Source: KFF Health News

Florida’s delayed KidCare expansion leaves thousands of children in coverage limbo

Like many parents, Tatiana Lafortune wants her children to get a good education, eat nutritious food, and see a doctor when they’re not feeling well.

Public schools and her church’s pantry help with the first two. But insurance to cover doctor visits has been the most difficult to secure.

As nursing assistants near Tampa, Lafortune and her husband cannot afford employer coverage and earn too much for subsidized coverage through Florida KidCare.

Unable to afford KidCare’s full-price premium, she purchased a marketplace plan with higher out-of-pocket costs and no dental coverage.

“KidCare is better for children,” she said. “But at least I have something for them.”

In 2023, Florida lawmakers unanimously approved expanding KidCare eligibility to cover more than 40,000 additional children, but the expansion has not taken effect despite federal approval.

Instead, implementation has been stalled by lawsuits and ongoing disputes between the state and federal regulators.

“I don’t know what they’re waiting for,” Lafortune said. “They should see people in Florida have needs.”

Entitlement vs. Personal Responsibility

At issue is a federal rule requiring 12 months of continuous coverage for children enrolled in Medicaid and CHIP programs, including Florida KidCare.

Florida has challenged the rule in court and delayed its planned expansion, while continuing to disenroll children for unpaid premiums.

Advocates argue the delay may violate federal law and undermines child health coverage.

“It’s something that goes back to this mentality of people needing to pull themselves up by their bootstraps,” said Melanie Andrade Williams of the Florida Health Justice Project.

Health policy advocates also note Florida’s position conflicts with broader efforts to improve child wellness and reduce uninsured rates.

Florida and Texas have among the nation’s highest numbers of uninsured children.

Choosing Between School Supplies and Health Insurance

According to Florida Healthy Kids Corp., roughly 43,000 children lost subsidized coverage after parents missed premium payments.

Advocates say missed payments often occur when families must choose between essentials like school supplies, holiday expenses, and health insurance.

“You have working parents here who are struggling and they have to choose between their child’s school supplies and their health insurance,” said Joan Alker of Georgetown University.

Meanwhile, lawmakers recently redirected $32 million in KidCare surplus funds to the general fund, drawing criticism as expansion remains stalled.

The proposed expansion would raise income eligibility and provide more affordable, comprehensive coverage than many ACA marketplace plans, including dental and vision benefits.

For families like Lafortune’s, the delay has real consequences as insurance costs continue to rise.

“I tried to get something cheaper, but it’s not like I cannot have it,” she said. “I have to do something.”

As legal challenges continue, advocates say thousands of children remain at risk of losing or lacking affordable coverage.

“Children are the ones who are going to replace everyone here,” Lafortune said. “When you give them opportunities — for their health, for school, to eat — you make your country healthy and better.”

Adapted from reporting by KFF Health News.

Read the full article at KFF Health News

Source: WUSF Public Media, with reporting from News Service of Florida

Both measures were priorities for Gov. Ron DeSantis before his term ends in January, but House Speaker Daniel Perez announced members will vote on redistricting and be dismissed.

The Florida House won’t take up bills to eliminate vaccine exemptions and create artificial intelligence guidelines at this week’s special session, as Gov. Ron DeSantis expected.

On Tuesday, as lawmakers opened the session primarily aimed at redrawing congressional districts, House Speaker Daniel Perez said the ancillary issues are off the table this week because no bill was filed in his chamber.

Perez said House members will be free to return home after Wednesday’s vote on redistricting.

“There are, of course, other issues contained in the call; however, there were no bills filed on these policies prior to the start of this special session,” Perez said. “Consequently, we will not be taking up those issues.”

The vaccine and AI issues were top priorities for the governor, who postponed the special session a week to make a final push before his term ends in January.

Also Read: Florida's redistricting session is delayed as DeSantis adds AI and vaccines

Perez's move means the medical freedom bill “seems dead in this special session,” said Aubrey Jewett, a professor of political science at the University of Central Florida.

“Both the House and the Senate have to pass the same version of the bill and send it to the governor, and the speaker has made a pretty clear declarative statement that they are not taking up medical freedom,” Jewett said.

“And thus, if the House isn't going to take it up, it's just not going to go anywhere. It's not going to become law, not this special session.”

Florida's former surgeon general Scott Rivkees also applauded the move.

“This shows what happens when common sense, the public voice, and strong rooted medical practice prevails over fringe science,” Rivkees told WUSF.

“One thing that I learned from my time in Tallahassee is that politicians listen to the public. With recent polling showing overwhelming support for required school vaccines, it is not surprising that legislation that would topple a clear public health success would not go through.”

“Voters elected Republicans to protect freedom against both the Big Tech cartel and the medical industrial complex,” DeSantis wrote on X after Perez’s announcement. “Yet, when given the chance to deliver for their constituents, not a single Republican House member could even be bothered to file a bill. Typical political shenanigans.”

During the regular legislative session this spring, the vaccine bill was supported by parents' rights advocates and opposed by medical professionals worried it could lead to a larger spread of preventable diseases.

Also Read: Florida's DeSantis unveils a voting map that could add to Trump's GOP redistricting

During the regular session, the Senate passed a version of the measure, but it received no attention in the House. On Friday, bill sponsor Sen. Clay Yarborough, R-Jacksonville, refiled an identical measure.

The bill (SB 6D) would have expanded vaccine exemptions for K-12 schools, creating a new “conscience” category for parents to opt out of immunizations. It also would have required health care workers to provide alternative vaccine schedules for children and make ivermectin available without a prescription.

Florida’s surgeon general would also be stripped of the power to require a vaccine during a public health emergency under the bill.

Also Read: So far, Florida has failed to end vaccine mandates. Now there's a last-ditch effort

The bill, though, would have fallen short of Florida Surgeon General Dr. Joseph Ladapo’s push to repeal all vaccine mandates.

Since then, the Department of Health started the rulemaking process of repealing requirements for Hepatitis B, varicella (chicken pox), Haemophilus influenza type b (Hib) and pneumococcal conjugate vaccines for public school attendance.

The repeal of the measles, mumps and rubella vaccine, polio, diphtheria, rubeola and tetanus vaccines, however, required legislative action. No legislator filed a bill to remove those requirements from Florida law this year.

Source: Adapted from reporting by WUSF Public Media, with information from News Service of Florida.

Read original article at WUSF

Florida Medicaid Health Care Alert

April 28, 2026

Provider Type(s):ALL

Children’s Medical Services (CMS) Plan Transition

Effective October 1, 2026, the operation of the Children’s Medical Services (CMS) Plan will move from Sunshine State Health Plan, Inc. to Molina Healthcare of Florida, Inc.

Certain children with special health care needs are eligible to enroll in Florida’s Children’s Medical Services Plan (CMS Plan) for enhanced services. Currently, Sunshine State Health Plan, Inc. (Sunshine) operates the CMS Plan contract for both Medicaid (Title XIX) and CHIP (Title XXI) recipients. The Agency recently awarded Molina Healthcare of Florida, Inc. (Molina) the CMS Plan contract statewide. The Agency is working closely with Molina and Sunshine to ensure a seamless transition. After October 1, 2026, recipients and providers wanting to participate in the CMS Plan must enroll with Molina. Molina will be the single plan that offers all services in the CMS Plan.

What does this mean?

Starting on October 1, 2026, Molina will be the only SMMC plan to administer the CMS Plan. Current CMS Plan recipients will be automatically transferred to CMS Plan operated by Molina as part of the transition.

Recipients who do not wish to move to CMS Plan operated by Molina will have the option to choose another plan.

• Title XIX recipients may choose to enroll in another SMMC plan:

Florida Medicaid Choice Counseling: 1-877-711-3662. Staff are available to assist with plan changes Monday-Thursday 8 a.m. - 8 p.m. and Friday 8 a.m. – 7 p.m.

