Background Advanced Practice Registered Nurses (APRN) are licensed registered nurses who have earned a graduate degree at the master’s or doctorate level and achieved national advanced practice certification for their specific area of practice. The APRN designation includes Nurse Practitioners, Certified Registered Nurse Anesthetists, Certified Nurse Midwives and Clinical Nurse Specialists. Currently, Florida law requires APRNs to practice within a collaboration protocol with a physician or dentist. Issue Florida statute requires a career-long collaboration protocol with a physician for APRNs. Currently, Florida is one of the most restricted practice states in the nation. APRN scope of practice varies widely by state and specialty, however, there are 28 states that authorize full practice authority for nurse practitioners. There is strong evidence that aligns APRN autonomous practice with significant health care cost savings and increased access to care. The Florida Hospital Association has long supported increasing access to care and lowering health care costs across our state. Developing and retaining a workforce that is prepared to meet the demand for care in our growing and aging state is a top priority, especially in underserved communities where access to basic health care services is limited. Solution Florida should remove regulatory barriers that prohibit autonomous practice for select APRNs who have met increased practice standards.

2020 Florida Hospital Association Issue Paper

Advanced Practice Registered Nurses - Autonomous Practice House Bill 607 | Rep. Pigman No Senate Companion

Remove regulatory barriers that prohibit autonomous practice for select APRNs who have met increased practice standards.

Background Florida’s charitable, non-profit hospitals provide more than $4 billion a year in programs, services and activities to improve the health and well-being of their communities. The community benefit provided by Florida’s hospitals and health systems are unique and tailored to the needs of the specific region of the state they serve. To meet federal community benefit requirements, non-profit hospitals must conduct Community Health Needs Assessments (CHNAs) every three years. These assessments are conducted in partnership with stakeholders and community partners across multiple counties. Hospitals then identify, prioritize and develop initiatives to address the significant health care needs identified. Hospitals focus on both short-term and long-term health improvement, promoting healthy living and quality of life. Issue Florida’s tax-exempt hospitals already meet significant federal community benefit standards and requirements. Hospitals, like social service agencies, are only exempt from federal, state and local taxes if they meet certain criteria to qualify as a charitable organization under section 501(c)(3) of the Internal Revenue Code. These well-established criteria have been in place since 1956 and were strengthened significantly in 2010 as part of the Affordable Care Act. Hospitals routinely report comprehensive, thorough and detailed financial data, including charity care costs, to the state and federal governments. Solution Protect against unnecessary, duplicative community benefit reporting regulations that provide no additional, meaningful information to publicly reported data already required and available by federal law and Internal Revenue Service regulation.

2020 Florida Hospital Association Issue Paper

Community Benefit Transparency

House Bill 919 | Rep. Caruso No Senate Companion

Publicly Available Hospital Financial Data Sources

Federal Form 990: IRS

apps.irs.gov/app/eos projects.propublica.org/

nonprofits

guidestar.org/search

Florida Hospital Uniform Reporting System: Agency for Health Care Administration floridahealthfinder.gov

(Reports and Studies) Community Hospital Finances: Florida Hospital Association

MissiontoCare.org

fha.org/communitybenefit

Background In Florida, nearly four million people rely on the Medicaid program for access to health care services. Pregnant women, elderly and disabled Floridians are all served by the fourth largest Medicaid program in the nation. And, low-income children are the largest group of people served, comprising 60 percent of the program’s enrollees. Therefore, ensuring access to health care services in all communities is critical. Florida’s hospitals are committed to support innovative Medicaid policy and payment models that improve access, increase efficiency in care delivery and advance high-value care, which improves patient outcomes and health.

Issue With its recent proposed Medicaid Fiscal Accountability Rule (MFAR), the federal government is contemplating significant changes to how states finance their Medicaid program, specifically new limitations for providers and local governments financing the state’s share of program costs. The rule would significantly change how providers and local governments could finance base rates and supplemental payments; Disproportionate Share Hospital (DSH) payments; health care-related taxes and provider-related donations. Florida’s Medicaid program relies heavily on the use of intergovernmental transfers (IGTs) to make up the Legislature’s significant reductions to hospital Medicaid payments over the last several years. In fact, hospitals, in partnership with their local governments, provide over $881 million in IGTs to fund the state share of Florida’s Low Income Pool, Medicaid and Graduate Medical Education programs. The MFAR rule, as proposed, would put all IGTs – $881 million total – at risk due to uncertain authority to continue utilizing local contributions to fund Florida’s state share obligation.

Solution

Given the uncertainty at the federal level, it is critical that the Legislature provide stability and protect vital state funding for the Medicaid program, ensuring the continuation of essential health care services for low-income children, pregnant women, the elderly and disabled people. Florida should continue to focus efforts on reducing costs by advancing “value-based principles of patient-centered outcomes and quality care.” Florida’s hospitals strongly support initiatives to: ✓ Improve health outcomes through pay-for-performance and value-based incentive programs that

align with federally recognized models for hospitals serving patients with Medicaid coverage.

