HB 935

1	A bill to be entitled
2	An act relating to the physician workforce; repealing s.
3	381.0403, F.S., relating to the Community Hospital
4	Education Act and the Community Hospital Education
5	Council; amending s. 381.4018, F.S.; providing
6	definitions; revising the list of governmental
7	stakeholders that the Department of Health is required to
8	work with regarding the state strategic plan and in
9	assessing the state's physician workforce; creating the
10	Physician Workforce Advisory Council; providing membership
11	of the council; providing for appointments to the council;
12	providing terms of membership; providing for removal of a
13	council member; providing for the chair and vice chair of
14	the council; providing that council members are not
15	entitled to receive compensation or reimbursement for per
16	diem or travel expenses; providing the duties of the
17	council; establishing the physician workforce graduate
18	medical education innovation pilot projects under the
19	department; providing the purposes of the pilot projects;
20	providing for the appropriation of state funds for the
21	pilot projects; requiring the pilot projects to meet
22	certain policy needs of the physician workforce in this
23	state; providing criteria for prioritizing proposals for
24	pilot projects; requiring the department to adopt by rule
25	appropriate performance measures; requiring participating
26	pilot projects to submit an annual report to the
27	department; requiring state funds to be used to supplement
28	funds from other sources; requiring the department to
29	adopt rules; amending ss. 458.3192 and 459.0082, F.S.;
30	requiring the department to determine by geographic area
31	and specialty the number of physicians and osteopathic
32	physicians who plan to relocate outside the state,
33	practice medicine in this state, and reduce or modify the
34	scope of their practice; authorizing the department to
35	report additional information in its findings to the
36	Governor and the Legislature; amending s. 409.908, F.S.;
37	conforming a cross-reference; providing an effective date.
38
39	Be It Enacted by the Legislature of the State of Florida:
40
41	Section 1.  Section 381.0403, Florida Statutes, is
42	repealed.
43	Section 2.  Section 381.4018, Florida Statutes, is amended
44	to read:
45	381.4018  Physician workforce assessment and development.-
46	(1)  DEFINITIONS.-As used in this section, the term:
47	(a)  "Consortium" or "consortia" means a combination of
48	statutory teaching hospitals, statutory rural hospitals, other
49	hospitals, accredited medical schools, clinics operated by the
50	Department of Health, clinics operated by the Department of
51	Veterans' Affairs, area health education centers, community
52	health centers, federally qualified health centers, prison
53	clinics, local community clinics, or other programs. At least
54	one member of the consortium shall be a sponsoring institution
55	accredited or currently seeking accreditation by the
56	Accreditation Council for Graduate Medical Education or the
57	American Osteopathic Association.
58	(b)  "Council" means the Physician Workforce Advisory
59	Council.
60	(c)  "Department" means the Department of Health.
61	(d)  "Graduate medical education program" means a program
62	accredited by the Accreditation Council for Graduate Medical
63	Education or the American Osteopathic Association.
64	(e)  "Primary care specialty" means emergency medicine,
65	family practice, internal medicine, pediatrics, psychiatry,
66	obstetrics and gynecology, and combined internal medicine and
67	other specialties as determined by the Physician Workforce
68	Advisory Council or the Department of Health.
69	(2)(1)  LEGISLATIVE INTENT.-The Legislature recognizes that
70	physician workforce planning is an essential component of
71	ensuring that there is an adequate and appropriate supply of
72	well-trained physicians to meet this state's future health care
73	service needs as the general population and elderly population
74	of the state increase. The Legislature finds that items to
75	consider relative to assessing the physician workforce may
76	include physician practice status; specialty mix; geographic
77	distribution; demographic information, including, but not
78	limited to, age, gender, race, and cultural considerations; and
79	needs of current or projected medically underserved areas in the
80	state. Long-term strategic planning is essential as the period
81	from the time a medical student enters medical school to
82	completion of graduate medical education may range from 7 to 10
83	years or longer. The Legislature recognizes that strategies to
84	provide for a well-trained supply of physicians must include
85	ensuring the availability and capacity of quality graduate
86	medical schools and graduate medical education programs in this
87	state, as well as using new or existing state and federal
88	programs providing incentives for physicians to practice in
89	needed specialties and in underserved areas in a manner that
90	addresses projected needs for physician manpower.