• Title XXI recipients may choose to enroll in another Florida Healthy Kids plan:

Florida KidCare: 1-888-540-KIDS (5437)Staff are available to assist with plan changes Monday through Friday, 8 a.m. - 5 p.m.

Continuity of Care

All recipients initially transitioning from Sunshine to Molina will have a continuity of care (CoC) period of up to eight months. This means recipients may continue seeing their current providers until May 31, 2027, or until their care plan is finalized and ongoing services are authorized, whichever is sooner. Molina is required to reimburse non-participating providers at the rate they received for services rendered to recipients prior to the transition for up to eight months, unless there is an agreement to an alternative rate.

All SMMC plans are required to provide CoC periods for transitioning recipients. Details regarding CoC periods for plans other than Molina can be found on the Agency website at SMMC 3.0_Continuity of Care Provisions.

The Agency has instituted the following CoC provisions:

• Health care providers should not cancel appointments with current patients.
• Providers will be paid promptly by the recipient’s new managed care plan.
• Prescriptions will be honored by the recipient’s new managed care plan.
• Existing prior authorizations approved prior to October 1, 2026, will be honored by the recipient’s new managed care plan.

Providers interested in contracting with Molina can find additional information at Molina_CMS Providers. Molina is contracting with CMS Plan providers now and will prioritize contracting inquiries that promote Continuity of Care. Molina is providing essential information, training sessions, and reference materials for support throughout this transition.

Please visit Molina’s website at Molina_CMS Providers for the most current updates and answers to Frequently Asked Questions.

Additional communications from the Agency regarding this change will be shared at CMS Plan Transition | Florida Agency for Health Care Administration.

The 2025 FMA Annual Meeting was a reminder of what is possible when physicians come together with a shared mission. Through dialogue, evidence-based advocacy, and cross-county collaboration, physicians strengthened the bonds of the profession and reaffirmed their commitment to the values that define them: ethics, science, compassion, and professional integrity.

The South Florida Caucus, representing physicians from Broward County Medical Association, Miami-Dade County Medical Association, and Palm Beach County Medical Society, was actively engaged in shaping policy during this year’s meeting. The Caucus submitted three resolutions, or formal proposals of policy to be adopted by the FMA’s House of Delegates, all of which were adopted. 

- Resolution 25-302: “Restoration of Due Process and Legal Protections for Physicians in Hospital Peer Review Proceedings” 

- Resolution 25-401: “Prevent patients from being ‘trapped’ into Medicare Advantage Plans” 

- Resolution 25-402: “Enhancing Oversight and Transparency in Healthcare Transactions” 

Additionally, on Resolution 25-305: “Protecting Patients from Misuse of Artificial Intelligence (AI) in Healthcare”, submitted by Collier County Medical Society and Hillsborough County Medical Association, Miami-Dade County delegate Dr. Steven Falcone worked with the American College of Radiology, the Florida Radiological Society, Collier and Hillsborough Counties and others to develop amended language that was modified by the reference committee and then adopted by the House of Delegates.

As the 2025 FMA Annual Meeting comes to an end, we extend heartfelt appreciation to the FMA 148th President Dr. Lisa Cosgrove Lisa Cosgrove, and congratulate incoming president, Dr. Ashley Norse, President-Elect Dr. Alma Littles, Vice President Dr. Charles Chase, Speaker Dr. Mark Rubenstein, Vice Speaker Dr. Sanjay Pattani, Secretary Dr. Ryan Hall, and Treasurer Dr. Rebekah Bernard, whose leadership will shape the year ahead. 

We are proud to report that, Dr. Patricia Ares-Romero, Immediate Past President of the Miami-Dade County Medical Association (MDCMA), was elected District G representative on the FMA Board of Governors. 

Dr. Vicki Norton, president-elect of the Palm Beach County Medical Society (PBCMS), and Dr. Aaron Elkin, 2011 President of the Broward County Medical Association (BCMA), were elected to the FMA’s delegation to the American Medical Association. 

Thank you to the delegations from BCMA, MDCMA, and PBCMS, for your time and dedication to the important business of organized medicine; in particular, to Dr. Norton, who chaired the South Florida Caucus this year, and to the delegates who participated as reference committee captains for the Caucus, doctors Shawn Baca, Rose Berkun MD, FASA, Adriana Bonansea Frances, Aaron Elkin, and Julie Kantor.

If you are a physician practicing in Florida, your local county medical association is where advocacy begins. It is where you will find peers who understand your day-to-day challenges, where ideas take root, and where the collective voice of our profession becomes stronger. Whether it is Broward, Miami-Dade, Palm Beach, or any other county in the state, your participation matters. Join your county medical association. Engage in the dialogue. Be part of the solution.

Dr. Ashley Booth Norse, a Jacksonville emergency medicine physician, has been installed as the 149th president of the Florida Medical Association (FMA). The announcement came Saturday during the organization’s annual meeting in Orlando, where the group also named its slate of officers for the 2025–26 term.

Norse, who is board-certified in emergency medicine, began her career at the University of Florida College of Medicine-Jacksonville in 2005 and has served in multiple academic and administrative roles, including associate chair of operations and medical director for the emergency department and observation unit. She remains a part-time professor in the department of emergency medicine.

FMA Chief Executive Officer Chris Clark praised Norse’s appointment, citing her involvement in medical leadership across the state.

“Dr. Norse has served in numerous local, state and national leadership positions for more than 15 years and her dedicated service and invaluable expertise will allow our organization to continue its impactful presence as the state’s premier voice of medicine,” Clark said.

A graduate of Louisiana State University School of Medicine in New Orleans, Norse completed her residency and a healthcare policy fellowship at UF-Jacksonville, where she was named chief resident in her final year. She has served on the FMA Board of Governors since 2008 and previously held the positions of president-elect, vice president, speaker and vice speaker.

Norse is also a past president of the Florida College of Emergency Physicians and the Duval County Medical Society, and serves on the FMA PAC Executive Committee while representing the American College of Emergency Physicians as a delegate to the American Medical Association.

Dr. Norse succeeds Lisa A. Cosgrove of Jacksonville, who will serve as immediate past president.

Other officers named for the 2025–26 term include President-Elect Alma Littles of Tallahassee, Vice President Charles Chase of Winter Park, Speaker Mark Rubenstein of Jupiter, Vice Speaker Sanjay Pattani of Windermere, Secretary Ryan Hall of Lake Mary and Treasurer Rebekah Bernard of Fort Myers.

During the recent launch of the 2023 South Florida Physician Leadership Academy (PLA), I had the opportunity to represent the Dade County Medical Association (DCMA) as we rallied participants around the importance of physician leadership in the community, industry, organized medicine and throughout the healthcare system.

There is a huge amount of evidence about the positive impact physicians can have when placed in leadership roles. The American College of Physician Executives (ACPE), the nation’s oldest and largest leadership education and career support organization for all types of physicians, champions the view that physicians are best suited to lead clinical efforts to achieve true patient-centered care. It is well-recognized that, at some level, all physicians are regarded by our society as leaders.

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Many physicians in Florida — even those who do not participate in the Medicare fee-for-service program — stand to be affected by an 8.42% Medicare physician payment cut that will take effect in 2023 unless Congress intervenes. As explained in a recent FMA update , “Since commercial payment rates are generally a function of Medicare rates, any reduction in the value of Medicare payments will also likely spill over to the commercial rates paid to many physician practices.”

You can support our efforts to prevent this egregious payment cut by sending a pre-written, customizable letter to your Congress members. Read our update for details about the potential impact on Florida’s Medicare beneficiaries and physicians.

Click here to submit your letter now.

• An increasing percentage of physicians feel there are advantages in leveraging digital health solutions. The percentage of physicians who feel digital health tools are an advantage for patient care grew from 85% in 2016 to 93% in 2022, and increases were measured across all ages and specialties.

