The Home Care Association of Florida (HCAF) drew over 95 home care providers to its May 12th District 11 meeting held at the Double Tree Hotel in Miami. They came to learn about the impact of Senate Bill 1986 on Miami-Dade County.

Senate Bill 1986 passed in the Senate and House of Representatives this past legislative session without opposition and is expected to be signed into law by Governor Charlie Crist on July 1, 2009. Senate Bill 1986 designates Miami-Dade as a health care fraud area of concern and introduces new regulations pertaining to the licensing of agencies in an effort to prevent, reduce, and mitigate health care fraud, waste, and abuse in Miami-Dade and Broward counties. The Bill was sponsored by Florida State Senators Don Gaetz and Peaden Durrell.

The proposed new regulations mandate that no new agencies will be licensed until 2010 unless the agency had applied for accreditation by May 1, 2009 and submitted a license application by July 1, 2009. Currently, there are 894 home care agencies operating in Miami-Dade County serving a total population of 2,487,118. Regulations call for a new provider-to-population ratio of 5,000 persons per home care agency. It is estimated that there is an excess of 401 home care agencies serving the current population based on that formula. Miami-Dade County’s Medicare population age 65 and over is approximately 383,000, and this means that there is currently one agency per 335 Medicare beneficiaries in Miami-Dade County. It is estimated that approximately 519 of the 894 existing agencies are not needed to serve the existing Medicare population.

(l-r) Bobby Lolley, R.N., Executive Director Home Care Association of Florida and José R. Fox, President & CEO United HomeCare Services

Bobby Lolley, R.N., Executive Director of HCAF, gave an overview of the proposed regulations and Gene J. Tischer, Esq., Regulatory Compliance Director of HCAF, fielded many questions from concerned members seeking clarity on the details of the proposed new regulations. The Agency for Health Care Administration (AHCA) will have the authority to decide how the new legislative statues are interpreted and enforced.

Below are highlights of the proposed regulatory changes:

  • In Miami-Dade County only, AHCA may not issue a renewal license for a home health agency that has been administratively sanctioned during 2 years prior to the submission of licensure or for an intentional or negligent act affecting the health or safety of a client or for knowingly providing home health services to an unlicensed assisted living facility.
  • The sale or change of ownership of existing agencies will be prohibited in Miami-Dade County for one-year with the possibility of renewal for a longer period of time.
  • AHCA may not issue or renew a license to a provider that has more than one agency in operation in the same county.
  • AHCA may not pay for home health services for Medicaid beneficiaries, unless the services are medically necessary, and the services are ordered by a physician.
  • The physician ordering home health services for Medicaid enrollees must have examined the patient within 30 days preceding the initial request for services and bi-annually thereafter.
  • A Nurse Registry is exempt from the remuneration prohibition policy if it does not bill the Florida Medicaid or Medicare Program or have a controlling interest with an agency that is licensed, registered, or certified.

José R. Fox, District 11 Representative and Board Member of HCAF, raised concerns about amendments and exemptions that were added to Senate Bill 1986 that can potentially weaken the enforcement of the current law, which prohibits “remuneration.” Sections E & J of the bill use vague and difficult to enforce Federal Kickback Laws and Stark Laws to prosecute agencies that violate the “no remuneration” law. The current law is effective to prevent “pay to play” practices that encourage providers to give doctors and other referral sources gifts for client referrals. Gene J. Tischer, Esq. added that the HCAF membership was split on the remuneration issue.



Several prominent orthopaedic surgeons in South Florida believe that medical liability, or tort, reform could lower costs and improve patient care. Many physicians and surgeons, in fact, are concerned with the lack of medical liability reform in the proposals for national health care reform being discussed in Washington DC.

