2008 Legislative Priorities
Click on the initiatives below to learn more about each legislation.

Medicaid Budget

SAFEGUARD BENEFITS OF LOCALLY FUNDED MEDICAID PROGRAMS FOR SAFETY NET HOSPITALS
(Low Income Pool, DSH & Rebasing)
2008 SNHAF Position:
Support the Low Income Pool Council recommendations for $43 million in general revenue appropriations to partially finance the $100+ million deficit in the Low Income Pool (LIP)/Rebasing programs. Protect funding to hospitals providing a disproportionate amount of care to Medicaid patients and the uninsured, and delivering the vast majority of graduate medical education in the state. Any reductions in LIP program funding should be tiered to protect the patient care and programs provided through Florida’s safety net hospitals.
Brief Statement of Issue:
Review of LIP: As a key component of the Medicaid Reform Plan approved by CMS and implemented by the Legislature, the federal government approved a $1 billion Low Income Pool (LIP) to replace funding from the Medicaid Upper Payment Limit. While the $1 billion represented an increase of $300 over the previous year’s Upper Payment Limit Program funding, LIP funding is limited to the $1 billion annually (no growth) over the five-year life of the waiver.

VIABLE MEDICAID HOSPITAL REIMBURSEMENT RATES
2008 SNHAF Position:
Support a Medicaid hospital payment methodology that reimburses safety net hospitals 100% of their audited cost of providing care to their Medicaid patients. Oppose any erosion of Medicaid eligibility for any optional Medicaid groups.
Brief Statement of Issue:
As part of their efforts to balance the state budget over the last decade, the Legislature has sought to implement various cost-containment initiatives for the Medicaid program. While some of these efforts delineate true attempts for greater efficiencies, a significant number of their decisions represent reimbursement or eligibility changes that create additional uncompensated care. The financial burden of this new uncompensated care is cost-shifted to safety net hospitals, local governments and their communities. The decline in state revenues projected over the next several years has created a financial crisis of historical proportion, and it is anticipated that the Legislature will respond by significantly slashing state expenditures. It is reasonable to assume that this will translate into attempts to implement large reductions in Medicaid provider reimbursement and/or significant changes in eligibility (i.e., elimination of Medically Needy program).

VULNERABLE MEDICAID ELIGIBILITY GROUPS
Proposed 2008 SNHAF Position:
The Florida Legislature should refrain from eliminating vulnerable eligibility groups from the Medicaid program. Reducing eligibility does not affect the need for health care services. It merely shifts the burden from the state to the hospitals and reduces available funding to provide those services.
Brief Statement of Issue:
Florida’s safety net providers disproportionately care for the state's uninsured and most vulnerable Medicaid populations. The 14 members of SNHAF provide almost half of the Medicaid services delivered in Florida. There are very few remaining "optional" Medicaid eligibility categories, but when the state budget approached a $1 billion shortfall prior to the Special Session, legislators took a long, hard look at optional eligibility categories and ultimately reduced two of them. The state is facing unprecedented revenue shortfalls, and the likelihood of more severe programmatic reductions is great. How those cuts are achieved will have significant repercussions on the safety net providers' ability to maintain and support access to services for persons in need.

SPECIALIZED SURGERIES REIMBURSEMENT FOR PEDIATRIC-ORGAN/DUAL-ORGAN TRANSPLANTS
2008 SNHAF Position:
Monitor the “rollout” of the Senate Interim Project on sovereign immunity for RPICCs and monitor any legislation on same. Monitor legislation creating sovereign immunity for ER physicians and ERs at hospitals. Support these two measures, with modifications, if they become viable. Modifications may include language to protect meetings and records and avoid increased liability.
Brief Statement of the Issue:
RPICC Sovereign Immunity:
Based on concerns expressed by physicians participating in the RPICC program, the Senate Health Regulation Committee is evaluating the policy implications of extending sovereign immunity to contract health care providers in RPICCs, and legislation may be introduced on this subject as a result of the Interim Project. The underlying issue is the cost of medical malpractice insurance for RPICC participating physicians and the risk associated with treating the high-risk patients in the RPICC program. SNHAF members, staff and consultants have worked closely with the staff responsible for the Interim Report.
ER Sovereign Immunity:
The ER physicians are rumored to be seeking legislation that would extend sovereign immunity to ER and on-call physicians working in the emergency department and possibly extend it to the facility itself. Again, the underlying issue is the cost of liability insurance for ER physicians, the risk of treating ER patients, and the fact that ERs are required by law to treat all patients that present.

