- Agency for Health Care Administration
- Chad Poppel
- Chiquita Brooks-LaSur
- Dana Trabulsy
- Edward Forster
- Elizabeth Rochaine
- Florida Board of Medicine.
- Gregory Coffman
- John P. Fogarty
- Liz Dudek
- Matthew Benson
- Nathan Landsbaum
- Robin Bartleman
- Ron DeSantis
- Shaddrick Hattson
- Veronica Catoe
- Wellington Regional Medical Center
Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
— Another Medicaid ITN —
The state Agency for HealthCare Administration (AHCA) dropped its third Medicaid procurement of the year, the latest to test pilot the managed care delivery system for people with developmental and intellectual disabilities who live in Medicaid Regions D and I.
Interested parties have until Dec. 8 to submit their responses to the Comprehensive Intellectual and Developmental Disabilities (CIDD) Managed Care Pilot Program invitation to negotiate (ITN).
AHCA intends to negotiate with interested managed care plans Jan. 22-26 and post the names of the vendors it wants to award contracts to Jan 31. AHCA intends to issue one contract for each region.
According to the ITN, only managed care plans awarded Medicaid managed long-term care contracts are eligible to participate in the new managed care pilot program.
In an attempt to keep people with intellectual and developmental disabilities out of institutions, Florida created the Medicaid iBudget program. Enrollees are provided with a budget and can procure the home and community-based services they require to keep them living in the community and outside of an institution.
According to the ITN, there are currently approximately 35,000 Floridians enrolled in the iBudget and roughly another 22,000 individuals on a waiting list for services.
While funded with Medicaid dollars, the iBudget program is one of the few safety net programs not administered through Medicaid managed care. For years, there has been an effort to roll iBudget into Medicaid managed care, but advocates and former legislative leaders beat it back.
Lawmakers last year passed SB 2510, which authorized the state to test whether managed care would work for people with intellectual and developmental disabilities. House Speaker Designate Danny Perez championed the move.
The pilot will be open to people residing in Medicaid Regions D or I who are 18 years or older and on the iBudget waitlist. The initial enrollment phase will include enrollment of up to 600 slots. Specific goals for this Pilot Program include:
— Maximizing managed care flexibility to provide additional services.
— Increase access to providers and services.
— Maintain the highest quality of care coordination and person-centered care plans.
— Increasing opportunities for community integration.
While lawmakers only included one year of funding for the pilot, the ITN anticipates the contracts will remain in effect through Sept. 30, 2030.
In addition to the Medicaid CIDD ITN, AHCA released its Medicaid managed care ITN and a Medicaid dental ITN this year.
I welcome your feedback, questions and especially your tips. You can email me at [email protected] or call me at 850-251-2317.
— Abortion rights —
Organizers behind a proposed initiative on abortion rights are calling the passage of a measure in Ohio a sign of things to come in Florida.
It’s also been seen by many national political observers that abortion rights continue to be a driving force a year after the U.S. Supreme Court overturned Roe v. Wade.
Voters in Ohio, which has a Republican Governor who signed into law a six-week abortion ban, on Tuesday overwhelmingly approved a constitutional amendment that protects reproductive decisions, including the right to abortion. It allows the state to restrict abortion after fetal viability with exceptions for the life of the mother.
Florida voters in 2024 may get a chance to decide whether to protect abortion rights up until viability. So far, those backing the amendment have collected nearly 492,000 verified signatures. They have until February to get just under 900,000 signatures.
“The win in Ohio gives us further insight into how we can win in Florida, including early organizing and fundraising,” said Lauren Brenzel, campaign director for Floridians Protecting Freedom, the committee working on the initiative. “The Ohio ballot initiative began its organizing efforts in March of this year, nearly a year later than Floridians Protecting Freedom began organizing.”
Brenzel added, “Our campaign has the time, resources and momentum to win. Tonight’s victory in Ohio only strengthens our resolve to return the freedom to make decisions about abortion to the people of Florida, where it belongs.”
The Florida amendment, however, still needs to get cleared by the Florida Supreme Court to make the ballot. Attorney General Ashley Moody contends that the initiative is misleading and should be blocked. Organizers sharply disagree and claim Moody is making “disingenuous” arguments.
