— From middleman to ballers —
Former longtime Florida Pharmacy Association (FPA) lobbyist Michael Jackson had an interesting take on pharmacy benefit managers (PBMs).
Forget the “middleman” moniker; Jackson, who no longer professionally lobbies for the FPA but appears as an interested private citizen, used a football game analogy to explain PBMs and how he thinks they have created an “unstable” marketplace that benefits the PBM-affiliated pharmacies.
Jackson commented during an Aug. 4 rule hearing held by the Florida Office of Insurance Regulation.
“The field that the two teams play on is owned by the PBM-affiliated pharmacies. Referees, field judges, the umpires, scorekeepers are on the PBM-affiliated pharmacy, where you receive 6 points for scoring touchdowns.
“The non-affiliated pharmacy will receive 3 points for scoring a touchdown and must first cross the finish line with their left foot, carrying the ball with their right arm. Non-affiliated pharmacies will receive 3 points for kicking a field goal but must do so from 55 yards away through a goal post that is 4 feet wide and 40 feet up.
“The game begins with the affiliated PBM pharmacy starting with 21 points and the non-affiliated pharmacy with no points. If the non-affiliated pharmacy commits an infraction rule at the discretion of the field judge, which we call the auditor and the non-affiliated pharmacy will be penalized 15 yards and surrender 40% of any points scored as a recoupment for the infraction.
“Unfortunately, it is the patient, what we call a football, that must be carried across the finish line of improved health, but the unaffiliated pharmacy must do so with their left arm tied behind their back and not permitted to wear protective gear such as helmets.
“All this sounds strange, but it is the life that pharmacy providers in the state of Florida have had to live with, as well as pharmacy providers across the United States.”
OIR wants to take its proposed rules to the Financial Services Commission, Florida’s Cabinet, at its Aug. 22 meeting for approval.
I welcome your feedback, questions and especially your tips. You can email me at SextonHealthNewsletter@gmail.com or call me at 850-251-2317.
— Getting close now —
After a slow summer — and seemingly most of the attention focused on Gov. Ron DeSantis’ presidential campaign — there are a few signposts to look for as the 2024 Legislative Session draws closer.
A reminder: Session starts on Jan. 9, 2024.
Aug. 10: State economists will come together to draw up new estimates for Florida’s state employee health insurance trust fund — the account that pays for health care coverage for state workers. This has been a hot spot the last few years as lawmakers have been forced to pour in more taxpayer money to keep the main trust fund in the black. Lawmakers have done this while keeping health insurance premiums paid by workers at the same level.
Aug. 14: State economists are expected to draw up updated estimates for how much Medicaid will cost this year and over the next several years. This will be the first time that economists — in concert with the Agency for Health Care Administration (AHCA) — crunched expenditures in the wake of enrollment changes following the end of the COVID-19 public health emergency.
Aug. 18: State economists will hold the all-important general revenue estimating conference. A large part of Florida’s taxes is deposited into this account and what happens here will dictate how much money DeSantis and state legislators will have for next year’s budget, including health care programs. A recently posted financial outlook statement shows that the size of Florida’s much-vaunted budget surplus will shrink heading into the 2024-25 fiscal year.
Sept. 15: This is the yearly deadline for the Legislative Budget Commission to approve a new three-year financial outlook that takes forecasts on incoming money and balances it against all the estimates for programs such as Medicaid, public schools and universities.
Also, on Sept. 15: This year’s budget instructions require all state agencies — including Florida’s health care agencies — to submit their legislative budget requests and capital improvement plans by this date.
— Even closer —
With just days left before the Aug. 22 at noon deadline, plans and provider-sponsored networks that want to participate in Florida’s Medicaid managed care program are, as one lobbyist put it, busy dotting their “I’s” and crossing their “T’s.”
The timeline shows AHCA plans to open the responses at its Tallahassee headquarters later that day at 3 p.m.
AHCA anticipates (the word is bolded in the ITN, for what it’s worth) making the information available two days later at its Medicaid procurement site so providers can submit comments to the state. AHCA has established a provider survey tool asking providers to return comments online by 5 p.m. Sept. 7. The provider comments can account for upward of 100 points.
