The Florida Senate BILL ANALYSIS AND FISCAL IMPACT STATEMENT (This document is based on the provisions contained in the legislation as of the latest date listed below.) Prepared By: The Professional Staff of the Committee on Fiscal Policy BILL: CS/SB 7016 INTRODUCER: Health Policy Committee SUBJECT: Health Care DATE: January 16, 2024 REVISED: ANALYST STAFF DIRECTOR REFERENCE ACTION Brown, et al. Brown HP Submitted as Comm. Bill/Fav 1. Brown, et al. Yeatman FP Fav/CS Please see Section IX. for Additional Information: COMMITTEE SUBSTITUTE - Substantial Changes I. Summary: CS/SB 7016 revises or creates numerous provisions of Florida law relating to the state's health care workforce, health care services, health care practitioner licensure and regulation, health care facility licensure and regulation, the Medicaid program, and health-care-related education programs. Specifically, the bill revises: The Dental Student Loan Repayment Program (DSLR Program); The Florida Reimbursement Assistance for Medical Education (FRAME) Program; The Telehealth Minority Maternity Care Program; The Statewide Medicaid Residency Program (SMRP); and The Access to Health Care Act. The bill amends statutes relating to: The definition of and standards for clinical psychologists; The definition of and standards for psychiatric nurses; Mobile response team standards; Licensure for foreign-trained physicians; Certification of foreign medical schools; Medical faculty certificates; Autonomous-practice nurse midwives; The Florida Center for Nursing’s annual report; Developmental research laboratory schools; and The Linking Industry to Nursing Education (LINE) Fund. BILL: CS/SB 7016 Page 2 The bill creates: The Health Care Screening and Services Grant Program; An advanced birth center designation; The Training, Education, and Clinicals in Health (TEACH) Funding Program; Emergency department diversion requirements for hospitals and Medicaid managed care plans; A requirement for the Agency for Health Care Administration (AHCA) to produce an annual report entitled “Analysis of Potentially Preventable Health Care Events of Florida Medicaid Enrollees;” A requirement for the AHCA to seek federal approval to implement an acute hospital care at home program in Florida Medicaid; Limited licenses for graduate assistant physicians; and Temporary certificates for physician assistants (PA) and advanced practice registered nurses (APRN) to practice in areas of critical need. The bill provides that Florida will enter into the Interstate Medical Licensure Compact, the Audiology and Speech-Language Pathology Interstate Compact, and the Physical Therapy Licensure Compact. The bill contains numerous appropriations related to the programs and revisions listed above, as well as for provider reimbursement in the Medicaid program. See Section V. of this analysis. Except as otherwise provided, the bill takes effect upon becoming law. II. Present Situation: The Health Care Workforce Shortage The term “health care workforce” means a health care professional working in health service settings. Physicians and nurses make up the largest segments of the health care workforce. 1 The United States has a health care professional shortage. A Health Professional Shortage Area (HPSA) is a geographic area, population group, or health care facility that has been designated by the federal Health Resources and Services Administration (HRSA) as having a shortage of health professionals. As of December 3, 2023, there are 8,544 Primary Care HPSAs, 7,651 Dental HPSAs, and 6,822 Mental Health HPSAs nationwide. To eliminate the shortages, an additional 17,637 primary care practitioners, 13,354 dentists, and 8,504 psychiatrists are needed, respectively.2 1 Spencer, Ph.D., M.PH., Emma, Division Director, Division of Public Health Statistics and Performance Management, The Department of Health, Florida’s Physician and Nursing Workforce, presented in Florida Senate Health Policy Committee meeting Nov. 14, 2023, published Nov. 15, 2023, (on file with the Senate Health Policy Committee). 2 U.S. Department of Health and Human Services, Health Resources and Services Administration, Health Workforce Shortage Areas, available at https://data.hrsa.gov/topics/health-workforce/shortage-areas (last visited Jan. 14, 2024). BILL: CS/SB 7016 Page 3 This shortage is predicted to continue into the foreseeable future and will likely worsen with the aging and the growth of the U.S. population3 and the expanded access to health care under the federal Affordable Care Act.4 Aging populations create a disproportionately higher health care demand due to seniors having a higher per capita consumption of health care services than younger populations.5 Additionally, as more individuals qualify for health care benefits, there will necessarily be a greater demand for more health care professionals to provide these services. Health Care Shortage Designations The HRSA designates health care shortage areas in the U.S. The two main types of health care shortage areas designated by the HRSA are HPSAs and Medically Underserved Areas (MUA). Health Care Professional Shortage Areas There are three categories of