Christine Jordan Sexton
Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
— It’s coming —
Florida health care officials are expected to drop another invitation to negotiate (ITN) a Medicaid program, this one for The Children’s Medical Services (CMS) Health Plan.
The nearly $13 billion contract to provide health care services for medically complex children who are Medicaid or state children’s health insurance program (CHIP) eligible expires Dec. 31, 2025, and the Florida Department of Health (DOH) is expected to drop an invitation to negotiate (ITN) to procure the program any day.
The soon-to-be-released ITN follows the DOH’s decision in May to extend its current contract with Sunshine Health Plan by one year. Under the amended contract Sunshine will be paid an additional $3 billion for the year-long extension, bringing the total value of the contract with the state to no more than $12.9 billion.
Florida requires most Medicaid beneficiaries, including medically complex children who can require specialty health care services, to enroll in managed care plans. Families have a choice of enrolling their children in one of the plans participating in the statewide Medicaid managed care program or the CMS Health Plan.
While AHCA administers the statewide Medicaid managed care program, DOH is in charge of the CMS Health Plan. However, AHCA, which houses the Medicaid program, has been a guiding force in the development of the upcoming CMS Health Plan ITN.
The CMS Health Plan contract was first procured in 2019. Sunshine State Health Plan is the sole Medicaid provider for the CMS Health Plan currently under contract with the state. Sunshine also is the largest provider in the statewide Medicaid managed care program.
The May agreement to extend the contract’s length came during the statewide Medicaid managed care program re-procurement and was a tacit recognition by the DeSantis administration that it couldn’t simultaneously procure the two Medicaid health care programs.
The DOH issued a request for information (RFI) in June 2022 designed to obtain input on best practices and innovative ideas and to help inform the future development of the CMS Health Plan ITN.
In an amendment to the RFI posted the following month the state said, “The details of the proposed procurement are not yet known.” The amendment included answers to questions including whether the state will contract with more than one plan and whether the state prefers to work with managed care plans over community-based networks of providers with experience in the care.
I welcome your feedback, questions and especially your tips. You can email me at [email protected] or call me at 850-251-2317.
—The other Medicaid managed care program—
Call it a legal flip-flop.
ImagineCare, a provider sponsored network hoping to break into Florida’s Medicaid managed care market, filed legal challenges to AHCA’s procurement in both administrative and Leon County Circuit Court.
The health plan earlier this week surprisingly dropped both challenges to the state’s decision to award Medicaid managed care contracts to Aetna Better Health, Community Care Plan (CCP), Florida Community Care (FCC), Humana Medical Plan, Molina Healthcare, Simply Healthcare, Sunshine and United Healthcare.
The move means AHCA will have one less lawsuit to resolve before implementing the new statewide Medicaid managed care contracts, but other suits remain.
AmeriHealth Caritas and Sentara have not dropped their administrative challenges to the Medicaid ITN, according to a review of the docket.
Division of Administrative Hearings Judge Robert Cohen has scheduled an Aug. 8 Zoom conference regarding scheduling. Meanwhile, CCP Sunshine, Humana, Molina, and FCC have intervened on behalf of the state in the administrative challenges.
Florida officially launched the Medicaid re-procurement in April 2023 with the release of a massive ITN.
— More Medicaid —
A highly anticipated class action trial over Florida’s handling of its Medicaid program wrapped up last week in a Jacksonville courtroom, but don’t expect a ruling anytime soon.
The state was sued in federal court over how it removed people from the rolls of the safety-net health care program following the end of the COVID-19 public health emergency. Those suing have asked for notices to be revamped and to reinstate those that they say were improperly dropped from the program. State officials contend this would cost the state millions of dollars in the program that is jointly funded by state and federal tax dollars.
At the end of the trial last Friday, U.S. District Judge Marcia Morales Howard gave attorneys 30 days after the trial transcript was filed to turn in proposed findings of fact and conclusions of law. Those filings will likely be used to come up with Morales’s final ruling.