AHCA plans on beginning negotiations with the top-scoring health plans and providers’ service networks just one month later, the timeline shows, with the agency setting aside Oct. 2 through Nov. 27 for negotiation.
Ultimately, the state wants to announce the winning contracts on Dec. 11.
The subsequent contracts will be in effect until Dec. 31, 2030.
— Automated scoring —
AHCA is slated to start negotiating with what it deems are the top provider candidates 41 calendar days after the submission deadline and 25 calendar days after the provider comment deadline.
AHCA’s use of auto-scoring benefits the ambitious deadline. A review of the ITN shows each response can be awarded up to 5,900 points.
Of that, 80%, or 4,725 points, will be auto-scored based on the responses the plans provided the state.
About 15% of the overall points, or 875, are doled out by AHCA staff reviewing the responses to the invitation to negotiate.
The respondents’ financial information is worth 200 points and the responses to the providers’ surveys are worth upward of 100 points.
Those involved in past ITNs say automated scoring is a new one. It could help eliminate the seemingly inevitable challenges accompanying such big contract awards. Still, it also removes the human element in determining which company will be responsible for the health care of millions of Floridians.
— Butts good for now —
The Florida Board of Medicine is withdrawing its proposed rule regarding gluteal fat grafting, commonly known as Brazilian Butt Lifts.
Last week, members of the Florida Boards of Medicine (BOM) and Osteopathic (BOOM) Medicine Joint Surgical Care Quality Assurance Committee agreed to withdraw from consideration a proposed rule to update the safety standards for gluteal fat grafting.
The move was championed by BOM Chair David Diamond, who said that the rule was no longer necessary given the Legislature had passed HB 1471, a DOH bill amended to include the controversial issue. The bill became law July 1.
“Is language different? Is the approach slightly different? Of course, it is, but the general premise — is this going to improve safety — I think has been thought through quite well,” Diamond said.
Members of the joint committee had agreed in June to consider amending a rule it had previously published in April regarding board certification, which the BOOM’s counsel called concerning.
Diamond says the proposed new rules made gluteal fat grafting a safer procedure by increasing the requirements on those who perform it.
“It’s my personal thinking it’s a moot exercise,” he said of pursuing the proposed rules. “Because the law that is going into effect will be able to satisfy the concerns that we’ve had in protecting the public and to go ahead and proceed with this would be, again, moot.”
— RULES —
—AHCA proposes amending Rule 59G-4.127 to incorporate by reference the revised Florida assertive community treatment (FACT) services coverage policy to align with the Department of Children and Families (DCF) guidance 16 that took effect July 1. More here.
—The Board of Hearing Aid Specialists proposes amending Rule 64B6-8.003 to incorporate two updated DOH forms regarding training programs for hearing aid specialists. More here.
—The Board of Hearing Aid Specialists proposes amending Rule 64B6-8.002 regarding the application for training program registration. The changes to this form are necessary to clarify that the form only applies to prescription hearing aids and does not apply to over-the-counter hearing aids. More here.
— The Board of Hearing Aid Specialists proposes amending Rule 64B6-2.003 to update and make current the application form DH-MQA 1155, the form for licensure by examination. More here.
—The Board of Hearing Aid Specialists proposes amending Rule 64B6-3.001 to update and make the current hearing aid specialist application form DH-MQA 1156, the form for an initial license. More here.
—The Board of Pharmacy proposes amending Rule 64B16-31.007 regarding collaborative practice certifications to add a chronic medical condition that can be treated by pharmacists certified to be collaborating with physicians. More here.
—The Board of Speech-Language Pathology and Audiology proposes amending Rule 64B20-7.001 to reflect a new statutory distinction between over-the-counter and prescription hearing aids. More here.
—The Board of Acupuncture proposes amending Rule 64B1-8.003 to clarify pursuant to JAPC notification. More here.
— LOBBYISTS —
Brian Ballard, Dane Eagle, Ballard Partners: Natural Health Partners
Christopher Finkbeiner, Rubin Turnbull & Associates: Nomi Health
— ETC —
—The Florida Policy Institute published its annual in-depth report on the enacted fiscal year 2023-24 budget, which went into effect July 1. More here.
