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An Open Letter to the Members of the Select Committee of

Affordable Health Care Access
From Representatives Julio Gonzalez and Fred Costello
October 1, 2015
Dear Members of the Select Committee of Affordable Health Care Access:

As the only two health care providers in the Florida House who are not members of the
Select Committee on Affordable Health Care Access, we want to share with you our vision for
the future of Florida's health care system and of the interventions we believe will help maintain
the high quality of care Floridians demand while keeping health care in Florida affordable. Our
approach is founded on the notion that the best solution for health care is individual ownership,
and the best way to promote individual ownership is through jobs and financial security.
We also acknowledge that every regional health care system requires the inclusion of a
safety net, strictly defined and efficiently operated, so that those members who are not able to
access care continue to have access to the care they need.
In the pages that follow, we share with you our vision for a health care system that will 1)
maximize access to quality health care through the unleashing of free market forces designed to
optimize price lowering pressures; 2) create more attractive conditions with the aim of bringing
health care professionals to our state; 3) improve health care workforce flexibility while
maintaining safety and quality of care, and 4) provide a targeted safety net that essentially
guarantees some form of coverage for every Floridian-Everyone Gets Access.

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We are very excited about the work you will be undertaking through this Select
Committee and look forward to supporting you in every way possible.
We begin by providing you with a summary of our recommendations and then proceed to
develop our thoughts in greater detail.

EXECUTIVE SUMMARY
Florida's approach to creating the nation's model health care system should be founded on
the concept that the best solutions for health care lie with individual ownership, and the best way
to promote individual ownership is through jobs and financial security.
With the numerous and conflicting priorities the state must balance, health care
expenditures for the state must be capped at 33% of the state's budget. To achieve these ends we
identify at least three areas that must be prioritized: A) maximizing financing options for an
individual's health care; B) increasing the size, versatility, and quality of the health care
workforce; and C) enhancing quality promoters within the state's health care system. We present
our recommendations at achieving each of these goals.

A) Maximizing Financing Options for an Individual's Health Care.

1. Pass legislation asserting that Direct Primary Care (DPC) agreements are not insurance
agreements.
2. Pass legislation that will disrupt the price-fixing influences of third-party payers.
3. Allow surgery centers to deliver overnight care to postoperative patients.
4. Explore the possibility of adding surgical recovery centers.
5. Discontinue the certificate of need requirement for building hospitals.

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6. Promote individual ownership of health care coverage plans.
7. Create the Florida Health Savings Account (FHSA) Program.
8. Request federal waivers to allow flexibility in employer health insurance policies including
portability.
9. Revamp Medicaid to provide for a targeted approach to coverage, defined by Floridians and
run by Floridians, and designed to provide variable levels of coverage for those truly
needing health care coverage when they need it.
10. Remove mandated reimbursement fees from Medicaid contracts and create a fee-savingssharing program with beneficiaries.
11. Implement the Medicaid Direct Primary Care Plan (MDPCP) as a viable Medicaid
contracting alternative that encourages beneficiaries to participate in price negotiations
with their providers and share in the cost savings with the State.

B) Increasing the Size, Versatility, and Quality of the Health Care Workforce;
1. Repeal Article X; Section 26 of Florida's Constitution requiring removal of licensure with
three successful medical malpractice claims.
2. Provide advanced registered nurse practitioners (ARNPs) and physician assistants (PAs)
working under physician supervision the authority to prescribe Schedule II medications.
3. Increase funding for graduate medical education in Florida for physicians and educational
opportunities for ARNPs and PAs.
4. Establish a loan forgiveness program for health care providers graduating from Florida
schools and practicing in underserved areas.
5. Expand medical research opportunities within the state.

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6. Define the practice of telemedicine and require that only health care providers licensed in
Florida be authorized to deliver telemedicine services within the state. Additionally,
require that third party payers in the state honor and reimburse telemedicine services.
7. Require that only physicians or dentists own outpatient medical or dental practices.
8. Prohibit the bundling of payments to health care providers within the state.

C. Enhancing Quality Promoters Within the States Health Care System;

1. Promote tighter oversight of health care boards over practitioners whose performance has
fallen below the standard of care.
2. Explore and implement health care quality enhancement measures into Florida's health care
delivery system, including expedited censure of healthcare practitioners when they do not
meet the standard of care.

I. INTRODUCTION:

Health care and its availability have become a matter of great public and governmental
importance within the State of Florida. The onslaught of federal regulatory intrusions, the everchanging insurance environment, and the dynamics of our state's demographics have made health
care access an issue that will continue to figure prominently for years to come.
There have been numerous approaches in implementing a system to maximize Floridians'
access to healthcare. Of course, no approach will hold complete solutions to all the complex
health care challenges confronting our state. However, any plan will have significant and direct
impacts upon the lives of millions of Floridians. Consequently, and in light of the direct and

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palpable effects these important decisions will have upon our citizens, Florida must build a
healthcare delivery system that upholds the highest quality standards for patients while observing
the keenest sense of fiscal responsibility and stewardship for its taxpayers.