91	(3)(2)  PURPOSE.-The Department of Health shall serve as a
92	coordinating and strategic planning body to actively assess the
93	state's current and future physician workforce needs and work
94	with multiple stakeholders to develop strategies and
95	alternatives to address current and projected physician
96	workforce needs.
97	(4)(3)  GENERAL FUNCTIONS.-The department shall maximize
98	the use of existing programs under the jurisdiction of the
99	department and other state agencies and coordinate governmental
100	and nongovernmental stakeholders and resources in order to
101	develop a state strategic plan and assess the implementation of
102	such strategic plan. In developing the state strategic plan, the
103	department shall:
104	(a)  Monitor, evaluate, and report on the supply and
105	distribution of physicians licensed under chapter 458 or chapter
106	459. The department shall maintain a database to serve as a
107	statewide source of data concerning the physician workforce.
108	(b)  Develop a model and quantify, on an ongoing basis, the
109	adequacy of the state's current and future physician workforce
110	as reliable data becomes available. Such model must take into
111	account demographics, physician practice status, place of
112	education and training, generational changes, population growth,
113	economic indicators, and issues concerning the "pipeline" into
114	medical education.
115	(c)  Develop and recommend strategies to determine whether
116	the number of qualified medical school applicants who might
117	become competent, practicing physicians in this state will be
118	sufficient to meet the capacity of the state's medical schools.
119	If appropriate, the department shall, working with
120	representatives of appropriate governmental and nongovernmental
121	entities, develop strategies and recommendations and identify
122	best practice programs that introduce health care as a
123	profession and strengthen skills needed for medical school
124	admission for elementary, middle, and high school students, and
125	improve premedical education at the precollege and college level
126	in order to increase this state's potential pool of medical
127	students.
128	(d)  Develop strategies to ensure that the number of
129	graduates from the state's public and private allopathic and
130	osteopathic medical schools are adequate to meet physician
131	workforce needs, based on the analysis of the physician
132	workforce data, so as to provide a high-quality medical
133	education to students in a manner that recognizes the uniqueness
134	of each new and existing medical school in this state.
135	(e)  Pursue strategies and policies to create, expand, and
136	maintain graduate medical education positions in the state based
137	on the analysis of the physician workforce data. Such strategies
138	and policies must take into account the effect of federal
139	funding limitations on the expansion and creation of positions
140	in graduate medical education. The department shall develop
141	options to address such federal funding limitations. The
142	department shall consider options to provide direct state
143	funding for graduate medical education positions in a manner
144	that addresses requirements and needs relative to accreditation
145	of graduate medical education programs. The department shall
146	consider funding residency positions as a means of addressing
147	needed physician specialty areas, rural areas having a shortage
148	of physicians, and areas of ongoing critical need, and as a
149	means of addressing the state's physician workforce needs based
150	on an ongoing analysis of physician workforce data.
151	(f)  Develop strategies to maximize federal and state
152	programs that provide for the use of incentives to attract
153	physicians to this state or retain physicians within the state.
154	Such strategies should explore and maximize federal-state
155	partnerships that provide incentives for physicians to practice
156	in federally designated shortage areas. Strategies shall also
157	consider the use of state programs, such as the Florida Health
158	Service Corps established pursuant to s. 381.0302 and the
159	Medical Education Reimbursement and Loan Repayment Program
160	pursuant to s. 1009.65, which provide for education loan
161	repayment or loan forgiveness and provide monetary incentives
162	for physicians to relocate to underserved areas of the state.
