Christine Jordan Sexton
Welcome back to Diagnosis, a vertical that focuses on the crossroads of health care policy and politics.
It’s all settled.
Three providers filed administrative challenges to the Agency for Health Care Administration’s decision earlier this year to award Medicaid managed care contracts.
As of Sept. 3, AmeriHealth Caritas, the only plan currently under contract to participate in the Medicaid managed care program that wasn’t offered a new contract, withdrew its challenge. AmeriHealth Caritas attorneys did not explain why the company withdrew.
Sentara Care Alliance and ImagineCare LLC, the other two entities to request administrative hearings, had previously dropped their challenges.
With no challenges, AHCA is free to begin rolling out the new six-year Medicaid managed care contracts to provide services to beneficiaries enrolled in Florida’s mandatory Medicaid managed care program. Florida requires most Medicaid enrollees, from the cradle to the grave, to enroll in a managed care program to receive their health benefits.
Florida officially launched the Medicaid re-procurement in April 2023 with the release of a massive ITN. AHCA published its initial decision nearly a year later, announcing its intent to award contracts. AHCA published a second decision in July.
ImagineCare and Sentara were hoping the state would offer them six-year contracts. AmeriHealth Caritas is already contracted with the state to provide services but was not offered a new contract.
Meanwhile there’s still no news on the invitation to negotiate the children’s medical services Medicaid managed care plan. The nearly $13 billion contract to provide health care services for medically complex children who are eligible for Medicaid or the state children’s health insurance program (CHIP) expires Jan. 31, 2025.
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— Opioids, Moody and the Supreme Court —
Attorney General Ashley Moody is asserting that the state could lose $87 million in payments from opioid manufacturers and distributors and potentially “hundreds of millions” more in the wake of an appeals court ruling that put limits on her authority.
Moody late last week asked the 1st District Court of Appeal to officially request that the Florida Supreme Court resolve the legal question of whether the Attorney General can block other governments in Florida from filing their own lawsuits over the opioid crisis.
Florida negotiated a $3.1 billion settlement over the opioid crisis, but as part of that arrangement, Moody’s office has tried to block several school boards and hospital districts from filing their own lawsuits.
A circuit court judge sided with Moody. But a panel of appeals judges in August overturned that decision arguing that giving her the power to block lawsuits would elevate the Attorney General’s power to that of the Governor and Legislature. During May oral arguments Judge Brad Thomas theorized the reasoning offered by Moody’s office could lead to a future Attorney General suing cattle ranchers over climate change despite opposition from others.
In an Aug. 29 court filing, attorneys for Moody wrote that it was important for the state’s highest court to take up the dispute because the “answer will have sweeping effects on the State’s ability to abate a devastating opioid epidemic. And it will resolve the fate of hundreds of millions of dollars in public funding.”
The filing contends the ruling against Moody “hamstrings” efforts to battle the opioid crisis but that it would also limit the ability of the Attorney General to reach future settlements and undermine the ability of the state to litigate cases in federal court. Moody’s office wrote the opinion “opens a Pandora’s box of problems.”
— Slight reduction —
A national rating organization is proposing a 1% reduction in workers compensation rates for the coming year, the smallest proposed rate reduction in years. And the organization is pointing the finger at physician rate increases as to the reason why.
The Legislature unanimously passed SB 362 in 2024, which increased physician and surgeon payments to 175% and 210% of the Medicare rate, respectively. That’s a significant increase from the rates physicians and surgeons currently are paid, which are 110% and 140% of Medicare, respectively.
The increases were the first for physicians in years, and the National Council on Compensation Insurance (NCCI) estimates that they will have an overall 5.6% increase in workers’ compensation system costs. According to the NCCI, excluding the increases would have resulted in an overall rate decrease of 6.4%.
The proposed rate filing was based on experience data for Policy Years 2021 and 2022 as of year‐end 2023.
Florida’s worker’s compensation law requires employers to provide injured employees with all medically necessary remedial treatment, care, and attendance the injury requires until they can go back to work.
The increase in system costs comes as no surprise. NCCI estimated that SB 362 would increase costs by as much as 7.3% though the analysis was conducted on an earlier version of the bill that would have increased reimbursements for physicians and surgeons to 200% of the Medicare rate.
Despite the far-reaching financial effects, SB 362 drew just 14 lobbying registrations, mostly on behalf of insurance carriers and the state’s plaintiff attorneys organization.