— Pot amendment —
Some justices on the Florida Supreme Court are publicly expressing skepticism to arguments that a proposed initiative legalizing recreational marijuana should be kept from the 2024 ballot.
The Supreme Court is charged with reviewing whether or not the proposed amendment sticks to a single subject and whether the ballot summary is misleading. The court review is the last major hurdle left for organizers. Smart and Safe Florida, the committee backing the proposal, has already collected more than 1 million verified voter signatures.
During an hourlong hearing, justices peppered lawyers for both Moody and the Florida Chamber of Commerce about their legal arguments on why the measure should be tossed.
At one point, Chief Justice Carlos Muniz contended that the points made by Jeffery DeSousa, the Chief Deputy Solicitor General, were “super lawyerly.” He questioned how it applied to a voter trying to understand the amendment.
Justice John Couriel also questioned the opinion that voters would fail to understand that recreational marijuana would remain illegal under federal law. He said it was in the text of the measure.
“Where’s the hidden ball?” Couriel said.
Later in the hearing, Justice Charles Canady took issue with the argument made by Sam Salario, an attorney representing the Chamber, regarding whether or not the amendment’s wording would violate the single-subject requirement because it would allow both the sale and possession of recreational marijuana.
Canady suggested the interpretation put forward by the Chamber would turn into a “straitjacket on the people.”
“We might think that the people would be making an unwise choice, but that’s a different question than whether the constitution prohibits them from effectively acting in this arena,” Canady said.
Justice Meredith Sasso questioned some of the logic asserted by John Bash, a Smart & Safe Florida lawyer. But Bash repeatedly told justices the measure was carefully worded to follow the “road map” included previous rulings handed down by the court in recent years on other proposed constitutional amendments.
— Data, but no solutions —
The Department of Health had plenty of data to share with House Healthcare Regulation Committee members on Wednesday.
But DOH Division of Public Health Statistics and Performance Management Director Emma Spencer was all statistics and not much else, which prompted committee member Rep. Kelly Skidmore to offer: “You are the Department of Health, and we need answers from you on how we can fix (health care workforce issues). We’re not all experts, but we’re here to help. And you’re giving us data and nothing to do with it.”
According to a 2022 physician workforce study, 58,062 physicians provided direct primary care to patients, a 33.8% increase since 2012 for an average annual growth of about 3.8%; Spencer said nothing that the state’s population has increased by 15% during that same period.
Administered by the DOH to physicians during the biennial licensure process, the 2022 survey shows that of the 58,062 physicians providing direct primary care, 14,658 doctors were between the ages of 50-59, 14,525 were between the ages of 40-49 and 9,743 were under the age of 40.
According to national data from the Association of American Medical Colleges, Florida ranks 25th among the 50 states in the number of active physicians per 100,000 people, with a rate of 273.9.
Spencer said state data showed that Miami-Dade County has the most significant number of physicians in the state, with 8,486. However, the highest rate of physicians per capita is in Palm Beach County, with 327.4, followed by Hillsborough (323.2), Orange (319.8), Miami-Dade (296.6) and Broward (270.9).
She also told the committee that 5% said they would move out of state. A third (34%) cited family as the main reason.
When House Healthcare Regulation Committee member (and physician by trade) Rep. Joel Rudman asked about physician reimbursement rates in Florida and whether low rates — he didn’t specify Medicaid or commercial — impacted physicians’ decisions to practice in Florida.
He also asked about noncompete clauses impacting Florida physicians. Rudman filed legislation to ban noncompete clauses.
Spencer had no answers.
— Doctor’s orders —
Two Democratic lawmakers have filed legislation that they think will help bolster the number of physicians in Florida.
Skidmore and Sen. Bobby Powell filed the bills (HB 345/SB 316), coming as the Florida Medical Association (FMA) reports that more than half of physicians are employees in their practice and have no ownership stake.
The trade association representing Sunshine State doctors asserts the current dynamic prioritizes profits over patient care.