163	(g)  Coordinate and enhance activities relative to
164	physician workforce needs, undergraduate medical education, and
165	graduate medical education provided by the Division of Medical
166	Quality Assurance, the Community Hospital Education Program and
167	the Graduate Medical Education Committee established pursuant to
168	s. 381.0403, area health education center networks established
169	pursuant to s. 381.0402, and other offices and programs within
170	the Department of Health as designated by the State Surgeon
171	General.
172	(h)  Work in conjunction with and act as a coordinating
173	body for governmental and nongovernmental stakeholders to
174	address matters relating to the state's physician workforce
175	assessment and development for the purpose of ensuring an
176	adequate supply of well-trained physicians to meet the state's
177	future needs. Such governmental stakeholders shall include, but
178	need not be limited to, the State Surgeon General or his or her
179	designee, the Commissioner of Education or his or her designee,
180	the Secretary of Health Care Administration or his or her
181	designee, and the Chancellor of the State University System or
182	his or her designee from the Board of Governors of the State
183	University System, and, at the discretion of the department,
184	other representatives of state and local agencies that are
185	involved in assessing, educating, or training the state's
186	current or future physicians. Other stakeholders shall include,
187	but need not be limited to, organizations representing the
188	state's public and private allopathic and osteopathic medical
189	schools; organizations representing hospitals and other
190	institutions providing health care, particularly those that have
191	an interest in providing accredited medical education and
192	graduate medical education to medical students and medical
193	residents; organizations representing allopathic and osteopathic
194	practicing physicians; and, at the discretion of the department,
195	representatives of other organizations or entities involved in
196	assessing, educating, or training the state's current or future
197	physicians.
198	(i)  Serve as a liaison with other states and federal
199	agencies and programs in order to enhance resources available to
200	the state's physician workforce and medical education continuum.
201	(j)  Act as a clearinghouse for collecting and
202	disseminating information concerning the physician workforce and
203	medical education continuum in this state.
204	(5)  PHYSICIAN WORKFORCE ADVISORY COUNCIL.-There is created
205	in the Department of Health the Physician Workforce Advisory
206	Council, an advisory council as defined in s. 20.03. The council
207	shall comply with the requirements of s. 20.052, except as
208	otherwise provided in this section.
209	(a)  The council shall be composed of the following 23
210	members:
211	1.  The following members appointed by the State Surgeon
212	General:
213	a.  A designee from the department.
214	b.  An individual recommended by the Area Health Education
215	Center Network.
216	c.  Two individuals recommended by the Council of Florida
217	Medical School Deans, one representing a college of allopathic
218	medicine and one representing a college of osteopathic medicine.
219	d.  Two individuals recommended by the Florida Hospital
220	Association, one representing a statutory teaching hospital and
221	one representing a hospital that is licensed under chapter 395,
222	has an accredited graduate medical education program, and is not
223	a statutory teaching hospital.
224	e.  Two individuals recommended by the Florida Medical
225	Association, one representing a primary care specialty and one
226	representing a nonprimary care specialty.
227	f.  Two individuals recommended by the Florida Osteopathic
228	Medical Association, one representing a primary care specialty
229	and one representing a nonprimary care specialty.
230	g.  Two individuals who are program directors of accredited
231	graduate medical education programs, one representing a program
232	that is accredited by the Accreditation Council for Graduate
233	Medical Education and one representing a program that is
234	accredited by the American Osteopathic Association.
235	h.  An individual recommended by the Florida Justice
236	Association.
237	i.  An individual representing a profession in the field of
238	health services administration.
239	j.  A layperson member.
240
241	Each entity authorized to make recommendations under this
242	subparagraph shall make at least two recommendations to the
243	State Surgeon General for each appointment to the council. The
244	State Surgeon General shall appoint one member for each position
245	from among the recommendations made by each authorized entity.
246	2.  The following members appointed by the respective
247	agency head, legislative presiding officer, or congressional
248	delegation:
249	a.  The Commissioner of Education or his or her designee.
250	b.  The Chancellor of the State University System or his or
251	her designee.
252	c.  The Secretary of Health Care Administration or his or
253	her designee.
254	d.  The executive director of the Department of Veterans'
255	Affairs or his or her designee.
256	e.  The Secretary of Elderly Affairs or his or her
257	designee.
258	f.  The President of the Senate or his or her designee.
259	g.  The Speaker of the House of Representatives or his or
260	her designee.
261	h.  A designee of Florida's Congressional Delegation.