Morales told lawyers for both sides that “I don’t think either one of you is going to be totally thrilled” according to Florida Phoenix. She also suggested that the two sides could come up with a better way to resolve the dispute than pursuing litigation.
During the trial, state officials testified that computer errors and problems with companies helping handle the Medicaid system resulted in people losing their coverage, including new mothers, according to trial coverage by The Tributary.
Another problem highlighted during the trial was the Department of Children and Families blocked hundreds of thousands of callers to people trying to reach a person to ask questions about Medicaid or Supplemental Nutrition Assistance Program, the Phoenix reported.
—Not happy—
Patients continue to be unhappy with health insurance policies and pharmacy benefit managers.
A new PhRMA poll shows that eight in 10 Americans are concerned that pharmacy benefit managers profit from financial assistance intended to help patients access.
Of those polled, 68% ranked the rising costs of health insurance with reduced benefits as their top concern, and eight in 10 expressed concerns that three PBMs control about 80% of the domestic drug market. That compares to 32% who said the costs of prescription drugs are their main concern.
The PhRMA poll also found that 64% of those polled opposed government price-setting Boards if they limit access to new prescription medicines; 65% oppose government price-setting boards if they are comprised of bureaucrats instead of doctors; and 74% believe that bureaucrats shouldn’t have the power to set maximum prices on medications.
The PhRMA poll is released on the heels of a Federal Trade Commission interim report that is part of an ongoing inquiry into PBMs launched by the FTC in 2022. The FTC report details how increasing vertical integration and concentration has enabled the six largest PBMs to manage nearly 95% of all prescriptions filled in the United States.
This vertically integrated and concentrated market structure has allowed PBMs to profit at the expense of patients and independent pharmacists, the report details.
“The FTC’s interim report lays out how dominant pharmacy benefit managers can hike the cost of drugs — including overcharging patients for cancer drugs,” said FTC Chair Lina M. Khan. “The report also details how PBMs can squeeze independent pharmacies that many Americans — especially those in rural communities — depend on for essential care. The FTC will continue to use all our tools and authorities to scrutinize dominant players across health care markets and ensure that Americans can access affordable health care.”
The interim report stems from special orders the FTC issued in 2022 to the six largest PBMs — Caremark Rx, Express Scripts, OptumRx, Humana Pharmacy Solutions, Prime Therapeutics and MedImpact Healthcare Systems.
In 2023, the FTC issued additional orders to Zinc Health Services, Ascent Health Services, and Emisar Pharma Services, which are each rebate aggregating entities, also known as “group purchasing organizations,” that negotiate drug rebates on behalf of PBMs.
With the support of DeSantis, who was poised to launch an ill-fated presidential run, Florida passed what many consider to be one of the most far-reaching PBM laws in the nation in 2023.
—In the red again—
Preliminary estimates show that Florida’s health insurance program for state workers could be in the red in the next two years.
Economists and officials with the Department of Management Services met on Wednesday to draw up a new forecast for the program that covers nearly 175,000 people. Several factors are affecting the trust fund’s overall finances, including the expected addition of nearly 20,000 state college employees in January and the increased use of diabetes-related drugs that have become popular in recent years.
Economists plan to tweak some of the final cost factors but the preliminary estimate suggested the trust fund used to cover state employees will finish the current fiscal year next June 30 with an ending balance of slightly more than $226 million. But that is expected to swing to a deficit of $417 million by the end of the 25-26 fiscal year.
This could continue to put even more pressure on state legislators to make changes to either coverage or premiums when they meet in session next March. State lawmakers injected $350 million of general revenue during the 2024 session in order to avoid the fund from going into a deficit.
A January 2024 forecast projected that the state would spend $3.59 billion on the state group health insurance program during the current fiscal year but that was drawn up before legislators decided to let employees at the state’s 28 colleges enroll. The costs are now projected to grow to $3.9 billion for this year and then $4.5 billion in the 25-26 fiscal year.
