Teaching Hospitals

Jackson Health System

Mount Sinai

Medical Center

Orlando Health

UF Health Shands Hospital

UF Health Jacksonville

Tampa General Hospital

Public Hospitals

Halifax Health

Lee Memorial Health System

Memorial Healthcare System

Broward Health

Sarasota Memorial

Health Care System

Children’s Hospitals

All Children’s Hospital

Nicklaus Children’s Hospital

Anthony Carvalho

President

www.safetynetsflorida.org

Safety NetHospital Alliance

of Florida

SNHA

Regional Perinatal IntensiveCare Center

Sacred Heart Health System

CHIEFS&GOVERNMENTRELATIONSREPRESENTATIVES

TELECONFERENCE/MEETINGTuesday,January12,201612:00p.m.–1:00p.m.ESTCall-In:(888)684-4447

ConferenceID:8504255685

Welcome

1. LowIncomePoolUpdate

2. MedicaidOut-PatientConversionfromFFStoEAPG

3. PublicHospitalBillsa. HospitalExecutiveCompensation(SB686Gaetz-EE/HB593Metz-GO)

4. HospitalIndustryBills

a. Transparency/All-PayerClaimsDatabase(Gov/HB1175Sprowls/SB1496Bradley)

b. CONHospitalDeregulation(HB437Sprowls-HCA/SB1144Gaetz)c. AmbulatorySurgeryCtrs24hrs&RecoveryCareCtrs72hrs(HB85

Fitzenhagen-HCA/SB212Gaetz-HP)d. EDProviderPriceFixing(HB221TrujilloB&I/SB1442Garcia)

5. SNHAFTraumaDirectorsWorkgroup

TeleconferenceonFriday,January15,2:30-3:00

6. MedicaidReimbursementofPediatricHospital-BasedPsychologicalServices

7. OtherIssues

KeyDates:ü NextWeeklyTeleconference:January19thü SNHAFHospitalDay’sintheCapitol:February22nd–23rd

ImpactofOutpatientEAPG(preparedDecember3,2015)

Note:AsofDec.3,2015,notallproviderclaimshadtheinformationnecessaryforNaviganttorunasimulation.Thisisbeingaddressedbytheproviders,AgencyandNavigant.

EAPG-Simulation7,NavigantincludesFFSandMCOVolumeProjectionforSFY2016-17

OPClaims(SFY1314volume)

OPCaseMix OPCostBasePayment

(SFY1314volumewithSFY1516Rates)

SimulatedPaymentforSFY1617

PaymentDifference

A B C D E F=E-DAllChildren'sHospital 385,233 1.4891 63,980,754 64,773,333 66,719,639 1,946,306

BrowardHealth 699,894 49,212,989 40,639,488 52,733,811 12,094,323BrowardGeneral* 374,964 1.3304 26,583,376 22,250,760 27,886,146 5,635,386CoralSprings 161,664 1.5694 10,737,143 9,057,230 11,689,534 2,632,304ImperialPoint 42,913 1.7021 3,539,006 2,429,389 3,100,403 671,014N.BrowardMedicalCenter 120,353 1.8045 8,353,464 6,902,109 10,057,728 3,155,619

HalifaxMedicalCenter 196,163 1.2551 18,072,178 10,118,884 12,025,795 1,906,911

JacksonMemorial* 690,811 1.2656 83,925,927 77,087,845 53,176,732 (23,911,113)

LeeHealthSystem 550,865 40,980,736 26,404,061 35,770,215 9,366,154LeeMemorial 305,766 1.2300 25,559,884 16,395,917 25,172,090 8,776,173CapeCoralHospital 143,610 0.9612 7,434,488 4,816,075 5,904,476 1,088,401HealthParkMedicalCenter 0 0.0000 0 0 0 0GulfCoastMedicalCenter 101,489 1.3569 7,986,365 5,192,068 4,693,649 (498,419)

MemorialHealthcareSystem 0 0 0 0 0MemorialHollywood 0 0.0000 0 0 0 0MemorialMiramar 0 0.0000 0 0 0 0MemorialPembrokePines 0 0.0000 0 0 0 0MemorialWest 0 0.0000 0 0 0 0