“When Floridians go to the doctor, they want to know that the care they are receiving is based on that doctor’s medical expertise and experience,” Skidmore said in a news release. “Unfortunately, in Florida, health care is often decided by corporate entities whose only interest is the bottom line. This bill does for doctors what we have already done for dentists and lawyers. Only a dentist can own a dental practice and only a lawyer can own a law firm. The same should be true for physicians.”
Powell added, “The practice of medicine is increasingly being controlled by corporate interests. This legislation takes the first steps in bringing Florida in line with a majority of states exerting some modicum of restraint over corporate domination of the medical profession. A physician’s first duty is to the well-being of the patient, not the stockholders.”
Under the legislation, only physicians, groups of physicians, nonprofit hospitals or medical schools would be allowed to employ physicians, “interfere with a physician’s clinical judgment,” or allow an unlicensed practitioner to exercise control over treatment selection, patient records, billing decisions or policies regarding staffing, office personnel or hours of practice.
— Long-term care workforce woes —
Florida’s two nursing home associations are asking the Biden administration to rethink its proposed minimum staffing standards for nursing homes.
The largest statewide group, the Florida Health Care Association, and LeadingAge Florida, which represents an array of senior care providers, submitted comments to the Centers for Medicare & Medicaid Services on its proposed new regulations for long-term care staffing requirements.
In a letter to CMS, FHCA CEO Emmett Reed said the proposed rules are unnecessary given Florida’s “already robust staffing requirements.” He added that it would only compound the staffing problems that nursing homes and long-term care facilities are already experiencing.
According to FHCA, the new rules would require Florida providers to hire more than 3,500 additional staff, including 2,662 nurse aides and 885 registered nurses. Hiring those high-demand employees would cost providers an estimated $188 million. If facilities cannot comply with the new regulation, as many as 12,000 of the state’s 70,000 facility residents could lose care.
“We agree that improving and providing the highest quality of care should be the goal that everyone is working toward; however, a one-size-fits-all staffing model is not the way to achieve that goal,” Reed said.
“Arbitrary and unfunded mandates such as proposed in this rule will only create access issues because the staff required in this proposal do not exist, are not projected to exist, and the proposed requirements certainly cannot be met if CMS is unwilling to provide any additional funding for centers to hire the staff needed to comply.”
FHCA noted that the CMS staffing proposal does not consider using licensed practical nurses. LPNs, which have a higher level of training than CNAs, currently make up over 61% of the workforce, helping to meet the staffing mandates in Florida facilities.
Meanwhile, the number of Floridians earning CNA certifications has halved over the past decade, falling from 5,090 in 2012 to 2,590 in 2022.
“This ongoing environment of unavailability of staff, in combination with funding at levels that are inadequate to compete with other professions, must be factored in as an unfortunate reality when considering staffing minimums,” Reed wrote.
LeadingAge Florida President and CEO Steve Bahmer said that more than 80% of the nursing homes would not meet the minimum staffing requirements proposed in the new rule.
“With the current shortfall of nurses and the outlook worsening in the future, this proposal is simply not realistic. The education system cannot meet the current demands. The added demand that this rule would create would dramatically increase scarcity, with ripple effects throughout the entire health care system.”
— DeSantis is mum —
Fifteen Republican Governors are pushing back against CMS and the proposed new regulations, but not Florida Gov. Ron DeSantis.
DeSantis was one of 11 Republican Governors who did not sign the Republican Governors Association’s letter directing President Joe Biden to reconsider the rules, an effort led by Iowa Gov. Kim Reynolds and Nebraska Gov. Jim Pillen.
Further, the letter states that the Centers for Medicare and Medicaid Services proposed rule disregards results from its study on long-term care facility staffing.
The Biden administration in September issued a proposed rule that, for the first time, sets national minimum nurse staffing standards. According to a CMS news release, the proposed rule “builds on Biden’s historic Action Plan for Nursing Home Reform launched in the 2022 State of the Union.”
Florida’s requirements for licensed nursing services, signed into law by DeSantis in 2022, run afoul of the requirements in the proposed new rules.
— Saving lives —
Currently, 5% of Leon County residents know how to administer overdose-reversing drugs. The Rotary Club of Tallahassee wants to quadruple that.
