Health Plan from the Candidate for Governor Charlie Crist

Dear Friends and Colleagues:
Attached you find Charlie Crists "Prescription for a Healthy Florida" outlining his Healthcare proposals.
The plan contains many positive elements, but lacks certain important component(s) such as health information technology, funding for primary care sustainable health insurance beside of HSA's
I have added some of my comments and look forward to your input.
Yours

Bernd








CHARLIE CRIST’S PRESCRIPTION TO KEEP FLORIDA HEALTHY:
LOWERING DRUG COSTS AND INCREASING ACCESS TO QUALITY HEALTHCARE

Policy Overview

Charlie Crist knows that Floridians’ health is crucial to every person’s quality of life and paramount to the vitality of our state. Florida is a leader in biomedical innovation, consumer-driven healthcare and Medicaid reform. But great challenges are ahead.
Health insurance, for many, is unaffordable and healthcare, including prescription medications, unavailable; emergency rooms are overcrowded; and there has been an increase in the prevalence of preventable diseases. Charlie Crist will reorient Florida’s healthcare system by focusing on the individual, lowering drug costs, and providing better access to doctors and medicine.

Comment: providing accessible and affordable primary care services for all Floridians.

Highlights of the Crist Prescription to Keep Florida Healthy

1. Making Health Care Affordable

o Lower the cost of prescription drugs for working families and seniors.
o Make health insurance affordable.
o Reform the public health system to lower costs, empower recipients, and
maximize KidCare.

Comment: to expand access a defined set of primary health care services at affordable prizes, empower healthcare consumers, and maximize KidCare.

2. Increasing Access to Care

o Increase health care options so that emergency care is not the only choice.
o Increase healthcare resources in rural communities.
o Train more doctors, nurses and health practitioners for Florida’s patients.




3. A Commitment to Prevention

o Refocus the Department of Health to be headed by the State Surgeon General
as a leading advocate for wellness.
o Promote healthy lifestyles in schools and in the workplace.
o Advocate early intervention in substance abuse and mental illness
Comment: and provide community-based in- and outpatient treatment facilities for those suffering from the disease of addiction.

4. Improving the Quality of Care through Innovation

o Create (Comment: objective) standards for best practices to reduce hospital-acquired infection rates and improve outcomes in hospitals, clinics, and doctors’ offices.
o Provide Floridians with more information and control regarding healthcare
decisions and costs.


Specific Policy Proposals

1. MAKING HEALTH CARE AFFORDABLE

Lowering the Cost of Prescription Drugs

As our Governor, Charlie Crist will continue his longstanding commitment to lowering the costs of prescription drugs for all Floridians. As Attorney General, he fought for cheaper medicine by taking action against drug companies that kept low cost generics off the market, and brought suit against companies for falsely reporting their wholesale prices. He also launched MyFloridaRX.com, a website that allows Floridians to compare and shop for the very best price on their medicines. Already, this has reduced price disparities between drugs at some neighboring pharmacies.

His initiatives to lower the cost of prescription drugs as Governor will include the
following:

• Leveraging the power of Floridians to negotiate better prices for prescription drugs for seniors and working families ( Comment:for all Floridians). As Governor, Charlie Crist will negotiate with the drug industry to get volume discounts on their drugs. He will pass these savings on to (Comment:all Floridians) working families and seniors who are struggling to pay for prescription drugs by providing them with discount prescription drug cards. He will then partner with pharmacies throughout the state so that these participating pharmacies will accept these discount cards to provide drugs at a lower cost. This could save eligible consumers as much as 40% on the cost of their prescriptions.

• Encouraging competition in the private marketplace to benefit all consumers.
Already, major retail companies are offering hundreds of generic drugs for $4.
Charlie Crist applauds these market-based solutions and will continue to encourage these companies to continue treating their customers fairly.
Comment: These low-cost prescription options are currently only offered in certain markets and will be expanded gradually depending on the companies perception of its market value,

• Providing more information to them about drug costs. He will expand the number of drugs presented for comparison on MyFloridaRx.com; and will expand search options on the website so that consumers may order lower-priced prescriptions from pharmacies across the state that offer mail delivery services. Crist will also partner with private companies that provide online tools for consumers to learn about additional prescription discount programs.