II. FLORIDIANS DESERVE THE BEST HEALTHCARE SYSTEM AVAILABLE

Florida's impact to the nation with its status as the third most populous state and
possessive of the country's fourth largest gross state product is immeasurable.1 The
implementation and maintenance of a quality health care system accessible to all is of
compelling state and national importance. As a result, it should be the goal of the state of Florida
to achieve and maintain the highest quality health care system available that preserves and
promotes the practice of medicine as a scientific pursuit and an art to be developed, and which
promotes the robustness and vibrancy of its ancillary professions. Florida's health care system
ought to be of such high standards that it motivates providers from around the nation and the
globe to come to our state to practice their professions.
We believe Florida's health care system must also demand accountability from its
providers and a commitment for continued intellectual and professional improvement. We
further believe that an ideal health care system will employ a team-centered approach that
maximally employs the skills and expertise of each member. In order to maximize the quality
and efficacy of the care delivered, the health care team must be headed by a physician, defined as
a doctor of medicine or doctor of osteopathic medicine in the medical arena, and a doctor of

1 In 2015, Florida's GSP is $800.492 billion dollars accounting for nearly 4.8% of the nation's
gross domestic product. U.S. Bureau of Economic Analysis;
http://www.bea.gov/newsreleases/regional/gdp_state/gsp_newsrelease.htm on June 3, 2015.

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dentistry in the dental arena.2 Although much independence and autonomy may be imparted
upon every other member of the health care workforce to maximize productivity and efficacy,
only these health care team-leaders possess the necessary skills and expertise to 1) coordinate the
delivery of health care in an effective manner and 2) maximally identify and prevent
complications and pitfalls in care.
Additionally, we recognize that Florida is in possession of only a finite number of
resources for the delivery of care. Consequently, those persons relied upon to deliver health care
to Florida's patients are also required to act as responsible stewards of those limited and precious
resources. Just as these professionals must apply their assets with great care and deliberation, it
also falls upon the legislature, governor, and policymakers to devise a plan that responsibly
applies these assets in as cost-effective a manner as possible while providing the state's health
care workforce the flexibility it needs to adapt and accommodate to the very fluid challenges
before them. We believe there is no greater check on the spending and expansive tendencies of
health care professionals than the oversight of patients empowered with the ability to
individually contract with those professionals and who possess a say in the direction, price, and
extent of their care.

2 The term "team" is used as it applies to the coordinated structure of health care providers
throughout the state and their ancillary and supporting members.

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III. CHALLENGES TO BECOMING THE FINEST HEALTHCARE STATE IN THE
NATION

Building a health care system uniquely suited to meet Floridians' needs is a demanding
task. As of 2015, the State of Florida had a total budget of approximately $78.7 billion.3
Medicaid expenditures within the state accounted for $25.8 billion, or approximately 32.9% of
Florida's budget.4 With the numerous and conflicting priorities the state must balance, such as
protecting and maintaining its water supplies and natural resources, its infrastructure, and its
educational system, we certainly believe these non-health care expenditures must account for at
least 67% of the state's overall budget, leaving approximately 33% of the state's budget for health
care related expenditures. It is therefore our aim to work within a framework of health care
expenditures capped at 33% of the state's budget.

We recognize at least four components to Florida's health care funding structure: 1) the
private component, 2) the Medicare component, 3) the VA component, and 4) the safety net, or
state run component, which includes Medicaid. Each component has its own individual and
indispensible roles.
The private component of health care funding is central, and the one component to which
the general population should be directed. Floridians engage in privately funding for their health

3 2015 Legislative Sessions Including Special Session A: Fiscal Analysis in Brief. General
Appropriations Act Chapter 2015-232, Laws of Florida Adjusted for Vetoes and Supplementals.
The Florida Legislature. August, 2015,
http://www.flsenate.gov/UserContent/Session/2015/Publications/2015FiscalAnalysisBrief.pdf on
September 6, 2015.
4 Id.