HPSA: primary care, dental health, and mental health.6 HPSAs can be designated as geographic areas; areas with a specific group of people such as low- income populations, homeless populations, and migrant farmworker populations; or as a specific facility that serves a population or geographic area with a shortage of providers.7 As of September 30, 2023, there are 304 primary care HPSAs, 266 dental HPSAs, and 228 mental health HPSAs designated within the state. It would take 1,803 primary care physicians, 1,317 dentists, and 587 psychiatrists to eliminate these shortage areas.8 Each HPSA is given a score by the HRSA indicating the severity of the shortage in that area, population, or facility. The scores for primary care and mental health HPSAs can be between 0 and 25 and between 0 and 26 for dental health HPSAs, with a higher score indicating a more severe shortage.9 3 The U.S. population is expected to increase by 79 million people by 2060, and average of 1.8 million people each year between 2017 and 2060. See U.S. Census Bureau, Demographic Turning Points for the U.S.; Population Projections for 2020 to 2060 (February 2020), available at https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf (last visited Jan. 14, 2024). 4 Association of American Medical Colleges, The Complexities of Physician Supply and Demand: Projections from 2019 to 2034, (June 2021), available at https://www.aamc.org/media/54681/download (last visited Jan 14, 2024). 5 The nation’s 65-and-older population is projected to nearly double in size in coming decades, from 49 million in 2016 to 95 million people in 2060. See: U.S. Census Bureau, U.S. and World Population Clock, available at https://www.census.gov/popclock/, and U.S. Census Bureau, U.S. Population Projected to Begin Declining in Second Half of Century (Nov. 9, 2023), available at https://www.census.gov/newsroom/press-releases/2023/population-projections.html (both sites last visited Jan. 14, 2024). 6 Health Professional Shortage Areas (HPSAs) and Your Site, National Health Service Corps, available at https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/workforce-shortage-areas/nhsc-hpsas-practice-sites.pdf, (last visited Jan 14, 2024). 7 What is a Shortage Designation?, HRSA, available at https://bhw.hrsa.gov/workforce-shortage-areas/shortage- designation#hpsas, (last visited Jan 14, 2024). 8 Bureau of Health Workforce, Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services, Designated Health Professional Shortage Areas Statistics, Fourth Quarter of Fiscal Year 2023 (Sept. 30, 2023), available at https://data.hrsa.gov/topics/health-workforce/health-workforce-shortage-areas?hmpgtile=hmpg- hlth-srvcs (last visited Jan 14, 2024). To generate the report, select “Designated HPSA Quarterly Summary.” 9 HRSA, Scoring Shortage Designations, available at https://bhw.hrsa.gov/workforce-shortage-areas/shortage- designation/scoring, (last visited Jan 14, 2024). BILL: CS/SB 7016 Page 4 Primary Care HPSAs Below is a map of primary care HPSAs in Florida with their associated HPSA scores.10 10 The three maps were generated with HRSAs map tool, available at https://data.hrsa.gov/maps/map-tool/, (last visited Jan 14, 2024). BILL: CS/SB 7016 Page 5 Mental Health HPSAs Below is a map of mental health HPSAs in Florida with their associated HPSA scores. BILL: CS/SB 7016 Page 6 Dental HPSAs Below is a map of dental health HPSAs in Florida with their associated HPSA scores. BILL: CS/SB 7016 Page 7 Medically Underserved Areas MUAs identify an area with a lack of primary care access. MUAs have a shortage of primary care health services within geographic areas such as: A whole county A group of neighboring counties A group of urban census tracts A group of county or civil divisions.11 Below is a map of the MUAs in Florida. 11 National Health Service Corps, Health Professional Shortage Areas (HPSAs) and Your Site, available at https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/workforce-shortage-areas/nhsc-hpsas-practice-sites.pdf, (last visited Jan 14, 2024). BILL: CS/SB 7016 Page 8 The Florida Physician Workforce In 2020, there were 286.5 physicians actively practicing per 100,000 population in the United States.12 There were 94,925 total allopathic and osteopathic physicians with an active license in Florida.13 Of these active physicians, 79,045 or 83.27 percent renewed their medical licenses from July 1, 2021–June 30, 2023, and responded to the statutorily required workforce survey. The DOH used that survey in preparation of the 2023 Physician Workforce Annual Report, which made the following findings regarding the adequacy of Florida’s physician work force providing direct patient care to Floridians: Of these physicians, there were 56,769 or 72 percent that provide direct patient care. Those who renewed during this survey cycle and responded to the survey, were 87.97 percent allopathic physicians and 12.03 percent osteopathic physicians; Statewide, 35.82 percent of Florida’s 67 counties have a per capita rate of 10 or fewer physicians per 10,000 population; The physician work force survey showed that 98.11 percent of physicians work in urban counties while 1.89 