2010 Legislative Priorities
Click on the initiatives below to learn more about each legislation.

MEDICAID LOW INCOME POOL (LIP)
2010 SNHAF Position:
Support the LIP Council Recommendations for FY2010-11. The LIP Council recommendations for SFY 10-11 assume a six-month extension of the enhanced FMAP (federal matching rate for Medicaid) provided for in the federal stimulus program. If Congress fails to extend the enhanced FMAP, then SNHAF supports using the SFY 09-10 (current year) appropriated LIP program, reduced proportionately in the program areas that benefited from the federal stimulus monies.
Background:
The LIP program has been used to finance increases in Medicaid payments rates to a more financially viable level for teaching, specialty and high charity care/Medicaid hospitals. This adjustment is made to 66 qualifying hospitals and increases their reimbursement rates to be about 86% of the cost of serving the Medicaid patient. Relying on the additional benefits created by the increase federal matching rate, the LIP Council took this special rate adjustment another step for trauma centers by increasing their rates to reflect their full allowable cost. 

While Congress is seriously considering an extension of the increased FMAP rate for six months, there has been no final action to date. Consequently, both state House/Senate preliminary budget bills will only include LIP funding based on six-months of enhanced federal match. The LIP Council’s recommendations and the enhanced trauma adjustment are not financially feasible under these circumstances. As of this writing, we believe that the legislature will reconsider using the LIP Council’s recommendations, if Congress approves a full year of FMAP enhancement.

PRESERVE MEDICAID RATES AND MEDICALLY NEEDY
2010 SNHAF Position:
Oppose any erosion of rates or eligibility standards in the Medicaid program. Reasonable Medicaid rates must be maintained to sustain the financial viability of many safety net providers. Current law must be amended to prevent the Medically Needy and the Medical Assistance for the Aged and Disabled (MEDS-AD) programs from being terminated on December 31, 2010.
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).

PROVIDER SERVICE NETWORKS (PSNs) (Medicaid Reform Pilots)
Keep Successful Components of Current Medicaid Pilot (1115 Waiver)
Authorize New Efficiencies and Foster Creation of PSNs

Improve the Pilot and Non-Pilot Medicaid Programs

Proposed 2010 SNHAF Position:
Support a three-year extension of the current Medicaid 1115 waiver that ends June 30, 2011. Preferences like - a minimum assignment of enrollees - should be adopted to encourage the creation of PSNs in more counties. Furthermore, all PSNs who remain under a fee-for-service payment arrangement should be allowed to implement prescription management programs.

As the State examines the Medicaid Program and cost-effective options, we should look to the pilot counties for guidance. The Medicaid Reform Pilot offers patients ‘choice’ between commercial HMOs and hospital-based provider service networks. Almost five years into the reform project, the HMO’s are pulling out of reform areas while the PSN’s are offering plans that are demonstrating cost savings to the state and are popular with enrollees.

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.

SUPPORT OUT-OF-NETWORK HOSPITAL MEDICAID RATE CLARIFICATION
2010 SNHAF Position:
Support legislative clarification of “Medicaid Rate”, so that out-of-network hospitals will be paid their full, rebased Medicaid rate for emergent care. This bill closes a loophole that the HMO’s use to try and pay out-of-network hospitals less reimbursement than the legislature intended and that the state contemplated when determining the HMO Medicaid rates.

Brief Statement of the Issue:                                                                                         When Medicaid HMO's patients need care and treatment from hospitals outside of the patient's HMO network, HMO's sometimes ignore state law and pay hospitals based on a "county contribution rate".  The county rate is only intended to apply when determining a county's contribution to fund hospital services under Medicaid.  It is NOT the providers "Medicaid rate".

SUPPORT FUNDING FOR GRADUATE MEDICAL EDUCATION & RESIDENCY POSITIONS
2010 SNHAF Position:
Support state funding for residency positions, both existing and the creation of new residency positions and programs. Also support SB 1256 by Sen. Durell Peaden and HB 935 by Rep. Ed Homan to address the physician workforce needs of Florida.