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care in at least three ways: 1) self-financing; 2) financing through the individually contracting of
third party payers; and 3) group contracting of third party payers.
The number of Floridians in a position to finance their own health care without third
party payer assistance is admittedly small to negligible. Presently, approximately, 5% of
Floridians are enrolled in some form of private insurance plan designed to offset medical care
costs as individuals, and 48% of Floridians are enrolled in some form of group coverage plan,
mostly through their employer.5 These three groups essentially make up the totality of the
private component.
The second component is the federally funded Medicare system tailored to our nation's
seniors and to those Americans who have been deemed completely disabled. Presently 14% of
Floridians are enrolled in Medicare.6
The third component, also largely federally funded, is the VA health care system tailored
to our nation's veterans. There are presently 544,022 veterans in Florida who receive their care
from the VA system.7
The state's government-funded health care component addresses those residents who
cannot provide for themselves and are afflicted by medical conditions. The exact number of
Floridians unable to afford any insurance is debatable. Although the American Community
Survey finds that approximately 3.6 million Floridians are uninsured,8 recent estimates place the
number of adult Floridians who have earned-incomes under Federal Poverty Level (FPL) at
5 State Health Facts; Health Insurance Coverage of the Total Population, The Henry J Keiser
Family Foundation, http://kff.org/other/state-indicator/total-population/ on June 5, 2015.
6 Id.
7 Email from Donal Davis, VISN8 Strategic Planner September 9, 2015.
8 The Florida Senate Committee on Health Policy, Bill Analysis and Fiscal Impact Statement for
SB 2-A, 2 June 1, 2015 quoting Kaiser Family Foundation, State Health Facts, Health Insurance
Coverage of the Total Population (2013), http://kff.org/other/state-indicator/total-population/
(last visited May 26, 2015).

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approximately 900,000.9,10 Additionally, there are 250,000-800,000 people who earn between
100% and 138% of the FPL, are not eligible for participation in Medicaid, and are also not
eligible to receive subsidies to participate in the federal healthcare exchange.11 These two
groups add up to about 1.7 million Floridians who would greatly benefit from assistance
provided by a state run health care program. The level of care, its expense, and its intensity,
however, vary amongst the members of that group at any particular time, from no significant care
requirements to intensive, expensive, and life preserving care. Only by maximally employing all
available assets as efficiently and economically as possible can Florida stand to make its health
care delivery system the best in the nation.

IV. SPECIFIC AIMS TOWARDS MAKING FLORIDA THE NUMBER ONE

HEALTHCARE STATE IN THE NATION

Making Florida's health care system a beacon for the rest of the country requires a
multifaceted approach aimed at optimizing the efficiency and delivery capacity of each of the
previously identified components. Ultimately, the desired aim is to create an environment where
Floridians can maintain the highest standard of health possible. Such a system is necessarily one
that provides robust and achievable funding options for the individual and contains a vibrant and
dynamic set of health care professionals who stand prepared to deliver that care. To achieve
these ends we identify at least three areas that must be prioritized: A) maximizing financing
9 The Florida Senate Committee on Health Policy, Bill Analysis and Fiscal Impact Statement for
SB 2-A, 2 June 1, 2015, quoting Kaiser Family Foundation, State Health Facts, Health Insurance
Coverage of the Non-Elderly (0-64) with Income Below 100% Federal Poverty Level (FPL)
http://kff.org/other/state-indicator/nonelderly-up-to-139-fpl/ (last visited May 26, 2015).
10 Federal Poverty Level determinations are made yearly by the United States Census Bureau.
11 Justin Senior, Oral Testimony at the Health and Human Services Committee Workshop on Bill
SB 2-A, June 1, 2015.

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options for an individual's health care; B) increasing the size, versatility, and quality of the health
care workforce; and C) enhancing quality promoters within the state's health care system.

A. Maximizing financing options for an individual's health care: The ultimate goal of the
state with regard to health care delivery is to create and maintain a health care system that
allows for maximum access to quality health care tailored to the unique circumstances and
needs of each citizen. To accomplish this, each of the financing components of the health
care system need be groomed so as to maximally play its role in supporting the state's health
care delivery system. Additionally, although we acknowledge the necessity of a safety net
for those unable to finance their own health care, every effort should be undertaken to
minimize the size requirement of that safety net. In other words, every effort should be made
to optimize the opportunity for productive economic endeavors for Floridians, to keep the
cost of living down so that a greater percentage of an individual's personal budget is available
for provisions such as accessing health care, and to make health care as affordable as possible
so that as many as possible of those financially stable individuals are able to access the care
they need. Below we provide some ideas that may help accomplish these aims.

1. Improve Florida's economy. As previously asserted, possessing a stable and well-paying

job is the most effective way to secure access to health care. Regardless of whether one's
health care is financed through one's employer, through contracting with a third party
payer on an individual basis, or through the achievement of sufficient wealth so that one's
health care may be directly funded, financial self-sufficiency is the optimal method of

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ensuring access to health care and should be the aspirational goal of the state's health
policy.
Indisputably, efficiency is maximized and the cost of delivery minimized, when the
individual receiving care has a primary stake in his or own health care and has the
principal say in the make up of the care received and the price that is paid for it.
Consequently, accessing quality health care in Florida tailored to the patient's needs is
inextricably linked to achieving financial self-sufficiency, which in turn depends upon
building and maintaining a vibrant, freely accessible economy. We therefore strongly
support and encourage any measure by the legislature designed to improve job creation
and economic growth.