• Adoption of digital tools has grown significantly among all physicians regardless of gender, specialty, or age. The average number of digital health tools in use by a physician grew from 2.2 in 2016 to 3.8 in 2022. Improved clinical outcomes and work efficiency are the top factors influencing physician interest in digital health tools. The ability to help reduce stress and burnout has also gained importance as a key driver of digital tool adoption. Liability coverage remains the most important requirement for physician adoption of digital health tools followed by integration with their EHR and assurances for data privacy.

• The largest growth in adoption was among digital health tools that aid in remote care. The percentage of physicians using tele-visits/virtual visits grew from 14% in 2016 to 80% in 2022 while the percentage of physicians using remote monitoring devices grew from 12% in 2016 to 30% in 2022.

• The digital health tools that garner the most enthusiasm among physicians are tele-visits (57%) followed by remote monitoring devices (53%).

• Intentions are high for the future adoption of emerging technologies, but current usage is low. Two in 5 physicians plan to adopt augmented intelligence in the next year, while nearly 1 in 5 physicians are currently using augmented intelligence in their practices. While current usage of digital therapeutics is low, they have the highest percentage of planned incorporation in the future.

The AMA is dedicated to shaping a future that ensures digital health solutions are an asset and not an additional burden for physicians and patients.  Also, emerging digital tools must be designed with an equity lens so that they address and do not exacerbate health inequities. Through its ongoing work, the AMA is committed to ensuring physicians have a greater role in leading the design and implementation of health care technologies to ensure they are evidence-based, validated and actionable to enhance patient care, shape a better health care system, and improve the health of the nation.

Learn more about the AMA digital health initiatives including the AMA Physician Innovation Network, AMA Telehealth Immersion Program, and In Full Health, as well as resources such as the AMA Return on Health Virtual Care Value Framework, AMA Digital Health Playbook Series, and AMA Privacy by Design Playbook and Principles.

Media Contact:
Robert Mills
AMA Media & Editorial
robert.mills@ama-assn.org

About the American Medical Association
The American Medical Association is the physicians’ powerful ally in patient care. As the only medical association that convenes 190+ state and specialty medical societies and other critical stakeholders, the AMA represents physicians with a unified voice to all key players in health care. The AMA leverages its strength by removing the obstacles that interfere with patient care, leading the charge to prevent chronic disease and confront public health crises, and driving the future of medicine to tackle the biggest challenges in health care. For more information, visit ama-assn.org.

The AMA’s Recovery Plan outlines a five-point strategy to strengthen our physician workforce, recover from the trauma of this pandemic, and improve health care delivery by eliminating some of the most common pain points that threaten to drive physicians from practice. The AMA’s comprehensive approach includes:

• Supporting telehealth to maintain gains in coverage and payment.
• Reforming Medicare payment to promote thriving physician practices and innovation.
• Stopping scope creep that threatens patient safety.
• Fixing prior authorization to reduce the burden on practices and minimize dangerous care delays for patients.
• Reducing physician burnout and addressing the stigma around mental health.

Each of these objectives is within our grasp, and achieving them will streamline health care delivery, improve patient care, and support innovation while simultaneously allowing us to respond more effectively to future public health emergencies. Let’s take a brief look at each component of the overall strategy.

Supporting telehealth expansion

The widespread adoption of telehealth services and technology throughout the pandemic allowed physicians to serve patients’ needs in a comprehensive and cost-effective manner. The AMA is working to build upon that success by permanently eliminating pre-pandemic coverage restrictions, ensuring that physicians have the tools and resources they need to seamlessly integrate telehealth into their practices, and enabling patients to access telehealth services from wherever they are.

Medicare payment reform

Diverting the Medicare physician payment system from its current unsustainable path and steering it instead toward physician practice sustainability will protect patient access to quality, evidence-based care while easing administrative burdens. When inflation in practice costs is considered, Medicare physician payment plunged 20% from 2001 to 2021. Medicare spending on physician services per enrollee retreated by 1% between 2010 and 2020, even as spending per enrollee for other parts of Medicare jumped by 3.6% to 42.1%. The AMA’s Recovery Plan tackles Medicare physician reimbursement by emphasizing simplicity, relevance, alignment and predictability.

Stopping scope of practice creep

Patients rely on physicians to direct the care they receive, and the Recovery Plan presses our AMA’s vigorous opposition to inappropriate scope of practice expansions by nonphysicians. Patients are at the center of everything physicians do, and ensuring their protection and well-being in the modern health care environment continues to drive our emphasis on physician-led teams. Every member of health care teams brings important skills to patient care, and nonphysicians made major contributions during the pandemic. That said, patient safety demands that we lift up physicians for their expertise as leaders of health care teams, and their ability to draw out valuable contributions from each professional on that team.

Fixing prior authorization

Prior authorization programs that insurers often use to deny care and increase their own profits have grown out of control. The AMA Recovery Plan will press the fight against this archaic process that delays necessary medical care and routinely causes patients to abandon treatment entirely, often with disastrous results. We intend to right-size prior authorization through multiple reform initiatives underway at both the state and federal levels while offering physicians the resources and tools needed to slash the burden this process imposes on their practices.

Reducing physician burnout

Physicians struggled with professional burnout long before the pandemic pressed them to the very limits of human endurance. Although each physician may experience burnout differently, the cause is nearly universal: An overly bureaucratic and burdensome work environment that steals time from patient care and finds physicians feeling powerless to change it. The well-known resiliency that physicians routinely display is not without limits – but we know that a sizable percentage do not seek counseling or other help for anxiety, depression or even suicidal ideation for fear of being judged inadequate by colleagues, or having to disclose this action to a state licensing board. The recovery plan includes action at the state and national levels to strip away outdated language on applications for medical licensing, health care sector employment and credentialing that promotes stigmatization of behavioral health care.

The AMA’s Recovery Plan for America’s physicians is ambitious, yet achievable. Prioritizing and meeting the needs physicians will improve patient care and health outcomes. Working closely with all members of the Federation of Medicine, the AMA intends to reach these goals and help fulfill our mission to promote the art and science of medicine, and the betterment of public health.

Tallahassee, Fla. — Last week, First Lady Casey DeSantis brought together the Florida Department of Children and Families Secretary Shevaun Harris, State Surgeon General Dr. Joseph Ladapo and law enforcement to discuss the recent increases in overdoses associated with fentanyl in Gadsden County.

Following that meeting, Florida Department of Children and Families (DCF) and Florida Department of Health (DOH) worked together to deploy public awareness materials regarding the dangers of substance abuse, specifically fentanyl-laced drugs. Responding to overdose requires education and readily available resources at the hands of communities, families, law enforcement, emergency medical services, and health care providers.

Today, educational materials are being deployed statewide to ensure Floridians are aware of the signs of overdose and how to respond. Print and digital materials can be downloaded here. A public health and safety alert was also deployed by DOH on July 8, 2022 to ensure Floridians remain vigilant of the signs of overdose. This alert can be found here.

“When a person is suffering from a substance use disorder, it can be difficult to know where to turn,” said DCF Secretary Shevaun Harris. “Families and individuals can feel lost, but there are many resources available to help in every community across the state. Whether it’s finding a treatment program, recovery support or just someone to talk to, we can help connect individuals to supports that may save a life. By partnering with the First Lady and DOH we are working to ensure that these services are more prominent, available, and accessible than ever before.”

“Substance use disorder significantly impacts the health and lives of individuals suffering from it,” said State Surgeon General Dr. Joseph Ladapo. “Increasing awareness of drug abuse and available resources can help save Floridians from devastating and fatal health consequences. Our collaboration with DCF and alongside our communities is an essential part of the state’s continuing efforts to provide assistance and comprehensive resources to save lives together."

For questions regarding potential overdoses and other drug-related exposures, Florida’s Poison Control Centers are a valuable resource to individuals throughout Florida, including emergency personnel. Poison Control Centers are staffed by health care professionals that are specifically trained to provide assistance in treating drug overdoses or assessing patients exposed to drugs of abuse. Medical toxicologists are available 24/7 for physician consultations. For poisoning questions or emergencies, call 1-800-222-1222. Visit the website at floridapoisoncontrol.org.