On the American Academy of Orthopaedic Surgeons Web site, Dr. Stuart Weinstein, past president of the AAOS and current chair of the Orthopaedic Political Action Committee, mentions that some of the unintended consequences as a result of the medical liability system include:

  • A decrease in access to care in a growing number of states and an increase in healthcare costs.
  • Access is affected as physicians move their practices to states with lower liability rates and change their practice patterns to reduce or eliminate high-risk services.
  • A fundamental change in doctor-patient relationships since many now adopt the attitude that “every patient as a potential lawsuit.”

“I’m very concerned with this issue primarily because if we are going to reform healthcare and try to address the issue of providing care/coverage to all of those uninsured people, I think the best way to do it is to drive down the cost for everyone else,” says Dr. Alan Routman of Ft. Lauderdale.

Like Dr. Weinstein, Dr. Routman believes that “defensive medicine” is driving up the cost of healthcare. Dr. Weinstein defines defensive medicine as providing medical services that are not expected to benefit the patient but are undertaken to minimize the risk of a subsequent lawsuit.

“If we want to make healthcare more affordable and more accessible for people, addressing the cost of defensive medicine is an important factor and totally overlooked by the people writing the healthcare bills in Washington,” says Dr. Routman. “They paid little attention to it.”

Dr. Kevin Shrock, also of Ft. Lauderdale, agrees.

“As far as tort reform is concerned, nothing is being promoted,” he says. “The President feels that this is something that the legal system should be addressing. The situation is such that the attorneys have made the rules and the laws as they are applied to medical malpractice. They set them down and we’re faced with the rules being imposed upon us. There’s nothing we can do except be there in Congress trying to help rewrite the laws which, historically, has not been our greatest strength. They’re still laying down the rules that favor themselves at the expense of physicians.”

Dr. Routman and Dr. Shrock both agree that tort reform could lead to lower healthcare costs.

“That’s the crux of the issue,” says Dr. Routman. “We order too many tests and over order imaging studies and expensive tests like MRI scans and CAT scans based on defensive medicine practices.”

So, as an example, Dr. Routman says imagine if 1,000 people go to the emergency room and complain of headaches. All of them will have a CAT scan or MRI scan of their head but there may be only one person that has a lesion on their head that is diagnosable on the scan.

“But we have to scan everyone to find the minuscule lesion and that is not cost-effective,” he says. “The cost-effective way to treat them is to treat them for their headaches and if they go away, like most do, you don’t need to order tests. If the one person who has a headache that persists, you can order a test for that person, so you don’t have to scan and radiate 999 others. If we didn’t have to worry about getting sued, then we can wait and order the scans more appropriately for the people who really need it and not waste our money and time on everyone getting scans.”

Worry about being sued has caused many physicians and surgeons to alter their practice patterns. While some are practicing defensive medicine, others are restricting the types of patients they will see or simply avoiding patients with complex problems or patients perceived as litigious.

Dr. Shrock urges his fellow physicians and surgeons to take action and to talk to their local legislatures to make tort reform a key issue in the plan to reform the healthcare system.

“We may get a seat at the table if we can demonstrate that we are trying to be part of the solution,” he says. “We’re trying to identify things that are wasteful in the system, and not just related to defensive medicine. If we can show ways to save money and implement ideas that can help make healthcare more efficient, then maybe we will get the chance to bring up the issue of tort reform with those people who have the power to include it in the discussion.”



Even in this challenging economic environment with healthcare legislation imminent, the need for improvement to our healthcare facilities stays consistent. Changes in healthcare construction in 2010 will showcase quality in lieu of quantity; that new projects will emphasize the most important needs within any facility and deliver them with excellence. In 2010, the new healthcare projects will be smaller in size but more responsive than ever to the patient and family.

One of the greatest challenges in the design of healthcare facilities is the creation of comfortable and appealing spaces that convey clinical excellence along with a sense of quality and comfort. From the views out the windows to the materials on the walls, odors in the air and pictures on the walls, the healthcare delivery needs to be within a complete package. Not only will patients sense the quality of the built environment, physicians and staff also respond in a positive way to the attributes of the spaces as well.