Florida is seeing a rise in its pharmacy costs due to increased awareness and use of diabetes-related drugs that one Department of Management Services official said were “being marketed as miracle drugs.” While the drugs are designed for diabetes patients they also can cause patients to lose weight.
— Girl power —
Meet the new president of the state’s largest physician association.
Jacksonville physician Lisa A. Cosgrove was installed as the 148th president of the Florida Medical Association (FMA) at the group’s annual conference in early August. She is a board-certified pediatrician who retired in 2019 after four decades of practicing medicine, and she remains an influential advocate for Florida’s physicians and their patients.
Cosgrove is a native of Little Rock, Ark., and a third-generation physician. She began her health care career as a nurse in the pediatric/neonatal intensive care unit at Miami Children’s Hospital.
She earned her medical degree from the Ross University School of Medicine and completed residency training in pediatrics at Emory University. Cosgrove moved to Florida in 1993 and joined Atlantic Coast Pediatrics, a private practice on Merritt Island.
Meanwhile, Ashley Norse was installed as president-elect, Charles Chase as vice president, Mark Rubenstein as treasurer, Sanjay Pattani as speaker, Alma Littles as vice speaker, and Jason Goldman as immediate past president.
“As the Florida Medical Association celebrates its 150th anniversary this year, we congratulate Dr. Lisa Cosgrove on being named to lead the FMA as our 2024-2025 President,” said FMA CEO Chris Clark.
“Dr. Cosgrove’s distinguished leadership and dedication to Florida’s patients and to the field of medicine will allow our organization to continue its impactful presence as the state’s premier voice of medicine.”
Julie Morris of New Smyrna Beach has been elected President of the Florida Health Care Association, the largest nursing home association in the state. In that capacity, Morris will lead the FHCA’s 30-member Board of Directors and will focus her term on strengthening partnerships across the continuum of care and bolstering the next generation of long-term care professionals.
“The success of our Association for the past 70 years is a result of an actively engaged membership that recognizes the fact that our people drive progress and quality,” said Morris. “My goal is to continue finding innovative ways for the Association to further invest in our caregivers — from leadership development, mentorships, scholarship opportunities and grassroots advocacy. The future is bright for Florida and our long-term care community, and I’m thrilled to lead this Board through the opportunities that lie ahead.”
Morris is vice president of Operations for Aston Health, which manages 47 skilled nursing and rehabilitation facilities across Florida. She has worked in long-term care for over 30 years, both in nursing home administration and regional operations.
While it’s her first term as president, Morris has experience on the FHCA’s executive team, previously serving as the FHCA senior vice president, treasurer, and secretary. She also has served on the Board of Directors as both a regional vice president and district president and has also chaired the association’s Workforce and Annual Conference committees.
Also elected to the FHCA Board of Directors were: Senior Vice President Joshua Wagoner of North Campus Rehabilitation and Nursing Center in Leesburg; Treasurer Patricia Spears of Topaz Fiscal Services in Jacksonville; Secretary Isis Fernandez of Hialeah Shores Nursing & Rehabilitation in Miami; Independent Owner Vice President Neil Sutton of NuVision Management in Ft. Lauderdale; Not-for-Profit Vice President Mike Ward of Pines of Sarasota; and Member at Large Mel Beal of Facility Support Company in West Palm Beach. Anita Faulmann of Excelsior Care Group in Tierra Verde is the immediate past President.
—RULES—
The Board of Medicine proposes amending Rule 4B8-4.009 to conduct a comprehensive review of the rule, address any recent legislative changes, and update the forms incorporated by reference in the rule. More here.
The Board of Medicine proposes amending Rule 64B8-13.005 to add an additional provider for the controlled prescribing course. More here.
The Board of Osteopathic Medicine proposes amending Rule 64B15-13.001 to update CME requirements to add an additional provider for the controlled prescribing course. More here.
The Board of Pharmacy proposes amending Rule 64B16-27.700 regarding compounding. More here.