HEROS (Helping Emergency Responders Obtain Support) is a DOH program that provides free naloxone to emergency response agencies. Since the inception of the program in 2018, over 455,000 doses have been distributed to emergency response agencies in Florida through HEROS. All first responders in Florida are eligible to request free naloxone through this program. More information can be found here.

If you or your organization are interested in obtaining or managing naloxone for the community, please visit I SAVE FL to find available resources through DCF.

About the Florida Department of Health

The Florida Department of Health, nationally accredited by the Public Health Accreditation Board, works to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts.

The Florida Department of Health in Miami-Dade County (DOH-Miami-Dade) is offering appointments for Jynneos Vaccine for the prevention of Monkeypox. To become fully immunized you must be vaccinated with 2 doses, the second dose 28 days after receiving the first.

Currently, we are only providing the vaccine to certain populations that are at high-risk for infection, these groups include:

• Laboratory personnel and select health care personnel at high risk for monkeypox
• Close contacts of Monkeypox cases
• Immunocompromised MSM (men who have sex with men) with HIV (<200 CD4 white blood cells per ml³)
• Other MSM with a recent history of a sexually transmissible diseases (STD)

DOH-Miami-Dade is providing vaccines to individuals that are at high-risk for infection. If you are currently experiencing symptoms of monkeypox, we encourage you to get tested first to ensure you are not already infected. Symptoms of monkeypox include:

• Fever
• Headache
• Muscle aches and backache
• Swollen lymph nodes
• Chills
• Rash that can look like pimples or blisters that appears on the face, inside the mouth and on other parts of the body like the hands, feet, chest, genital, and anal area. 

Please only schedule your appointment for your first dose if you are in one of the high-risk categories. Also, be aware that you should only make one appointment. Once you receive the first dose our clinic staff will provide you with a follow-up appointment for the second dose. 

To schedule an appointment for Monkeypox or other vaccines such as the COVID-19 vaccine for ages 5 and older, vaccine booster follow the attached link on Google Chrome, Microsoft Edge or mobile devices:  https://book.appointment-plus.com/d6b7yl3g

https://www.hhs.gov/sites/default/files/emergency-medical-care-letter-to-health-care-providers.pdf

CMS also released an updated guidance to hospitals reinforcing that EMTALA requirements apply to all hospitals in all states regardless of the state law to the contrary.   

https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/reinforcement-emtala-obligations-specific-patients-who-are-pregnant-or-are-experiencing-pregnancy-0

Yesterday, CMS held a conference call with stakeholders on these communications.  There were a number of questions about preemption.  CMS officials repeatedly stated that EMTALA would preempt state law and would be a defense for criminal prosecutions.  AMA staff fully anticipate that this issue will end up in the courts. 

The AMA has been and will remain in touch with the Federation about EMTALA and other emerging issues as a result of Dobbs. 

CMS would adopt changes to several evaluation and management (E/M) code families, including hospital, emergency medicine, nursing facility and home visits, as recommended by the CPT Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC). These changes are estimated to require an additional reduction of about 1.5% to the 2023 Medicare conversion factor due to statutory budget neutrality requirements. In addition, under the Medicare Access and CHIP Reauthorization Act (MACRA), the final performance year that physicians are eligible to earn the 5% Advanced Alternative Payment Model (APM) incentive payment and $500 million Merit-based Incentive Payment System (MIPS) exceptional performance bonus is 2022, which will affect payment adjustments made in 2024. Therefore, the proposed rule does not contain any estimates of MIPS participants exceeding the exceptional performance threshold in 2023 or Advanced APM participants earning 5% incentive payments.

The confluence of these cuts, coupled with the 0% payment update that fails to account for significant inflation in practice costs, is creating long-term financial instability in the Medicare physician payment system and threatening patient access to Medicare-participating physicians. The AMA and our partners in organized medicine have developed a set of principles to guide advocacy efforts on Medicare physician payment reform. This is part of the AMA’s Recovery Plan for America’s Physicians and represents our ongoing work to establish a rational Medicare physician payment system that provides financial stability through positive annual payment updates, improves the financial viability of physician practices, and eases administrative burdens.

Finally, services that were going to be covered via telehealth only through the end of the COVID PHE would now be covered for an additional five months after the PHE ends, including the CPT codes for telephone visits.

The text of the proposed rule can be accessed at: https://public-inspection.federalregister.gov/2022-14562.pdf.

Additional links include:

• CMS Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-physician-payment-rule-expand-access-high-quality-care
• Physician Payment Schedule Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule
• QPP Fact Sheet: https://qpp-cm-prod-content.s3.amazonaws.com/uploads/1972/2023%20Quality%20Payment%20Program%20Proposed%20Rule%20Resources.zip
• CMS Blog on Behavioral Health Care: https://www.cms.gov/blog/strengthening-behavioral-health-care-people-medicare

Source: AMA

The move increases the number of residents training in community health centers and other outpatient community clinics.

The federal government is making a push to expand residency programs, with the Department of Health and Human Services announcing more than $155 million in awards for 72 teaching health centers that operate primary care medical and dental residency programs. These programs will include high-need specialties such as psychiatry.

Administered through the Health Resources and Services Administration (HRSA), the awards are being funded by the American Rescue Plan Act of 2021 and Fiscal Year 2022 funds.

HHS Secretary Xavier Becerra framed the move as a key part of the administration's plan to address health inequities in underserved and vulnerable communities, in part by increasing the number of residents training in community health centers and other outpatient community clinics.

"We will continue to expand the primary care workforce supply line to help meet community needs," said Becerra.

HRSA Administrator Carole Johnson said the effort will contribute to a stronger primary care and mental health workforce.

"The American Rescue Plan has been a game-changer for growing this critical program and helping us build a workforce that best reflects and serves the communities that need these resources the most," said Johnson.

WHAT'S THE IMPACT

The awards include $135 million in American Rescue Plan funds to support existing and new teaching health centers to create additional resident positions; and $20 million in Fiscal Year 2022 funds to support existing Teaching Health Center Graduate Medical Education residency programs to continue resident training in the upcoming academic year.

HRSA's Teaching Health Center Graduate Medical Education program focuses on supporting residents in primary care residency training programs to meet the medical and mental health care needs of rural and underserved communities. It currently includes more than 970 full-time residents.

Previous HRSA investments under the American Rescue Plan are supporting the planning and development of additional teaching health center primary care residency programs.

THE LARGER TREND

This isn't the first time the current administration has made a push to expand medical residency slots. In December, the Centers for Medicare and Medicaid Services distributed 1,000 new medical residency slots in hospitals serving rural and underserved communities.

The additional residency program positions are to address hospital labor shortages, particularly for hospitals serving rural and underserved communities.

Doctors are most likely to practice in the areas where they do their residencies, said Director of the Center for Medicare, Dr. Meena Seshamani. 

"Having additional residents train in the very areas that need the most support can, not only bolster the numbers of providers in these underserved areas, but also train them with a unique understanding of the specific needs of these communities," Seshamani said in a statement.

Source: https://www.flmedical.org/

More than three months after the end of the 2022 Legislative Session, all the bills that passed both chambers have finally been presented to and acted upon by Gov. DeSantis. The following is a summary of the healthcare-related bills that were tracked by the FMA, including the action taken by the Governor and the effective date of the legislation.

HB 5 – Reducing Fetal and Infant Mortality (Rep. Grall, Sen. Stargel) Creates fetal and infant mortality review committees in all regions of the state to gather data and develop recommendations on how to reduce fetal and infant mortality rates.

Prohibits abortions if the physician determines the gestational age of the fetus is more than 15 weeks. Only exception is to save the life of the mother or if the fetus has not achieved viability and has a fatal fetal abnormality. Does not include the Texas civil remedy provision.

Approved 4/14/22 – Effective 7/1/22

HB 173 – Care of Students with Epilepsy or Seizure Disorders (Rep. Duran, Sen. Garcia) Requires schools to provide epilepsy or seizure disorder care based on student’s individualized seizure action plan. The ISAP must be developed and signed by medical professional in consultation with the student’s parents. Medical professional is defined as MD, DO, PA or APRN.

