Moderator: … have left the building. Team 8?

Female Participant 1: They’re all doing that point to each other thing.

[Laughter]

Speaker: There are three members of our team, Pat, David and myself. We’re glad, quite frankly, to go last although we start off at A. We don’t have the answers to solving all of Florida's problems. We have the questions but we don’t pretense to have the answers, which we think is the way it should.

What our challenge was to identify how AHCA of the state can enable a co-op relationship between providers and consumers. We began our challenge by identifying, asking questions for the most part, what is the proper role of state government? Is it to provide? Is it to meet the public’s need? Certainly that's a national debate that’s going on now. Many would argue that the state is doing too much, as it is, and that’s aggravating the problem.

01:16

Others might argue that the state is not doing enough. It’s defaulting on it’s responsibilities. Certainly, as example of law came up in our discussion. The revolt relating to property taxes in Florida, etc. You have to understand that if the state is mandating - its compensating providers. The money has to come from somewhere. You’re looking at it—from you, your pockets. There has to be a give and a take.

We dealt with a number of issues that’s facing the national state, that's affecting also the state level. And we talked about some of those.

02:00

And then we talked about the specific concerns of consumers. We talked about specific concerns of providers. If the team did this. In the area of consumers, what do consumers want? Various issues of growing population. Well, that’s something that affects both the consumers and also the provider population.

There’s too many people wanting to drink from the same fountain. I mean, can we nurture them all? Do we have enough treatment providers? Maybe that accounts for the long number of lines we have. Maybe that affects the wait-time that inconveniences the physicians and plans of patients. There's just too many people there.

Aging populations, well that’s getting worse. We have the baby-boomers we’re dealing with. They’re getting ready to retire. How do we plan for that?

03:01

Particularly as it relates to Florida, as you have the baby-boomers from the Northern climates retire and move to Florida, placing an increased burden on our healthcare system. How are we planning to deal with that? Care demands.

Male Participant 1: What we did, basically, was went down putting the issues and the needs down first, and ran, and we went to the other side. Then we thought of how are we going to connect these. So, we changed the pen to purple, went down medical and try to do a 'connect-the-dots'. The dots weren't always directly across from each other.

So, the attempt here was to say, “AHCA facilitation. This is where we saw it might be able to go from that perspective."

04:00

So, again, these were issues for the consumers, OK? We feel that the number of immigrants increased in sort of the variable population who seems to be increasing in the state of Florida and that the question was, how do they get access? Should they get access? Should they also be allowed to go into the general medical community population for the treatment or should they have a separate set of support systems?

We felt that the consumers want the following. They, and I think this is something that we look at: What would you as a consumer want if you’re developing a medical care problem? You want to know the location providers in the state - who is the closest? Where can you get your care?

We felt also that consumers, at least once they can get on the Internet, would be interested in the outcomes of how our providers are doing, both the hospitals and the doctors.

They would like an idea of their costs. And I just heard, it came in on the tail end of the last conversation that’s going to be a difficult challenge. At the moment, most of the providers and hospitals are not putting their costs out there.

05:23

They would like disease-specific information. They would like the types of insurance that may be available and then we talked a little bit about that yesterday that the Medicare plans vary in what they cover and they don’t cover what the co-pays are, what the non co-pays are. I think they want no-wait service.

Frankly, I think this is a McDonald’s society. And these people do not want to July 17th to visit the doctor. And a matter of fact in many cases the disease is going to be over by that time. And I believe that this is definitely a need that I hear every day in the emergency department and I’m not sure how to solve that other than to set up the network of providers a little bit differently.

They went all the accoutrements. Patients, when they come to the hospital now expect it to by somewhat like the Hyatt. They want their beds to be soft, they want their televisions to be nice. They want their.... for a CEO now, if you're a CEO at the hospital, you live and die by the gallant poll and by press gaming.

06:39

And you leave a question about press gaming. It’s not how well that your doctor treat your hypertension. Did he bring it down in the long range? Questions on press gaming or were people on the briefing station nice to you? Did the doctor care about your problems? Did nurses keep you informed? Were meals warm? How was the bed? Was it good? Was the TV working? Did you get cable and 72 channels?

[Laughter]

07:08

Speaker: That’s what people want. That’s what people want and that’s what they expect. And another thing that I found that’s interesting was it doesn't matter what the care price is, the expectations is pretty much the same.