WTXL Tallahassee recently spotlighted the club’s initiative, spearheaded by Mariah Kill. The club is explicitly training residents in administering Klaxxado, a pharmaceutical that includes double the dose of naloxone as the more commonly used Narcan.
Klaxxado’s use has seen an uptick due to the increasingly high potency of synthetic opioids, such as fentanyl, which have tested the limits of Narcan, which is typically administered in 4-milligram doses.
A recent study shows that in 78% of overdose treatment events where 4 mg Narcan was administered, two or more doses were needed. In 30% of cases, it took three or more doses. The study also found that 86% of participants reported more confidence in an 8 mg naloxone nasal spray like Klaxxado versus a 4 mg naloxone nasal spray.
The Rotary Club’s effort comes after Tallahassee overdoses hit 31 last year. One of those deaths was a friend of Kill’s, which has served as a motivator to get the initiative off the ground.
“One year ago today, a friend of mine overdosed on fentanyl. So, they lost their life, and it’s a hard thing to talk about, but it’s the reality of what we’re living in,” she told WTXL.
“ … In a perfect world, we wouldn’t be using these kinds of drugs because we don’t want to see people overdosing, but it is the unfortunate reality of the situation.”
— BILLS OF INTEREST —
Here is a list of the bills of interest filed between Nov. 2 and 8.
HB 327 by Rep. Shane Abbott — Placement of Surrendered Newborn Infants: Placement of Surrendered Newborn Infants; Requires community-based care lead agencies to maintain specified registry; requires that certain information be removed from registry; prohibits lead agency from transferring certain costs to prospective adoptive parents; revises entity responsible for surrendered infants from licensed child-placing agencies to community-based care lead agencies; provides requirements for lead agencies once they take physical custody of surrendered newborn infant. Effective date: July 1, 2024.
SB 302 by Sen Jim Boyd — Dental Services Dental Services: Requiring every dentist and specific individuals, partnerships, corporations, and other entities to provide specified information to certain patients; requiring a dentist of record to remain primarily responsible for all dental treatments for a patient treated through telehealth; requiring advertisements of dental services provided through telehealth to include a specified disclaimer for certain dental services, etc. Effective date July 1, 2024.
SB 306 by Sen. Gayle Harrell — Placement of Surrendered Newborn Infants: Defining the term “community-based care lead agency”; requiring community-based care lead agencies to establish and maintain a specified registry; revising the entity responsible for surrendered infants from licensed child-placing agencies to community-based care lead agencies; providing requirements for the hospital once they take physical custody of a surrendered newborn infant, etc. Effective date: July 1, 2024
SB 310 by Sen. Jonathan Martin — Recovery of Damages in Claims for Medical Negligence: Removes a provision that prohibits parents of an adult child from recovering certain damages in medical negligence suits, etc. Effective date: July 1, 2024.
SB 362 by Sen. Jennifer Bradley — Medical Treatment Under the Workers’ Compensation Law: Increasing limits on witness fees charged by certain witnesses; increasing maximum reimbursement allowances for physicians and surgical procedures. Effective date: July 1, 2024.
— RULES —
AHCA proposes amending Rule 59G-4.072 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for specialized services. More here.
AHCA proposes amending Rule 59G-4.073 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for orthotic and prosthetic services. More here.
AHCA proposes amending Rule 59G-4.074 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for respiratory services. More here.
AHCA proposes amending Rule 59G-4.075 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for wheelchairs, hospital beds and ambulatory services. More here.
AHCA proposes amending Rule 59G-4.076 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for continence, ostomy and wound care services. More here.
AHCA proposes amending Rule 59G-4.077 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for enteral and parenteral services. More here.
AHCA proposes amending Rule 59G-4.250 to incorporate by reference the Florida Medicaid Durable Medical Equipment and Medical Supply Services Coverage Policy for prescribed drug services. More here.