Approved 3/25/22 – Effective 7/1/22

SB 282 – Mental Health and Substance Use Disorders (Sen. Rouson, Rep. Fetterhoff) Allows for peer specialists to assist in recovery from substance abuse or mental illness. Requires peer specialists to meet specified qualifications and modified background screening and be reimbursed for services.

Approved 3/10/22 – Effective 7/1/22

SB 292 – Newborn Screenings (Sen. Polsky, Rep. Aloupis) Requires hospitals, prior to the earlier of discharge or 21 days after birth, to test newborns for congenital cytomegalovirus if the newborn fails the screening for the detection of hearing loss.

For home births, the healthcare provider in attendance must make this referral – if none, the newborn’s primary healthcare provider is responsible for coordinating the referral.

Approved 4/6/22 – Effective 1/1/23

SB 312 – Telehealth (Sen. Diaz, Rep. Fabricio) One of the last bills passed. The Senate version contained a provision to include audio-only in the definition of telehealth, but the House refused to concur. As passed, the sole provision in this bill is that physicians will be able to prescribe Schedule III-V controlled substances via telehealth.

Approved 4/6/22 – Effective 7/1/22

HB 357 – Pharmacies and Pharmacy Benefit Managers (Rep. Toledo, Sen. Rodriguez) Transfers the audit provisions of the Florida Pharmacy Act to the Florida Insurance Code giving the Office of Insurance Regulation (OIR) the authority to enforce provisions and respond to violations. The bill also authorizes pharmacies to appeal audit findings made by health plans and PBMs using the existing dispute resolution program available through the Agency for Health Care Administration (AHCA). It also establishes a financial penalty for PBMs that fail to register with OIR. Lastly, the bill establishes a $10,000 fine for any PBM failing to register with OIR and makes health insurers or HMOs responsible for violations of the pharmacy audit provisions, even if a PBM is contracted to manage benefits for the insurer or HMO.

Approved 6/20/22 – Effective 7/1/22

HB 459 – Step-Therapy Protocols (Rep. Wilhite, Sen. Harrell) Not the same FMA-supported bill as in years past, but one that takes a few small steps toward solving the problems with step therapy. This legislation requires health insurers that have a step-therapy protocol to actually tell the patient and the physician what the protocol requires. If a protocol exemption request is denied, the insurer must provide a written explanation that includes the reason for the denial, the supporting clinical rationale, and the procedure for appeal.

Approved 4/6/22 – Effective 7/1/22

HB 469 – Patient Care in Health Care Facilities (Rep. Trabulsy, Sen. Bradley) Allows for certain unlicensed persons (home health aides and certified nursing assistants) to assist patients with specified tasks (for example, the self-administration of medications) in an assisted living facility. Allows a registered nurse to delegate to a home health aide or CNA, in a home health setting or a county detention facility, the direct administration of a prefilled insulin syringe.

Requires an ALS ambulance transporting a patient between two facilities to be occupied by two people, including one patient attendant who may be a paramedic, RN or a physician, but removes the requirement for the driver to be an EMT, paramedic, RN or physician.

Approved 4/6/22 – Effective 7/1/22

SB 534 – Prescription Drugs Used in the Treatment of Schizophrenia for Medicaid Recipients (Sen. Harrell, Rep. McFarland) A stronger, but very limited step-therapy bill. Provides that for a Medicaid patient, a drug product prescribed for the treatment of schizophrenia or delusional disorders may be approved without meeting the step-therapy prior authorization criteria if prior authorization has been granted previously for the prescribed drug and the medication was dispensed during the previous 12 months.

Approved 4/6/22 – Effective 7/1/22

HB 543 – Uterine Fibroid Research and Education (Rep. Omphroy, Sen. Gibson) Requires DOH to develop and maintain an electronic database of information related to uterine fibroids and requires healthcare providers who diagnose or treat a woman with uterine fibroids to submit information related to such diagnosis and treatment to DOH on a Department-approved form.

Approved 4/6/22 – Effective 7/1/22

SB 544 – Drug-Related Overdose Prevention (Sen. Boyd, Rep. Caruso) Allows pharmacists to order an emergency opioid antagonist with an autoinjection delivery system or intranasal application for patient or caregiver use.

Requires hospital emergency departments and urgent care centers that treat and release persons in response to a suspected or actual overdose of a controlled substance to report such incidents to DOH if the patient was not transported to the facility via ambulance.

Approved 4/6/22 – Effective 7/1/22

SB 768 – Department of Health Bill (Sen. Rodriguez, Rep. Drake) The Department of Health bill often becomes a train of multiple unrelated issues that dies of its own weight. This year’s version avoided becoming overly bloated and actually passed both chambers. The bill contains provisions on a number of subjects:

• Encourages high-risk pregnant women to be tested for STDs
• Contains provisions related to medical marijuana treatment centers
• Makes changes to the Rare Disease Advisory Council
• Requires physician applying for licensure to provide proof of payment of NICA fees
• Increases those who are eligible for a retroactive increase in compensation under the NICA program and makes a few other small changes to the program
• Makes minor changes to the Chiropractor, Psychologist and Midwife practice acts

SB 806 – Alzheimer’s Education (Sen. Perry, Rep. Salzman) Requires DOH, through existing programs, to provide physicians and APRNs with additional education on Alzheimer’s disease and related forms of dementia.

Approved 6/23/22 – Effective 7/1/22

HB 817 – Emergency Medical Care and Treatment to Minors without Parental Consent (Rep. Massullo, Sen. Bradley) The FMA fix to the parental consent bill that passed last session. Allows for the provision of emergency care to minors without parental consent in any situation, not just care provided in a hospital or college clinic. The FMA would have liked more to be done, but given the situation, fixing the emergency care exception through a change to a different statute was the best available option.

Approved 4/6/22 – Effective 7/1/22

HB 855 – Managed Care Plan Performance (Rep. Bartleman, Sen. Jones) Requires managed care plans participating in the Medicaid Managed Medical Assistance program to collect and report an expanded set of performance measures. Beginning in 2025, each MMA plan must collect and report all of the Adult Core Set behavioral health measures (not currently required by AHCA). Beginning in 2026, each MMA plan must stratify all performance data by recipient age, race, ethnicity, primary language, sex and disability status.

Approved 4/6/22 – Effective 7/1/22

SB 988 – “No Patient Left Alone Act” (Sen. Garcia, Rep. Shoaf) Requires hospitals, nursing homes and certain other facilities to establish visitation policies and procedures, which may not require proof of vaccination and must allow consensual physical contact between patients and visitors. Visitation policies and procedures must allow in-person visitation in enumerated circumstances. Allows for the designation of an “essential caregiver.” Must allow for in-person visitation by essential caregiver for at least two hours daily in addition to any other visitation authorized. Policies and procedures may require a visitor to agree in writing to follow provider’s policies and procedures and may suspend in-person visitation of a specific visitor who violates the established policies and procedures.

Approved 4/6/22 – Effective upon becoming law (thus 4/6/22)

HB 1099 – Living Organ Donors (Rep. Barnaby, Sen. Cruz) Life insurance companies may not limit coverage for an individual solely due to the person’s status as a living organ donor.

Approved 4/6/22 – Effective 7/1/22

HB 1209 – Administration of Vaccines (Rep. Tuck, Sen. Burgess) Allows registered pharmacy technicians to administer certain vaccines if they meet certain educational requirements. Removes the current one to one ratio of supervision in favor of a one to five ratio of pharmacists to interns or registered pharmacy technicians.

Approved 4/6/22 – Effective 7/1/22

SB 1222 – Acute Hospital Care at Home (Sen. Bean, Rep. Altman) Allows for the provision of acute and post-acute healthcare services in a qualified patient’s permanent residence through a program approved by CMS and AHCA. Allows paramedics to provide basic and advanced life support services to patients in their homes as specified in the paramedic’s supervisory relationship with a physician.

