Medical costs
to stop the excessive hospital readmissions that may be unnecessary and drive up costs.
“We have preventable admissions, readmissions into hospitals and preventable use of the emergency departments,” she said. “We are trying to isolate what could have been available in the community that would have prevented that readmission.”
Mental health
The state’s Medicaid program is the dominant payer for mental health patients seeking care. Mental health has become a huge concern in the state, Mayhew said.
“We need a sea-change in the way in which we support the continuum of services for individuals with mental illness and substance use disorder,” she said. “There are some pilots and initiatives we are looking at.”
In Central Florida, the state has launched a pilot to focus on housing stability for people with mental illness. While Medicaid can’t pay for rent, it can pay for housing services that will help keep mentally ill Floridians off the streets and encourage them to get treatment.
Access to mental health has been a much discussed concern as well. Floridians complain about waiting lists for therapists and psychiatrists and difficulty finding substance abuse programs.
“The first focus for us has to be when someone asks for help, they need to know where to turn and the door has to be open,” Mayhew said. “You’ve got to be able to embrace them when they are ready.”
Mayhew said the state has obstacles: Medicaid is not reimbursing at rates and with incentives that drive quality; there is a lack of mental health professionals in the state; and when people use the ER for mental health crises, there is a lack of follow up after discharge.
To address the challenges, she said her agency is building a dashboard for every plan in the
Medicaid program to hold them more accountable for mental health treatment, outcomes and follow-up on hospital discharges after a crisis.
She also wants to better leverage telehealth. “Kids these days are going to be more comfortable if it’s an app on their phone,” she said. “It still needs to be the same high quality.”
The state has built a Florida Health Price Finder to allow people to compare health care costs. Mayhew says her agency refreshed the website in November with new information based on more detailed average costs for procedures. “We tried to bundle them so you see the costs not just for surgery but also for the physicians, operating room and other costs,” she said. “If you are doing a knee replacement, you could price shop from one hospital to the next.”
Mayhew said struggling with a
“What should a cost?”
Walmart recently announced an effort to curb its health care spending, claiming approximately one third of medical costs in the U.S. are raised by unneeded treatment. Now, the retailer is testing programs that prevent users from running up unnecessary or avoidable costs. Mayhew said she wants to study how Florida could benefit from a similar program.
“We need to keep our efforts underway to create greater transparency, to drive efficiency, but I think there’s a lot of opportunity to look at what procedures should not be happening.”
Another key area for medical cost savings in Florida is the importation of prescription drugs. The federal government has given the OK for Florida to import drugs from Canada at lower prices and make them available to participants in state-funded entities such as Medicaid. The state now needs to build an infrastructure to make it happen and get Canada on board.
“This is intended to be disruptive ... to get at the stranglehold her agency is basic question: surgical procedure
that pharmaceutical manufacturers have had on this country. We believe it will create pressure for change,” Mayhew said.
Nursing home care
The Florida Agency for Health Care Administration oversees the state’s 695 nursing homes and 3,093 assisted living facilities. Claims of abuse, neglect or mistreatment flow in regularly.
“It is a huge concern that some of our most vulnerable individuals are in settings that make them more vulnerable to abuse and neglect,” Mayhew said. “It is the responsibility of my agency to oversee, regulate and protect them.”
Mayhew said her agency has identified several ways to improve the quality of care.
First, she has made a request for additional staffing to inspect nursing homes. As the population has increased in the state, the number of nursing homes has expanded, too. “We need to make sure we have adequate staffing to get out there and identify risks and red flags,” she said.
Second, the agency has asked the Legislature to allow it to give it more flexibility around inspections to spend less time in highperforming, long-term care facilities and more time inspecting problem providers. Critics of the legislation worry about negative ramifications of cutting back on the administration’s inspection mandates.
“If you are a high performer, we don’t need to be in there as frequently,” Mayhew said. “Now, we will always do a sampling so you need to be prepared that we will come in. We want to have a risk stratification so we can effectively deploy our staffing resources to where the acute needs are.”
Mayhew said she also wants to tap into an overlooked funding source and spend it on staff training to improve the quality of care at long-term care facilities.
“Any penalties we assess nursing homes go into an account that we oversee that the federal government controls,” Mayhew said. “The state previously has not leveraged or maximized the
availability of those resources, so I am putting together a plan to more aggressively use those dollars.” There is more than $28 million in that fund, she said.
A big issue with nursing homes has been patient safety during and after a hurricane. After 12 heatrelated deaths in a Hollywood facility after Hurricane Irma, the state now requires long-term care facilities to have generators.
Some still are not in compliance with the law. Mayhew said she has given facilities another extension until April 1 to have their generators onsite before the 2020 hurricane season.
“I was reluctant to allow extensions beyond the end of the year,” she said. “Many of these facilities are going beyond what the rule requires . ... We didn’t anticipate the time it has taken for the local permitting and for my staff to review their construction plans.”
During Dorian, hundreds of long-term care facilities were out of compliance and scrambled to bring temporary generators onsite. Mayhew said that won’t happen in the future.
“Every facility has to have their generator onsite ... even if it’s temporary, they must have it on-site, so if there is an emergency they are not dependent on it being transported.”
At this time, she said, about 98% of all assisted-living facilities are in compliance, but about 200 nursing homes are not. “They may have generators, but they are still waiting for some level of local permitting, so that is what we are trying to focus on right now.”
Health care availability
In the last few years, Florida has passed several laws to encourage competition.
Last year, Florida removed a barrier to health care competition by eliminating the Certificate of Need requirement. Now, providers can expand health care services without having to prove a need in a geographic area. Mayhew said the Florida consumer should benefit — if providers are strategic.
“We know that increasing the supply can help stimulate price and quality competition. What we have to be clear about, though, is when business decisions and investments are made, if assumptions are wrong and they have financial losses, what we can’t have is an expectation there will be a bailout with taxpayer dollars.”
Mayhew said because the state — and its large population — represents an opportunity, health care companies with an interest in coming to Florida are closely watching the rules the Legislature proposes.
“The challenge is you have two dominant public payers — Medicare and Medicaid — and that can sometimes be counterproductive to the competitive markets we are accustomed to in other parts of the country,” she said.
Still, Mayhew acknowledges she wields significant control over encouraging competition through her oversight of $29 billion in Medicaid spending. She is promoting telehealth, telemonitoring and expansion into underserved areas.
“As hospitals expand, we can look across ZIP codes and tie our payments to their success in improving outcomes for the population being served.”
Mayhew said she recognizes some of the big problems in health care: people are scared to go to the doctor because they are unsure of their out of pocket costs; if they have Medicaid, they are worried they can’t get into a doctor, and if they are physicians, they are frustrated with the administrative burden.
Her job requires addressing those concerns and keeping Floridians healthy.
“In this role and in the managed care environment, I am in the driver’s seat,” she said. “The accountability lies at my feet for how $29 billion is spent and for the health outcomes for nearly 4 million Floridians, and I have to guard against ceding that control.”