— LOBBYISTS —
Slater Bayliss, Christopher Chaney, The Advocacy Partners: Advocating for Seniors
Cory Dowd, Capital City Consulting: Florida Association of Nurse Anesthesiology
Lauren Lange, Johnston & Stewart Government Strategies: Agency for Community Treatment Services, American Heart Association, Brightstone Therapy, Florida Council for Behavioral Healthcare, Florida State Massage Therapy Association, HCA Healthcare, Purdue Pharma, Tender Care Admin and Humana.
—ETC—
— Tenet Healthcare Corporation ( has entered into a definitive agreement with Orlando Health for the sale of Tenet’s 70% majority ownership interest in Brookwood Baptist Health in Birmingham for approximately $910 million in cash (after-tax proceeds of approximately $790 million), according to a Tenet news release. The transaction will include five hospitals – Brookwood Baptist Medical Center, Princeton Baptist Medical Center, Walker Baptist Medical Center, Shelby Baptist Medical Center, Citizens Baptist Medical Center – as well as affiliated physician practices and other related operations. Brookwood Baptist Health will remain a joint venture with Baptist Health System.
— LeadingAge Southeast has been named the Association of the Year by the Florida Society of Association Executives (FSAE). This prestigious recognition honors the association’s exceptional service, innovation, and commitment to excellence in the association management industry. “We are incredibly honored to receive this award from FSAE,” said Steve Bahmer, LeadingAge Southeast President & CEO. “This recognition is a testament to the hard work and dedication of our incredible team, board of trustees, and members. It underscores our commitment to supporting our members and advancing their mission of providing compassionate and quality care and services to older adults.”
The FSAE “Association of the Year” award is presented annually to an association that has shown exemplary performance in all areas of association management. The criteria for the award include leadership, member engagement, financial stability, and the overall impact on the association’s industry.
—Opinion via Cyril Hopping: ”I always thought that paying health insurance premiums month after month, year after year, meant that my insurance would help me pay for necessary care when I needed it. Recently, I learned that’s not the case.” Read more here.
—ROSTER—
—Elizabeth Justen was elected chair of the South Broward Hospital District Board of Commissioners, Steven Harvey vice chair, and Douglas Harrison secretary-treasurer. The hospital taxing districts do business as Memorial Healthcare System. The Board is appointed by the Governor and is charged with overseeing the operations of Memorial Healthcare System, a national leader in quality care and patient, physician, and employee satisfaction with nearly 17,000 employees, six hospitals, and numerous ambulatory care centers.
—Former House Speaker Will Weatherford has joined the board of directors of GuideWell Mutual Holding Corporation (GuideWell), a leading not-for-profit, policyholder-owned health solutions company, and Florida Blue, the leading health insurer in Florida. Weatherford currently serves as the managing partner of Weatherford Capital, an investment management firm focused on technology, finance, and business and consumer services. Weatherford also serves as chairman of the University of South Florida’s board of trustees aimed at positioning USF as one of the top public research universities in the country. He was speaker of the Florida House of Representatives in 2012, becoming the youngest presiding officer of any state legislative chamber in the U.S. at the time.
—ICYMI—
In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.
“Then there were two: ImagineCare drops Medicaid managed care challenge” via Christine Jordan Sexton of Florida Politics – ImagineCare has filed notice with the Agency for Health Care Administration (AHCA) of its intent to voluntarily drop its administrative challenge to the statewide Medicaid managed care procurement. ImagineCare was one of three rejected plans intending to challenge the latest round of Medicaid managed care contract awards in state administrative court. ImagineCare also filed a challenge in Leon County Circuit Court, though the plan is also expected to withdraw that challenge. AmeriHealth Caritas and Sentara — the two other Medicaid managed care plans that notified the state of their intent to challenge the procurement — appear to be moving ahead with their challenges.
“Group backing marijuana legalization takes in $116K in last week of July” via Christine Jordan Sexton of Florida Politics ——The group pushing the passage of Amendment 3 took in more than $116,000 in the final week of July, according to the latest campaign finance reports. Smart & Safe Florida, which has raised nearly $67 million over the past two years to try to legalize recreational marijuana, received $100,000 from Insa, which operates several medical marijuana dispensaries across the state. The campaign report also showed that Verano Holdings donated more than $9,000 worth of T-shirts to the committee.
