Florida Surgeon General Responds To HIV Criticism, Staff Cuts

Feb 8, 2016

State Surgeon General John Armstrong, who heads the Florida Department of Health, has faced scrutiny from lawmakers recently on a number of high-profile issues. The issues include the state's rising HIV rate, cuts to county health departments and 9,000 kids who lost places in the Children's Medical Services program --- which serves youngsters with "serious and chronic" conditions --- under a new eligibility screening process last year.

Also, Armstrong faces a Feb. 16 confirmation hearing in the Senate Health Policy Committee, according to committee Chairman Aaron Bean, R-Fernandina Beach. "He has my full support," Bean texted. Last year, the Senate had the chance to confirm Armstrong and didn't, so he would have to step down if he is not confirmed this session.

Armstrong was appointed surgeon general by Gov. Rick Scott in April 2012. Previously, he had been chief medical officer of the University of South Florida's Health Center for Advanced Medical Learning and Simulation and an associate professor of surgery.

The News Service of Florida has five questions for John Armstrong:

Q: Why does Florida have such high rates of diagnosed HIV cases, and what are we doing about it?

ARMSTRONG: Well, I think that's an important point. I'm very familiar with HIV/AIDS, very familiar as a professional. I trained when HIV/AIDS was emerging, and I saw it for what it was: A very cruel disease, very cruel. So I invested a lot of time learning about it, so that I understood what needed to be done: how to be safe, but how to really help people. And I've carried that with me. So when I came into this department and looked at where we were with HIV/AIDS, I kind of reset the playing field. I talk a lot about eliminating things. I find in general there's talk about, "Let's reduce this." … I don't want to reduce it, I want to eliminate it. To those who push back and say, "You'll never eliminate it" --- well, of course you won't, if you say you'll never eliminate it. You've got to start somewhere. And it turns out remarkable things have happened when people say, "You know what? We're going to eliminate this."

So we've had an uptick in newly-diagnosed HIV. And it reflects behaviors. We have to acknowledge that HIV/AIDS is a sexually transmitted disease. If you look nationally at other sexually transmitted diseases, the gradient is up. And so we need to look at this broader context about how it is that we help people make better choices for safe sex.

We understand where there are particular people at risk for HIV, and what we have done is to work to invest in those communities. And we have done this in partnership with a whole host of organizations. … Public health really has to be about partnerships, and it has to be local energy. And we've done an awful lot in outreach and messaging, and with testing. … So I think we've had some success with that, but clearly, there's more work to be done.

Q: Patient services and contacts have plummeted at Florida's county health departments. Why is the state cutting positions at the Department of Health?

ARMSTRONG: So I asked an interesting question as I entered the department: "How many people work in the Department of Health?" And I got back a whole bunch of different answers. So I said, "Well, if we really don't understand our workforce, it's going to be awfully hard to make sure that we have resources where we need to keep the people of Florida ahead of threats."

So here's what the deal is: We have a workforce that is authorized by the Legislature. And within those positions --- most are filled, but some are vacant. The vacant positions have funding associated with them. And then we also have some that are authorized but not established. And those are positions that are truly phantom positions, so no money associated with them. So the concern I had as I was looking at this was, we don't want to fool ourselves that we have positions that we really don't have. And, importantly, if we thought these were positions to use in an emergency, they really aren't, because there's no funding associated with them. So what we did last year was to ask for a reduction in (full-time positions) that prominently involved the phantom positions, and we asked that there be no accompanying revenue reduction with those. Because we wanted to retain the revenue but shed the phantoms, right?

Understand that any time you talk about these positions, sometimes they are taken away from the vacant positions, which had funding streams, as opposed to the "authorized-not-established." So we asked for that, and in the governor's budget proposal last year, he agreed. So we asked for that reduction, (to) get better alignments so we actually know what we got, and retain the revenue. Well, through the budget cycle last year, the revenue was taken. So that's the only time in my tenure that there's been a reduction for the county health departments.

I have otherwise … I came into this position saying, "Public health happens locally." We have to make sure that the health departments have the resources they need, and I want to hold the health departments harmless.

If you look at the workload for the county health departments, I think it reflects some other currents. I think it reflects what's happened with transitions with health-care delivery that have been prompted by the (Affordable Care Act). And so people who previously were getting care in the health departments are now able to get care in other ways.

Q: Why hasn't the Department of Health directly notified the families of the 9,000 kids who lost their eligibility for Children's Medical Services last year that they can be rescreened?

ARMSTRONG: The direct answer is that CMS is a managed-care plan. That would be perceived as marketing. We're prohibited from marketing.