• Working with Congress to create conditions for the safe and affordable importation of drugs from Canada. Crist believes that if Floridians can purchase safe drugs from Canada, they should be able to do so. As Attorney General, he secured the passage of a bill to ensure drugs are tracked from the manufacturer to the drug store to guarantee their safety. He will work with experts in Washington to create an international methodology to maintain safety and consumer protection.
Comment: a very noble idea, but its often forgotten that MOST of the medications imported from Canada come from all over the world increasing the risk of adulterated or counterfeit drugs. At a time when FDA faces more challenges than ever in keeping America’s supply of prescription drugs safe and secure, legislation to liberalize drug importation could cause additional drug safety concerns. The volume of importation could easily overwhelm our already heavily burdened regulatory system. Increased rug importation would require to provide the FDA with adequate authority or resources to establish and regulate the distribution system for incoming foreign drugs - manufactured, distributed, labeled, and handled outside of our regulatory system - or even to ensure their safety.


3

Health Insurance Solutions for All Floridians

The Crist Administration will make it a top priority to increase the access and
affordability of health insurance for all Floridians. The uninsured suffer poorer health status and become dependent on emergency rooms and on state assistance for their care. Everyone benefits when more people are insured: enrollment drives down costs and reduces state spending on care. Charlie Crist will take immediate action to improve private health coverage through the following measures:

(A) Free-market solutions for small businesses: Florida is rated one of most
expensive states for small businesses seeking family healthcare policies. Small
businesses are at a disadvantage because they cannot spread their risk over large numbers of employees and insurance companies compensate by charging these businesses higher per-employee premiums. Another cause of high premiums is that state law is rigid with respect to small group policy design and benefit requirements. Charlie Crist will work to increase the flexibility and affordability of health plans for small groups by:

• Permitting more flexible plan and benefit designs: Charlie Crist believes that when it comes to healthcare coverage, Floridians should not have to choose between “all or nothing.” Rather than requiring rigid plan structures, he believes that Florida should allow the market to sell individualized benefits packages that will serve health needs while being more affordable. Charlie Crist will encourage flexibility in plans so that policies can be tailored to employers’ and employees’ needs and budgets.
Comment: An excellent idea and I hope that Governor Christ will have the backbone and stamina to overcome the resistance by insurance companies.

• Permitting small groups to join together to leverage purchasing power: Charlie Crist will work on improving the efficiency for small businesses to achieve lower employee premiums when they join together to leverage their buying power.

(B) Consumer-driven healthcare options for all Floridians: For most patients, health bills are paid for primarily by a third-party insurer or the government. This gives consumers little incentive to make cost-conscious decisions, and gives practitioners little incentive to offer competitive rates. Charlie Crist will move Florida in a direction where consumers gain more control over their healthcare decisions and spending, and where market dynamics keep costs affordable. One such opportunity exists through the increased use of Health Savings Accounts (HSAs). HSAs allow individuals and employers to pay into tax-free savings accounts while being enrolled in high-deductible health plans with catastrophic coverage. Unlike traditional policies, HSA owners control money in their accounts: funds may be invested, balances roll over year to year, and
funds are portable through job changes. Employers also contribute funds into employee accounts without having to pay high premiums. As Governor, Charlie Crist will promote the expansion of Health Savings Accounts, through increased awareness about how the plans work and how Floridians may benefit from these options.

Comment: HSAs are attractive and interesting options, but not suitable for everone and therefore should not be offered as the only or most important tool to achieve consumer driven healthcare solutions.
The advantages of HSAs include:
• Empowerment. HSAs allow patients and doctors more control over health care decisions because HSA dollars may be spent on any qualified medical expense, without regard to networks, utilization review, or other elements of managed care.

• Carryover. unused HSA funds may be used in subsequent years.

• Access to Funds. Individuals may withdraw funds from their HSAs at any time and for any purposes, although taxes and penalties apply if the distribution is not used for qualified medical expenses.

• Potential to Lower Employer Health Care Costs. HSAs make high deductible health plans more attractive to employees and give employees an incentive to be prudent with their health care expenditures.

• Tax Savings. Employees benefit from deductible individual contributions, tax-free employer contributions and tax-free earnings. Employers may deduct contributions and avoid payroll taxes on HSA contributions.

The disadvantages of HSAs include:
• Limits Health Plan Choice. Individuals who establish HSAs must participate in high deductible health plans (HDHP) that may not be suitable for all individuals.