2. Improve the efficiency and private access to Florida's health care system: Improving
the efficiency and private access to Florida's health care system may be accomplished
through a number of interventions.

a. Promote Direct Primary Care in Florida: DPC is a health care delivery model
where the patient directly contracts with a primary care provider for access to health care
delivery services. Usually contracted as a monthly payment plan between the patient and
the primary care provider, this arrangement allows for a direct contractual relationship
where the patient gains direct access to his or her physician in exchange for a periodic
fee. The DPC arrangement carries the advantage of allowing for the unfettered access to
a physician, ARNP, or PA without interference from third party payers or intervening
institutional policies or directives. The arrangement also produces greater efficiency in

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health care delivery since billing costs and reimbursement procurement efforts are
minimized. The plan generally does not cover the costs of ancillary services such as
laboratory costs, imaging services, or care from other providers although some DPC
agreements include provisions for negotiated discounts for these services. Most
significantly, the plan will also not cover hospitalization costs. However, using a DPC
model as a component of a multi-faceted health care financing plan may represent a
viable, cost effective alternative for many Floridians.
One threat to DPC is a judicial interpretation that such plans represent health insurance
plans rather than individual contractual agreements or club membership. Interpreting
DPC as an insurance plan is problematic because it would immediately threaten the
ability of health care providers to engage in such arrangements.

Legislative Opportunity: Improve the state's legislative DPC environment by passing

legislation asserting that DPC agreements are not insurance agreements.

b. Implement measures that help diminish the cost of health care delivery: No
measures will help in controlling the cost of health care delivery greater than those
fostering competition and the abilities for individuals to independently contract for health
care services. These free-market pressures are tempered in at least three ways within the
arena of health care delivery. First, in contradistinction to many other industries,
competition within the health care arena must be more strictly regulated since measures
aimed at achieving a competitive advantage by vendors could concurrently endanger
patient safety. Second, much of the pricing discretion by health care providers is

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inhibited by the cost fixing effects of third-party payers.12 Third are the inflationary
effects of meritless litigation.13
Since the minimum safety precautions cannot be tampered without negatively
impacting safety and quality, the most effective methods of ascertaining that marketbased, cost cutting pressures are felt evenly throughout the market are ones that disrupt
the artificial price-stabilizing pressures imposed upon the market and those streamlining
our civil justice system.

Legislative Opportunity: Florida should pass legislation that will disrupt the pricefixing influences presently countering the cost-containing effects of market competition
and contract negotiations and increase the efficiency with which our civil justice system
disposes of medical malpractice cases.

12 In Sarasota County, for example, where there is a sizable elderly population, Medicare can
account for over 70% of the medical market share. Under such circumstances, the costs savings
accommodations the health care market is willing to offer in response to competition is
essentially fixed by the colossal influence of one consumer; Medicare
13 The cost of medical liability to the nation has been estimated to run in excess of $55.6 billion.
Michelle Mello, et al, National Costs of the Medical Liability System, accepted for publication in
Health Affairs 2010, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3048809/ on September 6,
2015. According to the Office of Insurance Regulation, Florida's total malpractice premium costs
is the fourth largest in the nation, with about $540 million worth of premiums expended in 2013.
Medical Malpractice Financial Information Closed Claim Database and Rate Filings, Annual
Report, October 2014, Florida Office of Insurance Regulation, 8 October 1, 2014,
http://www.floir.com/siteDocuments/MedicalMalReport10012014.pdf on September 6, 2015.
The average cost of defending a case is $27,000.00 regardless of the outcome, and more
tellingly, the cost of defending a case requiring formal adjudication where a defense verdict will
be obtained (the health care provider prevails) runs about $125,000.00. Aeron Carroll, et al, The
Impact of Defense Expenses in Medical Malpractice Claims, The Journal of Law, Medicine, and
Ethics, Vol. 40, Issue 1, March 27, 2012, http://onlinelibrary.wiley.com/doi/10.1111/j.1748720X.2012.00651.x/pdf on September 6, 2015.

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Market interventions designed to promote less expensive and innovative ways of
delivering health care should be an integral component of the state's cost cutting efforts.
During the 2015 legislative session, the Florida House explored some of these measures
as possible ways in which to foster greater competition within the market. Amongst these
were the expansion of surgery centers as possible venues for delivering surgical care
normally requiring overnight stays, the creation of surgical recovery centers allowing for
the 3-day delivery of postoperative care, and the discontinuation of certificates of needs.
We agree that these market disrupters represent potential price reducing interventions that
when properly administered will serve to lower the cost of health care to consumers.