262	(b)  Each council member shall be appointed to a 4-year
263	term. An individual may not serve more than two terms. Any
264	council member may be removed from office for malfeasance;
265	misfeasance; neglect of duty; incompetence; permanent inability
266	to perform official duties; or pleading guilty or nolo
267	contendere to, or being found guilty of, a felony. Any council
268	member who meets the criteria for removal, or who is otherwise
269	unwilling or unable to properly fulfill the duties of the
270	office, shall be succeeded by an individual chosen by the State
271	Surgeon General to serve out the remainder of the council
272	member's term. If the remainder of the replaced council member's
273	term is less than 18 months, notwithstanding the provisions of
274	this paragraph, the succeeding council member may be reappointed
275	twice by the State Surgeon General.
276	(c)  The chair of the council is the State Surgeon General,
277	who shall designate a vice chair to serve in the absence of the
278	State Surgeon General. A vacancy shall be filled for the
279	remainder of the unexpired term in the same manner as the
280	original appointment.
281	(d)  Council members are not entitled to receive
282	compensation or reimbursement for per diem or travel expenses.
283	(e)  The council shall meet twice a year in person or by
284	teleconference.
285	(f)  The council shall:
286	1.  Advise the State Surgeon General and the department on
287	matters concerning current and future physician workforce needs
288	in this state.
289	2.  Review survey materials and the compilation of survey
290	information.
291	3.  Provide recommendations to the department for the
292	development of additional items to be incorporated in the survey
293	completed by physicians licensed under chapter 458 or chapter
294	459.
295	4.  Assist the department in preparing the annual report to
296	the Legislature pursuant to ss. 458.3192 and 459.0082.
297	5.  Assist the department in preparing an initial strategic
298	plan, conduct ongoing strategic planning in accordance with this
299	section, and provide ongoing advice on implementing the
300	recommendations.
301	6.  Monitor the need for an increased number of primary
302	care physicians to provide the necessary current and projected
303	health and medical services for the state.
304	7.  Monitor the status of graduate medical education in
305	this state, including, but not limited to, as considered
306	appropriate:
307	a.  The effectiveness of graduate medical education pilot
308	projects funded pursuant to subsection (6).
309	b.  The role of residents and medical faculty in the
310	provision of health care.
311	c.  The relationship of graduate medical education to the
312	state's physician workforce.
313	d.  The availability and use of state and federal
314	appropriated funds for graduate medical education.
315	(6)  PHYSICIAN WORKFORCE GRADUATE MEDICAL EDUCATION
316	INNOVATION PILOT PROJECTS.-
317	(a)  The Legislature finds that:
318	1.  In order to ensure a physician workforce that is
319	adequate to meet the needs of this state's residents and its
320	health care system, policymakers must consider the training of
321	future generations of well-trained health care providers.
322	2.  Physicians are likely to practice in the state where
323	they complete their graduate medical education. The in-state
324	retention rate following graduate medical education for
325	physicians in this state is more than 61 percent.
326	3.  It can directly affect the makeup of the physician
327	workforce by selectively funding graduate medical education
328	programs to provide needed specialists in geographic areas of
329	the state which have a deficient number of such specialists.
330	4.  Developing additional positions in graduate medical
331	education programs is essential to the future of this state's
332	health care system.
333	5.  It was necessary in 2007 to pass legislation that
334	provided for an assessment of the status of this state's current
335	and future physician workforce. The department is collecting and
336	analyzing information on an ongoing basis to assess this state's
337	physician workforce needs, and such assessment can serve as a
338	basis for determining graduate medical education needs and
339	strategies for the state.
340	(b)  There is established under the department a program to
341	foster innovative graduate medical education pilot projects that
342	are designed to promote the expansion of graduate medical
343	education programs or positions to prepare physicians to
344	practice in needed specialties and underserved areas or settings
345	and to provide demographic and cultural representation in a
346	manner that addresses projected needs for this state's physician
347	workforce. Funds appropriated annually by the Legislature for
348	this purpose shall be distributed to participating hospitals,
349	medical schools, other sponsors of graduate medical education
350	programs, consortia engaged in developing new graduate medical
351	education programs or positions in those programs, or pilot
352	projects providing innovative graduate medical education in
353	community-based clinical settings. Pilot projects shall be
354	selected on a competitive grant basis, subject to available
355	funds.
