From Nursing Homes to Medicaid to Pill Mills, Florida Re-Writes Austere Health Rules

In any other year, a historic overhaul of the Medicaid system would have overshadowed every health issue in the Legislature.

But when lawmakers went home early Saturday morning, Medicaid might not have even been the noisiest health-related debate of the 2011 legislative session.

Lawmakers passed a nearly $70 billion budget that included deep cuts to hospitals, nursing homes and dozens of other health programs. They also squabbled for weeks before approving a last-day deal to try to combat pill mills. And they spent hours arguing about issues such as abortion and medical malpractice.

Here is an overview of health issues during the session:

MONUMENTAL CHANGE: House and Senate Republican leaders agreed for months that the Medicaid system needed to be overhauled and on how to do it: Require beneficiaries to enroll in managed-care plans.

But until the final few days of the legislative session, the details remained cloudy. Rumors ranged from an imminent deal to a need for a Medicaid special session.

That ended Thursday afternoon, when the Senate released two intertwined Medicaid bills (HB 7107 and 7109) totaling 215 pages. By Friday night, both chambers had passed the bills and readied them for Gov. Rick Scott‘s signature.

If Florida gets federal approval — a huge if — almost all Medicaid beneficiaries will be enrolled in HMOs or other types of managed-care plans by the end of 2014. The state will be carved into 11 regions, where managed-care plans will compete for contracts and build networks of doctors, hospitals and other providers.

Perhaps no other issue from this year’s session will have a broader impact. The overhaul will affect the way 2.8 million of low-income and elderly people get health care in the future, while also trying to solve one of the state’s most-complex budget problems.

“This is the biggest part of our budget,” House Health & Human Services Chairman Rob Schenck, R-Spring Hill, said about one of the measures. “This bill is going to save Floridians billions of dollars.”

But the prospect of shifting almost all Medicaid beneficiaries into HMOs and other types of managed-care plans caused Democrats to line up in opposition. They argued that a pilot managed-care program in five counties has been hampered by problems that affect patient care.

“With HMOs having to deny services in order to make a buck, I see the same problems that happened in the pilot program,” said Rep. Elaine Schwartz, a Hollywood Democrat who is among the most-outspoken opponents.

BUDGET PAIN: Maybe the most-telling moment in this year’s struggle with the health- and human-services budget came April 28 during a lunchtime meeting in the Senate Office Building.

As lobbyists crammed into the committee room, House and Senate health-budget negotiators essentially gave up. With the two sides dug in about issues such as funding for nursing homes, mental-health services and the Medically Needy program, they punted the decisions to top legislative leaders.

The final version of the budget approved Saturday morning included wide-ranging cuts. Hospitals and nursing homes, for example, will get hit with nearly $700 million in cuts to Medicaid payment rates.

The nursing-home cuts also had a spin-off effect that drew repeated criticism. Trying to ease the financial pinch on nursing homes, lawmakers reduced a nursing-home staffing requirement that was designed to help improve resident care.

“I just don’t think it’s fair to tell nursing homes that you are going to be paid less by the state, but then you have the same costs,” said Senate Health and Human Services Appropriations Chairman Joe Negron, R-Stuart.

But critics said the move could hurt the quality of care in nursing homes. Under it, each resident would have to receive a weekly average of 3.6 hours of direct care each day, down from the current 3.9 hours.

“To jump that far (back), we’re going to have some serious problems,” said Sen. Tony Hill, D-Jacksonville.

Numerous smaller programs also will get whacked in the budget. For example, the Healthy Start program, which serves at-risk pregnant women and babies, will lose $5.4 million, while Area Health Education Centers will lose $4.8 million.

Some groups, however, were relieved by the budget agreement. Earlier, the Senate had proposed almost wiping out funding for adult mental-health and substance-abuse treatment — but the House fought the move and prevented cuts.

House Health Care Appropriations Chairman Matt Hudson, R-Naples, said lawmakers had to grapple with the costs of increased Medicaid enrollment and a loss of federal economic-stimulus money that had gone to health care.

“As a result of that, it became a true, true issue of prioritization,” Hudson said.

PILL PROBLEMS: As the House voted to approve a bill Friday to fight prescription-drug abuse, Scott and Attorney General Pam Bondi watched approvingly from the dais.

It looked like kumbaya, as state leaders all but joined hands in support of the bill, which will increase penalties for unscrupulous doctors and take a series of other steps to try to rid Florida of its reputation as a deadly pill-mill capital.

