Christine Jordan Sexton
Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
— 32-year reunion —
AHCA turns 32 in July and current Secretary Jason Weida held what could only be called a Secretary Homecoming, kicking off with a catered dinner at his house.
Doug Cook, the OG AHCA Secretary and brainchild behind the creation of the largest health care agency, broke bread with his successors Rubén José King-Shaw Jr, Alan Levine, and a spate of other former secretaries, including Holly Benson, Tom Arnold, Liz Dudek, Justin Senior, Mary Mayhew, Shevaun Harris and Simone Marstiller.
The menu featured fish, rice, and Brussels sprouts. The distinguished guests, some of whom head associations with business before Weida’s agency, shared their stories, experiences, and lessons learned while helming the largest health care agency.
“Yeah, it was great. I thought it was a great idea. Secretary Weida has been really good about reaching out to former secretaries, you know, learning from mistakes we made or the things we’ve done. And I think he has an appreciation for the history of the agency,” Levine told Florida Politics.
Levine, who headed the agency between 2004 and 2006, recalled meeting Cook, the longest-serving Secretary, and Dudek, who was in charge of the certificate of need program when Levine was a young 20-something hospital executive in Pasco County.
“We had an issue before AHCA. And I met with then-Director Cook. And I’ll never forget walking into that Secretary’s office and sitting on that couch to the right, which, by the way, was still there when I became Secretary. I had read about Doug Cook, and he was, at the time, a very powerful man in Florida, being so close to Governor (Lawton) Chiles. It never would have occurred to me at that moment, as I was sitting there, that three secretaries later, I’d be the one sitting in the Secretary’s chair. And the first CON I applied for was to build a new emergency department at that Pasco hospital, and I had to go meet with Liz Dudek. I never would have thought that years later, I’d be the Secretary and she’d be my Deputy Secretary.
“There were some people (at the dinner) that during their time in state government were very influential. And so I just appreciate it. I loved being in public service in Florida. And I appreciate people who go into public service. And I love listening to their stories. And that night was a great opportunity for us to just sort of take a few hours to celebrate the history of the department. “
King-Shaw’s story was about firsts.
Jeb Bush’s first AHCA Secretary, King-Shaw, was the first Secretary to bring a managed care background to the organization.
“Back then, managed care was new; it wasn’t trusted. And I, to my knowledge, I’m still the only Secretary that comes from a managed care background. And I think I’m the only one still who came out of Miami, also a place that would be a controversy back then. And yet today managed care is the dominant delivery system, not just for Medicaid, but for Medicare and commercial. And so what was seen as controversial or negative or disruptive back when I was Secretary is now accepted and dominant. So, I guess my story is, how times have changed, I think, for better accountability and quality and those kinds of things.”
Meanwhile, some of Levine and Senior’s stories and experiences involved hurricanes.
“Almost all of my time at the Agency — I mean, that — I thought it was very positive. Because ultimately it’s the people that you work with, and and, you know, I really appreciated everything that they did. I think probably the toughest time I had was with Hurricane Irma,” said Senior, who ran the agency from October 2016 to January 2019.
Irma was a Category 4 Hurricane when it hit South Florida in September 2017, knocking out power at The Rehabilitation Center at Hollywood Hills, a senior living center in Broward County where 12 seniors died following the storm.
Following the incident, then-Gov. Rick Scott mandated long term care facilities have generators and access to 72 hours of fuel.
“Actually, what we found shocking in the aftermath of that was how difficult assisted living facilities were to try to manage in a crisis, and the nursing homes were not generally an issue. But I can tell you, the real difficulty on a day-to-day basis during those weeks was trying to manage some of the assisted living facilities, which are very often small mom-and-pop facilities that have had vulnerable adults. “
Levine recalled the tumultuous 2004 hurricane season and sitting in a briefing with then-Gov. Bush. The Governor asked Levine how many patients were in intensive care units.
“We didn’t know because the whole system at the time was set up to wait until a request came up from the local emergency operations center. And the Governor said, ‘Well, that’s too late. If we’re waiting until they submit a request for help, then we’re already behind,’ And so he said, ‘Alan, you need to come up with a way to get that information real-time,’“ Levine recalled.