Mt.Sinai* 103,874 1.8747 9,406,128 8,354,008 6,851,928 (1,502,080)

NicklausChildren'sHospital 592,011 1.3250 78,423,750 88,823,353 89,717,661 894,307

OrlandoHealthSystem 800,215OrlandoHealth* 602,415 1.8455 55,168,533 48,154,393 60,327,049 12,172,656HealthCentral 111,473 1.1592 7,775,437 5,989,931 5,830,595 (159,336)SouthLakeHospital 86,327 1.5431 5,198,025 4,042,547 5,532,202 1,489,655

SacredHeartHealthSystem 393,112 42,747,639 31,037,844 21,716,609 (9,321,235)SacredHeartHospital 338,038 1.1275 36,980,211 25,618,778 18,375,792 (7,242,986)SacredHeart-Gulf 11,065 0.8211 2,060,514 1,793,376 543,886 (1,249,489)SacredHeartHospital~EmeraldCoast 44,009 1.1757 3,706,914 3,625,691 2,796,931 (828,760)

SarasotaMemorial 165,995 1.2669 14,797,366 9,499,462 10,124,812 625,350

TampaGeneral* 325,492 2.4305 27,568,528 27,545,430 24,828,640 (2,716,790)

UFHealthJacksonville* 0 0.0000 0 0 0 0

UFHealthShands* 0 0.0000 0 0 0 0

QUESTIONSFORAHCAMedicaidHospitalOutpatientReimbursementConversiontoEAPG

HEALTHCAREAPPROPRIATIONSCOM

3MSoftwareQuestions:• Doallhospitalshavethe3MsoftwarethatisnecessaryforEAPGs?

o No

• IstheEAPGsoftwareavailablefrommorethanonecompany?o No

• Didyouranalysistakeintoconsiderationthecostsforpurchasingthesoftware?

o NoIncompleteDataQuestions:

• DidyouhaveallFLhospitalsdatainyouranalysis?o No

• Howcouldyouformastatewiderecommendationwithonlyasubsetofhospitaldata?

o ?

• DidyouprovidethepublicacrosswalkcomparisonofthecurrentsystemcodestotherecommendedEAPGcodes?

o No

• Howmanyimpactanalysesdidyousharewiththepublic?o 2

• Didyoutakeintoconsiderationthereducedpricedrugfederalprogramcalled340B

codingrequirements?o No

o Doyouknowthatthefederal340BreducedpricedrugprogramsavesFlorida

Medicaidandpatientsalotofmoney?Children’sHospitalsQuestions:

• Didyouranalysisadjustforthehighercostsofpediatricservices?o No

1/10/16

##

SHOULDBEDELAYEDMedicaidHospitalOutpatientReimbursementConversiontoEAPG

WHATITIS:

• EAPG(EnhancedAmbulatoryPaymentGroups)isaMedicaidoutpatientreimbursementratecalculationmethodology.o TheLegislaturerequiredAHCAtoconverttheMedicaidhospitaloutpatientreimbursement

methodfromacost-basedmethodtoaprospectivemethodbyJuly2016;andconductastudytodeterminethebestprospectivemethodbyDecember2015.

• AHCAhiredNavigantConsultingtostudyandrecommendanewoutpatientmethod.• NavigantrecommendedEAPG,whichisa3Mproduct.

WHYITSHOULDBEDELAYED:

ForcesHospitalstoPurchaseNewSoftware:• EAPGsoftwareisproprietarytothe3MCorporation.• Manyhospitalsdonotcurrentlycontractwith3M.• EAPGswillalsorequireexpensivebillingsystemchangesinordertoprovideMedicaidpatients

accessto340Breducedpricepharmaceuticals.