percent work in Florida’s 31 rural counties. In all of the rural counties, at least 20 percent of physicians are primary care providers; Among physicians, 34.17 percent or 19,396 are age 60 and older; For physicians under age 40, the percentage of female physicians is 46.21 percent; The top three specialty groups for physicians providing direct patient care in Florida are: o Internal medicine (28.11 percent or 15,724); o Family medicine (14.64 percent or 8,191); and o Pediatrics (7.89 percent or 4,413); Primary care physicians account for 31.63 percent of physicians providing direct patient care; 77.45 percent or 40,132 of physicians practice in an office setting and 20.17 percent or 10,451 practice in a hospital; 75.28 percent of physicians report they accept patients with Medicare; 64.13 percent of physicians report they accept patients with Medicaid; A total of 9.56 percent or 5,429 of physicians providing direct patient care plan to retire in the next five years; and Just over 2 percent or 1,181 of physicians practice in Florida’s rural counties.14 IHS Markit Report – Physician Supply and Demand Deficit In 2021, HIS Markit prepared a report for the Safety Net Hospital Alliance of Florida and the Florida Hospital Association that examined Florida’s statewide and regional physician workforce 12 Association of American Medical Colleges, The Complexities of Physician Supply and Demand: Projections from 2019 to 2034, (June 2021), prepared for the AAMC by HIS, Ltd., p. viii, available at https://www.aamc.org/media/54681/download (last visited Jan 14, 2024). This includes both allopathic and osteopathic physicians. 13 Department of Health, 2023 Florida Physician Workforce Annual Report, Nov. 1, 2023, available at https://www.floridahealth.gov/provider-and-partner-resources/community-health- workers/HealthResourcesandAccess/physician-workforce-development-and- recruitment/2023DOHPhysicianWorkforceAnnualReport-FINAL.pdf (last visited Jan 14, 2024). 14 Id. BILL: CS/SB 7016 Page 9 with projections on workforce changes out to 2035.15 Between 2019 and 2035, the report estimates that while physician supply will increase by six percent overall and by three percent to four percent for primary care, the demand for physician services in Florida will grow by 27 percent.16 While there is already supply and demand deficits for physician services (estimated by 2019 numbers to be at 1,977 for primary care and 1,650 for non-primary care), the significant growth in the demand for physician services that may outpace the growth in the physician workforce over the next decade is estimated to create a shortfall of 7,872 in primary care physicians by 2035 and an overall decline in the adequacy for all non-primary care specialties from 95 percent in 2019 to 77 percent in 2035.17 The following chart details the estimated supply and demand deficits by physician specialty in 2035:18 15 Florida Statewide and Regional Physician Workforce Analysis: 2019 to 2035: 2021 Update to Projections of Supply and Demand 16 Id. at V. 17 Id. at VI. 18 Id. at 10. BILL: CS/SB 7016 Page 10 Florida Center for Nursing In 2001, the Florida Legislature created s. 464.0195, F.S., establishing the Florida Center for Nursing “to address issues of supply and demand for nursing, including issues of recruitment, retention, and utilization of nurse workforce resources.” The primary statutory goals address collecting and analyzing nursing workforce data; developing and disseminating a strategic plan for nursing; developing and implementing reward and recognition activities for nurses; and promoting nursing excellence programs, image building, and recruiting into the profession. The Florida Center for Nursing conducts an analysis of licensed practical nurses (LPN), registered nurses (RN), and APRNs annually to assess Florida’s nurse supply, including the numbers of nurses, demographics, education, employment status, and specialization pursuant to s. 467.019, F.S. The Florida Center for Nursing is required to submit a report to the Governor, the President of the Senate, and the Speaker of the House of Representatives by January 30 each year through January 30, 2025. The Florida Nursing Workforce During the 2020-2021, license renewal cycle, Florida was home to 441,361 active nursing licenses made up of 69,511 LPN; 326,669 RN; and 45,181 APRN licenses. These data reflect licensees who held either single-state or multi-state licenses. Multi-state licenses made up 19.6 percent of LPN licenses, 22.2 percent of RN licenses, and 16.9 percent of APRN licenses. There were 366,235 nurses in Florida (83 percent) that responded to the FCN Nursing Workforce Survey.19 The median ages of nurses was 46 for RNs, 48 for LPNs, and 45 for APRNs. The table below provides a comparison of the ages of the LPNs, RNs, and APRNs that make up Florida’s nursing workforce to the U.S. nursing workforce and state and U.S. census data.20 19 Florida Center for Nursing, The State of the Nursing Workforce in Florida, 2023, Tampa, Fl., prepared by Rayna M. Letourneau, PhD, RN, E.D., available at https://www.flcenterfornursing.org/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download