— LOBBYISTS —
Brian Ballard, Courtney Coppola, Dane Eagle, Adrian Lukis, Ballard Partners: AIDS Healthcare Foundation, Lighthouse Central Florida, Novavax
Christopher Dawson, Angela Drzewiecki, Katie Flury, Christopher Hansen, Leeann Krieg, GrayRobinson: Childcare Network, Community Rehabilitation Center, Vaxxinity
Kaley Flynn, Capital City Consulting: Sarasota Memorial Health Care System
Robert Holroyd, Tripp Scott: NAMI Florida
Amy Virgo, Travel Green Florida: Florida Cannabis Chamber of Commerce
— ETC —
— Palm Beach PACE has applied to a program of all-inclusive care for older adults in Martin and St. Lucie counties. Contact AHCA’s Bureau of Medicaid Policy at [email protected] for additional information.
— Hailey Lafferty, APRN, is asking the board of Nursing whether she can prescribe controlled substances schedules II-IV operating under a collaborative agreement with a psychiatrist. Contact the Board of Nursing for a copy of the petition for declaratory statement. (850) 245-4125. More here.
— The Board of Psychology filed rule 64B19-13.003 regarding continuing education credits with the Secretary of State this week. It takes effect Nov. 21
— ROSTER —
Former FSU baller and Florida State University College of Medicine graduate Myron Rolle announced he is returning to Florida for a pediatric neurosurgery fellowship at Johns Hopkins All Children’s in St Petersburg. He announced it on social media.
— ICYMI —
In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.
RIP: Longtime health care lobbyist Larry J. Overton has died. He was 78. Overton influenced Florida’s health care policy first as an executive at the (now defunct) Department of Health and Rehabilitative Services and later as a lobbyist. At HRS, he was in charge of Medicaid policy, aging and adult services, economic services, mental health, and children’s medical and developmental services. He was appointed Deputy Secretary of HRS in 1980. He founded the full-service governmental law firm Larry J. Overton & Associates five years later. Overton was remembered by contemporaries, lawmakers and influencers on Friday for his unparalleled access to health care agency staff and legislative leadership and his honest, upfront style.
Take it from a legend: Quarterback Jim Kelly played in four Super Bowls, but his greatest challenges in life tackled him off the field. His only son, Hunter, died at age 8 after a lifetime fighting Krabbe’s Disease. Later, Kelly survived four personal bouts with cancer. Kelly and his wife, Jill, launched the Hunter’s Hope Foundation, which continues to advocate for early screening for the disease. That’s part of Kelly’s message to Florida as he spoke at the Florida Association of Health Plans annual conference in Orlando. He notes that children in every state have a heel prick shortly after birth, which provides samples for early disease screenings.
Campaigning Ladapo: State employees and assets continue to buoy DeSantis’ campaign, with the latest example being Joseph Ladapo’s trip to the Granite State. The Surgeon General accompanied the Governor to a “Medical Freedom Town Hall” in Manchester, where the two brought their patented brand of COVID-19 mitigation contrarianism to a New Hampshire audience. Ladapo led off his remarks with comments on the “confusing” staging of the town hall itself. “There are people behind you, and I wonder who designed this,” the Surgeon General said. “I guess it gets the most people in the room, maybe. But, I feel, you know, I’m thinking, I, I want to be talking, and I want to see everyone I’m talking to, so maybe I’ll keep spinning.”
— FOR YOUR RADAR —
Aside from coverage by Florida Politics, these stories are worth your time.
“GOP-controlled Legislature rejects bills on affordable housing, property insurance, Medicaid expansion” via Jeffrey Schweers of the Orlando Sentinel — The Republican-controlled House rejected one last time an attempt by Democrats to expand this week’s Special Session to include bills addressing rising housing costs, the property insurance crisis, expanding Medicare for children and curbing gun violence. At the request of DeSantis, the Legislature called a Special Session to address support for Israel, provide money to boost security at Jewish day schools in Florida, and take further punitive measures against companies doing business with Iran. His requests include property tax breaks and other actions to aid the rural farm communities struck by Hurricane Idalia, increasing the amount of funding for the My Florida Safe Home program, and expanding the state voucher program to include more children with disabilities.
“Plans for UF graduate campus moving forward, possibly getting bigger, Mayor Donna Deegan says” via Hanna Holthaus of The Florida Times-Union — Plans for the University of Florida Jacksonville graduate campus is moving forward — and possibly expanding. Mayor Deegan met with UF President Ben Sasse over the Florida-Georgia football weekend and came away with a positive impression. “They’re very excited about the campus,” Deegan said. “In fact, it sounds like plans for that campus are actually getting bigger. So, I’m excited to move forward with it.” UF announced their intent for a Jacksonville campus focused on medicine, technology and engineering in February before Deegan entered office. In the months since, the City Council approved $20 million in spending for the campus — part of a $50 million allotment over three years.