Approved 4/6/22 - Effective 7/1/22

HB 1239 – Nursing Homes (Rep. Melo, Sen. Albritton) The bill reduces required CNA direct care from 2.5 hours to 2 hours per resident per day and retains current law requiring 1 hour of licensed nurse direct care per resident per day. For the remaining 0.6 hours of the required 3.6 weekly average of total hours of direct care, the bill allows nursing homes to count care provided by any combination of the following categories of disciplines and professions: nursing; dietary; therapeutic; mental health; and paid feeding assistants. The bill requires nursing homes to maintain records documenting compliance with minimum staffing requirements for at least five years and makes evidence of such compliance inadmissible as evidence of compliance with federal standards.

Approved 4/6/22 – Effective upon becoming law

SB 1260 – Independent Hospital Districts (Sen. Gruters, Rep. Botana) Establishes a process and requirements for the conversion of an independent hospital district to a nonprofit entity.

Vetoed by Governor on 6/24/22

SB 1262 – Mental Health and Substance Abuse (Sen. Burgess, Rep. Massullo) Revises the rules regarding the ability of a patient receiving services in a mental health facility to communicate with persons outside of the facility. Allows for the release of a patient receiving involuntary services at a mental health facility through telehealth and makes other revisions concerning the timing of release after the 72-hour examination period.

Approved 4/6/22 – Effective 7/1/22

SB 1374 – Clinical Laboratory Testing (Sen. Rodriguez, Rep. McClure) Exempts registered nurses from clinical laboratory personnel licensure requirements under certain circumstances.

Approved 4/6/22 – Effective 7/1/22

SB 1844 – Mental Health and Substance Abuse (Sen. Bean, Rep. Chaney) Revises the voluntariness provision under the Baker Act to allow a minor's voluntary admission after a clinical review of the minor’s assent, rather than a hearing on the minor’s consent, has been conducted. It also requires a clinical review be held to verify the voluntariness of a minor’s assent before a minor patient’s status is transferred from involuntary to voluntary. Lastly, the bill grants law enforcement officers the discretion on how they transport individuals for an involuntary examination to eliminate the requirement that the individual be handcuffed.

Approved 4/6/22 – Effective 7/1/22

SB 1950 – Statewide Medicaid Managed Care Program (Sen. Brodeur, Rep. Garrison) Revises the procurement process for the managed medical assistance program, including changing the number of regions in the state and the number of allowable plans in each region. Adds certain Florida cancer hospitals to the list of statewide essential providers.

There were a couple of contested provisions the House wanted that it ultimately backed off from.

Approved 4/6/22 – Effective 7/1/22

SB 7014 – COVID-19 Related Claims Against Health Care Providers (Sen. Burgess, Rep. Burton) Extends the COVID-19 liability protections for healthcare providers passed in 2021 for another year. The protections were set to expire in March 2022.

Approved 2/24/22 – Effective upon becoming law

Andrew Bade, who was diagnosed with Type 1 diabetes nearly two decades ago, is accustomed to all the medical gear he needs to keep his blood sugar under control. His insulin pump contains a disposable insulin cartridge, and a plastic tubing system with an adhesive patch keeps in place the cannula that delivers insulin under his skin. He wears a continuous glucose monitor on his arm.

Bade, 24, has used the same equipment for years, but every three months when he needs new supplies, his health insurance plan requires him to go through an approval process called prior authorization.

Getting that approval can take as many as three weeks, and Bade sometimes runs out of insulin before it comes through. When that happens, the resident of Fenton, Michigan, makes do with leftover preloaded insulin pens. They’re less precise than the pump, and he feels tired when he uses them. But they get him through.

“I don’t understand why they’re taking all this time to make these decisions and then they always say ‘yes’ anyway,” Bade said.

Michigan legislators in April sought to help patients like Bade by approving a law that sets standards meant to hasten that process. Beginning in June 2023, health plans will have to act on non-urgent prior authorization requests in nine calendar days and on urgent requests in 72 hours. In 2024, the time frame for non-urgent requests will shrink to seven days.

“We are ecstatic that it passed,” said Dr. Nita Kulkarni, an obstetrician-gynecologist in Flint and a member of the board of directors for the Michigan State Medical Society, which has pushed for the law for years. “It’s a step in the right direction in decreasing the wait time for therapy.”

Michigan’s law is the most recent example of efforts by states, insurers, and doctors to un-gum a process that is notoriously sticky. Yet most of the initiatives have had limited success.

At least a dozen states have passed broad reforms, according to tracking by the American Medical Association. Others have passed narrower laws that target the process or certain types of medical care or drugs. However, state laws don’t protect most patients because they are in so-called self-funded plans, in which the employer pays claims directly rather than buying insurance for that purpose. Self-funded plans are generally regulated by the federal government, not states. There’s no broad protection at the federal level for people with commercial coverage.

A 2018 consensus statement issued by key health plan and medical provider groups to improve the process has been slow to make inroads.

Prior authorization requirements are intended to reduce wasteful and inappropriate health care spending. Few would disagree with that goal. Studies have found that about a quarter of health care spending is wasteful, whether because of overtreatment, overpricing, fraud and abuse, or problems with health care coordination and delivery.

Health plans say that prior authorization requirements help them protect patients’ safety and improve the quality of care, in addition to rooting out waste and error. Doctors disagree. They say that the process too often leads to delays in patient care and that those delays can sometimes cause consumers to abandon treatment.

The complaints aren’t confined to regular commercial coverage. A report released in April by the U.S. Department of Health and Human Services’ inspector general examined a random sample of 250 prior authorization denials at 15 large Medicare Advantage plans in June 2019. It found that 13% of prior authorization denials by Medicare Advantage plans were for services that met Medicare coverage rules.

Health plans’ use of such requirements continues to rise, according to medical groups. In a March poll, 79% of medical practices said that prior authorization requirements had increased in the previous year, according to the Medical Group Management Association.

Even though insurers and providers may fundamentally disagree on the usefulness of prior authorization, many agree that the process needs to be improved. The consensus statement listed several areas that the groups agreed need fixing. For example, they said doctors and other health care providers who follow evidence-based treatment guidelines and have historically had high prior authorization approval rates may sidestep the process.

The groups also agreed that regular review of these requirements is a good idea, with an eye toward eliminating therapies from the list that no longer warrant it. Improved transparency and automation also made the list.

But doctors say that insurers have made little progress in the four years since the document was released.

“It’s been abysmal,” said Dr. Jack Resneck Jr., a dermatologist who is president-elect of the American Medical Association. “We see the problem getting worse, and we don’t see health plans taking any action to honor the commitments they made.”

Insurers say they’re working through the items on the list.

“We believe that a number of the concerns can be solved by innovations in technology,” said Kris Haltmeyer, vice president of policy analysis at the Blue Cross Blue Shield Association, one of the six organizations that partnered on the statement. He pointed to an electronic prior authorization pilot project undertaken by the insurers’ trade group, AHIP, that resulted in a 69% reduction in the decision time on requests, to just under six hours.

That sort of speedy turnaround would have made a big difference to Jodi Burk, 63, who has rheumatoid arthritis. Burk, who lives in Bellaire, Michigan, takes pricey biologic medications to control her pain and other symptoms. A few years ago, her medication stopped working, and the pain became so bad that she could no longer even take her dog for walks.

Her doctor prescribed a different biologic that she thought would treat her symptoms. But the insurer wouldn’t approve the prescribed drug until she had tried — and failed — four other medications, a prior authorization process called step therapy.

It was five months before Burk was approved and began taking a drug that effectively treated her symptoms. “With these time frames, you’re not getting any better,” Burk said. “You hurt more, and your life is put on hold. There were lots of things that I used to be able to do and couldn’t during those times.”