IncompleteData:• EAPGwasrecommendedwithoutreviewingdatafromallFloridahospitals.• Manyhospitalsdonotcontractwith3Mandassuchwereexcludedfromimpactanalysis.• Navigantsetanarbitrarythresholdandthrew-outhospitalswheremorethan33%oftheirclaim

linesprocedurecodeswerenotcompatible.• EAPGismuchmorecomplexthantheDRGinpatientreimbursementmethod.• EAPGhas19millionlinesofdataversusDRGthathas500,000lines. InadequateAnalysis:• NocrosswalkbetweenCPT/HCPCScodesandEAPGwasprovided.• EAPGrecommendationconflictswithfederal340Bpharmaceuticalrequirements.

o Grouped/bundleddrugpaymentsarenoteligibleunderfederal340B.o EAPGrecommendationtogroupcertainpharmaceuticalswasneveranalyzed.o EAPGwillhavesignificantnegativefinancialimpactonthosehospitalsqualifyingto

purchasedrugsatadiscountunderthefederal340Bprogram.

InadequateTimetoReview:• Hospitalsonlyoffered30daystoreviewimpactofAHCAsEAPGrecommendation.• Thehospitalsthatdon’thave3Msoftwarecouldnotreviewatall.• OnlyfourpublicmeetingspriortoNovember30threportrelease

o Mtg1&2:August19th&September17thInformationalo Mtg3:October20thFirstsimulationreleasedo Mtg4:November20thSecondandFinalsimulation/recommendation

WHYITHARMSCHILDREN’SHOSPITALS:

• EAPGrecommendationforasinglepaymentratewithnopolicyadjustorforpediatricencountersfailstorecognizethesignificantadditionalresourcesrequiredtotreatandmanagepediatricpatients.

SHOULDBEDELAYEDMedicaidHospitalOutpatientReimbursementConversiontoEAPG

MOREABOUTEAPG:

• EAPGgroupingsystemrequireshospitalstousecertainmedicalcodes(whicharenotcurrentlyrequired)toproperlyclassifytheoutpatientclaim.

• ManyhospitalsthatserveasignificantnumberofMedicaidrecipientswereexcludedbecausetheAgencylackedthedatatoproperlyclassifytheclaimsintheEAPGgrouper.

1/10/16

##

Teaching Hospitals

Jackson Health System

Mount Sinai

Medical Center

Orlando Health

UF Health Shands Hospital

UF Health Jacksonville

Tampa General Hospital

Public Hospitals

Halifax Health

Lee Memorial Health System

Memorial Healthcare System

Broward Health

Sarasota Memorial

Health Care System

Children’s Hospitals

All Children’s Hospital

Nicklaus Children’s Hospital

Anthony Carvalho

President

www.safetynetsflorida.org

Safety NetHospital Alliance

of Florida

SNHA

Regional Perinatal IntensiveCare Center

Sacred Heart Health System

FOR IMMEDIATE RELEASE Contacts: Tony Carvalho Ron Bartlett President Hill+Knowlton Strategies Safety Net Hospital Alliance of Florida ron.bartlett@hkstrategies.com (850) 201-2096 (813) 545-2399 JAN. 7, 2016

STATEMENT FROM TONY CARVALHO, PRESIDENT OF THE SAFETY NET HOSPITAL ALLIANCE OF FLORIDA, ON HEALTHCARE TRANSPARENCY

The Safety Net Hospital Alliance of Florida supports transparency in health care as a means to help patients and consumers make more informed, better decisions about their health care. While we are still evaluating the legislation put forth by Sen. Rob Bradley and Rep. Chris Sprowls, we are supportive of policies that improve healthcare transparency. The 14 teaching, public and children’s hospitals that make up the Safety Net Hospital Alliance of Florida have been leaders in transparency, operating fully in the public, with some governed by elected or appointed boards. For example, Lee Memorial Health System in Southwest Florida has a website dedicated to sharing the costs of their most common medical procedures, including the discounted rates for patients without insurance. Increasing transparency gives patients more control of their healthcare decisions and, ultimately, strengthens the community’s support of Florida’s safety net hospitals in their mission to provide critical, quality care to the state’s most vulnerable citizens.