Maternity and outpatient facilities are areas of competition between hospitals and private providers. Design is a key element and in some cases is the distinction between similar medial services. Given the choice, patients will go to the better designed facilities based upon the perception of quality. New urgent care facilities need to convey respect for those patients in need of treatment, be they insured or not insured; the traditional physician offices need to set themselves apart from the pack through contemporary designs and interior finishes.

Green architecture and new materials will allow us to do more with less, allowing low maintenance design elements to achieve high expectations with long term cost savings.

Those of you in the healthcare industry who will continue to provide outstanding medical care to the public in 2010 will find that job becomes a little easier to achieve in a quality designed facility.



As we enter “heart month” 2010, and with the healthcare debate fresh in everyone’s mind, it is important to reflect upon two remarkable facts: 1) despite continued and remarkable advances in scientific knowledge and therapeutic capability, cardiovascular disease remains the leading killer of men and women in this country and increasingly throughout the entire world; and, 2) perhaps in no other sphere of human disease (except, arguably, injury due to trauma) does human behavioral choice play such a major role in disease initiation and progression.

Years ago, when speaking about risk factors for cardiovascular disease, we used to distinguish between “modifiable” and “non-modifiable” risk factors. However, upon more careful reflection, the distinction is somewhat misleading. For example, hypertension, lipid abnormalities, cigarette smoking and physical inactivity are all potentially modifiable. Age, family history and diabetes were viewed as non-modifiable. Upon more careful examination, it may well be that age per se is not the core issue—i.e. that the physiology of aging, a very poorly understood phenomenon in and of itself, somehow promotes or accelerates the atherosclerotic process. Although that may certainly be true, we have very little evidence in this area. What we do know, however, is that age represents the length of time an individual has been living with the disease. Atherosclerotic vascular disease is a complex process that progresses over years. Autopsy studies dating back to the Korean war demonstrated that one fifth of ostensibly healthy young Americans in the 1950’s already harbored evidence of the early states of the atherosclerotic process in their aortas.

The evolution of that process into a clinically significant event, such as a heart attack, may, depending upon a given person and the complex milieu of risk factors, take any number of years. In fact, even in the presence of disease in an individual with a genetic predilection, a clinical event may never occur. Therefore, the most compelling contribution of age to risk is the length of exposure to disease. If other risk factors are rigorously controlled, disease progression may be slowed, arrested or even reversed sufficiently to protect a given individual from a clinical problem. Likewise, one can clearly see that while one can do nothing with current medical technology to alter one’s genetic predisposition (assuming that future studies will continue to tease apart the complex array of genetic markers for this multifactorial disease process) to cardiovascular disease, one may be able to accomplish a tremendous amount through control of known risk factors to help protect the genetically “at risk” individual from a clinical problem. Lastly, although we used to think of diabetes as somewhat of an unpreventable disease, the current epidemic of obesity is bringing with it an inexorable rise in the incidence of insulin-resistance “Type II” diabetes. Currently 33% of adults are obese, 29% exhibit signs of prediabetes and 7.7% have diagnosed diabetes. Alarmingly, almost a third (31.9%) of children aged 2 to 19 years are also overweight or obese. We are currently seeing the tip of the iceberg.

The news from the “modifiable” risk factors is far from optimal as well. High rates of men (25%) and women (20%) continue to smoke, despite that fact that this risk factor is synergistic with the others. Unlike the risk of cancer, which is cumulative, much of the risk of cardiovascular disease recedes immediately upon cessation of smoking. One third of adults have hypertension, while only two-thirds of these are being treated, and less than one half are meeting currently recommended therapeutic goals. Approximately one sixth of the adult population has elevated serum lipids, but less than half are receiving lipid-lowering therapy. Among adolescents, 31% of females and 18% of males recently reported no vigorous physical activity within the previous 7 days, while 59% of adults report engaging in no regular vigorous activity.