In addition to establishing time frames for acting on prior authorization requests, the new Michigan law sets standards for notifying doctors and other health care providers about changes or additions to existing requirements. And it requires insurers to implement standardized electronic transaction processes for prior authorization requests.

That standard web-based process was a key element of the law for insurers, said Dominick Pallone, executive director of the Michigan Association of Health Plans.

“Many times [providers] submit incomplete or incorrect information,” Pallone said. “We’re trying to make it easier for the provider to go through and complete it quickly.”

“At the end of the day, we do feel we reached a good compromise,” he said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Source: https://health.wusf.usf.edu/health-news-florida/2022-05-17/patients-doctors-insurers-agree-prior-approvals-for-treatment-should-come-faster

To see where and how the use of digital health tools is growing, take a look at the Current Procedural Terminology  (CPT^®) code set, which opened the door to payment for remote patient physiologic monitoring and is now doing the same for remote therapeutic monitoring and remote therapeutic treatment management.

“We anticipate that this new device family will expand as new proposals are introduced that represent an increasing variety of remote, non-physiologic monitoring and therapeutic functionality,” said David Kanter, MD, a member of the  CPT Editorial Panel and the AMA-convened Digital Medicine Payment Advisory Group . 

Dr. Kanter, a neonatologist, spoke during the CPT and RBRVS 2022 Annual Symposium .

Similar codes, different data

Related codes include:

• 98975 to report the initial setup, patient education and use of the equipment.
• 98976 and 98977 are intended to report a 30-day device supply with scheduled recordings or program alert transmission to monitor the respiratory system (98976) or musculoskeletal system (98977).
  

“Because these device codes 98976 and 98977 are reported to describe the cost of the device supplied to the patient, this family of codes was designed to accommodate additional technology and devices that may have variable costs depending on the therapeutic approach taken by the physician or other qualified health care professional,” he added.

• 98980 reports the first 20 minutes of management services.
• 98981 reports each additional 20-minute period of management services.
  

These management codes require at least one interactive communication with the patient or caregiver during the per-month reporting period. But time spent on that communication may represent a portion of the minimum 20 minutes required to at least report the initial base code 98980, Dr Kanter said.

While the overwhelming majority of cognitive behavioral therapy (CBT) occurs with direct face-to-face interaction between patient and therapist, digital technology is developing the capability to provide CBT to patients remotely through digital therapeutic programs, Dr. Kanter said. Two new category three codes, 0702T and 0703T, have been established to report remote therapeutic monitoring of a standardized online digital CBT program.

CPT codes for amblyopia treatment

Source: https://www.ama-assn.org/practice-management/cpt/remote-patient-monitoring-expands-so-does-cpt-describe-it

https://www.ama-assn.org/practice-management/private-practices/8-threats-facing-physician-private-practices

Physicians in private practice enjoy more flexibility in the way they practice medicine and have opportunities for deeper relationships with patients and their communities.

Yet a comprehensive study—“Supporting and Promoting High-Performing Physician-Owned Private Practices: Voices from the Front Lines” (PDF)—also identifies at least eight threats to that style of medical practice. 

“One of the things we were trying to learn was—what was really going in the decline of private practice?” said Carol Vargo, the AMA’s director of physician practice sustainability and one of the authors of the study, which was co-published with the Oakland, California-based consulting firm Mathematica. 

“For many patients, private practice is a lifeline,” Vargo said. “And the erosion of private practices undermines quality of health care for many.” 

The number of physicians working in a private practice is falling, partially because of these challenges, with 49.1% of doctors either owning or working in a physician-owned practice.  

It takes astute clinical judgement, effective collaboration with colleagues, and innovative problem-solving to succeed in an independent setting that is often fluid, and the AMA offers the resources and support physicians need to both start and sustain success in private practice.  

For the study, AMA and Mathematica researchers drew from a pool of 3,526 practices with fewer than 15 practitioners that were not owned by health systems and recruited 25 respondent practices, interviewing 25 physicians from these practices.  

The panel of physicians interviewed identified these eight threats to success in private practice. 

The difficulties of balancing clinical responsibilities with administrative work, such as coding and prior authorization, the physician respondents said. One doctor reported that the administrative burdens became so overwhelming that the physician partners decided to sell the practice to a hospital system.  

With the AMA STEPS Forward™ Saving Time Playbook (PDF), you can access best practices to optimize your practice’s most valuable resource—time. 

Respondents noted declining pay rates from Medicare, Medicaid and commercial insurers over time, as well as drastic differences in how independent physicians are paid compared with physicians employed by health systems. In many cases, they said, doctors delivering the same service were paid a higher rate because of their health system affiliation.  

Learn from AMA Senior Vice President of Advocacy Todd Askew why this is the year to reform Medicare pay and boost telehealth pay. 

Physician respondents expressed frustration with navigating insurer contracts. They felt they were at a disadvantage compared with physician practices owned by hospitals or health systems. For example, they said, doctor-owned practices sometimes didn’t have the resources to renegotiate contracts, or felt their points were not being heard by insurers.  

A few attempted to negotiate contracts on their own but made little progress, so they partnered with an outside entity for support, or hired additional personnel dedicated to contracting.  

The AMA Private Practice Toolkit: Payor Contracting 101 (PDF) is loaded with great tips, and is accompanied by this in-depth AMA webinar on payor contracting. 

Recruiting physicians was a universal challenge among the practices interviewed, except for a few physician practices in highly desirable geographic areas with rapid population growth. Physician respondents expressed difficulty recruiting new physicians because of the financial costs associated with recruitment, and a few turned to hiring family members to fill some open positions.  

Some respondents said they tracked potential recruits for years until they joined the practice. Others said they lacked the funds to support recruitment outreach, onboarding for new physicians, or new doctor salaries. Others expressed concern about hiring physicians who did not have strong ties to the community because of the costs associated with onboarding and subsequent losses from turnover. 

This AMA STEPS Forward toolkit outlines what physicians should look for in their first practice. 

Several physician practice leaders commented on how difficult it is to collect and analyze population-level data or manage their high-risk patients via registries or other systems without additional resources. 

Check out this step-by-step AMA guide to using patient care registries. 

The substantial cost of purchasing and updating EHRs to help collect and analyze meaningful data was another challenge named by the physician respondents. They also commented on the lack of support they get from IT vendors after the purchase. 

This collection of AMA STEPS Forward toolkits offers proven approaches on how to maximize the benefits of EHR use, strategies and tactics to successfully implement an EHR, and best practices in software selection. 

The physician respondents also mentioned feeling isolated in independent practice, and expressed the desire to network with other doctors around the country who lead similar high-performing physician-owned private practices. 

Learn about the AMA Private Practice Physicians Section, which seeks to preserve the freedom, independence and integrity of private practice. 

Several physician respondents emphasized the need to mentor physicians who have recently finished their residency or fellowship training to help them build up their individual practice and contribute to the business. That is especially vital, respondents said, in surgery, where physicians just out of residency or fellowship might not be entirely ready to work independently.  

Despite the threats, Vargo noted that physicians in private practice “can be very nimble” with the way they respond to challenges and the AMA has made supporting private practices a priority, with training and online assistance to help practices navigate challenges while delivering high-quality care with a personal touch.  

https://insidehealthpolicy.com/daily-news/becerra-hopes-work-congress-reform-medicare-doc-pay 

Prior authorization has in fact interfered with a patient’s job responsibilities, according to a majority of physicians (51%) who participated in a newly released AMA survey (PDF) of 1,004 physicians who treat active members of the workforce.

“Health insurance companies entice employers with claims that prior authorization requirements keep health care costs in check, but often these promises obscure the full consequences on an employer’s bottom line or employees’ well-being,” said AMA President Gerald E. Harmon, MD.

While health insurers tout prior authorization as a cost-saving measure, the AMA survey of 1,004 physicians conducted in December found that it can lead to absenteeism and a less productive workforce.

“Benefit plans with excessive authorization controls create serious problems for employers when delayed, denied or abandoned care harms the health of employees and results in missed workdays, lost productivity and other costs,” said Dr. Harmon, a family physician in South Carolina.