Brief Statement of Issue:
Surveys conducted in 2007 and 2008 on Florida's physician workforce show that only 43,000 of the 61,000 physicians licensed in Florida actually practice in the state, and 13 percent of those plan to leave or significantly reduce their practice within the next five years. The mean age of the responding doctors was 51, indicating that the workforce could be further affected as aging physicians retire. Now is the time to support graduate medical education in the state. Despite the fact that the federal government "froze" support for residents at the 1996 FTE-count, hospitals in Florida have maintained and grown their commitment to resident training.   In 1999, Florida had approximately 2,964 allopathic medical residents; for the 2007/08 academic year the number was 3,158 - still Florida ranks 44th of the 51 states and territories with residency programs in the number of allopathic residents on duty per population.

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.

OPPOSE UNIFORM PUBLIC HOSPITAL BOARD MANDATE
2010 SNHAF Position:
Oppose uniform public hospital board mandate, because health care delivery is unique to each geographic area in our diverse State, and while some public hospitals have elected boards, others do not. The legislature should allow these variations and oppose SB 1180 by Sen. Joe Negron and HB 493 by Rep. Carol Domino, which would impose statewide uniformity and require boards with the ability to levy millage rates to be elected.

Brief Statement of Issue:
Public hospitals in Florida have a rich and varied history -- some spanning over 100 years. As each area of the state developed, local communities created the health care infrastructure to meet their unique needs. There were no for-profit systems courting land developers, and communities had to come to determine how best to accommodate their unique health care needs in their communities.

Some but not all public hospitals have taxing authority. Some communities established elected boards, others have board members appointed by either the Governor or County Commission. There is no model public hospital board in the State. Each was locally determined and ultimately adopted by the Legislature through local bills, thereby providing legislated, elected oversight. It would be disruptive to dismantle and restructure public hospital boards in a “one size fits all” standard, particularly when those safety net health care boards oversee critical care and access to the community.

SOVEREIGN IMMUNITY
2010 SNHAF Position:
Oppose increase in Sovereign Immunity Caps. (HB 11078 by Rep. Nehr & SB 2060 by Sen. Bennett) This bill will increase costs for public hospitals in order to fund judgments and contingency fees for trial lawyers.

This bill increases the per person limits of sovereign immunity to $250,000 and removes the aggregate per incident/occurrence cap on sovereign immunity. Further, it annually increases the sovereign immunity cap with an automatic annual adjustment based on the CPI.

It perniciously provides that a subdivision of the state may pay a judgment in excess of the sovereign immunity limits from “other available funds” without filing a claims bill in the Legislature. The legislation increases attorney’s fees by 5% when a sovereign immunity case is appealed.

Brief Key Issues:

• Subdivisions of the state already have to work within the confines of incredibly lean budgets and depleted reserves. This bill would further constrain these subdivisions without any public benefit. In fact, the support for this bill is centralized within one group: trial lawyers. These trial lawyers would be able to receive increased compensation and fees. And, the limits of sovereign immunity are increased by 150% and the aggregate cap is totally eliminated - all to the detriment of the state budget and those of its subdivisions.
• The purported need for flexibility for the resolution of claims on behalf of a subdivision is a fiction created by this bill’s supporters. In fact, subdivisions have the flexibility and authority to settle for amounts above statutory limits by purchasing liability insurance. Not only does this resolve a subdivision’s desire to settle outside of the limits, but the purchase of insurance will help subdivisions to better manage and prepare for risk than would increased limits within which to settle.
• By providing that a subdivision can now settle above the limits using “other available funds,” the public can expect to see the trial bar drumming up media campaigns and related propaganda to pit the desired compensation of their client against the subdivision’s other budgetary items. For example, the trial bar could allege that the subdivision paid for a July 4th fireworks show instead of settling above the limits for a person injured by a bus accident.
• Most importantly, this bill does not create any flexibility or local control—in reality, this flexibility and control already exists. Rather, the only effect of the bill is to give trial lawyers more leverage in lawsuits to procure additional money at the expense of the public treasury and taxpayers.

TRAUMA
2010 SNHAF Position:
Support Red Light Camera Legislation that preserves trauma funding.  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 Issue:
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.

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