So, they also would like--and we said we took this up in one of the notes that we had-- information on individual providers. I think that means the doctors, the way I interpreted that they came off one of the other boards yesterday, and I interpreted that patients would be interested in how their doctor is doing. The doctors around here kind of all agreed yesterday that when we look for a doctor, we either ask they're guys from the staff or friends or we ask the OR nurses who does pretty well in the operating room.

That’s how we could—it would nice to be able to look into something a little more objective, maybeperhaps on quality outcomes and pricing. Perhaps that information can be out there. These were the questions that we felt were important for consumers. And did you want to talk on providers?

08:19

Male Participant 2: For providers, we thought that there was an issue about limited resources. Because resources cost and someone has to pay for it. And there’s not always an assurance that the payer of those services are going to be reimbursed for their expenses. So, it becomes limited.

Diminishing funding for services. It's more individuals utilize emergency rooms and other facilities. And before a lower-income individual seeks medical attention, there's not always an insurance that those treating providers are going to be reimbursed for all those expenses. Someone has to pay for it. They also have to be paid on that.

09:00

Availability and access to individual patients' health definition - doctor shopping, mobility of individuals - particular in today's society. Be able to track individuals across county, state boundaries, the growing immigration debate and individuals coming in. Doctors who maintain a paper-based healthcare tracking system versus those who maintain an electronic healthcare tracking system, that the correct information in order to make intelligent healthcare decisions relating to a patient.

And the jeopardy, if you treat that patient wrong based upon the absence of information, the potential liability that treating provider for not having any information or for not asking the intelligent questions. Reimbursement for expenses and compensated care. There’s no guarantee that the facility or providers are going to be reimbursed. Shrinking number of—especially buyers, as well as in some cases primary care providers. Just a concern.

10:19

Rigorous with meeting facility transfer or reporting requirements. This is the requirements of facilities to submit data to the agency. And we’re addressing the concerns also with the physician data and others. How do we collect that information systematically in a format as useful for the state to meet the statutory responsibilities to report to the consumers, to the public?

Standardizations. Can we use the same standards as the feds or do we have our own unique standards? We’re talking about Florida being on the cutting edge. As we all know, the cutting edge is often the bleeding edge. It’s the experimental age in many cases, that we pretend to be counseling in the forefront, coming up with new initiatives, challenging the envelope, to be more creative and report more, to be more demanding. Or do we sit back and see where the national debate is going and adhere to what other states are doing because it’s simpler, it is less complicated so then the providers will do something. Physician.

11:46

Speaker: How does the house-based physician afford all these regulations. We're looking forward to keeping staff up on supply and that I've mentioned that in the state.

Male Participant 2: Culture and language varies. With the mixed populations, probing into our healthcare environment with different expectations. I mean, there is a common expectation that quality of service is going to be able to address the needs of the patient. But you roll into that culture barriers, and that begins to change a little bit particularly when you’re dealing with language barriers.

12:32

You’re dealing with individuals and prefer to stay within the shadows in media occasions and so there’s reluctance to disclose information. Well how does the treating provider deal with that? They're all attempting to struggle with that now. And what becomes the role of the state facilitating that process?

Immigration, part of the national debate. Certainly, that’s going into thoughts of our healthcare community especially depending upon what’s going on in the national debate. Some figures says 20 million in population - undocumented Americans or aliens plus their relatives. If permitted to formally become part of our structure, what is that going to do to our healthcare environment?

13:33

Questions about working with providers. We’re talking about Code 15 reporting, 'the carrot or the stick' approach. What’s the best approach for dealing with providers - what’s the best way to say it - who makes mistakes in treating patients?

Is the state better taking a punishment approach and investigating, identifying these providers and weeding them out? Do we gain more information in improving the quality of care for citizens, if we do that? Or are we better as a state for working with facilities to identify the flaws that led to diminishing quality within that provider community as opposed to coordinating a safety report desk, we’re going to follow up and we’re going to punish them if there is a systematic repeat of error?

14:49

Or we’re going to work with you to identify what the costs of these new stakes are. Look at what training requires and see if we could eliminate the contributing causes of those mistakes.

Those were the issues we’re dealing with. And what becomes a role in the state in doing that and what becomes the role of the provider community in policing its own and correcting those problems.

15:23

We then talked broadly, as I indicated from the start, about the role of the state. Well the state can influence outcomes and in weights we can influence outcomes through the legislative process. AHCA is not the latest. I mean the role of AHCA is a regulator.

But certainly, we draft legislation, working with the public rules. We monitor performance, compliance, etc. We champion of public causes. We’re the lookout for the welfare of not only the consumer, but we also look out for the welfare of the payers as well as providers.