More than nine in 10 physicians (93%) reported care delays while waiting for insurers to authorize necessary care, and 82% said prior authorization can lead to treatment abandonment because of prior authorization struggles with their insurance company.

Learn what employers can do to grill their health plans on prior authorization.

Why it’s important: Prior authorization is a health plan utilization-management or cost-control process that requires physicians to get approval before a prescribed treatment, test or medical service qualifies for payment.

More than one-third (34%) of physicians reported that prior authorization led to a serious adverse event. This includes hospitalization (24%), and disability or even death (8%) for a patient in their care.

Meanwhile, 30% of physicians reported that prior authorization criteria are rarely or never evidence-based, with 91% saying prior authorization has a somewhat or significant negative impact on patients’ clinical outcomes.

“Now is the time for employers to demand transparency from health plans on the growing impact of prior-authorization programs on the health of their workforce,” said Dr. Harmon.

To help employers—the nation’s largest purchasers of health insurance—choose the right plan to provide coverage for their workforce, the AMA offers the recommendations below.

Ask health insurance plans questions during the next benefit-contracting season. The AMA offers employers a list of questions (PDF) to ask plans about how their prior-authorization requirements may affect employees.

Solicit feedback from employees about their experience with prior authorization. The AMA encourages employers to use a benefit satisfaction survey, anonymous human resources complaint line, or open engagement with HR representatives.

Take action by visiting FixPriorAuth.org. Employers and their workers can submit stories and sign the AMA’s reform petition.

Health plans, the AMA, hospitals and others agreed to make a series of improvements (PDF) to the prior-authorization process several years ago, but despite the harmful repercussions of delayed or disrupted care, most payers are not making meaningful progress on reforms.

Learn more: Prior authorization also has negative economic consequences for physician practices as a small business. On average, practices must complete 41 prior authorizations per physician each week. This workload consumes almost two business days of physician and staff time, with 40% of physicians reporting that they’ve hired staff who work exclusively on prior authorizations.

It’s no wonder, then, that 88% of physicians in the survey reported that the administrative burden associated with prior authorization is high or extremely high.

The AMA works to right-size prior authorization through research, collaborations, advocacy and leadership so physicians can focus on patients rather than paperwork. Patients, physicians and employers can read about reform efforts and share their personal experiences with prior authorization at FixPriorAuth.org.

The Provider Relief Fund Reporting Period 1 portal will be reopened from 9:00 a.m. Eastern Time on December 13, 2021 through 11:59 p.m. Eastern Time on December 20, 2021. During this time, PRF recipients may register, request corrections, and/or submit their report on PRF payments received prior to June 30, 2020. This one week will be the final opportunity for providers to report on Reporting Period 1 payments.  Providers who submitted their reports before November 30, 2021 may request to have their report reopened for revisions by contacting the Provider Support Line (866-569-3522). All reports must be finalized and submitted before December 20, 2021 at 11:59 pm ET to be compliant with the terms and conditions of the PRF program.

To access the PRF reporting portal, please visit https://prfreporting.hrsa.gov/s/

For additional information about PRF reporting, please visit the PRF webpage at https://www.hrsa.gov/provider-relief.

Source: AMA

Highlights of the physician payment provisions include:

• A delay in resuming the 2% Medicare sequester for three months (January 1- March 31, 2022), followed by a reduction to 1% for three months (April 1-June 30, 2022).
• A one-year increase in the Medicare Physician Fee Schedule of 3% (0.75% less than the conversion factor boost provided for 2021).
• A one-year delay in the cuts to the clinical lab fee schedule.
• A one year delay in the Medicare radiation oncology demonstration.

Additionally, the bill will erase the 4% Medicare PAY-GO cut and prevent any additional PAY-GO cuts through 2022.

The AMA released the following statement on tonight’s Senate vote to avert looming Medicare cuts to providers.

AMA: Patients and Physicians Grateful for Congress Fending Off Medicare Cuts 

December 9, 2021 

Statement attributable to:

Gerald E. Harmon, M.D.
President, American Medical Association    

“The wheels of Congress don’t always move quickly, but today they did move toward preserving the viability of physician practices and maintaining access to care. 

“Potential reductions in Medicare payments for physician services hung over the heads of patients and practices like a sword of Damocles. The Senate action today, following a similar House vote this week, would delay the reductions and give Congress time to work on reforms to address the flaws in the Medicare payment system. 

“There is no need to wait for the last minute to start working on the systemic problems. These automatic cuts should remind members of the needed reforms. Congress can get a head start on doing the right thing when it reconvenes early next year.” 

Source: AMA

The American Medical Association and American Hospital Association filed a complaint and motion to stay against the federal government today over the misguided implementation of the federal surprise billing law.  What follows is the press release.

Hospital and physician groups file lawsuit over No Surprises Act final rules that jeopardize patient access to care

December 9, 2021

WASHINGTON —The American Hospital Association (AHA) and American Medical Association (AMA), representing hospitals, health systems, and physicians, sued the federal government today over the misguided implementation of the federal surprise billing law. The associations are joined in the suit by plaintiffs including Renown Health, UMass Memorial Health and two physicians based in North Carolina.

The lawsuit challenges a narrow but critical provision of a rule issued on Sept. 30, 2021, by the U.S. Department of Health and Human Services (HHS) and other agencies. The provision being challenged ignores requirements specified in the No Surprises Act and would result in reduced access to care for patients. The rule and this flawed provision are set to take effect Jan. 1, 2022.

The AHA and AMA strongly support protecting patients from unanticipated medical bills and were instrumental in passing the landmark No Surprises Act to protect patients from billing disputes between providers and commercial health insurers.

The legal challenge became necessary because the federal regulators’ interpretation upends the careful compromise Congress deliberately chose for resolving billing disputes. According to the lawsuit, the new rule places a heavy thumb on the scale of an independent dispute resolution process, unfairly benefiting commercial health insurance companies. The skewed process will ultimately reduce access to care by discouraging meaningful contracting negotiations, reducing provider networks, and encouraging unsustainable compensation for teaching hospitals, physician practices, and other providers that significantly benefit patients and communities.

Congress created an independent dispute resolution process that is required when providers and insurers are unable to reach agreement on payment for out-of-network services from providers who are not under contract with the insurer. However, federal regulators have directed arbiters under independent dispute resolution to presume that the median in-network rate is the appropriate out-of-network rate and limiting when and how other factors come into play. The suit argues that the regulations are a clear deviation from the law as written and all but ensure that hospitals, physicians, and other providers will routinely be undercompensated by commercial insurers and patients will have fewer choices for access to in-network services.

Importantly, today’s challenge does not prevent the law’s core patient protections from moving forward and will not increase out-of-pocket costs to patients. It seeks only to force the Administration to bring the regulations in line with the law before the dispute negotiations begin.

“No patient should fear receiving a surprise medical bill,” said Rick Pollack, AHA president and CEO. “That is why hospitals and health systems supported the No Surprises Act to protect patients and keep them out of the middle of disputes between providers and insurers. Congress carefully crafted the law with a balanced, patient-friendly approach and it should be implemented as intended.”

“Congress established important patient protections against unanticipated medical bills in the No Surprises Act, and physicians were a critical part of the legislative solution,” said AMA President Gerald E. Harmon, M.D. “But if regulators don’t follow the letter of the law, patient access to care could be jeopardized as ongoing health plan manipulation creates an unsustainable situation for physicians. Our legal challenge urges regulators to ensure there is a fair and meaningful process to resolve disputes between health care providers and insurance companies.”

Last month, a bipartisan group of 152 lawmakers urged the Administration to fix the independent dispute resolution provisions, noting the rule’s approach “is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law.”

The AHA, AMA and their co-plaintiffs filed their lawsuit against the departments of HHS, Labor, and Treasury, along with the Office of Personnel Management in the U.S. District Court for the District of Columbia.

For additional information, please see copies of the filed complaint and motion to stay.