✓ Reduce health care costs by identifying and decreasing potentially preventable episodes such as nonemergent use of the emergency department and preventing avoidable readmissions.

✓ Increase access and integration of critical patient care information and data across all health care

settings to improve care coordination.

✓ Identify new funding opportunities at the federal level to innovate and improve Florida’s Medicaid program.

2020 Florida Hospital Association Issue Paper

Florida’s Medicaid Program

Promote innovative

Medicaid policy and

payment models

that improve

access, efficiency

and advance high-

value care.

Background Hospitals are experiencing rapid change in the competitive dynamics that shape the health care delivery system. Pressure to deliver cost-effective, value-based care continues to grow, and the challenge to respond to that pressure is made greater by the communities’ ever-evolving needs. Increasingly, hospitals are expected to take financial responsibility for the total cost of patient care, necessitating both volume and scale to mitigate risk and coordinate services across the continuum of health care services. In some cases, that volume and scale, which are also necessary to provide care at rates that are affordable and competitive, can only be achieved through mergers or acquisitions. Issue Hospital mergers and acquisitions, whether they involve for-profit or non-profit hospital systems, must comply with state and federal antitrust and related laws. For example, hospitals must report to the Federal Trade Commission when they are engaged in mergers or acquisitions that exceed certain monetary thresholds. Imposing extra regulatory burdens on hospitals by requiring additional formal reporting to the Florida Attorney General would be unnecessarily duplicative and will increase hospital costs at a time when reducing costs is critical to hospitals’ mission of providing cost-effective community care. Moreover, the additional reporting requirement is not necessary. In the event of meaningful concern with respect to compliance with state antitrust laws, hospitals engaged in larger mergers or acquisitions may apprise the Attorney General of the pending transaction to avoid post-transaction complications that might otherwise arise. Solution Protect against duplicative hospital merger and acquisition reporting regulations that add no meaningful information to publicly reported data already required by federal law.

2020 Florida Hospital Association Issue Paper

Mergers & Acquisitions House Bill 711 | Rep. Burton Senate Bill 758 | Sen. Albritton Protect against

duplicative hospital merger and acquisition reporting regulations that add no meaningful information to publicly reported data already required by federal law.

Background Developing a culture of safety is a core element of hospital efforts to improve patient safety and clinical performance. As defined by the Joint Commission, a culture of safety is the product of individual and group beliefs, values, attitudes, perceptions, competencies and patterns of behavior that determine an organization’s commitment to quality and patient safety. Hospitals use safety-culture surveys to measure employee perceptions about the organizational culture. Clinicians and staff are asked about aspects of their team, work area or hospital, such as communication about safety hazards, transparency, teamwork and leadership. Participants are assured that their responses are strictly confidential to encourage participation and honest feedback. Hospitals conduct surveys to assess patient safety culture at least every two years. The most common survey tool used is the Hospital Survey on Patient Safety Culture, which was developed by the Agency for Healthcare Research and Quality. In 2016, as a demonstration of our commitment to transparency, FHA launched www.MissiontoCare.org, an online resource that provides consumers with meaningful, useful information about hospital price and quality. Issue Publicly reported information on hospital clinical performance and, specifically patient safety culture, should be based on reliable, evidence-based data sources. Historically, Hospital Surveys on Patient Safety Culture have been used within hospitals by staff who are familiar with the tool’s terminology, methodology and correlating data points. Without a meaningful interpretation, hospital surveys on patient safety culture could confuse the general public. Solution FHA supports meaningful public reporting of patient safety culture surveys to ensure patients and their families have access to useful data and information. In addition, FHA supports requirements that hospitals conduct a safety culture survey every two years, such as the Agency for Healthcare Research and Quality (AHRQ) Survey on patient safety culture.

Patient Safety Culture Surveys House Bill 763 | Rep. Grant Senate Bill 1370 | Sen. Harrell

2020 Florida Hospital Association Issue Paper

Support meaningful public reporting of patient safety culture surveys to ensure patients and their families have access to useful safety data and information.

Background Florida’s law requires that all registered motor vehicle owners carry personal injury protection (PIP) insurance. The minimum amount allowed for PIP coverage was increased to $10,000 in 1979 and remains that amount today. PIP provides injured drivers up to $10,000 in immediate medical coverage in lieu of establishing fault through the court system. The 2012 Legislature passed major PIP reform to address increasing fraud and abuse in the system. Specifically, the legislation capped non-emergency medical services at $2,500 and excluded certain services from covered medical benefits. Issue Florida’s PIP program provides a basic level of coverage for more than 2.7 million uninsured residents should they become involved in a motor vehicle accident. In 2018, Florida’s hospitals treated over 153,000 patients ages 16-64 due to automobile accident-related injuries. Of those patients treated in the emergency department, 27 percent listed PIP as their primary source of health care coverage1. Proposals to repeal PIP, without replacing it with similar mandatory bodily injury and medical coverage requirements, would increase the cost of uncompensated care, which increases costs shifted to private health insurance premiums. Proposals to replace PIP with only mandatory bodily injury (BI) coverage are not a solution. Mandatory BI does not cover the injuries of the at-fault driver. The inclusion of a mandatory medical payment policy (MedPay), which covers medical expenses associated with auto accidents, would prevent the unintended consequence of shifting costs to commercial insurers and government programs such as Medicaid and Medicare. Further, proposals to move from PIP, which is a no-fault system, to a fault-based or tort system would prevent payment for provider services until legal cases are settled. In many cases, this would cause provider payment for emergency services to be delayed for years. Solution Ensure changes to Florida’s PIP program include mandatory bodily injury coverage and a mandatory medical payment policy.