SPECIAL DISTRICTS
Proposed 2008 SNHAF Position:
Support the continued existence of special districts in Florida.
Brief Statement of Issue:
Special districts in Florida were established even before statehood and have grown as a tool to meet the ever-expanding citizen’s needs for localized services. They are units of special-purpose government with limited authority to do only the things prescribed in their local act. In the last year, special districts have been swept up in the public policy debate over the state’s economic growth, demand for services, and state/local taxation policy and authority.

TRAUMA CENTER FUNDING
Proposed SNHAF 2008 Position:
Support the efforts of the FHA's Trauma Center Council ("Trauma Centers") to maintain the existing and secure additional dedicated funding streams for the state’s designated trauma centers. Trauma center designation should continue to be leveraged as a distinguishing factor in mitigating any required reduction in Medicaid hospital reimbursement due to state budget shortfalls.
Brief Statement of the Problem:
A trauma victim's ability to timely access a trauma center may be the difference between life and death or the difference between recovery and permanent injury. Trauma centers offer specialized care around the clock, and the readiness costs of 24/7 skilled personnel and dedicated treatment space are extraordinary. The Trauma Alliance has been successful in identifying new, sustainable sources of funding for trauma centers, but additional funds are needed.

Medicaid Managed Care and Reform

REVIEW & IMPROVEMENT OF MEDICAID REFORM PILOTS
SNHAF 2008 Position:
Support full implementation and evaluation of Medicaid Reform in the statutorily designated pilot areas before expansion to other areas of the state.
Brief Statement of Issue:
In 2004, the Florida Legislature agreed to explore new Medicaid delivery models in an effort to achieve cost-savings and quality-of-care improvements. As such, the state was granted a federal waiver to implement pilot plans in two urban and three rural counties. Florida is in the second year of these pilots, with further test concepts to be implemented in year three. Recent examinations of the pilots, of which managed care is the central component, have been critical, and recommendations to continue in the pilot programs in their current areas until improvements can be made are justified. Expansion of Medicaid reform and its managed care delivery model to other areas of the state may bring about significant barriers to forming and maintaining provider service networks (PSN). These barriers may prove fatal to the formation of PSNs, another key element of reform, and their ability to participate in the reform expansions to other areas of the state.

EXPANSION OF MANDATORY MANAGED CARE (Statewide Medicaid)
2008 SNHAF Position:
Florida’s Legislature should refrain from further statewide Medicaid enrollment mandates until the Medicaid Reform Pilot programs are fully operational and can be evaluated.
Brief Statement of Issue:
In the Medicaid Reform pilot counties — Broward, Duval, Bake, Clay and Nassau — 100 percent managed care (of the eligible population) is being tested. Pursuant to legislation passed in 2006 and recently modified during the 2007 Special Session C, Medicaid eligibles in the balance of the state are subject to the 65/35 automatic assignment threshold; Medicaid enrollees that do not elect a plan or decide to stay with their fee-for-service providers are assigned to HMOs until the 65 percent managed care threshold is reached. If mandatory managed care is expanded, the policy may bring about significant barriers to forming and maintaining provider service networks. These barriers may prove fatal to the formation of PSNs and their ability to participate in Reform expansions to other areas of the state. Further expansion may also have the unintended consequence of significantly reducing direct funding for safety net providers. Rebased hospital rates and supplement payments for faculty physicians are currently only available under the fee-for-service payment methodology.