Legislative opportunity: Allow surgery centers to deliver overnight care to

postoperative patients. Explore the possibility of adding surgical recovery centers and
discontinuing the certificate of need requirement for hospitals.

c. Promote individual ownership of health care coverage plans: Ideally, health

care insurance should be portable and uniquely suited to address the needs of each
individual. Consequently, Florida should undertake those measures that help to increase
the portability of health care insurance. This includes minimizing mandates that serve to
artificially increase the price of health care insurance within the State of Florida and
providing incentives for individuals to purchase their own private health care insurance
plans. Admittedly, these efforts are restricted by the regulatory restraints stemming from
federal regulations. Nevertheless, measures promoting individual ownership in health

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care should be explored and maximized. One option to maximize individual ownership
lies with health savings accounts (HSAs).
HSAs are a form of private health insurance arrangement where the owner of the
account owns the funds in the account and manages them. The owner would then be able
to negotiate the price of services as well as the extent of treatments and evaluations. A
truly effective HSA program would make the funds devisable and provide tax rewards to
offset funds that are placed into the accounts. The FHSA could be such a program.
With FHSAs, Floridians would be able to yearly deposit money into a health savings
account to be used for medical expenses. Fifty percent of any contributions would be tax
deductible from the individual's sales taxes. Such accounts would be devisable.
Floridians would be able to purchase an electronic card that would track their FHSA and
earned tax credits. At the time of any taxable transaction within the State of Florida, the
purchaser would present the FHSA card and the deductible sales tax would be adjusted at
the time of purchase from applicable earned credits. The tax credit would then be reset at
the end of each calendar year.

Legislative Opportunity: Create the Florida Health Savings Account Program

c. Group and Employer health care insurance: Although group coverage plans
suffer from a lack of flexibility and portability, the premium lowering advantages of cost
averaging amongst the different members provides significant advantages for many.
Florida can help cut costs on employer-mandated insurance policies by diminishing
regulations that deter cost cutting options for employers and contracting beneficiaries.

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Additionally, Florida can incentivize employer participation through corporate tax
adjustments.
Unfortunately, many restrictions on employer health insurance stem from federal
regulations and severely curtail the state's ability to enact meaningful reform.
Consequently, until these federal regulations are repealed, many of the interventions that
the state could implement remain unavailable. However, members of the state legislature
may work with Congress to help open up those avenues and promote badly needed
reforms to the employer and group health insurance laws.

Legislative Opportunity: Request federal waivers to allow flexibility in employer

health insurance policies. Require that employees who change jobs be given the
opportunity to privately keep their policy for up to three years after changing jobs by
paying both the employer and employee portions of the same rate they enjoyed under the
previous employer.

e. The safety net. Practically speaking, Florida's safety net is Medicaid, covering
approximately 17% of Floridians.14 Presently, Medicaid is suboptimally designed to
balance the availability of resources with the effort at maximizing access and cannot
achieve this end without a significant redesign.

14 The number of Medicaid enrollees in Florida obtained from Presentation by Health and
Human Services Committee Workshop on Bill SB 2-A, June 1, 2015, Slide 3
http://myfloridahouse.gov/Sections/Documents/loaddoc.aspx?
PublicationType=Committees&CommitteeId=2857&Session=2015A&DocumentType=Meeting
%20Packets&FileName=hhsc%206-1-15.pdf on September 7, 2015.

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i. Prioritization: With the limitations on available resources, Florida cannot fund
healthcare coverage for all Floridians, nor should it, as this would run counter to the goal
of moving citizens out of Medicaid and into private healthcare insurance programs. Until
now, Florida's approach has been to participate in national programs that define the
patient groups to be covered and the terms of allocations of those associated funds.
We disagree with this approach. We believe Florida's goal ought to provide fullservice coverage to that limited portion of its citizens truly in need of coverage and
unable to provide for themselves regardless of federal definitions or requirements. The
state's analysis should therefore begin by calculating the cost of providing health care
services to those Floridians needing assistance. It should then design a system of variable
coverage where the driving factor for the allocation of funds and system design is not
participation or compliance with federal programs, but rather tailoring the resources
available to the variable needs of the various subpopulations of Florida's poor and
disabled. Additionally, Florida must allocate a reserve fund to cover the care of those
individuals actuarially predicted to require care over the span of a year. In this way, all
Floridians unable to purchase health care insurance on their own will be covered, but
only to the extent of services they require. Those who did not have health care coverage,
but through an unforeseen event develop a condition under circumstances where the state
would have to intervene and then regain the ability to provide for themselves are enrolled
in a payback program through the Department of State by which the beneficiary would
pay back the state for the funds allocated towards his or her care during the temporary
time of need.