NCCI only recommends rates, but the actual rates are set by Florida’s Insurance Commissioner. To that end, the Florida Office of Insurance Regulation will schedule a public meeting on the proposed rate recommendation and ask NCCI to explain its recommendations. That meeting hasn’t been set but will likely be held in October.
—LOIs accepted—
AHCA accepted 20 letters of intent for the hospice certificate of need (CON) batching cycle that ended Aug. 26.
AHCA announced earlier this year a need for one new hospice program in Marion County and one in Miami-Dade County. Not surprisingly, those areas drew the most interest. Eight LOIs were submitted for a new hospice program in Marion County and six were submitted for a new program in Miami Dade County.
But LOIs were also submitted for new programs in Brevard, Orange, Osceola, Sarasota and Palm Beach counties.
CONs are licenses of sorts that Florida requires for long term care facilities and programs in Florida. There are four “batching cycles” annually where state regulators announce the need for a new service and then competitively review CON applications. LOIs are not binding but they are a prerequisite for CON applications.
Sept. 25 is the CON application deadline for the current hospice batching cycle. Health care regulators will announce tentative approval of the CON applications Dec. 20
According to an AHCA report, the state currently has 94 licensed hospice programs, and another 12 have been approved.
—Breakdown—
Negotiations between United Healthcare and UF Health have come to a halt and as of Sept. 1 UF Health hospitals and physician groups in Gainesville, Jacksonville and St. Johns are no longer in-network for Medicaid managed care and commercial health plans. Medicare advantage patients in St. Augustine are also shut out from using UF Health providers and hospitals.
“We are sensitive to the challenges this poses for our patients, and despite the outcome, we continue to earnestly work with United Healthcare toward a solution. Our commitment to placing patients at the heart of our efforts is unwavering, and we have put processes in place to minimize any disruption in care to the extent we can, but unfortunately, United Healthcare has given us no other choice,” said Marvin Dewar, M.D., J.D., CEO of UF Health Physicians.
“We even invited United leadership to meet with us on site to finalize the agreement but they declined. We continued to try to reach an agreement right up to the deadline but United insisted upon linking other products to the negotiations and abruptly imposing new conditions and changing language to items that had already been agreed upon. As a physician, my job is to care for my patients, and we did our best to avoid this situation.”
According to a UF Health news release, United offered UF Health commercial reimbursement rates below general inflation and “far below” rising annual costs.
“To make matters worse, they offered no increase to UF Health’s physician practices for the coming 12 months,” UF Health said in a release. The release also notes that “worse yet United also has refused to honor their commitment to pay rates previously agreed to.”
“As the state’s leading academic health system that researches leading-edge treatments, educates future generations of clinicians, and treats a disproportionate number of underserved patients, we deserve to be paid fairly and competitively for the care we provide to patients and the services we offer,” Dewar said. “Reasonable compensation is necessary for us to sustain our mission.”
UHC said in a statement that it repeatedly tried to find a solution and that UF Health walked away from the negotiations.
“We delivered a contract on Aug. 31 to finalize the terms UF Health had indicated they’d accept for our Medicaid plan, only for the health system to never respond and unnecessarily disrupt access to care for Floridians. We also delivered a proposal to UF Health on Aug. 30 that included significant compromises for our employer-sponsored commercial plans. The health system never countered,” UHC said in a statement to Florida Politics. “UF Health’s last proposal included a 30% price hike over two years and a more than 20% rate increase in one year, which is not affordable for consumers or employers. While we remain committed to continued discussions, our focus now is ensuring Florida families have access to the care they need through continuity of care or a smooth transition to another provider, as appropriate.”
The insurance company also said in a statement that UF Health’s assertion that it hasn’t received reimbursement increases since 2016 is not true. “They have received rate increases in nine of the last 10 years,” the company said.
Medicare Advantage patients are not affected except for those seeking care with UF Health St. Johns. UF Health Central Florida is not part of these current negotiations and remains in the network with United Healthcare.
The impasse won’t adversely impact University of Florida students who have a United Healthcare plan through the university’s student health insurance program. Students covered by their parent’s United Healthcare policy can continue to receive services at the Student Health Care Center location with no changes in co-pays or deductibles.
UF Health has made thorough arrangements to continue to care for patients with urgent care needs such as pregnancies, nonelective surgeries, emergency medicine, and cancer care, and for those requiring other services such as behavioral health and transplants.
“We are committed to doing our part to reach an agreement that would prevent disruption to all our patients’ continued access to UF Health physicians and facilities for non-emergency services and care,” Dewar said. “We are continuing to negotiate in good faith but we are waiting for the health plan to respond with a fair and sustainable offer to make that happen. Again, this includes streamlining their claims process and reducing administrative demands.”