• Nondiscrimination Requirements. Employers that contribute to employees' HSAs must comply with the HSA nondiscrimination requirement and face an excise tax penalty for failure to do so.

• Contribution Limits. The current HSA contribution limits combined with the HDHP participation requirement may make it difficult for employees to accumulate funds in their HSAs. Individuals who incur significant health care expenses will not find HSAs to be attractive.

• Adverse Selection. An employer that offers an HSA / HDHP option and a more comprehensive health plan option may experience a migration of healthy employees to the HSA / HDHP option, leaving less healthy employees (but fewer premium dollars) in the comprehensive health plan thereby undermining the premise that the premiums of healthy participants pay for the expenses for sick health plan recipients. Eventually, this will jeopardize the financial stability of such plans.



(C) Achieving federal participation in providing for the uninsured: The problem of covering the uninsured is not just a matter for individual states. Charlie Crist will take the lead nationally to bring federal funding to states that develop strategies for covering the uninsured. These coordinated federal and state efforts must:
• Encourage personal responsibility and consumer-driven healthcare;
• Strengthen the private insurance market and offer free-market solutions;
• Cover catastrophic events and preventative care; and
• Redirect state dollars toward primary care medicine.

Further, Charlie Crist supports interstate purchasing pools, called Association Health Plans, which would allow organizations like the Chamber of Commerce to negotiate on an interstate basis on behalf of their members. Achieving this will take Congressional action, and Charlie Crist will work with Florida’s delegation to achieve this agenda.
Comment: Excellent idea!!!

2. INCREASE ACCESS TO CARE

Building Networks of Care

Charlie Crist believes that every Floridian should have a “medical home” with a primary care doctor. He is committed to shifting the delivery of healthcare from the ER to doctors’ offices. He will work to reduce hospital crowding, increase Floridians’ access to primary and preventative care, and modernize care networks for the poor. To achieve this, the Crist Administration will:

(A) Increase health care options so that emergency care is not the only choice:
County Health Departments provide various health services, and many communities also have locally funded healthcare clinics. These facilities can fill an important role in providing care to the underserved but are underutilized. In addition to increasing awareness about these options, Charlie Crist will encourage partnerships between private health clinics and hospitals so that patients know where they can receive reatment outside of emergency rooms.

(B) Strengthen health in our rural communities: Many rural hospitals suffer from mismanagement, outdated infrastructure, and difficulty recruiting skilled staff. This year, two rural hospitals were closed by the state for failing to keep even minimal levels of quality. In some areas, women must drive an hour away to deliver a baby. Charlie Crist knows that this is unacceptable. He will help rural communities with capital improvements and developing coordinated delivery systems, including shared management, workforce recruitment, and long-term planning with hospitals.

(C) Increase the quality of emergency care: Federal laws currently prevent hospitals from forming regional on-call networks of emergency specialists. Charlie Crist will work to change these laws. This would permit EMS drivers and patients to know where to go for certain kinds of emergencies, and would increase the efficiency of care. Further, the
Crist Administration will work to increase the availability of emergency specialists by evaluating and building on medical malpractice reforms.

(D) Minimize red tape in the building of new health facilities: Charlie Crist will reform the process by which new facilities are approved. When the need for a hospital or nursing home is established, red tape should not prevent their opening.

(E) Increase the availability of Home & Community Based Services (HCBS):
Charlie Crist believes that the home is often the best place to receive continual care. He will work to increase the availability of HCBS options, where Floridians can avoid seeking institutional care and maintain independence and comfort.

Providing More Healthcare Practitioners for Florida’s Patients

Florida faces critical shortages of nurses and specialists. For example, while Florida’s demand for nurses will increase by 40% by 2020, the number of nurses is expected to grow by only 6%. The average age of nurses in Florida has increased as well, which means Florida has a shortage of nursing instructors. Consequently, nursing programs must turn away thousands of qualified applicants due to the lack of staff. A similar problem exists for physicians and specialists. While Florida’s population has exploded in the past ten years, our medical school enrollment has not increased at all. Charlie Crist
believes that we must attract and retain healthcare practitioners, and believes that the key to this is education. Charlie Crist will focus on developing the state’s higher education capabilities in math and science, and will further promote the development of public universities in Florida that will focus, or increase their focus, on math and science. This emphasis will create the workforce that Florida needs to fulfill our growing healthcare workforce needs.