“So we set up a call, you know, basically, we had AHCA employees around the clock, calling hospitals and nursing homes twice a day, to get an update on your patient count, fuel, how much water they had, how much food they had, how many days of fuel for the generators. And so that became the norm. And by the third hurricane of that season, the AHCA team had automated that process using the Internet, which was a really early use of the Internet for this. And that became the ESS system. And ESS is now used by multiple states. I mean, we literally invented it on the fly between hurricanes. So I told that story about just the ingenuity of the department and what it took to kind of meet the needs of the time. And it didn’t take long for us to figure that out. “
Cook’s shared story was about appreciating those who are in public service and recognizing that it transcends partisan politics.
“We inherited a group of great public servants (from Republican Gov. Bob Martinez) when we came in people who were Republicans and Democrats, conservatives and liberals, but they were superbly experienced. They had worked a long time and had learned a lot of lessons. And they gave us the ideas that allowed us to serve better. And my message was public service, in my opinion, is almost a sacred thing. Because it’s that experience, that wisdom, that knowledge accumulated throughout the years — having the time to make the mistakes and to correct them — that we aspire to.”
While most of the former secretaries reside in or near Tallahassee and didn’t need to travel for the event, Levine and King-Shaw flew into Tallahassee for the reunion. Both told Florida Politics they absorbed their own travel costs and that it wasn’t paid for by the state.
The dinner was a precursor to a May 23 panel the secretaries (sans Levine, who left to be with his wife on their 25th wedding anniversary — CONGRATS!) held with current AHCA staff. One of the questions asked focused on the redesign of the Medicaid managed care information system. The new Florida Health Care Connections (FX) system has beleaguered AHCA.
The Legislature required the Department of Management Services to contract with an outside consulting firm to analyze the project.
Dudek joined AHCA when it was first created, worked in various positions, and headed the agency for six years before retiring in 2016.
Dudek shared with staff a sobering lesson learned while traveling across the state for the first statewide Medicaid managed care rollout.
“We went out to towns I never even heard of. To places that people were not aware of AHCA. I was astounded; saddened is not the word, but I found out there were people who couldn’t read or write. How do we get messages to them? Who was in the community to help those folks? How do we color code letters so they would recognize something in the mail? And it was really eye-opening. You think you know a lot and you think you have a pretty good grasp of who’s out there. And still being surprised at that point that in the mid-2000s you find that. It’s like, ‘Wow. Oh my gosh. How is that possible?’ “
Dudek told staff that while it was never her goal to be Secretary, it’s something that is attainable.
Anybody can almost do that. If you try to work with other people and get interested in things and being in the right place at the right time, there’s opportunity for everybody,” Dudek told staff during the 90-minute panel.
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— Save the date —
The much-anticipated trial over Florida’s handling of the Medicaid program has been rescheduled and is expected to start later this summer.
The trial was initially scheduled to begin earlier this month, but it was delayed due to a death in the family of U.S. District Judge Marcia Morales Howard.
Howard held a scheduling hearing on Tuesday with lawyers representing the Florida Health Justice Project and their clients and the attorneys representing the two agencies — the Agency for Health Care Administration and the Department of Children and Families — involved in administering the health care program.
The plan is to take testimony from one witness on July 11, but the full-blown trial will not start until July 29. Howard, however, said she may seek to delay until the first week of August if another trial she’s handling is settled ahead of time.
The lawsuit, filed last August, asserts that Florida improperly removed people from the Medicaid program under the “unwinding” process that began after the federal COVID-19 emergency expired. Florida’s Medicaid population surged under a pandemic-era requirement that provided states extra Medicaid funding in exchange for not removing people from the rolls.
The lawsuit, filed on behalf of several people who had been in the Medicaid program, seeks to change the process used to notify people when they are no longer eligible. However, those who filed the lawsuit also want Howard to pause eligibility redeterminations while a new process is implemented and to reinstate those who were dropped from coverage.
— Regrets —
Florida is one of 10 states that has not expanded Medicaid to low-income, uninsured, childless adults.
The decision to not expand Medicaid impacts an estimated 570,000 Floridians annually, something that former Agency for Health Care Administration Secretary Doug Cook says he struggles with.
Why?
Years before the Florida House of Representatives illegally adjourned Session over a Medicaid expansion dispute, the Florida Legislature in 1994 was willing to expand Medicaid for childless adults earning 150% of the federal poverty level.
Cook countered with an expansion to 200% of the federal poverty level, which was less than the 250% of the FPL that Cook and then-Gov. Chiles wanted. This was the centerpiece of Florida Health Security, their plan to provide access to health care for low-income Floridians.