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In other words, although only a few exceptionally needy Floridians will need full
state-arranged and administered coverage, all needy Floridians will be covered if a
debilitating and unexpected health event were to take place. Everyone Gets Access.

Legislative Opportunity: Revamp Medicaid to provide for a targeted approach to

coverage, defined by Floridians and run by Floridians, and designed to provide variable
levels of coverage for those truly needing health care coverage when they need it.

ii. Medicaid Cost-Containment Measures: Commensurate with its prioritization

efforts, steps to contain costs within the state's Medicaid healthcare system must also be
implemented.

A) Reimbursement provisions in Medicaid contracts ought to be written as "no

more than" 100% of Medicare reimbursement rates, leaving the beneficiary
free to negotiate a lower fee with the provider. Savings in the agreed-upon
price for the service will be split equally between the state and the patient.
A binding fee schedule would be applicable to emergency room visits and
urgent care delivered within Florida's hospitals since these situations
represent times where the patient would be unable to effectively negotiate an
appropriate reimbursement fee. Being that most providers are hesitant to
accept reimbursements of less than Medicare rates, Medicare rates would be
used as the benchmark for reimbursing Florida's providers.

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Legislative Opportunity: Remove mandated reimbursement fees from Medicaid
contracts and create a fee-savings-sharing program with beneficiaries.

B. Implement the Medicaid Direct Primary Care Plan. Under the MDPCP,
Medicaid would contract with participating providers to enter into DPC
relationships with patients. The arrangements could be designed, for
example, so that Medicaid would offer to pay up to $100.00/mo per patient
to the provider, or $1,200.00 per year, for participation in the program. The
patient would then use only his or her DPC health care provider in accessing
care except in emergency situations. Any discounts negotiated by the
patient would be shared equally with the state. Medicaid would also cover
basic laboratory and imaging services. Emergency room visits and
hospitalizations would be covered by the conventional fee arrangements
between Medicaid and hospitals.
An incentive program could be established whereby health care
providers with a practice of at least 500 DPC Medicaid patients would be
eligible for financial assistance in staffing the practice with ancillary
personnel, including ARNPs and PAs who themselves are caring for over
500 DPC patients.
Under this model, a physician would conservatively be able to handle
approximately 1,000 patients per year,15 and that's without the broad practice
expansion capabilities made possible with additional ARNPs. Recruitment
15 John Goodman, Everyone Should Have a Concierge Doctor, Forbes, August 28, 2014
http://www.forbes.com/sites/johngoodman/2014/08/28/everyone-should-have-a-conciergedoctor/ on September 2, 2015.

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of 100 strategically located physicians would allow for over 100,000
Medicaid patients to be serviced.
Using the MDPCP program, the overall savings to Medicaid would be
sizeable. According to one study, employing DPC with a Value-inPrevention approach combining DPC with a comprehensive prevention
management realized $119.4 million in cost savings in the five states
employing the program (Florida, Virginia, New York, and Arizona).16
Interestingly, when broken down per capita, the cost savings were even
larger, with a cost savings estimate of $2,551 per patient, which incidentally,
was greater than the per capita cost of participation in the program. This
program would maximally be used in regions where high concentrations of
Medicaid patients reside.
The versatility of the MDPCP, if innovatively applied, we believe will be
staggering. For example, we foresee the merging of the MDPCP with
Florida's hospitals allowing for agreements to be made to contract for
unlimited access to necessary hospital services by patients enrolled in the
MDPCP. The patient then would have access to a primary care physician
through MDPCP, and also, if faced with a serious condition or emergency,
would be able to also gain access to the hospital through a Medicaid Direct
Catastrophic Care Plan (MDCCP). As an incentive, patients who do not
inappropriately access hospitals for a calendar year may then have credits
applied to their HSAs.
16 Andrea Klemes, et al., Personalized Preventive Care Leads to Significant Reductions in
Hospital Utilization. The American Journal of Managed Care, Vol. 18, No12, 453 December
2012.

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We also believe that giving participants the ability to directly negotiate
with the provider while splitting the negotiated cost savings with the
Department would maximize the cost lowering pressures on the industry,
thus improving economic efficiency. When this program is combined with
the robust utilization of ARNPs and PAs delivering care under physician
supervision, the program design would unleash even greater potential for
cost containment and volume expansion to meet the demands of Florida's
Medicaid population.

Legislative Opportunity: Create MDPCP as a viable Medicaid

contracting alternative while allowing the beneficiaries to participate in
price negotiations with their prospective providers and sharing in the cost
savings with the State; authorize the creation of MDCCPs with incentives
for beneficiaries who do not misuse hospital Emergency Rooms.