“OneBlood says systems are rebooting after cyberattack” via Christine Jordan Sexton of Florida Politics – Florida’s top blood supplier says its critical software systems are starting to come back online following a cyberattack that led to some state hospitals canceling optional surgeries.“ ”We continue to move in the right direction and anticipate solid improvement of the blood supply over the next few days,” said Susan Forbes, OneBlood’s senior vice president of corporate communications and public relations. OneBlood supplies products that are used by 80% to 90% of the hospitals in the state. After a July 29 ransomware attack, the supplier had to switch to manual processes and procedures.
“Ashley Moody defends controversial financial impact statement for abortion rights initiative” via Gabrielle Rouson of Florida Politics — Attorney General Ashley Moody argued a state panel “was well within its authority” to redraft a new financial impact statement to go on the November ballot for the abortion rights initiative. She defended the statement, calling it “a model of clarity” in a 47-page response filed Friday evening. The Amendment 4 campaign is suing over a controversial financial impact statement and has asked the state Supreme Court to invalidate it.
—FOR YOUR RADAR—
Aside from coverage by Florida Politics, these stories are worth your time.
“Orlando Health to buy five-hospital system in Alabama for more than $900M” via Leslie Postal of the Orlando Sentinel – Orlando Health announced it will buy a majority interest in a five-hospital health system based in Birmingham, Alabama. The Orlando company is purchasing Tenet Healthcare Corporation’s 70% share in Brookwood Baptist Health, Tenet announced, for about $910 million. Orlando Health already operates 17 hospitals and other medical facilities and employs about 4,500 physicians. Brookwood Baptist operates five hospitals in Central Alabama and employs about 1,500 physicians. Brookwood Baptist is a religious organization and will remain so under Orlando Health’s ownership, the Orlando company said. “There is a need and opportunity for a private, not-for-profit health care system in this market,” said David Strong, Orlando Health’s president and CEO, in a statement posted on the company’s website.
“DCF blocked more than 700,000 calls in April from people who wanted to speak to a real person” via Jackie Llanos of Florida Phoenix – The Florida Department of Children and Families blocked 54% of phone calls from people wanting to reach one of its call center agents in April. The agency, which handles calls related to Medicaid and the Supplemental Nutrition Assistance Program, lacks standards governing the number of blocked calls or hang-ups by clients because they can’t remain on hold, the call center’s director, Nichole Solomon, testified on Wednesday. DCF hung up on 744,000 people waiting on hold before they could talk to employees in April alone because the call center lacks the capacity to manage all the calls it gets, said Solomon, who has been in charge of the call center since early 2023. Instead, those 744,000 callers who opted to speak to a person instead of the automated system heard a message saying all agents were busy and to call later.
“New report reveals Havana Syndrome case numbers. More than 300 Americans treated” via Nora Gámez Torres of the Miami Herald – Spies, active-duty military, FBI agents, diplomats and at least 15 children are among the 334 Americans who have qualified to get treatment for Havana Syndrome in specialized military health facilities – numbers that conflict with an earlier assessment by U.S. intelligence agencies minimizing the problem. The new data was published Monday in a study conducted by the U.S. Government Accountability Office, which examined the challenges patients face accessing care in the military health system and whether the Department of Defense has facilitated it, as required by federal law. The office concluded that Americans affected by these still unexplained cases of what the government refers to as “anomalous health incidents” struggled to get proper care, confirming earlier reports by the Miami Herald that some had been denied medical treatment by their agencies and suffered retaliation.
—PENCIL IT IN—
Thursday
1 p.m. — The Health Information Exchange Coordinating Committee meets. Register here. A copy of the agenda may be obtained by contacting Crystal Ritter at (850) 412-3763, or [email protected].
Wednesday
Happy birthday to Rep. Shane Abbot!
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Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson and Phil Ammann.