• Attract students to healthcare professions: Charlie Crist will work to attract more
young people, minorities and men to healthcare professions through scholarship
programs and outreach to students in middle and high school. Further, Charlie Crist believes that it is important that more healthcare personnel are defined as “essential service personnel” by local affordable housing boards so that they may qualify for housing assistance.

• Increase residency opportunities for Florida medical students: Florida just
established two new medical schools at FIU and UCF. Charlie Crist will push for
additional residency spots in order to keep new doctors in Florida and benefit from our investment in their training.
Comment: Excellent idea!!!
Unfortunately, the plan does not address how to retain doctors in Florida. Problems include: high costs of living, high costs for medical practice, high professional liability, unfavorable medico-legal environment (just to mention a few)

Empowering & Improving the Medicaid System

(A) Eradicating fraud: The costs of Medicaid fraud are enormous and the eradication of fraud should be a top priority. As Attorney General, Crist aggressively investigated and prosecuted Medicaid fraud and abuse. He filed lawsuits against drug manufacturers for inflating prices, prosecuted doctors who were diverting controlled substances or billing illegally. These efforts recovered over $150 million to taxpayers, in contrast to only $6 million recovered in 2002 prior to Crist’s Administration. Charlie Crist will maintain focus on preventing and penalizing fraud.

(B) Evaluating and expanding Medicaid reform: In only seven years, the Medicaid budget more than doubled. Today, it consumes a quarter of the state budget, up from ten percent ten years ago. Governor Bush and the Legislature responded to this broken system by passing a Medicaid reform package designed to use the power of consumer choice to improve care and efficiency. Charlie Crist believes that these reforms must continue. This year, the new Medicaid plan offered expanded services without costing the taxpayers an additional dime; offered aged and disabled people home delivered meals after discharge from the hospital; provided adults with preventive dental care,
paid for over-the-counter drugs and more. With the initial implementation, there have been very few complaints. Now, we must watch, learn, and adjust as issues arise. Crist will evaluate Medicaid Reform as it develops in Broward and Duval Counties, will improve aspects that need development, and will implement further reforms to ensure hat all patients have access to the best care.


(C) Maximizing Florida’s KidCare resources: The Florida KidCare program provides insurance to qualifying children as a safety net for families who work hard but do not earn enough to purchase private policies. Enrolling the maximum number of eligible children in KidCare promotes the future of Florida. The Bush Administration increased funding for KidCare and Medicaid for children by more than 85%, and increased enrollment in KidCare by nearly 94%. Charlie Crist will work to make the application
process less complicated by unifying the process to a single application for all child services, so that parents do not need to approach multiple programs to determine eligibility. He will also encourage schools and Pre-K programs to boost awareness about KidCare, will use all available federal funds, and will work to permit the use of funding from local governments to open up more slots.





3. A COMMITMENT TO PREVENTION

The Sunshine State should be a healthy state. Public health challenges such as obesity, Alzheimer’s, and emergency preparedness are eminent. For example, from 1997 to 2004, diabetes has increased by 40%. Thousands of Florida’s children have early stages of diabetes without diagnosis, and they will face serious health problems by the time they are 30. We must be aggressive in tackling these problems, and Charlie Crist proposes a comprehensive approach involving the following initiatives:

(A) Refocus the Department of Health to be headed by the State Surgeon General
as a leading advocate for wellness: Florida needs a strong advocate so that all Floridians will achieve a lifetime of wellness. Charlie Crist will refocus the role of the Secretary of the Department of Health to be the State Surgeon General. Florida’s Surgeon General will act as the leading voice on wellness and disease prevention and will focus on advocating healthy lifestyles, prevention of substance abuse, suicide and mental illness, and personal responsibility in disaster preparation.



(B) Promote school and workplace-based fitness and nutrition initiatives: Charlie Crist will emphasize fitness and nutritional awareness in schools and in the workplace.