But that picture belied one of the messiest health debates of the session. At one point, Scott and House leaders called for eliminating a planned prescription-drug database — a cornerstone of the state’s past strategy to combat the problems — because of privacy concerns.

Bondi, who has made prescription-drug abuse one of her top priorities, helped pull together the deal. One of Bondi’s aides, Kimberly Case, could be seen shuttling around the fourth floor of the Capitol during the session’s final days working on the issue.

“This is a horrible, horrible epidemic in our state,” Bondi said after watching the Senate unanimously pass the bill (HB 7095).

Despite the messiness, the prescription-drug issue offered a window into how issues affect lawmakers personally.

Reps. Rich Glorioso, R-Plant City, and Fred Costello, R-Ormond Beach, both spoke emotionally on the House floor about how family members struggled with prescription-drug problems.

Even Stephanie Haridopolos, a physician married to Senate President Mike Haridopolos, became involved in pushing for the legislation. She said patients have come to her office seeking help with addictions.

“The trickle-down effect of this epidemic is enormous,” Dr. Haridopolos said.

WINNERS AND LOSERS: Declaring legislative winners and losers can be a tricky business, but it is safe to say abortion opponents were a big winner during the 2011 session.

Lawmakers approved four significant abortion measures, including a bill (HB 1127) that will require women to have ultrasounds before abortions. Also, they passed a fifth bill dealing with “Choose Life” license plates, an issue long associated with abortion opponents.

Planned Parenthood and the American Civil Liberties Union lobbied against the bills in committee after committee but could not gain enough Republican support to block them.

The measures include a 2012 ballot proposal that would make clear tax dollars cannot pay for abortions; a bill tightening the parental-notification law for minors seeking abortions; and a bill banning abortion coverage in policies sold through a future state health-insurance exchange.

Also winning during the session were Republican opponents of last year’s federal health overhaul. They approved a proposed constitutional amendment (SJR 2) that seeks to allow Floridians to opt out of a future requirement that they buy health insurance — part of the federal law commonly known as the “individual mandate.”

The measure, a top priority of Senate President Mike Haridopolos, will go on the 2012 ballot. The Florida Supreme Court rejected a similar proposal last year because of misleading wording, but Haridopolos and other backers eliminated the disputed language.

More difficult is determining the winners and losers in a series of bills aimed at shielding doctors, hospitals and nursing homes from lawsuits.

Personal-injury attorneys fought the bills and sustained some losses. As examples, the Florida Medical Association pushed through a bill that will place new certification requirements on out-of-state expert witnesses who testify against doctors in medical-malpractice cases.

Also, the big Medicaid bill includes $300,000 caps on pain-and-suffering damages in malpractice cases filed by Medicaid beneficiaries against doctors, hospitals and surgical centers.

But the Florida Justice Association, the group representing personal-injury attorneys, fended off other proposals. Among them: a proposal that would have limited some damages in lawsuits against nursing homes and a proposal that would have shielded hospitals from liability when contracted physicians are accused of malpractice.

MAYBE NEXT YEAR: When lawmakers finally ended the session at 3:35 a.m. Saturday, dozens of health-related bills — big and small — headed into legislative purgatory. They are dead this year, but might come back to life in 2012.

For instance, some Republican lawmakers and state Chief Financial Officer Jeff Atwater started the legislative session vowing to clean up the personal-injury protection insurance system.

They argued that Florida had become a hotbed of staged auto accidents and shady PIP clinics. But efforts to pass a wide-ranging bill to deal with the issue died in committees.

Similarly, the Senate let die a controversial bill that would have required judges to sign off on sales or leases of public hospitals. Publicly funded hospitals and the Florida Hospital Association fought the proposal, while for-profit hospital companies supported it.

The proposal stemmed from disputed deals such as a merger between the publicly owned Bert Fish Medical Center in Volusia County and the private Adventist Health System. That deal was scuttled after revelations that the Bert Fish board violated the Sunshine Law by holding closed-door meetings to discuss it.

While the PIP and public-hospital bills at least made it through some committees, others died with less dignity.

For instance, Sen. Mike Bennett, R-Bradenton, has long pushed for the state to expand the drug-prescribing powers of optometrists and advanced registered nurse practitioners. He argues such a move would save health-care costs, including in Medicaid.

But this year — as in the past — Bennett ran into opposition from the Florida Medical Association, which says should powers should be reserved for physicians.

So Bennett took a new tack. He combined the optometrist proposal with a bill that would give doctors increased malpractice protections. But not even that could sway the FMA, and the bill died in committee.

–Jim Saunders, News Service of Florida