“Ron DeSantis targets Donald Trump’s COVID response” via Trent Spiner of The Messenger — DeSantis aimed at Trump, along with federal health agencies, for what he called a failed response to the COVID-19 pandemic at a campaign stop in New Hampshire. DeSantis promised a “total overhaul” of federal agencies that led the response to COVID-19 under Trump, including the Food and Drug Administration and the National Institutes of Health. He had extra ire for the Centers for Disease Control and Prevention, which he called a “total medical swamp right now.” As President, he said he would institute “term limits for bureaucrats” at those agencies. The most recent poll of New Hampshire voters, conducted by USA Today and Suffolk University, showed DeSantis in third place with 10% of likely voters, while Nikki Haley was in second place with 19%. Trump had a commanding lead with 49%.
“Sarasota High School subject of CDC health evaluation following anonymous mold complaints” via Steven Walker of the Sarasota Herald-Tribune — Some buildings at Sarasota High School have been the subject of an ongoing mold issue for years, causing some teachers to report illnesses and breathing struggles, problems the district said it was aware of and has been working with health officials to fix, according to federal officials. On Oct. 13, the National Institute for Occupational Safety and Health at the Centers for Disease Control and Prevention sent a letter to the Sarasota School District responding to a confidential report from a Sarasota County School District employee. The anonymous complainant detailed concerns regarding respiratory issues, headaches, nose and ear bleeding, and sinus infections attributed to mold in buildings 13 and 14 on campus.
“Fentanyl overdose dangers are rising. What Miami-Dade schools are doing to cut the risk” via Michelle Marchante of the Miami Herald — All Miami-Dade County public schools are now stocked with naloxone, the medication that reverses opioid overdoses. Also, “Say no to Fentanyl” assemblies will begin at high schools across the county this month as part of the district’s effort to combat the opioid crisis in South Florida. “We have a crisis in our country that is absolutely unacceptable. It is taking the lives of our youth, our future leaders of tomorrow, and we can no longer sit back and just accept it,” Miami-Dade School Board Chair Mari Tere Rojas said at a news briefing at Miami Senior High School announcing the start of the district’s fentanyl awareness campaign. “We need to be proactive in lieu of being reactive,” she said.
— PENCIL IT IN —
Happy birthday to Rep. Chase Tramont.
11 a.m. — The House Health Care Appropriations Subcommittee meets for an overview of 2023-25 the legislative budget requests submitted by the Department of Elder Affairs the Agency for Persons with Disabilities and the Florida Department of Veterans’ Affairs. Morris Hall, House Office Building.
Happy birthday to Sen. Nick DiCeglie.
Happy birthday to Rep. Sam Garrison.
3:30 p.m. — The House Select Committee on Health Innovation meets. The Committee will be briefed by the Department of Management Services on the state employee group health plan and will hear presentations from Bill Kampine, Healthcare Bluebook and Ryan Burke, Employer Direct Healthcare. Room 17, House Office Building.
8:30 a.m. — The Senate Military and Veterans Affairs, Space, and Domestic Security Committee meets and will hear from Luke Strickland, chief of staff, Division of Emergency Management and Major General John Haas, Adjutant General, Department of Military Affairs. The committee will also consider SB 174. Room 301, Senate Office Building.
4 p.m. — The Senate Health Policy Committee meets and will hear presentations on the shortage of health care professionals from the DOH and AHCA. The committee will have a panel presentation on innovative approaches to health care workforce challenges. Room 412, Knott Office Building.
Happy birthday to Reps. Michael Gottlieb and Will Robinson.
8:30 a.m. — The Senate Appropriations Committee on Health and Human Services meets and will hear from APD on technology updates. The committee will be updated on the opioid settlement funding. The committee will also be updated on the pilot program in SB 2510 for individuals with developmental disabilities. Room 412, Knott Office Building.
Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson and Phil Ammann.