— Morbidity and Mortality Weekly seeks input from healthcare providers and public health professionals. It asks people to sort a list of public health-related items into groups they think make sense. This exercise takes about 15 minutes and can be taken from any computer anytime. To consent to participate in this study, please click on the health care provider or the public health professional study link, whichever most applies to you.
— ROSTER —
— Kiki Litchford was named the Director of Business and Professional Development for LeadingAge Florida. Litchford will develop relationships with business members and drive participation in LeadingAge Florida’s exhibiting sponsorship and advertising opportunities. She will also be responsible for the creation and execution of professional development opportunities for LeadingAge Florida members. Before joining LeadingAge Florida, Litchford was the chapter and education manager for the Florida Assisted Living Association.
— ICYMI —
In case you missed them, here is a recap of other critical healthcare policy stories covered in Florida Politics this past week.
New rules: Pharmacy benefit management regulation was a top priority issue during the 2023 Session, and now implementation of the new law appears to be an equally hot issue. Not surprisingly, lobbyists and lawyers representing the insurance industry and pharmacists attended the public meeting in person and through teleconference. But only those representing the latter group made public comments. The proposed rule requires PBMs to notify the state within 30 days of any complaint settlement or discipline against it or its affiliates. OIR staff attorney Michael Lawrence said the OIR wants to take the proposed rules to the Financial Services Commission on Aug. 22. To that end, the office will accept written comments on the draft rules until Aug. 11 at noon.
Overstep: In recognition that an emergency rule overstepped regulators’ authority, the state’s medical boards agreed to strip a month-old requirement from consent forms that transgender adults undergo a “thorough psychological and social evaluation” before initially receiving hormone replacement therapy and every two years after that. The emergency rules were enacted in response to a new law (SB 254) that limits access to gender-affirming care and requires patients to sign informed consent forms. The law had directed the Board of Medicine and Board of Osteopathic Medicine to create the informed consent forms, which went into effect July 7. But Joint Administrative Procedures Committee Chief Attorney Marjorie C. Holladay flagged these new rules suggesting the boards’ requirement for psychological evaluations may have overstepped their legislative authority.
Throwback: Asked about gun rights during a Q&A session, DeSantis pivoted to questioning former President Ronald Reagan’s decision in the 1980s to close mental hospitals, which preceded an uptick in the homeless population. Reagan repealed legislation championed by Jimmy Carter that supported mental health institutions. DeSantis did not advocate for a return to federal policy driving mental health institutions in Iowa Friday. Instead, he recommended being more “forward-leaning” in schools, even though he warned of potential ideological issues. “Unfortunately, we’ve seen, like, the mental health people try to use that to impose leftism,” DeSantis said. “Are you kidding me? No, you don’t do that. You got to do it straight up, and it’s got to be about the well-being of the youth.”
Act fast: Today marks a year since President Joe Biden signed the PACT Act, the most significant expansion of benefits for veterans exposed to toxic substances in over 30 years. The Department of Veterans Affairs (VA) has received more than 770,000 PACT Act claims, of which 78% were approved. That includes some 65,000 Florida veterans who signed up for benefits since the legislation was enacted last year. There has yet to be a formal date by which veterans must apply for the new benefits. However, the coming anniversary of the PACT Act’s ratification, Aug. 9, is the last day veterans may apply for those benefits to be retroactive to when the measure was signed.
Buzzkill: In a 26-page brief filed to the Florida Supreme Court, Attorney General Ashley Moody blasted the “misleading” language in a proposed citizen initiative that would legalize marijuana in Florida, raising concerns about how the measure would square with federal prohibition, which continues under the Biden administration as it has for decades. She also raises the issue of the amendment enriching Trulieve, which has plowed $38 million into the Smart and Safe Florida political committee leading the legalization effort. Moody worries medical marijuana treatment centers, in a “worst-case scenario,” would concentrate production on the recreational market. She devotes much of the brief to alleging defects in the language contemplated by sponsors.