• School-based obesity & healthy eating initiatives: Charlie Crist believes that every child should have physical activity every day, and he will seek to integrate fitness into educational opportunities inside and outside the classroom. He will also seek legislation requiring every school district to maintain an independent physical fitness advisory panel to assess the school environment using the Centers for Disease Control and Prevention’s School Health Index to determine further recommendations or student fitness testing every year beginning in the first grade. Those panels will provide input to a volunteer panel of physical fitness experts that will serve as the Governor’s Commission on Physical Fitness. Finally, nutritious food options should be available in Florida schools. Charlie Crist will promote school districts to partner with Florida agriculture to offer salad bars with fresh produce and meats. These partnerships will nourish both student health and the vitality of Florida’s food
industries.

• Workplace obesity & healthy eating initiatives: In 2006 the legislature passed a law equiring state agencies to develop strategies for promoting healthy lifestyles among
employees. Charlie Crist will require systematic evaluation of these programs to
determine which strategies are most effective; and will then publish model policies for other agencies as well as private companies to learn from and adopt.

Comment: excellent ideas that require SUSTAINABLE FUNDING!!!

(C) Encourage early intervention & awareness about substance abuse and mental illness:

• Integration of mental health services: The President’s New Freedom Initiative is an important guide for how to modernize our mental health system, and the Florida Substance Abuse Mental Health Corporation provides guidance in these matters. Crist will appoint people to this board who believe in community-based and integrated treatment, to develop a roadmap to independence for the mentally ill.
Comment: I would separate mental health and substance abuse issues. Addiction illness is a clearly defined complex medical illness comparable to Diabetes or Hypertension. It requires focused attention on disease management and relapse prevention. Many of those suffering from substance abuse problems are concerned that they are being stigmatized suffering from a mental illness or that the fact that they are being treated indicates active disease often leading to denial in life-, disability and even health insurance.

• Suicide prevention: Suicide is the third leading cause of death for 15-24 year olds in Florida. The suicide rate is more than twice that of homicide but is often treated as a private matter relating only to affected families. Governor Bush’s Task Force on Suicide Prevention recommended greater early intervention and screening efforts, and Charlie Crist believes that Florida must move forward in these efforts.

4. IMPROVING THE QUALITY OF CARE THROUGH INNOVATION

The Charlie Crist Quality Care Initiative

Measuring quality and rewarding performance provide better results for patients, lessen the duration of illness, and reduce costs for care. The Crist Quality Care Initiative brings new focus to healthcare quality and is based on two sound principals:


(A) Create standards for best practices to reduce hospital-acquired infections and improve outcomes in all healthcare settings: Most adverse events in medicine are preventable. For instance, hospital-acquired infections are responsible for an estimated 103,000 deaths each year in the U.S. Reporting systems that collect information on
errors are essential to improve the safety and quality of care. For example, by
participating in one national pilot program, Tallahassee Memorial Hospital reduced mortality after strokes by 41% and for pneumonia by 32% in a two-year period by adopting best practices and establishing better communication between emergency room doctors and specialists. The Crist Administration will utilize improved measures of healthcare performance and will encourage the collection of data on mistakes or oversights. These measures allow researchers to develop best practices, avoid future mistakes, and provide important information for consumers.
Comment: these measures should be coordinated with the Florida Medical Association and other entities involved in patient safety and quality improvement and not being directed by a government agency.

(B) Provide more consumer healthcare information: Floridians should have as much information as possible when making healthcare decisions. Charlie Crist has been at the forefront of making Florida a national leader in such transparency efforts. As Attorney General, he launched the pharmacy pricing website, MyFloridaRx.com, where consumers compare drugs prices between pharmacies. These programs make Florida a national leader in transparency efforts; however, we can do more to empower consumers. Today, three websites present data to consumers on the quality and cost of healthcare, and Crist will integrate them into a user-friendly MyFloridaHealth.gov. This site will offer a greater scope of information that is meaningful to patients, such as data on patient satisfaction at facilities, a comparison of provider performance between health plans and an expanded drug price component as described above.


Comment:
Even though I cautiously support the ideas outlined above I am surprised that the Crist team has omitted to mention the importance of health information technology including Electronic Health Records for doctors office and no mention is being made of how (or if) Governor Crist would support the development of Regional Health Information Organizations (RHIOs) and allocate sufficient funding to these projects.
Health Information Technology (HIT) solutions will provide the data and information flow across the horizontal and vertical spectrum of healthcare providers to guarantee the optimal utilization of health care resources, to reduce duplication of diagnostic testing, to guarantee patient safety and quality of care.


Comments by Bernd Wollschlaeger,MD,FAAFP