B. Increase the size and versatility of the healthcare workforce: Florida is presently
undersupplied with health care providers. Certain areas, such as psychiatry and primary care,
are demonstrating critical regional shortages. In order to alleviate this undersupply, certain
steps should be considered:

1. Promote an economic, professional, and legislative environment that will encourage

health care providers to move to Florida and establish their practices here. A hostile tort
environment, economic considerations, a high dependence on Medicare with its

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depressive effects on reimbursement rates, and the negative image resulting from a threestrikes-you're-out rule relating to medical licensure play integral roles in deterring health
care providers from moving to the Sunshine State. Addressing these issues would be
very beneficial in improving the supply of medical personnel throughout the state.
Legislative opportunity: Sponsor legislation placing a constitutional amendment
on the ballot to Repeal Article X; Section 26 of Florida's Constitution.

2. Implement measures that will increase the use and productivity of the various support,
ancillary, and physician-extension health care professionals. Improving the versatility
and scope of the medical workforce is critical to improving Florida's health care system.
However, these measures cannot be undertaken at the expense of patient safety and
quality.
ARNPs, PAs, and other health care workers play a vital role in supporting the
delivery of health care within the state. However, none of these providers is an adequate
substitute for a physician or dentist, which is the only member of the healthcare
workforce trained to independently evaluate disease, diagnose it, and develop a plan to
treat or cure it. As a result, physicians and dentists are best suited, by virtue of their
training, to identify complex medical conditions that may escape the evaluation of other
members of the health care workforce.
Presently, ARNPs and PAs share a substantial degree of autonomy in delivering
health care to Florida's patients. However, while PAs must remain within a reasonable
distance of the overseeing physician, ARNPs are not restricted by the reasonable distance
rule so long as they are governed by a supervisory agreement with a physician.

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Additionally, neither ARNPs nor PAs possess the authority to prescribe Schedule II
medications such as narcotic medications.17

Legislative Opportunity: Provide ARNPs and PAs with the authority to prescribe
Schedule II medications so long as the care they deliver continues to be delivered under
the supervision of a Florida-licensed physician.

3. Support training and research efforts to turn Florida into the leading medical research
forum in the nation. Expanding intrastate medical training opportunities is an established
method for increasing a state's medical workforce.18 However, in order for such growth
efforts to be successful, intrastate class expansion must be tied to effective graduate
medical education efforts.
Residency training is the phase in a physician's training following medical school.
It does little good to spend state funds in initiating the training of new physicians if we
lose them to other states through the scarcity of post-graduate training programs.
Consequently, the expansion of graduate medical education in Florida is crucial to
enhancing retention. In 2015, the legislature explored a $20 million allocation in
17 Commentary is appropriate regarding prior efforts to expand the scope of practice of ARNPs.
Due to the paucity of scientific data on the matter, we harbor significant concerns about the
advisability of promoting the unrestricted practice of medicine by ARNPs. Until additional data
becomes available that would allow for the further assessment of the risks and benefits of such a
broad scope of practice expansion, we believe it is best for the Florida legislature to expand
scope of practice of ARNPs only to the point of allowing for the prescription of narcotic
medications, which would place Florida in line with the plurality of states (and with Florida's
addition, the majority), which similarly limit ARNP scope of practice. House of Representatives
Staff Analysis PCB SCHCWI 14-01, Advanced Practice Registered Nurses, 11 February 27,
2014.
18 Recent Studies and Reports on Physician Shortages in the U.S., AAMC, October 2012,
https://www.aamc.org/download/100598/data/ on September 6, 2015.

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recurring general revenues with a $30 million federal match for the expansion of graduate
medical education opportunities within the state. We favor this approach.
Additionally, as the role of ARNPs and PAs in the delivery of health care expands,
the demand for ARNP and PA education opportunities will also predictably increase. The
legislature ought to promote ARNP and PA training opportunities within the state in order
to create an ample supply of these professionals to address the state's health care delivery
needs.

Legislative opportunity: Increase funding for graduate medical education in

Florida for physicians and educational opportunities for ARNPs and PAs.

Another key method by which the legislature may improve retention is the
development of a robust loan forgiveness program. A loan forgiveness program for
health care providers serving in underserved areas will go a long way towards promoting
the establishment of a robust health care delivery environment within our state and foster
the relocation of health care resources to regions where their services are required.

Legislative Opportunity: Establish a loan forgiveness program for physicians,

dentists, PAs, and ARNPs graduating from Florida schools and practicing in underserved
areas for prescribed periods of time.

Finally, few interventions will attract more health care professionals than a robust
medical research environment. Programs such as those undertaken at the Children's

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Research Institute at All Children's Hospital,19 Moffitt Cancer Center, the Mayo Clinic in
Jacksonville, the Miller School of Medicine, and at Shands Hospital, to name a few,
represent near limitless opportunities for the promotion of a vibrant medical research
environment within Florida, which will promote the economy, grow jobs, and ultimately
result in advances that alleviate human suffering and cure diseases. No better location
can exist to house these noble endeavors than in Florida.