356	(c)  Pilot projects shall be designed to meet one or more
357	of this state's physician workforce needs, as determined
358	pursuant to this section, including, but not limited to:
359	1.  Increasing the number of residencies or fellowships in
360	primary care or other needed specialties.
361	2.  Enhancing the retention of primary care physicians or
362	other needed specialties in this state.
363	3.  Promoting practice in rural or medically underserved
364	areas of the state.
365	4.  Encouraging racial and ethnic diversity within the
366	state's physician workforce.
367	5.  Encouraging practice in community health care or other
368	ambulatory care settings.
369	6.  Encouraging practice in clinics operated by the
370	Department of Health, clinics operated by the Department of
371	Veterans' Affairs, prison clinics, or similar settings of need.
372	7.  Encouraging the increased production of geriatricians.
373	(d)  Priority shall be given to a proposal for a pilot
374	project that:
375	1.  Demonstrates a collaboration of federal, state, and
376	local entities that are public or private.
377	2.  Obtains funding from multiple sources.
378	3.  Focuses on enhancing graduate medical education in
379	rural or underserved areas.
380	4.  Focuses on enhancing graduate medical education in
381	ambulatory or community-based settings other than a hospital
382	environment.
383	5.  Includes the use of technology, such as electronic
384	medical records, distance consultation, and telemedicine, to
385	ensure that residents are better prepared to care for patients
386	in this state, regardless of the community in which the
387	residents practice.
388	6.  Is designed to meet multiple policy needs as enumerated
389	in subsection (3).
390	7.  Uses a consortium to provide for graduate medical
391	education experiences.
392	(e)  The department shall adopt by rule appropriate
393	performance measures to use in order to consistently evaluate
394	the effectiveness, safety, and quality of the programs, as well
395	as the impact of each program on meeting this state's physician
396	workforce needs.
397	(f)  Participating pilot projects shall submit to the
398	department an annual report on the project in a manner required
399	by the department.
400	(g)  Funding provided to a pilot project may be used only
401	for the direct costs of providing graduate medical education.
402	Accounting of such costs and expenditures shall be documented in
403	the annual report.
404	(h)  State funds shall be used to supplement funds from any
405	local government, community, or private source. The state may
406	provide up to 50 percent of the funds, and local governmental
407	grants or community or private sources shall provide the
408	remainder of the funds.
409	(7)  RULEMAKING.-The department shall adopt rules as
410	necessary to administer this section.
411	Section 3.  Section 458.3192, Florida Statutes, is amended
412	to read:
413	458.3192  Analysis of survey results; report.-
414	(1)  Each year, the Department of Health shall analyze the
415	results of the physician survey required by s. 458.3191 and
416	determine by geographic area and specialty the number of
417	physicians who:
418	(a)  Perform deliveries of children in this state Florida.
419	(b)  Read mammograms and perform breast-imaging-guided
420	procedures in this state Florida.
421	(c)  Perform emergency care on an on-call basis for a
422	hospital emergency department.
423	(d)  Plan to reduce or increase emergency on-call hours in
424	a hospital emergency department.
425	(e)  Plan to relocate their allopathic or osteopathic
426	practice outside the state.
427	(f)  Practice medicine in this state.
428	(g)  Reduce or modify the scope of their practice.
429	(2)  The Department of Health must report its findings to
430	the Governor, the President of the Senate, and the Speaker of
431	the House of Representatives by November 1 each year. The
432	department may also include in its report findings,
433	recommendations, or other information requested by the council.
434	Section 4.  Section 459.0082, Florida Statutes, is amended
435	to read:
436	459.0082  Analysis of survey results; report.-
437	(1)  Each year, the Department of Health shall analyze the
438	results of the physician survey required by s. 459.0081 and
439	determine by geographic area and specialty the number of
440	physicians who:
441	(a)  Perform deliveries of children in this state Florida.
442	(b)  Read mammograms and perform breast-imaging-guided
443	procedures in this state Florida.
444	(c)  Perform emergency care on an on-call basis for a
445	hospital emergency department.