Discouraging? Perhaps. But the “full” half of the glass teaches us that the potential for improvement rests largely in our own hands. It is for this reason, the Florida Heart Research Institute, while pursuing an aggressive and innovative program of scientific research, balances these efforts with an active program of screening and education, especially in currently underserved high risk populations. It is only through translating our scientific knowledge into individual and community awareness through education that we can begin to harvest the benefits of our knowledge and reduce the incidence and danger of this lethal disease.



Given the complex, health-related challenges that often burden the elderly, delivering healthcare tailored to their needs can be daunting. On the other hand, the Miami Jewish Home and Hospital for the Aged has cared for the elderly in such a focused way since its inception in 1945. Today, this institution stands out as the most comprehensive, not-for-profit, geriatric healthcare center in the Southeastern United States.

“When you walk onto this campus, you enter a rare care-giving environment for older people. Our system of care supports those who live independently and those needing different levels of medical care and support,” said Fred Stock, Chief Operating Officer and Executive Director.

Older adults who live independently with some support reside in 98 modern, tastefully designed studios and one-bedroom suites in the Irving Cypen Tower. Here, they access recreational, emotional, physical, and medical support unavailable in the community.

As the elderly age, they may need a higher level of care and choose to live in the Hazel Cypen Tower, an assisted living facility consisting of 92 apartments for residents who prefer to live independently, but who require a certain level of physical care. “Older people who live here don’t need to be in a nursing home, because they are not sick. But they do need a level of care they cannot get in an independent setting,” said Stock

A major clinical situation may create the need for greater supervision in the 462-bed nursing home on the campus of the Miami Jewish Home and Hospital for the Aged. Specialized units attend to the needs of dementia patients and residents whose clinical needs require specialized medications, more monitoring, and greater medical and registered nurse supervision. The home is fully accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

“Some patients in the nursing home require only short-term care following a broken hip or knee. Some may have cardiac issues requiring rehabilitation. Currently, about 30 to 40 such patients participate in the rehabilitation program on average for 30 days, and then return to the community to be assisted with home-care services,” said Stock.

In February 2004, the home launched a service that accommodates patients suffering from extremely complex medical conditions – pulmonary problems, for example – who may need to continually be on a ventilator. The home currently serves the needs of 15 residents requiring this level of medical care.

With few facilities serving patients this way in Miami-Dade County, the service addresses a major underserved need in the area and complements the work of hospitals in the region. “Besides the medical and nursing staff serving this ventilator unit, we provide the services of a full-time social worker and recreational therapist to assist patients,” Stock emphasized.

The ventilator service underscores the role of the Miami Jewish Home and Hospital for the Aged as a resource for Dade County and southern Broward County. “We take a holistic approach to patient care in a comfortable environment. We take these people out of bed and put them in wheelchairs so they can be outside. The quality of life that we provide on a long-term basis for people who are so clinically complex is much greater than they could find in a hospital,” he said.

According to Stock, the home offers a level of nursing, medical, social work, recreation, and rehab services that few other nursing homes can match. The home employs a medical staff of three, full-time physicians and four, full-time nurse practitioners.

Just as important, the staffing ratio at the home consistently exceeds the per-patient nursing ratios mandated by the State of Florida. “The state ratio for certified nursing assistants is 2.6 hours of nursing care per resident. We run between 2.8 and 2.9 hours for certified nursing assistants. For LPNs and RNs the state ratio is 1 hour of care per resident. We run at about 1.26 hours of care,” Stock said.

In an industry that suffers from high staff turnover, the Miami Jewish Home and Hospital for the Aged prides itself on the longevity of its staff. Stock attributes this to hiring the best people and offering them an unparalleled wage and benefit program. In fact, he anticipates that by July 2004, the home will be one of 11 nursing homes out of 700 in Florida to be designated as meeting the Florida Gold Seal standard.

A stable staff assures that the home will continue to serve the aged with high-quality continuum of care as it has now for nearly 50 years.

Fred Stock may be reached at (305) 751-8626 or at fstock@mjhha.org.