Now, that's the direct answer. But I want to give you the broader answer here. So the Legislature in 2011 said that the Children's Medical Services Network would be a managed-care plan. That's the law, so it had to transition to managed care. Then in 2012, the Legislature said, "This is a plan for children with serious and chronic medical conditions." So we, I think, were fortunate to have a longer transition period for this, because this was a major cultural change. We worked steadfastly with a whole host of stakeholders to really get input, and in the end met some resistance from those who don't like managed care. My commitment is to see that the children with serious and chronic medical conditions receive the services that they need.

Q: CNN reported that Florida dumped its pediatric cardiology standards when Tenet, a hospital chain, contributed $200,000 to Florida Republicans. Fair or unfair?

ARMSTRONG: Unfair. There's no connection with that at all. So I think that this department is committed to making sure that children with serious and chronic medical conditions, to include our children with congenital cardiac disease, that they receive the care that they need.

What we have recognized was a gap between what was in statute and what was actually happening, so the Legislature eliminated the (CMS) cardiac subcommittee (which could put the program's providers on probation for failure to meet standards) in 2001, and yet it continued. And what it created was a regulatory framework for these programs. So when I became aware of this, I said, "Well, I appreciate the enthusiasm of this group, and so I think the solution is to acknowledge that this is not the right structure, and to create a Cardiac Technical Advisory Panel for Children's Medical Services." So that's exactly what I did. And it was designed to promote performance improvement. That's a very distinct model. And so we've moved forward with that, and the technical advisory panel has wonderful opportunities to influence programs in the state that offer pediatric cardiology services.

Major concern that the previous framework was really unfair --- to families, to parents, to children with serious congenital cardiac disease --- because it created the impression that the state had oversight when, in fact, we didn't. So that bothers me. And so I really think that we have created a framework for the sharing of information and best practices, and also emphasized the importance of public reporting of outcomes. So of the eight pediatric cardiac programs in the state, three publicly report. It's on the Society of Thoracic Surgeons website. I think right there is a golden opportunity for professionalism, to put your results online and to make that known to the parents, the guardians, the families, so that they can really see what's happening. And it turns out that when you start looking at things, you start improving things.

(One of the Tenet hospitals is St. Mary's in West Palm Beach, which CNN reported had an unusually high rate of infant deaths following heart surgery.) I think the sad reality is that we will likely never know the truth of what was going on. Just looking at what was out there with an organization that was starting up a new program, when you start up a new program, the denominator is pretty small. And so, my message is that we want to make sure that there are opportunities for improvement in performance of, in particular, pediatric cardiac surgery programs, and that professionals take the opportunity to publicly report their outcomes. And they have a ready-made vehicle to do it. Again, three of eight (programs) have already done it. So I think there's an opportunity to take that to eight of eight, and to then use this technical advisory panel to have the conversations about what's happening and what can be done to improve performance in general. Because you can always improve.

Q: Given the savings in treasure and heartache provided by the Early Steps early intervention program, why doesn't the Department of Health expand those services to more babies and toddlers with developmental disabilities and delays?

ARMSTRONG: I'm a big fan of Early Steps.

The good news is we are (screening more children for Early Steps eligibility). Last year we saw 3,000 more children than the previous year who were referred. The program takes referrals from any source. This is wide open. It's an entitlement program, so it's open to any family with a child who is at risk for developmental delay or has developmental delay. So I was very pleased to see that. In the end, the number of Individualized Family Support Plans (treatment plans detailing the services children will receive) to come out of that was smaller, and so that meant there were referrals that didn't meet the eligibility screen for Early Steps.

We're continuing to work with the local Early Steps providers. It really is a public-private partnership. What we're emphasizing is the importance of the portfolio of services and making sure all the services are available to any child who ultimately is enrolled. What we recognized … was that it was a sizable percentage of dollars going to administrative and operational expenses. And so I think we all agreed that these resources need to go to direct services for the kids. And "direct services" also includes case management, so I was pleased, working with the Legislature last year, that they actually put proviso language in to cap those expenses at 15 percent --- which is, if you look at other organizations, still pretty high. But it's out of respect for the local Early Steps providers that that was chosen, I think.

I'm pleased with the new approach that I'm seeing. We appreciated the additional funds from the Legislature last year ($10 million added to Early Steps' budget by Senate President Andy Gardiner).

And if you think about this program, the state really made its mark by significantly increasing the funding, so that now, general revenue constitutes two-thirds of the program, with the federal grant as one-third of the program. I think that sends a powerful message. And I am continuing to work with the Legislature to make sure that, one, we identify children at risk for developmental delay or with developmental delay; two, get the referral; and then three, get the services that they need.