446	(d)  Plan to reduce or increase emergency on-call hours in
447	a hospital emergency department.
448	(e)  Plan to relocate their allopathic or osteopathic
449	practice outside the state.
450	(f)  Practice medicine in this state.
451	(g)  Reduce or modify the scope of their practice.
452	(2)  The Department of Health must report its findings to
453	the Governor, the President of the Senate, and the Speaker of
454	the House of Representatives by November 1 each year. The
455	department may also include in its report findings,
456	recommendations, or other information requested by the council.
457	Section 5.  Paragraph (a) of subsection (1) of section
458	409.908, Florida Statutes, is amended to read:
459	409.908  Reimbursement of Medicaid providers.-Subject to
460	specific appropriations, the agency shall reimburse Medicaid
461	providers, in accordance with state and federal law, according
462	to methodologies set forth in the rules of the agency and in
463	policy manuals and handbooks incorporated by reference therein.
464	These methodologies may include fee schedules, reimbursement
465	methods based on cost reporting, negotiated fees, competitive
466	bidding pursuant to s. 287.057, and other mechanisms the agency
467	considers efficient and effective for purchasing services or
468	goods on behalf of recipients. If a provider is reimbursed based
469	on cost reporting and submits a cost report late and that cost
470	report would have been used to set a lower reimbursement rate
471	for a rate semester, then the provider's rate for that semester
472	shall be retroactively calculated using the new cost report, and
473	full payment at the recalculated rate shall be effected
474	retroactively. Medicare-granted extensions for filing cost
475	reports, if applicable, shall also apply to Medicaid cost
476	reports. Payment for Medicaid compensable services made on
477	behalf of Medicaid eligible persons is subject to the
478	availability of moneys and any limitations or directions
479	provided for in the General Appropriations Act or chapter 216.
480	Further, nothing in this section shall be construed to prevent
481	or limit the agency from adjusting fees, reimbursement rates,
482	lengths of stay, number of visits, or number of services, or
483	making any other adjustments necessary to comply with the
484	availability of moneys and any limitations or directions
485	provided for in the General Appropriations Act, provided the
486	adjustment is consistent with legislative intent.
487	(1)  Reimbursement to hospitals licensed under part I of
488	chapter 395 must be made prospectively or on the basis of
489	negotiation.
490	(a)  Reimbursement for inpatient care is limited as
491	provided for in s. 409.905(5), except for:
492	1.  The raising of rate reimbursement caps, excluding rural
493	hospitals.
494	2.  Recognition of the costs of graduate medical education.
495	3.  Other methodologies recognized in the General
496	Appropriations Act.
497
498	During the years funds are transferred from the Department of
499	Health, any reimbursement supported by such funds shall be
500	subject to certification by the Department of Health that the
501	hospital has complied with s. 381.4018 s. 381.0403. The agency
502	may is authorized to receive funds from state entities,
503	including, but not limited to, the Department of Health, local
504	governments, and other local political subdivisions, for the
505	purpose of making special exception payments, including federal
506	matching funds, through the Medicaid inpatient reimbursement
507	methodologies. Funds received from state entities or local
508	governments for this purpose shall be separately accounted for
509	and shall not be commingled with other state or local funds in
510	any manner. The agency may certify all local governmental funds
511	used as state match under Title XIX of the Social Security Act,
512	to the extent that the identified local health care provider
513	that is otherwise entitled to and is contracted to receive such
514	local funds is the benefactor under the state's Medicaid program
515	as determined under the General Appropriations Act and pursuant
516	to an agreement between the Agency for Health Care
517	Administration and the local governmental entity. The local
518	governmental entity shall use a certification form prescribed by
519	the agency. At a minimum, the certification form shall identify
520	the amount being certified and describe the relationship between
521	the certifying local governmental entity and the local health
522	care provider. The agency shall prepare an annual statement of
523	impact which documents the specific activities undertaken during
524	the previous fiscal year pursuant to this paragraph, to be
525	submitted to the Legislature no later than January 1, annually.
526	Section 6.  This act shall take effect July 1, 2010.

CODING: Words stricken are deletions; words underlined are additions.