###

2016LEGISLATIONTOOPPOSE

DraftSeptember2015 1

OPPOSERepealofHospitalCertificateofNeed(CON)(HB/SBbyGaetz)

Whatitdoes:RepealshospitalCertificateofNeed(CON).CONprogramsareaimedatrestraininghealthcarefacilitycostsbycoordinatingnewservicesandconstruction.TheCONlawisonemechanismthatFloridaandotherstatesadministertoreduceoverallhealthandmedicalcosts. WhyitdoesNotwork:ThehospitalCONprocesshelpspreventprofit-drivenhealthcareexpansionbycurtailingtheproliferationofsmallspecialtyhospitalsthatcherry-pickwealthyneighborhoodsandonlyofferprofitableprocedurestoinsuredpatients.EliminatingCONjeopardizesourSafetyNetprovidersbystripingpayingpatientsfromhospitalsthatprovidespecializedproceduresandservelargenumbersofuninsuredandunder-insuredpatients.AllofFlorida’scommunities–urban,rural,suburban--wouldsufferassafetynethospitalswouldbeforcedtoshutdownunprofitable-butlifesaving-programsandservices,suchasLevel1trauma,regionalperinatalintensivecare,burncentersandcommunityclinics.Hospitalsarenotdrugstoresthatstocksimilarinventoryandcompeteoneverycorner.Addingnewhospitalsdoesnotincreaseaccess;itactuallyreducesaccesstolifesaving,mission-drivenhospitalcare.RepealingCONwouldultimatelyincreasehealthcarecostsasthe“buildit–theywillcome”encouragesincreasedutilizationoftestingandservices.

OPPOSERepealofRehabilitationCenterCertificateofNeed(CON)(HB/SB)Whatitdoes:RepealsrehabilitationcenterCertificateofNeed(CON).CONprogramsareaimedatrestrainingrehabcentercostsbycoordinatingnewservicesandconstruction.TheCONlawisonemechanismthatFloridaandotherstatesadministertoreduceoverallhealthandmedicalcosts.

WhyitdoesNotwork:TheCONprocessforrehabilitationcentershelpspreventprofit-drivenhealthcareexpansionbycurtailingtheproliferationofsmallspecialtyrehabcentersthatcherry-pickwealthyneighborhoodsandonlyofferprofitableservicestoinsuredpatients.Eliminatingitwouldstrippayingpatientsfromexistingrehabilitationcentersthatprovideexpensive,specializedcareandservelargenumbersofuninsuredandunder-insuredpatients.Rehabilitationcentersarenotdrugstoresthatstocksimilarinventoryandcompeteoneverycorner.Addingnewrehabilitationcentersdoesnotincreaseaccess;itactuallyreducesaccesstospecializedlife-extendingmission-drivenrehabilitationcare.

OPPOSE24HourAmbulatorySurgeryCenters&72HourRecoveryCareCenters(HB85byFitzenhagen/SB212byGaetz,D.)

Whatitdoes:Authorizesovernightstaysinambulatorysurgicalcenters(ASC)andcreatesanewfacilitylicensurecategorytobeknownasrecoverycarecenters(RCC).

WhyitdoesNotwork:Dangerousandfalselyimpliesthatthesefacilitiesoffersafetystandardsandoversightregulationonparwithhospitals.ThesefacilitiesshouldbeofsignificantconcernforFlorida’sseniorsasdemonstratedbyMedicare’srestrictionsofover1,800surgicalprocedurecodesthatarenotreimbursablewhenperformedinASCs.And,MedicaredoesnotcoverservicesprovidedinRCCs.Theseboutiquecenterswillcatertoonlytheinsuredandwealthyself-payindividuals,stripingpayingpatientsfromhospitalsthatprovidespecializedproceduresandservelargenumbersofuninsuredandunder-insuredpatients.

ASC&RCCFiscalImpactSampleAnalysisTool

DatapreparationforuseinassessmentofthemigrationoffacilitybasedsurgicalcasestoAmbulatorySurgeryCenters(ASC)authorizedupto24hoursofrecoverycareand/orRecoveryCareCenters(RCCs)authorizedforupto72hoursofrecoverycareservices.Optimallythehealthsystemdataharvestwouldcontainthefollowingpatientleveldetail.

