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Doctors insist on lead role in any merger

By Jim Saunders and Carol Gentry
Gov.-elect Rick Scott's transition team offered a controversial proposal this week to merge the Florida Department of Health and Agency for Health Care Administration. But doctors and public-health advocates immediately said one thing is not negotiable: A physician needs to be in charge.

The Florida Medical Association and the Florida Public Health Association said it is critical that a doctor have direct access to the governor's office to prevent public health from getting overshadowed by other issues, especially Medicaid.

The current Secretary of DOH, Ana Viamonte Ros, is an M.D. So were her predecessors: James Howell under the late Gov. Lawton Chiles and then three physicians -- Bob Brooks, John Agwunobi and Roni Francois -- under former Gov. Jeb Bush.

AHCA, by contrast, has been led mostly by non-physicians. Elizabeth Dudek, long-time administrator at AHCA, is interim Secretary, following Tom Arnold, a former Medicaid division director.

The transition team had said the merged agency should have a physician as State Health Officer and be in charge of quality-of-care issues. But the team didn't say the Secretary needed to be a doctor.

That provoked an immediate response from FMA, a statement quoting Executive Vice President Timothy Stapleton: "Due to bio-terrorism threats and other potential public health epidemics, it is imperative that a medical doctor be in charge of protecting the citizens of our state. This is a public safety concern and the Governor must have a medical doctor advising him of these issues rather than another government bureaucrat."

Sandra Magyar, executive director of the Florida Public Health Association, added: "The head of the agency has got to be a doctor.''

Alan Levine, who led the health and human services transition team, said the State Health Officer would naturally be called on to advise the governor's staff in times of epidemics and disasters. But that doesn't mean the Secretary of the entire department requires a medical-school degree, he said.

"It needs to be someone who’s a strong manager," he said, someone who has the savvy to figure out cost-efficiencies and the courage to tell the Legislature that it needs to kill or outsource some programs.

When advocates for the disabled bring people in wheelchairs to testify against closing a program they favor or against extending Medicaid managed care to new counties, he said, "the Secretary of the department has to be able to step up and take the heat."

Levine mused, "You don’t hear the Florida Nursing Association saying the head of the department ought to be a nurse."

'Overlaps and redundancies'

It is far too early to know whether the transition team's proposal to create a mammoth agency will be approved. Already, critics are likening the idea to re-creating the old Department of Health and Rehabilitative Services -- an assertion Levine denies, saying child and family welfare programs should remain independent.

The proposal comes at a time of great unrest in Tallahassee about the state's health-care programs. Sen. Joe Negron, chair of Health and Human Services Appropriations, said this morning he is open to considering "any bold and innovative ideas that will help us manage health and human services in a better way.''

"My opinion (is), there are overlaps and redundancies that hopefully can be avoided in the future,'' said Negron, R-Stuart.

At a minimum, it appears that lawmakers are ready to overhaul DOH. The House pushed such a proposal during the 2010 legislative session, and Negron said he thinks the Senate will also focus more on reorganizing the department during the 2011 session.

The transition-team report, issued Monday, offered a blistering critique of DOH and called for sweeping changes, including the possible merger with AHCA, the Agency for Persons with Disabilities and the Department of Elder Affairs.

It describes, for example, the department's response to a legislative requirement that it review its operations and justify the existence of programs and divisions. Lawmakers clearly wanted to see if there were ways to pare the agency.

But after pondering for months, DOH officials suggested they could find virtually no fat to cut, according to the transition-team report. They were willing to give up less than 1 percent of the budget and only nine positions out of many thousands (The report said DOH has nearly 22,000 staff positions, 10 percent of which are vacant; however, a House analysis this year put the number at 17,000).

DOH’s structure discourages the best and the brightest from taking initiative, said Levine. “It’s a culture that says it’s okay to be mediocre, okay to be satisfactory.”

Everyone is average

The report offered a couple of specific examples:

--A transition team member who asked a receptionist for directions got no help; the employee pointed to the clock and noted that it was 6:58 a.m. and office hours didn’t start until 7 a.m.

--Nearly everyone gets a “3” (satisfactory) rating on evaluations because of a human-resources policy that requires supervisors who give above- or below-average ratings to write an explanation.

While Secretary Ana Viamonte Ros has been told to vacate the office by early January, “I don’t think they were pointing fingers at any one individual,” Levine said. “It’s structured to engender that culture.”

The report portrays a department that lacks a focused mission. At the request of lobbyists and vendors, the Legislature has added programs that the department never sought but had to carry out.

When the Legislature told DOH to set up a reorganization plan, Levine said, it was a perfect opportunity to hit the “reset” button and shear off all the accumulated dross. But that didn’t happen.

The report calls for the department to largely get out of the business of providing primary care, since in many counties it duplicates the work of federally qualified health centers and other clinics. Health departments should do direct care only as a last resort, the report says.

Will 2011 be the year?

In many ways, the report dovetails with criticism that some lawmakers raised during the 2010 legislative session, when the House called for a department reorganization.

"I think there's certainly an opportunity to get that done this year (2011),'' said House Health Care Appropriations Chairman Matt Hudson, a Naples Republican who has been one of the department’s most vocal critics.

Former AHCA Secretary Doug Cook said he could see advantages in a merger. “There is a lot of coordination that should be taking place,” he said.

Former Medicaid director Bob Sharpe agreed. “It’s hard to manage a large organization but there are benefits to be gained. The concept is good.”

But Dr. Leslie Beitsch, associate dean for health affairs at the Florida State University Medical School, said he was disappointed in the transition-team report. He said he is concerned about its recommendation of merging DOH with AHCA, which is primarily involved in running the Medicaid program and has a much smaller footprint.

"It's a minnow-whale merger,'' said Beitsch, who is among a group of longtime public-health advocates who have made recommendations they hope the Legislature will consider. "It's a relationship of very different people.''

The transition team offered wide-ranging criticism of the department, with part of it stemming from what members saw as a lack of focus.

"The lack of a clear mission has resulted in the scope and size of the department to expand substantially over the years,'' the report said. "As well-intended health-care providers try to improve the health and welfare of those that they serve, there is an opportunity, without a clear and narrow mission, for natural 'mission creep' to occur.''

Hudson said part of the mission-creep issue stems from whether the department or the private sector should provide services. And if the department is a better fit, how should it carry out the job?

"I think the first question of government is, should government be the one providing this service?'' Hudson said.

Transition-team members outlined six core services for the department, such as monitoring and preventing the spread of communicable diseases, emergency and disaster-preparedness response and being a care provider of "last resort'' for Floridians.

But Beitsch said the list falls short of national standards for public health and also leaves out important duties. As an example, he said it does not include activities aimed at preventing water contamination.

"Who's paying attention to that kind of stuff?'' he asked. "The answer in looking at this is, no one will.''