“I feel a lot of personal responsibility for not taking the deal, and I didn’t,” Cook lamented, recalling that he incorrectly thought he had secured the necessary votes to push the 200% FPL plan through the Legislature.
“I was always too optimistic. I, you know, I shot too high and I thought if we won the election, I’d have another shot. And we won the election.”
But Cook said following the win the Chiles administration made it a priority to try to sue Big Tobacco to recoup the costs of caring for Medicaid patients.
“The tobacco lawsuit came out of Medicaid and Florida Health Security came out of Medicaid and they were two big ideas and only one of those big ideas survived. But we also believed in a lasting impact of getting as many people health care as we could. That, unfortunately, didn’t happen. It is one of the profound regrets that I have.”
Cook later established a nonprofit Medicaid health plan.
“I just, I wish, you know, and when I look back at my time with AHCA, I respect what we tried to do. I only wish I’d been able to do more. And, I think the partisan divide is a pernicious thing. You know, I think it hurts,” Cook said.
— Levine’s nightmare —
Levine also shared an experience he had as AHCA Secretary that he said he never saw coming but continues to haunt him.
“There was a gentleman in Palm Beach County who had a tumor on his liver. And he had hepatitis and cancer that had metastasized to his liver. And he needed a liver transplant,” Levine recalled. “The problem was under the guidelines for Medicaid, the tumor on his liver was too large. And so I was under enormous pressure to override the Medicaid program and to authorize payment for a transplant. And I spent probably two weeks talking to transplant experts and to ethicists.”
“You know, when I signed up to be the Secretary, I never thought I would literally be making a decision about whether somebody would live or die,” Levine said. “And (then-Medicaid Director) Tom (Arnold) and I did everything we could to find a way. We assembled a team of physicians that just basically said, ‘Look, if you do this, if you override the program, this person will get a liver, but they will likely die anyway. And somebody else will not get that healthy liver.’”
“And that became a real ethical issue. We ended up not approving the transplant. And I said that was really truly the hardest — irrespective of all the political stuff that went on, and all the interactions with the Legislature, which all turned out to be really good — that’s the one thing I still have nightmares about .“
Levine said that he doesn’t regret the decision, but he regrets having to make it.
“I remember one evening I was sitting in my office and I have a Bible on my desk,” Levine said. “And I just sat there. I said I just need a moment to just sort of think about this from the perspective of the gentleman whose life is in my hands at the moment. And that’s way more than I ever bargained for. And I just sat and prayed on it. And I know a lot of people might think that’s strange, but I literally prayed on it. Somebody died to donate that liver, and somebody else other than that gentleman needed that liver, and they would more likely live. And at the end of the day, that was what drove my decision. And it was brutal. No, I don’t, regret it. I regret that I had to make it,” he said.
— Second interim report —
The statewide grand jury created at the urging of the Governor to look at COVID-19 vaccines and any potential wrongdoing issued its second interim report this week.
The 26-page report covered “infection-derived immunity” and some of the more contentious treatments that were touted at times during the pandemic.
The report echoes criticism that DeSantis leveled at federal health experts — especially in conjunction with vaccine mandates — that they did not take into account the immunity of those who had already been infected with COVID-19.
But the report also delves into the treatment guidelines issued by federal health authorities in conjunction with everything from antiviral medicine such as Remdesivir to more controversial drugs such as hydroxychloroquine and Ivermectin.
Those on the grand jury criticized federal health authorities over their criticism of those suggesting that Ivermectin should be used to treat COVID-19.
“To this day, the best we can come up with is that it didn’t work,” states the report. “That’s a fine (and likely conclusion), but there was, especially early on, at least some evidence it might be effective. In such a fast-moving research environment, what was the harm in letting people try it as part of a COVID-19 treatment regimen?”
The report also contended that the rejection of Ivermectin led to a rise in conspiracy theories about it and chided federal health authorities for letting this “vilification” occur.
“Where accurate information probably would have quieted the storm, the credibility vacuum created by Invermectin’s unnecessary vilification fanned the flames of those conspiracy theories,” the report states. “Some people became so desperate to get this supposed miracle drug, so sure they were being lied to, that they began to resort to doses and formulations of the drug meant for animals, resulting in a number of well-publicized Ivermectin overdoses. Once again, opponents looked down their noses at the foolishness of these desperate, misguided fools.”