— FOR YOUR RADAR —
Aside from coverage by Florida Politics, these stories are worth your time.
“U.S. judge asked to block Florida’s ban on transporting immigrants with unsettled status” via Michael Moline of Florida Phoenix — The provision “is illegal under binding precedent and imposes a staggering hardship on Plaintiffs, other Floridians, and travelers to Florida, who now face criminal penalties for visiting their families, doing their jobs, seeking medical care, and engaging in other everyday activities,” attorneys for the groups wrote in a memorandum filed in the U.S. District Court for the Southern District of Florida. Additionally, those attorneys argued that the U.S. Court of Appeals for the 11th Circuit, which holds jurisdiction over Florida, more than a decade ago invalidated similar laws in Alabama and Georgia, where that court’s rulings also control, as infringements on the federal government’s power over immigration policy.
“How leprosy arrived in Florida and how it is spreading: New clues are emerging” via Cindy Krischer Goodman of the South Florida Sun-Sentinel — Health officials are seeing more cases of the rare disease of leprosy in Florida want to find out why. Are foreign travelers bringing the disease to Florida with them? Are people in the state getting it from armadillos, which are naturally infected with the bacteria that causes the disease? How is this rare disease spreading in the Sunshine State, and who is vulnerable? Leprosy, known as Hansen’s disease, has existed for centuries, mainly in India, Brazil and Indonesia. Untreated people with the infectious disease caused by Mycobacterium leprae often have disfiguring skin sores or deformities like claw hands or hammer toes.
“A month after new Florida immigration laws took effect, advocates report rising in fear, confusion” via Natalia Jaramillo of the Orlando Sentinel — Before July 1, Marlyn Bonzil-Juste’s van carrying people back and forth to doctors’ appointments and Central Florida hospitals was an everyday occurrence through her company, Top Choice Medical Transport. Now, a month after new state immigration laws backed by DeSantis went into effect, Bonzil-Juste said she is beginning to see its impact on the immigrant community she serves. Bonzil-Juste said her drivers, who are mainly Haitian and Hispanic to cater to the patients she typically transports, often hear immigrants say they are scared of going to the hospital.
“A COVID-19 (remember that?) Summer surge is hitting Florida, but there’s a silver lining” via Chris Persaud of The Palm Beach Post — Another COVID-19 wave is sweeping Palm Beach County and Florida, but unlike previous Summers, this one has been far less dangerous. Sewage testing and regular COVID-19 testing show an undeniable surge of infections since early July. But few of those infected have gone to hospitals. Local doctors say the COVID-19-positive patients they have seen recently are not as sick as those they tended to during previous waves. Doctors said that could result from immunity granted by vaccines and previous infection, along with the latest coronavirus strains being weaker than their ancestors.
“With pickleball injuries mounting, physical therapist Dr. Frank Allen focusing on player health” via Doug Fernandes of the Sarasota Herald-Tribune — He was perfectly content being Dr. Allen, a Sarasota physical therapist since 2020 and owner of Your Place Physical Therapy, catering to athletes of all persuasions. Discovering he could tap into a vein no other physical therapist had, Allen went about becoming the first. He started the branding process by originating the moniker “Pickleball PT.” Allen’s two principal areas of focus are injury treatment and injury prevention. For the latter, he said the best protection against injury is simply warming up before taking the court.
— PENCIL IT IN —
7:30 a.m. — The Board of Dentistry will meet at Embassy Suites Tampa, USF, 3705 Spectrum Boulevard. A copy of the agenda may be obtained by contacting floridasdentistry.gov.
9 a.m. — The Board of Massage Therapy will hold a conference call to discuss general board business. For a copy of the agenda, email email@example.com. Video conference link: gotomeet.me/FL-BOMT/conference-calls. To join by telephone, call (877) 309-2073; participant code: 985-532-741.
1 p.m. — The Health Information Exchange Coordinating Committee (HIECC) meets. Meeting link here. Contact Crystal Ritter at (850) 412-3763 or email firstname.lastname@example.org for the agenda.
Diagnosis is written by Christine Jordan Sexton and edited by Drew Wilson.
This article originally appeared here and was republished with permission.