16:11

So what becomes the role of the state? Well, I think the role of AHCA presently would be to do things like we’re doing here: to bring interested bodies together to talk about the issues and how could we work together for it becomes a win-win scenario as we move forward

Reward success. Look at incentivizing providers to pursue those areas where we don’t have enough specialties - or treaty providers, our primary care providers - to go into those areas where we had the greatest need. Questions?

17:07

Male Participant 3: I have a question, that you could look into in the state and give some access. We’re having a problem with getting anybody...

Speaker: I'm sorry?

Male Participant 3:  The hospital’s got a problem with getting calls and plastic. I remember last year I had a lady, an 18-year old girl here in Jackson. She went to Jacksonville who was given hand surgery at Gainesville. A three-week appointment, she showed up in my office two days after the fracture because her father didn't want it .

That’s always lack access and lack of an appropriate access. And just I think that happened. And I do find one of those every other year, OK, but they couldn’t get treatment in Jacksonville. They couldn’t get appropriate treatment in Gainesville and so, because in doing, they were in camp.

Do we have a way to, is it possible that the agency can look at hospitals and access? When you go to the emergency room, it seems to me Jacksonville should have an answer to on-call. If they don’t, they have to refer to Gainsville. Gainsville may get overwhelmed or not even want to see, I got to see somebody from Jacksonville.

Female Participant 1: I can answer that. The agency is looking at creating, I guess for a lack of better term, it's not an 'ER diversion program,' and maybe that ER on-call issues as it relates to the specialty providers that are accessible in community. And they said that Oklahoma went through the CMS to get a waiver on some of the requirements. We’re looking at more of a regional on-call schedule than a tab on general hospital on-call schedule.

So, we are in the process of working with the federal government and trying to redefine how we can get around some of the anti-trust laws. It’s related to collaborating on a community-wide basis to get those specialty physicians within the region on-call versus your on-call staff in Orlando and Tampa.

Female Participant 2: And also the legislation that was just passed, it's going to need help on that. Because while we may have lot of orthopedics on-call, physicians are saying, “I am up against.”

So until we can include strong database of what really physicians... Look, a physician conflicts and if they’re practicing and if they limit their practice because no longer their core privileges anymore. It doesn’t matter what you do, the doctors, the neurosurgeons, they're all being very selectively in want to see with their bill and can do it with their own calls. So we have a very large issue that will come from that database of legislation.

Palm Beach County put together the study in specifically of the shortage, of the history and the probability of physician in each category for Palm Beach County through the medical society and the hospital grouping to talk about this issue. But I have to tell you that it took them $600,000 and two and a half years to get as far as they got to document the problem.

Male Participant 2: And you charge them a lot more?

[Laughter]

Female Participant 1: Well needless to say, I didn’t have anything to do with this. And basically, that’s what they have now, is the documentation and the problem and some recommendations about who the community calls, scheduling and things like that.

Aside from all of the legal concerns, right now it is not in the physician's interest to solve these problems. There are physicians in Palm Beach County who are being paid by four or five hospitals at the same time, $1,000 a day to take calls.

The truth is, that if in any given day, one of them was called by one of the places that has them on call for that $1,000, it means they’re now not unavailable to the other three irrespective of the fact that they took the money from the other three.

So, then they turn around and they take with a piece of that money and they pay some other guy to be on-call on the case, in case they are put on call twice on the same day. The truth is, is that the physician population has no financial interest in solving the problem. Some of my favorite people are doctors in Palm Beach County but the truth be known, they have no financial interest in solving that problem.

Moderator: One more and we’re going to go on.

Male Participant 4: I think that this is an area that’s become increasingly important as you discussed it for some sort of public disclosure. Let me explain why. It’s so ironic that when the entertain the people from the House of Commons when they talk about policy, it happened to UK. And when talked here earlier about the massive outrage with our healthcare system among the typical person in the street. And we say, "Thank goodness, we don’t have a UK socialized system." That is what you just described is no better than access to sub-specialists I get in the UK. And so, somewhere along the way—

Speaker: It’s a lot worse.

Male Participant 4: Worse, and in some way, along the way here if we don’t flush this things out, there is not much credibility among the sub-specialists physicians to not having go in the same way. I just find it ironic and I understand the social terms but this is a market basis from this network.

So this is the kind of thing I think you’re committee ought to look at. Because again if I’m a voter right now and you tell me this story, I’m saying, "Why not have a single therapist tell me it’s going to be worse. It won’t be."

Moderator: All right. On that note, we'll move right along...

[Applause]