Legislative Opportunity: Expand medical research opportunities within the state.

4. Promote telemedicine opportunities within Florida. Telemedicine, or the practice of

medicine from remote locations appears to be a very versatile and powerful method of
both, increasing competition within the health care market and increasing the effective
number of health care providers practicing within the state. Statutorily, telemedicine
remains undefined and consequently fraught with difficulties in reimbursement. Florida
can easily alleviate this deficiency by defining telemedicine and requiring that
telemedicine services be mandatorily reimbursed by participating insurers.20 A
prerequisite to guaranteeing appropriate oversight of a telemedical practice is that

19 All Children's Hospital in St. Petersburg has combined with Johns Hopkins University and
created a pediatric biorepository program that is unique in the field of medical research.
20 Possible telemedicine definition and reimbursement requirement: Telemedicine is the use of
telecommunications technology by two or more health care professionals all of whom are
licensed to practice medicine, advanced nurse practice, or dentistry within the State of Florida,
but who may be separated by great distances for the purposes of providing health care services to
a patient physically within the State of Florida exclusive of audio-only transmissions, email
messages, or facsimile transmissions. Any telemedicine healthcare services provided using a
telemedicine platform shall be subject to the same billing and reporting guidelines as face-to-face
interactions and shall be reimbursable subject to the same rules as would apply to face-to-face
healthcare services.

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telemedicine professionals delivering care inside Florida be licensed to practice in
Florida.

Legislative Opportunity: Define the practice of telemedicine while requiring that

only health care professionals licensed in Florida be authorized to deliver telemedicine
services within the state. Additionally, require that third party payers in the state honor
and reimburse telemedicine services.

5. Support measures that will counteract hospital intrusions into the health care
practice market. A significant threat to quality of care and to the persistent autonomy of
the patient-physician relationship is the ongoing expansion of hospitals into the outpatient
health care delivery market with a resultant decrease in competition and often a
concurrent price increase.21 Driven largely by national policy forces, hospitals
throughout the state are gobbling up practices that traditionally have been free-standing
and independent organizations, resulting in mini, regional monopolies where the care and
price are dictated by the area's hospital at the expense of practice autonomy and patient
care. This trend must be countered within the state.
Another nationally driven model is that of bundling of payments. Payment
bundling is a technique whereby the facility, in this case the hospital, gets reimbursed for
what the third party payer believes is the full cost of the care delivered, then leaving to
the hospital the responsibility of distributing the funds to the participating providers as it
sees fit. We believe the policy of allowing a hospital to control who to pay and how
21 Anna Wilde Mathews, Health-Care Providers, Insurers Supersize, The Wall Street Journal,
Sept. 21, 2015, http://www.wsj.com/articles/health-care-providers-insurers-supersize1442850400 on September 23, 2015.

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much to be an ominous threat to the independent practice of medicine and to patient
autonomy.
The Florida legislature can counteract the tendencies of hospital-centered
oligopolies by requiring that only physicians or dentists possess any ownership interests
in Florida's outpatient clinics22 and by prohibiting the bundling of payments to Florida's
health care providers.

Legislative Opportunity: Require that only physicians or dentists own outpatient

medical or dental practices. The Florida legislature should also prohibit the bundling of
payments to health care providers within the state.

C. Promote quality enhancers in Florida: The quality of health care delivery must remain
unparalleled in the nation.

1. Enhance the robustness of the oversight of the Board of Medicine. The legislature
ought to tighten up the guidelines by which failing health care providers are sanctioned so
as to minimize the presence of dangerous practitioners within the state.

Legislative opportunity: Promote tighter oversight of health care boards over practitioners.

2. Implement measures to cut down on Medicaid fraud. Medicaid fraud represents a

significant drain on taxpayer dollars. We strongly favor and encourage attempts by the
Florida Legislature to improve the ability for law enforcement to detect, prosecute, and
22 This is the same standard maintained by Florida's lawyers.

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punish those who engage in what is essentially the theft of the people's money for their
personal and illegal gain.

Legislative Opportunities: Explore and implement methods to detect, stop, and

punish Medicaid fraud perpetrators.

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In closing, we once again express our anticipation at seeing the results of the work
you are about to undertake and thank you for taking the time to review our ideas. We
look forward to the prospect of interacting with you in committee and hope that together
we may promote the betterment of our great state. Please let us know if we may be of
any assistance in this endeavor.

Sincerely,

Representative Julio Gonzalez

District 74

Representative Fred Costello

District 25

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