— Hurricanes and long term care—
The main organization representing long-term care facilities in Florida says it has worked on preparations for this year’s hurricane season, which starts this Saturday.
The Florida Health Care Association says its members have engaged in year-round preparations and supplemental training and that it has met rules and regulations imposed by both state and federal regulators.
“When catastrophic storms take aim at Florida, it’s imperative for our members to respond with the preparedness plans they have in place,” said Emmett Reed, CEO of FHCA. “Our members have comprehensive emergency plans outlining their practices and the resources needed before, during, and after a natural disaster to ensure the care and safety of their residents and the staff who care for them. During times of crises, the first and greatest priority is their well-being.”
The storm plans involve fuel checks and generator preparations, emergency supply restocking, and partnerships with outside entities such as utilities and transportation providers. Nursing homes and other long-term care homes have also considered several scenarios, including how to handle potential evacuations and what to do during a power outage.
The association recently met with state regulators and the Florida Division of Emergency Management and held an emergency preparedness webinar for assisted living facilities in April. In early June, the Agency for Health Care Administration, along with safety and security consultants Jensen Hughes and FHCA emergency response team members will share strategies and tools to assist nursing centers and assisted living facilities with preparing for the 2024 hurricane season.
“The planning and preparedness efforts our members put in throughout the year allow for streamlined and efficient action when disaster strikes. I’m confident the planning and training completed this year will equip our members to meet our highest priority of ensuring the safety of all those entrusted to their care.”
Florida, meanwhile, will hold two disaster preparedness sales tax holidays, with the first one running Saturday through June 15. A second two-week disaster sales tax holiday will take place from Aug. 24 through Sept. 6. During the sales tax holidays, Floridians can purchase disaster supplies without having to pay sales taxes on items such as batteries, generators, and flashlights.
— RULES —
AHCA has altered proposed Rule 59A-8.0099 regarding the Minimum Training Requirements for Home Health Aides for Medically Fragile Children. More here.
The proposed change allows “pseudo patients” to be used in the mandated 16 hours of clinical competency. The rule doesn’t address most of the concerns raised in a public hearing last month.
— LOBBYISTS —
Christopher Chaney, Stephen Shiver, The Advocacy Partners: Imagine Pediatrics
Mark MacMillin Slobodien: VITAS Healthcare Corporation
Christopher Snow, Snow Strategies: All Kids Care of Orange Park
—ETC—
— AHCA approved an expedited CON application from TBO holdings to add 45 community nursing home beds to the already approved 60-bed 60-bed community nursing home by de-licensure/transfer of 45 beds from Miami Jewish Health Systems.
— Erica Floyd Thomas, Assistant DCF Secretary, was one of several featured speakers in the Florida Hospital Association’s webinar highlighting the increased demand for health care and the available pathways in communities to access behavioral health care. The webinar coincided with Mental Health Awareness Month.
“As we observe Mental Health Awareness Month, we recognize the demand for mental health care is rising exponentially along with our state’s growing population. We must continue advocating for solutions to expand access to the behavioral health care services Floridians need,” said Mary Mayhew, FHA president and CEO.
“Florida hospitals continue to engage state leadership and community-based organizations to promote an integrated, collaborative local approach to reach Floridians, ensuring they can access the behavioral health care treatment and support services they need to thrive.”
DeSantis has helped champion increases in mental health funding and so has the Florida Legislature. Senate President Kathleen Passidomo’s “Live Healthy” bill also expanded behavioral health mobile response teams and championed investments in Baker Services for discharge planning to increase crisis beds and expand short-term residential treatment, the 988 suicide hotline, hospital behavioral health care services and school programs that promote mental health.
“Our mobile response teams are teams that are available to serve someone 24/7 a day and 365 days a year, and the goal is to help defuse the crisis and to divert individuals from a Baker Act. The teams are designed to provide on-demand crisis services – this is done in the community, a home, a school or a workplace. One of the goals of that mobile response team is to make sure that individuals are able to be placed in the appropriate level of care,” said DCF’s Thomas. “Our diversion rate for the use of mobile response teams has been 82%, so 82% of the time, when deployed, individuals are able to remain safely in the environment where they are without having to be transported to a Baker Act receiving facility or go into inpatient services. This is essential because it’s helped us as a state to be able to reduce our total footprint of our Baker Acts.”
Bishoy Kolta, a child and adult psychiatrist at Lakeland Regional Health (LRH), presented the critical role hospitals play in ensuring timely and quality care for those experiencing a serious mental illness.