NON-CONTRACT PROVIDER RATE CLARIFICATION (Statewide Medicaid HMOs)
2008 SNHAF Position:
Support legislative clarification of “Medicaid Rate,” so that non-contracted providers will be paid their full, rebased rate for emergent and non-emergent care.
Brief Statement of Issue:
Under current law, Medicaid managed care organizations must reimburse out-of-network providers for emergency care and treatment at the lesser of one of the following rates: the provider's charges, the usual and customary charges in the community, a mutually agreed-upon rate, or the Medicaid rate. Since the Medicaid rate is the lesser of the options listed in the law, Medicaid managed care companies usually offer to pay a non-contracted hospital its Medicaid rate. There is, however, a difference of opinion as to what constitutes a hospital's Medicaid rate. The distinction is very important to safety net hospitals whose rates have been rebased to an amount that more accurately reflects their full costs. Conversely, HMOs claim that the Medicaid rate is the lower county-capped rate.

PROVIDER SERVICE NETWORKS (PSNs) (Medicaid Reform Pilots)
Adequate Enrollment, Accelerated Phase-In for Risk-Adjusted Rates &
Extend the Conversion from Fee-for-Service to Capitated Rates
2008 SNHAF Position:
Support full implementation of the Medicaid reform provider service networks (PSN) pilot policies to ensure adequate enrollment, accelerate full implementation of risk-adjusted rates for PSNs, and extend for an additional two years the deadline for PSN conversion from fee-for-service to capitated rates. (Determine whether to employ an offensive or defensive strategy.)
Brief Statement of Issue:
Risk-Adjusted Rates: A key element of Florida’s Medicaid Reform Plan is that the monthly capitated fee paid to managed care entities will be adjusted to reflect the health status of the patients. For example, it was assumed that the capitated fee for an elderly patient with diabetes would be greater than the amount paid to cover a healthy child. The Medicaid HMOs, however, encouraged the Legislature to phase in this risk adjustment. As a result, managed care entities that are expected to enroll a Medicaid population with above-average health care utilization rates (due to illness or age) will be at a disadvantage. The delay in fully implementing the risk-adjusted rates would continue to hinder the implementation of an equitable reimbursement system for PSNs.

Conversion Extension: Under Reform, PSNs must convert from fee-for-service/sharing savings rates to capitated rates within the first three years of operation. Some PSNs may require flexibility and need to remain in a fee-for-service model for up to five years.

Adequate Enrollment: The inclusion of PSNs was a critical element in the design of the Florida Medicaid Reform Model. Although under the reform plan patients lose their option of staying in a fee-for-service system, the inclusion of PSNs gives patients an opportunity to pick from significantly different managed care environments. However, during the initial phases of reform implementation, PSN enrollment has been below the level that a successful program needs to survive. The reason for this low enrollment may be related to several factors. First, commercial HMOs already had a significant number of Medicaid patients enrolled in their plans prior to the initiation of Reform. Second, Medicaid HMOs are very experienced and astute in the marketing techniques used for attracting healthy participants. In any case, if enrollment is not increased in PSNs , a critical component of the reform plan may fail, and the state and its Medicaid patients will have limited options for their health care home.

Hospital, Regulation, Tort and Physician Workforce

GRADUATE MEDICAL EDUCATION (GME)
2008 SNHAF Position:
The position is four-fold: (1) support efforts to define the physician workforce shortage in Florida, (2) gather data regarding GME activities in Florida, (3) coordinate GME initiatives with other organizations engaged in GME (including the Florida Council of Medical School Deans and the Board of Governors), and (4) develop funding recommendations for existing and potential new residency positions and programs.
Specifically, create a multifaceted advocacy campaign to seek increased funding for GME. SNHAF will begin by commissioning an independent study to examine Florida's physician needs and under-funding of existing GME positions and programs. The study will also provide options for new funding models to expand GME programs and address the inequities that exist in current governmental support due to the federal funding cap on the number of GME residents in each state. These new funding methodologies shall take into consideration the impact of current federal support for children’s hospitals with low Medicare patient populations. The study will serve as the basis for a public relations campaign.
Brief Statement of the Problem:
SNHAF hospitals support a significant number of Florida's medical resident programs and positions; the cost of the programs and positions as well as the contributions to Florida's physician workforce are great.