1.) Casemixsystemwithcostaccountingcapability.2.) Facilitysurgerymanagementsoftwarewithaccountleveldetail.

Ideallythesedatasetsshouldbematchedattheaccountlevelprovidingcomplimentarydataforvalidationandeaseoffiltering.Suggestedprocessofeliminatingcases.

1.) Eliminatecasesbyadmittypeandlengthofstay.a. FilterinpatientswithanLOS>3days.b. Removecasesthataretrueoutpatientsmeaningthattheydon’trequirecarebeyond

thenormalpostanesthesiarecoveryperiod.c. Excludepatientswhoenteredyourinstitutionfromyouremergencydepartment.

2.) Selectonlycasesperformedbyprivatephysiciansbypractitionernameorgroup.3.) Filterdownfurtherusingsomemeasureofacuityastoremoveinpatientsthatwouldpotentially

havetoomanyriskfactorstobeperformedoutsideofanacutecarefacility.a. AmericanSocietyofAnesthesiologist(ASA)physicalstatusclassification.

i. Classificationsrangefrom1-6fromhealthiestleasthealthy.ii. Consultwithyouranesthesiadepartmentbutprobablyonlylevels1and2

wouldbeconsideredgoodcandidates.b. AnotherexamplewouldbetheAllPatientRefinedDiagnosisRelatedGroups(APR

DRG’s)by3M.i. Usescomplexalgorithmstostratifyclinicalstatusandriskintofourcategories.ii. 1-Minor2-Moderate3-Major4-Extremeiii. Severityofillness(SOI)or”howsickisthepatient”.iv. RiskofMortality(ROM)or“whatisthelikelihoodofdyingduringahospital

stay”.4.) Eliminateinpatientcasesthathadmorethanonesurgeryduringtheirstay.5.) Eliminatecasetypesbasedondraftedlegislationthatmightbeexcluded(ie,MedicareforRCC).6.) Includepayertypefromyourcasemixsystemsoyoucanfilterbypayermix.

FinancialAnalysis.Inordertoconsistentlyassesspotentialriskforlostprofitabilityuseindustrystandards.Obtainthefollowingatacasedetailleveltoevaluatebyserviceandcasetypefromyourcasemix/costaccountingsystem.

1.) DetermineexpectedpaymentbycontractualagreementorcalculatednetrevenueCNET.2.) EstimateexpensesusingtotalvariablecostsTVC.3.) Calculatecontributionmargin:ContributionMargin=CNET-TVC

December2015

Problem:AtAllChildren’sHospital,ahighlyspecializedtertiarycarepediatricmedicalcenter,wehaveasignificantneedforpsychologicalandmentalhealthcareforthemostmedicallyfragileandcomplicatedchildreninthestate.Thesechildrenrequirenotonlytop-notchmedicalcare,butalsothehighestlevelofspecialtypsychological/mentalhealthcare.Atthistime,psychologistscannotbillMedicaidinthestateofFloridaoutsideofcommunitymentalhealthcenters(CMHC),severelylimitingaccesstonecessarymentalhealthcareandpreventingthesechildrenfromreceivingthecaretheydesperatelyneed.AtAllChildren’s/JohnsHopkins,werequireagreaternumberofpsychologiststoappropriatelymeettheneedsofthesechildren.ResearchhasdemonstratedthathavingapsychologistinvolvedinoutpatientcareformedicallycomplexchildrenwithMedicaidcoveragelowershealthcarecostsbymorethan$1500/year(seeattached).Inaddition,mentalhealthcareresultsinimprovedqualityoflife,andimprovementsineducationalandvocationalattainment.Floridadoesnotallowbillingbydoctoral-levelpsychologistsenrolledinMedicaid,outsideofCMHCs,laggingbehindthemajorityofotherstates.

- Thislimitsaccesstocare.- ThispreventsqualifiedindividualsfrombillingMedicaidinthisstate.- Withoutaccesstohighqualitypsychological/mentalhealthcare,thispreventsourhighly

medicallycomplicatedpatientsfromattainingthehighestlevelofmedicalcare,mentalhealth,andeducational/vocationalsuccess.