“We should always remember that early intervention, early identification is the key. We need to early identify — we need to have a system and to identify symptoms and signs of depression and anxiety and other mood disorders in children,” Kolta said. “Lakeland Regional health system is the second and busiest emergency department in the U.S. with 200,000 patients last year… We offer dual diagnosis, geriatrics also, and, of course, child and adolescent services as well. We are trying to expand actually, so we can offer the services to more kids.”
Carrie Zeisse, CEO of Tampa Thrives, which is a mental health coalition and a local affiliate of Mental Health America, shared data gathered by Tampa Thrives on various programs available for children and adults, and how hospitals can become more involved in their communities to help children and adults access appropriate behavioral health services. She also highlighted the organization’s school-based project, also known as wellness rooms, that provide a safe haven for students.
“Mental health is very important in schools, so our students need every opportunity to be successful academically,” said Zeisse. “Improving the sense of connection within the school is a way to support graduation rates and achievements.”
— ROSTER —
— Mark Runyon, Executive Vice President and CFO at Tampa General Hospital, has been named a 2024 “Chief Financial Officer of the Year” by The Tampa Bay Business Journal.
—Sajeel Chowdhary was named Medical Director of the Neuro-Oncology program at the TGH Cancer Institute. Chowdhary is also a professor in the Department of Neurology and the Division of Neuro-Oncology at the USF Health Morsani College of Medicine.
—Sha Edathumparampil has been named the Chief Digital and Information Officer for Baptist Health South Florida.
— ICYMI —
In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.
“Florida’s 6-week abortion ban increases wait times in other states, study says” via Gabrielle Russon of Florida Politics — Wait times at abortion clinics in Virginia, North Carolina, Maryland and Washington, D.C., rose by about 30% since Florida’s six-week abortion went into effect May 1, according to a new Washington Post story. While the wait times are longer, the clinics have not been slammed to the brink of closing, the report also found. “Many said fewer Florida women appeared to be leaving the state for abortion care than was widely expected — a finding they largely attributed to the increasing availability of telemedicine and abortion pills, in addition to long driving distances that may leave some women feeling they have no choice but to carry their unwanted pregnancy,” the Post reported.
“Tampa General’s John Couris appointed to Florida’s Healthcare Innovation Council” via Florida Politics — Senate President Kathleen Passidomo appointed Tampa General Hospital President and CEO Couris to the newly established Florida Healthcare Innovation Council last month. The Council was recently created to address issues facing the health care industry with fresh perspectives from leaders and innovators across the industry. “John Couris was instrumental in the development of the Live Healthy initiative. His transformational vision for our health care system is increasing access, improving care and reducing costs for patients,” Passidomo said. “I am pleased to appoint him to the Live Healthy Innovation Council.”
— FOR YOUR RADAR —
Aside from coverage by Florida Politics, these stories are worth your time.
“Florida to allow doctors to perform C-sections outside hospitals” via Phil Galewitz of NBC News — Florida has become the first state to allow doctors to perform cesarean sections outside of hospitals, siding with a private equity-owned physicians group that says the change will lower costs and give pregnant women the homier birthing atmosphere that many desire. But the hospital industry and the nation’s leading obstetricians’ association say that even though some Florida hospitals have closed their maternity wards in recent years, performing C-sections in doctor-run clinics will increase the risks for women and babies when complications arise.
“Field shrinks in race for one Sarasota Memorial Hospital Board seat, candidate ineligible” via Earle Kimel of the Sarasota Herald-Tribune — Dr. Kendra Becker-Musante, one of three declared Republican candidates for At-Large Seat three on the Sarasota County Public Hospital Board, ended her campaign on May 22, citing a desire to stay out of a three-way battle that might have forced a runoff after the Aug. 20 Primary. But Becker-Musante was also not eligible to run this year, because she did not register as a Republican until Feb. 23, 2024. Since that was after closing the registration books for the Presidential Preference Primary, it did not go into effect until March 20. Any candidate seeking a party nomination must be registered as a party member for 365 days before the qualifying period.
— PENCIL IT IN —
Thursday
Happy birthday to Rep. Kaylee Tuck!
Saturday
Happy birthday to Sen. Danny Burgess!
Monday
9 a.m. — The Commission on Mental Health and Substance Use Disorder Subcommittee meets virtually. More here.
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Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson.