—RULES—
AHCA is withdrawing the proposed Rule 59 C-1.0355 regarding the regulation of hospice programs. More here.
—LOBBYISTS—
Jeff Aaron, Jason Unger, GrayRobinson: Community Care Plan
Nick Iarossi, Kaley Anne Flynn, Christopher Schoonover, Capital City Consulting: Orlando Health
Lauren Lange, Johnston & Stewart Government Strategies: American Association for Orthodontists, Novo Nordisk
—ETC—
— September is here, but summertime isn’t over in the Sunshine State. With an uptick in mosquito-borne disease activity, Florida’s mosquito officials are asking residents to remain vigilant. “So far this summer, Florida has seen increases in mosquito-borne disease activity – including locally transmitted and travel-related cases in humans. We have already seen reports of West Nile virus infections in humans, Dengue cases on the rise, and now Oropouche emerging as a new threat,” said Richard Weaver, president of the Florida Mosquito Control Association, a group of 67 mosquito control programs, including 15 independent districts. Mosquitoes will always be in the state, but Weaver said it remains safe for residents and visitors who take precautions. “We cannot emphasize enough that Floridians and visitors to our state need to take every precaution necessary to protect themselves and their families. It can be as simple as wearing long sleeves and long pants and using EPA-registered insect repellents that contain DEET, picaridin, IR3535, or Oil of Lemon Eucalyptus to protect their loved ones. Mosquitoes are most active at dawn or dusk, so be proactive when you head outdoors.”
—Vero Beach will soon be home to Florida’s newest Veterans Affairs clinic. U.S. Rep. Bill Posey announced the city had been selected for a new location within the West Palm Beach VA Healthcare System.“This is a long-awaited benefit that is owed to our Indian River County veterans, and I am pleased to hear the VA is moving in this direction,” the Rockledge Republican said. “Keeping our commitments to our veterans is a top priority. I would like to thank West Palm Beach VA Healthcare System Director Cory Price and his staff for bringing this to fruition.” Construction will begin in March on the facility, which will be located in the RiverSide Medical Center Plaza.
—ROSTER—
—Jorge Hernandez, Broward Health’s Vice President and chief procurement officer, was recognized in Becker’s Hospital Review 2024 list of “Supply Chain Leaders to Know.” Hernandez has more than 25 years of experience in leadership roles in for-profit and non-profit hospitals and corporate supply chains. Hernandez spearheaded a supply utilization transformation that optimized Broward Health Group Purchasing Organization contracts, consistently achieving savings of more than $1.5 million year after year.
—Miami Cancer Institute and Eugene M. and Christine E. Lynn Cancer Institute, part of Baptist Health Cancer Care, are making presentations at the American Society for Radiation Oncology (ASTRO) Annual Meeting. Minesh P. Mehta, M.D., deputy director and chief of radiation oncology with Miami Cancer Institute, said he“could not be more pleased with the quality of the research my colleagues and I will be presenting.” The meeting takes place in Washington D.C from Sept. 29 – Oct. 2, 2024 at the Walter E. Washington Convention Center. The presentations will focus on the latest treatment approaches to head and neck, lung, pancreatic, and prostate cancer as well as brain tumors and metastases.
—Patrick Steele left his post as legislative affairs director at AHCA to join SAS as a senior account executive in its government and public sector practice. Steele has previously worked in both the Florida House and Senate as well as government agencies. Ben Stuart, National Director of State and Local Government for SAS, said Steele is both liked and respected, something he said was a “a rare combination.”
— ICYMI —
In case you missed them, here is a recap of other critical health care policy stories covered in Florida Politics this past week.
“Governor says nearly $400M in nursing education investments is paying off” via Christine Jordan Sexton of Florida Politics — DeSantis took a victory lap at a news conference in Daytona Beach, celebrating nearly $400 million in nursing investments over the last three years to educate and train nurses, the central nerve in the health care delivery workforce. On Tuesday, DeSantis, whose mother was a nurse, said there are more than 3 million registered nurses in the state. But he said that isn’t enough to gird the workforce against a growing and aging Baby Boomer population. DeSantis committed to funding two education programs to increase the state’s working nurses. One program is called PIPELINE, an acronym for “prepping institutions, programs, employers and learners through incentives for nursing education.” The $100 million program rewards colleges and universities for nursing education programs based on student achievement and student success.