1 Agency for Health Care Administration, Emergency Department Data, 2018

2020 Florida Hospital Association Issue Paper

Personal Injury Protection House Bill 771 | Rep. Grall Senate Bill 378 | Sen. Lee

Ensure changes to Florida’s personal injury protection program include mandatory bodily injury coverage and a mandatory medical payment policy.

Background Florida’s hospitals work every day to ensure the best health care outcomes for the patients they serve. To achieve this goal, hospitals are required to meet rigorous clinical and operational safety standards to comply with state and federal law. Recovery Care Centers (RCCs) would be a new licensure category for facilities developed to provide post-surgical and post-diagnostic recovery nursing care services and post-surgical rehabilitation services for up to 72 hours for patients primarily undergoing procedures at ambulatory surgical centers (ASCs). RCCs would not be subject to the rigorous requirements that hospitals are expected to meet, including clinical performance standards necessary to ensure appropriate patient safety. In addition, RCCs pose a significant safety concern for patients who may unexpectedly require a higher level of care. Issue Nine months ago, the Legislature made landmark changes to Florida’s hospital regulations. The impact of repealing hospital certificate of need is unknown at this time as the Agency for Health Care Administration has yet to promulgate rules to implement this legislation. It is premature to implement further changes to facility licensure requirements before Florida’s health care system can respond to such a significant change. Furthermore, RCCs would become “mini-hospitals” with the ASCs providing surgery and discharging patients to these virtually unregulated facilities. This poses a significant risk for patients as neither entity is required to publicly report the same level of quality and finance data as hospitals. Solution To ensure adequate patient safety, maintain the current system of care for patients who require overnight, post-operative care and monitoring.

Recovery Care Centers House Bill 827 | Rep. Stevenson No Senate Companion

2020 Florida Hospital Association Issue Paper

Maintain the current system of care for patients who require overnight, post-operative care and monitoring.

Background Florida’s hospitals take their role as community anchor institutions very seriously, providing a wide range of acute care and diagnostic services, supporting public health needs and offering a myriad of other services to promote the health and well-being of their community. Three things make the role of a hospital unique: • The Standby Role - 24/7 Access to Care: the provision of

health care services, including specialty care, 24 hours a day, seven days a week, 365 days a year;

• The Safeguard Role: caring for all patients who seek emergency care, regardless of ability to pay; • Disaster Readiness and Response: ensuring staff and facilities are prepared to care for the

residents in their communities in the wake of large-scale accidents, natural disasters, epidemics and terrorist actions.

Issue Stand-alone specialty/boutique hospitals are not required to have emergency departments, provide community benefit or care for the uninsured. Any surgery can become high-risk, which is why it is critical that any specialty/boutique hospitals offering surgical services be co-located with a full service hospital to ensure rapid, quality responses to emergencies that can arise, even in surgeries considered to be low risk for complications. Furthermore, in 2019, the Legislature deregulated Florida’s Certificate of Need (CON) process, which formally required the state to evaluate a community’s need for additional hospital services or beds prior to building a new facility or duplicating an existing service. This review process was created to ensure there was not a proliferation of costly, unnecessary services. The Agency for Health Care Administration has not yet completed the implementation of this significant regulatory change, leaving the full impact unknown. Additional deregulation of the delivery system, prior to understanding CON deregulation’s impact on patient access and quality, would be premature. In addition to patient safety and quality concerns, specialty hospitals unnecessarily increase cost. A recent study by America’s Health Insurance Plans (AHIP) found that “patients receiving care from specialty hospitals faced far higher costs, as measured by allowed amounts, when compared to the same services provided at non-specialty hospitals. In general, this wide variation in costs makes care and coverage more expensive for consumers, especially for services that did not always need to be performed at the higher-cost specialty hospital.”1 Similarly, an analysis by the Medicare Payment Advisory Commission showed that specialty hospitals do not reduce health care costs because they simply charge Medicare and private insurance for more lucrative procedures than they actually perform. Solution Maintain current patient protections prohibiting stand-alone, single service boutique hospitals.

1 “Care Significantly More Expensive at Specialty Hospitals vs. Non-Specialty Hospitals During 2014”, Association of Health Insurance Plans

Specialty/Boutique Hospitals House Bill 6059 | Rep. Fitzenhagen No Senate Companion

2020 Florida Hospital Association Issue Paper

Maintain current patient protections prohibiting stand-alone, single service boutique hospitals.