ProposedSolution:Allowdoctoral-levelpsychologiststheabilitytobillMedicaidiflocatedatahighlyspecializedtertiarycareacademicmedicalcenter,suchasAllChildren’s/JohnsHopkins.Doctoral-levelpsychologistsinvolvedinthetreatmentofmedicallycomplexchildrenresultsin:

- Decreasedhealthcarecosts(Casey,Lyle,Bird,etal.,2011;McGradyandHommel,2015;Prins,Verhaak,Smit,andVerheij,2014;YarbroandMehlenbeck,2015)

- Reducedhospitalreadmission(Berry,Hall,Kuoetal.,2011)- Increasedadherencetotreatmentplans(MashandFoster,2011)- Increasedadherencetomedicationregimen(MashandFoster,2011- Improvementinqualityoflifeoutcomes(Ryan,McGrady,Guilfoyleetal.,2015)- Reducedpainmanifestationofsymptoms(Evans,Benonre,andBanez,2015;Logan,Carpino,

Chiang,etal.,2014)- Improvededucationaloutcomes(JohnsonandMurray,2003)- Improvedvocationaloutcomes(JohnsonandMurray,2003)- Increasedaccesstohighqualitymentalhealthtreatment(McGradyandHommel,2015;

RosenbaumAsarnow,Rozenman,etal.,2015)- Improvedpatientsatisfaction(Bodin,Yeates,Boyeretal,2007;Hilsabeck,Hietpas,andMcCoy,

2014;Temple,Carvalho,&Tremont,2006).Doctoral-LevelPsychologistsarebestequippedtomeettheneedsofthemedicallycomplexchildrenwithco-morbidpsychologicaldiagnoses.Doctoral-levelpsychologistsarerequiredtohavepost-doctoraltrainingintheirareaofspecialty(forexample,painpsychology,consultation-liaisonintheinpatienthospitalsetting,neuropsychology)foratleast1year(andoften2years)followingreceivingtheirdoctoraldegreepriortoindependentpractice.Thistotalsumoftrainingspans6-8years.Incontrast,Masters’leveltherapists(includingsocialworkers),typicallycomplete2yearsoftrainingand2yearsofpost-doctoraltraining,totaling4years.Often,theseindividualsarenottrainednorequippedtoworkwiththemostmedicallyandpsychologicalcomplexchildren(SteinandLambert,1995).

PersonalstoriesChildrenatAllChildren’sHospital/JohnsHopkinshavehighlycomplexmedicalconcerns,withrelatedadjustmentdifficultiesanddepression/anxietyrelatedtotheirmedicaltreatment.Thesechildrenarehighlycomplexandrequireaskilledindividualforcare.Forexample,achildwithahistoryofleukemia,chemotherapy,andstemcelltransplantmayrequiresignificantpsychologicalcarewhileinpatient,especiallywithcomplexitiesincludingorganfailureandstroke.Thesemedicalcomplicationsimpactthischildren’sbrainfunctioning,andinturnthinkingandproblemsolving,aswellasincreasedepressionandanxiety.MostofthesechildrenareenrolledinMedicaid,andoncedischargedfromthehospital,cannolongerbefollowedbythepsychologisttheywereworkingwithinpatient.Makingmattersmorecomplicated,mostofthesechildrendonothaveaccesstoapsychologistintheirhomelocationandcannotscheduleanappointmentwithinareasonableamountoftimefollowingdischarge,orcannotcoordinatecaregiventhehighnumberofongoingoutpatientmedicalappointments.Thus,thesechildrenaredischargedwithoutmentalhealthfollow-up,whichcouldbeeasilyachievedatAllChildren’s,coordinatedwiththeiroutpatientmedicalappointments.Advantages:

- Studiesshowcost-effectivenessanddecreaseinMedicaidbilling/spendingwhenadoctoral-levelpsychologistisinvolvedinchildren’smedicalcare(seeattached)

- PlacesFloridaonparwithotherstates- Increasesabilitytorecruitqualifiedmentalhealthproviderstothestate- Increasesaccesstocare- Providesthehighestlevelofcaretoourchildrenmostinneed