOP lawmakers and supporters of the law say taxpayers shouldn’t have to foot the bill for undocumented people’s medical care. Critics, meanwhile, say the question will cause “undue harm and fear” for migrants seeking care.

“FDA approves first OTC birth control pill” via Lauren Clason of Roll Call — On Thursday, the Food and Drug Administration approved HRA Pharma’s progestin-only birth control medication Opill, making it the nation’s first over-the-counter birth control pill. “Today’s approval marks the first time a nonprescription daily oral contraceptive will be an available option for millions of people in the United States,” said Patrizia Cavazzoni, director of the FDA Center for Drug Evaluation and Research. “When used as directed, daily oral contraception is safe and is expected to be more effective than currently available nonprescription contraceptive methods in preventing unintended pregnancy.”

“How much opioid settlement money coming this way? Collier at $13M and Lee at $26M” via Laura Layden of the Naples Daily News — Southwest Florida is preparing for millions in opioid settlement money to roll in from the state. A countywide community drug response team in Collier County is finalizing a plan to tackle the addiction epidemic that led to more than 1,100 overdoses in the county last year. According to the State Department of Health, there were 131 overdose deaths in 2021. In Lee County, the long-standing Public Safety Coordinating Council is designated as the local task force developing a strategy. The task force has approved two grants that will use local settlement funds. According to state data, EMS in Lee responded to 4,453 overdoses last year. There were 337 fatal drug overdoses in 2021.

“Malaria cases in Florida have been spreading. What happened in the 20 years since the last local spread?” via Jackie Llanos of Florida Phoenix — Two more cases of locally acquired malaria in Florida’s Sarasota County would make the spread that started in May as extensive as the Palm Beach County cases 20 years ago. The eight cases in Palm Beach in 2003 marked the last time the country experienced the spread of locally acquired malaria. Despite six cases in Southwest Florida and one emerging in Cameron County, Texas, the risk of someone getting malaria in the U.S. remains low. The federal CDC has issued a health advisory related to malaria cases, and the Florida Department of Health recently issued a statewide mosquito-borne illness advisory.

“FAMU’s School of Nursing dean resigns from university, interim dean is appointed” via Tarah Jean of the Tallahassee Democrat — Florida A&M University’s School of Nursing dean and professor Shelley Johnson has resigned from the university — a decision that was made effective last Wednesday. Her resignation comes after serving for three years as she led Florida’s oldest undergraduate nursing degree program on FAMU’s campus while it struggles to increase its annual licensure passage rates. The university’s Provost and Vice President of Academic Affairs, Allyson Watson, appointed Lisa Gardner, associate dean of graduate programs, to be the nursing school’s interim dean as a national search will be held during the upcoming 2023-2024 academic year for a permanent replacement.

—PENCIL IT IN —

Thursday

Happy birthday to lobbyist William Large.

2 p.m. — AHCA holds a meeting on three nursing home-related rules: 59E-4.101, 59E-4.102, and 59E-4.103, establishing a uniform system for financial reporting by nursing homes and their home offices. 2727 Mahan Drive, Building 3, Conference Room C, Tallahassee. Or call (888) 585-9008; participant code: 998518088. More here. Email [email protected] for more information.

Sunday

Happy birthday to former state Rep. Charlie Justice.

Monday

11:30 a.m. — The Physician Workforce Advisory Council meets to discuss developing a strategic plan for the state’s physician workforce. Join the virtual meeting via Microsoft Teams at floridahealth.gov. Or call (850) 792-1375; participant code: 742742076. Call Jon Conley at (850) 617-1439 for a copy of the agenda.

Tuesday

10 a.m. — AHCA holds a meeting on two proposed rules for assisted living facilities: 59A-36.019, regarding emergency management, and 59A-36.025, regarding emergency environmental control. 2727 Mahan Drive, Building 3, Conference Room A, Tallahassee. Or call 1 (888) 585-9008; participant code: 998518088. More information here.

Wednesday

Happy birthday to Larry Polivka, former director of the Claude Pepper Center.

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