“FABRE FIX” EFFORT BY TRIAL BAR TO REVERSE FABRE DOCTRINE
2008 SNHAF Position:
Aggressively assist the business community to defeat attempts by the Plaintiffs Bar to overturn the Fabre Doctrine, which currently allows juries to fairly apportion fault among all those responsible for a plaintiff’s injuries, including parties who are not named in a lawsuit.
Brief Statement of the Issue:
The Fabre Doctrine originated in a 1993 decision by the Florida Supreme Court holding that juries are allowed to fairly apportion fault among all those responsible for a plaintiffs injuries, including parties who are not named in a lawsuit. The Plaintiffs Bar wants to require named defendants to sue other parties and bring them into the case before the jury can consider their fault. This may require defendant hospitals to bring in otherwise unnamed health care providers.

PHYSICIAN-BASED FINANCIAL RESPONSIBILITY
2008 SNHAF Position:
Maintain current law that requires physicians to be responsible for complying with Florida’s physician financial responsibility law and oppose efforts to mandate that hospitals undertake the physician’s professional responsibility.
Brief Statement of Issue:
Section 458.320, Florida Statutes, requires physicians licensed in Florida to satisfactorily demonstrate to the Florida Board of Medicine their financial responsibility to pay medical malpractice judgments. On May 24, 2007, in Horowitz v. Plantation General Hosp. Ltd. Partnership, 959 So. 2d 176 (Fla. 2007), the Florida Supreme Court decided that hospitals could not be held liable for failing to ensure that their medical staff physicians comply with section 458.320. We expect the Trial Bar to seek legislation to overturn the Horowitz case and hence hold hospitals responsible for the professional responsibility of Florida physicians.

TEACHING HOSPITALS PATIENT SAFETY & LIMITED LIABILITY PROPOSAL
2008 THC Position:
Temporarily suspend until the 2009 Legislative Session lobbying efforts to support passage of legislation that will limit non-economic damages to $500,000 in medical malpractice actions against teaching hospitals, allow for the periodic payment of economic damages, and allow teaching hospitals to indemnify members of their medical staff for on-site practice, provided the teaching hospital complies with patient safety initiatives for the 2008 Session. Likewise, place on hold the proposal to support application of the non-economic damage provision and the periodic payment provision to non-profit medical schools whose faculty makes up 50 percent or more of the staff of a teaching hospital and reconsider the initiative in 2009.
Brief Statement of Issue:
Florida’s six teaching hospitals, working with affiliated medical schools, provide 80 percent of all medical residencies, 50 percent of all indigent care and at least 30 percent of all Medicaid treatment in Florida. Every day, Florida’s teaching hospitals and medical school partners deliver high-quality tertiary health care services to thousands of needy patients who often present themselves with advanced disease and are therefore at higher risk for poor health outcomes. The economic realities of providing medical care and treatment under these circumstances necessitate special provisions to stabilize medical liability expense. Teaching hospitals and medical schools also promote an important academic mission – medical education. Teaching hospitals and medical schools are uniquely suited to implement, evaluate and instruct on innovative patient safety initiatives.

Certificate of Need

CERTIFICATE OF NEED
2008 SNHAF Position:
Maintain current Certificate of Need (CON) and service licensure processes; oppose efforts to "carve out" CONs for special interests.
Brief Statement of Issue:
Observers are concerned that with the new leadership in the House and Senate and Governor’s Office, there will be a concerted effort to deregulate further or even eliminate the CON process entirely. With recent CON litigation and denials, there are again high-profile examples of the effects of CON regulation, which could serve as the impetus for both comprehensive and carve out legislative action. Carve-out bills are usually the result of unfavorable regulatory or legal decisions.