“Tampa General strengthens partnership with USF Health with $162M investment” via Peter Schorsch of Florida Politics — Tampa General Hospital and the University of South Florida (USF) Health Morsani College of Medicine have become quite a power couple — a relationship further strengthened with the influx of $162 million from Tampa General.The historic investment in academic medicine will enhance integration across the two organizations and deepen their commitment to excellence in quality health care.
“Family sues Disney World after child hit by fireworks ember in the eye” via Gabrielle Russon of Florida Politics — A 7-year-old standing near Magic Kingdom’s Cinderella Castle was hit in the eye by an ember from the fireworks last year. The child’s mother, Nicole Ufie, sued Disney last month in Orange Circuit Court for more than $50,000. “Our lawsuit alleges that he continues to have eye problems and permanent scarring, and that Disney World failed in their responsibility to maintain a safe environment at their park,” Morgan & Morgan attorney Roman Diveev said in a statement. “We will hold Disney and other parties involved accountable for their negligence to get justice for this family and hopefully prevent another child from getting injured by Disney’s fireworks.”
“More Medicare Rx cost savings coming, but some question whether it’s enough” via Christine Jordan Sexton of Florida Politics — Hundreds of thousands of Floridians are expected to save money under drug pricing changes pushed into law by President Joe Biden. But while seniors welcome the help, some say they still expect to struggle to pay for needed prescriptions. Initially passed in 2022, the Inflation Reduction Act made several changes to the Medicare prescription drug program. Those include capping co-pays for insulin at $35 a month, limiting out-of-pocket co-payments to $2,000 and allowing the federal government to negotiate with drug companies to lower spending on prescription drugs.
“Cigarette smoking hits record low, but FDA still ‘record slow’ on regulating vapes” via Peter Schorsch of Florida Politics —Fewer Americans are smoking cigarettes now than at any time in the past 80 years, but not all ex-smokers have given up tobacco products entirely — and public health experts want clear regulations on the nicotine products they choose as an alternative.
—FOR YOUR RADAR—
Aside from coverage by Florida Politics, these stories are worth your time.
“Supreme Court allows HHS to divert funds over abortion referrals” via Ann E. Marimow of The Washington Post — The Supreme Court on Tuesday cleared the way for the Joe Biden administration to strip millions of health care dollars from Oklahoma over its refusal to direct patients to information about abortions — a federal requirement that the state says would be at odds with its strict ban on terminating pregnancies. Last year, the Biden administration diverted $4.5 million from Oklahoma’s family planning program, primarily serving low-income or uninsured patients. In challenging that decision, Oklahoma Attorney General Gentner Drummond told the Supreme Court that state health care organizations cannot be punished for not advising patients about ending their pregnancies. The state said that the Health and Human Services Department is illegally imposing conditions on funding that are not specified in the half-century-old nationwide family planning program known as Title X.
“Trump met with top marijuana company CEO and Florida GOP Senator before supporting legalization measure” via Kyle Jaeger of Marijuana Moment — Ahead of announcing his support for the marijuana legalization initiative on Florida’s ballot this weekend, Trump met with the CEO of a major cannabis company, as well as with a GOP state Senator who is in favor of the reform. Trump took some by surprise when he took a position on the state measure — which he’ll have the chance to vote on in November as a Florida resident. Before making his announcement on Saturday, he met with Florida Sen. Joe Gruters and Trulieve CEO Kim Rivers. Trulieve has contributed over $70 million to the cannabis campaign Smart & Safe Florida behind Amendment 3.
“New funding coming to Florida to help keep women alive in childbirth” via Cindy Krischer Goodman of the South Florida Sun-Sentinel — Omari Maynard thought life was great when his partner Shamony came home from the hospital with a baby boy, their second child. Shamony died two weeks later from a pulmonary embolism, a pregnancy complication. Maynard now has two small children to care for and speaks out often to let single fathers whose partners died from childbirth know they are not alone. Losing a loved one from childbirth complications is more common than many realize. A five-year average shows that 24 women per 100,000 births in Florida died during pregnancy, delivery or shortly after delivery. Research shows the vast majority of pregnancy-related deaths are preventable. Only a year ago, the state’s high death rate triggered the Florida’s Hospital Association to issue a statewide call to action urging hospitals to play a more decisive role in reducing the incidence of maternal death in Florida.
— PENCIL IT IN —
Sunday
Happy birthday to Rep. Thad Altman!
Wednesday
4 p.m. — The Pediatric Cardiac Technical Advisory Panel (PCTAP) meets. Attend via Go-To-Webinar.
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Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson and Phil Ammann.
