Legislation aimed at fighting opioid abuse in Florida has raised concerns among doctors over provisions to impose limits as short as three days for prescriptions of the potentially addictive painkillers.
Physicians have mounted strong opposition to provisions being considered by House and Senate committees to limit prescriptions for Schedule II painkillers like Oxycontin and Fentanyl to three days — or seven days in some cases if a physician documents it as medically necessary.
Doctors have told lawmakers that such limits on prescriptions are not enough for some cases of acute pain. They also argue the limits would go too far in limiting flexibility for practitioners, and would place too much burden on patients — some of whom may have limited access to transportation and limits on their mobility — to renew prescriptions.
Tallahassee orthopedic surgeon Hank Hutchinson told a House Appropriations committee hearing last month that the proposed limits on prescriptions are too arbitrary.
“I don’t think any of us as competent physicians would write a prescription that wasn’t medically necessary,” he said. “Patients are different. Their pain is different. And we treat them all differently.”
Rep. Jim Boyd of Bradenton said that all parties have been “very open minded in working toward a solution.”
“We’re not trying to tell the doctors and the medical community how to practice,” said Boyd, a Republican who represents an area that had the state’s highest per capita death rate in 2016 for fentanyl analogs, which are synthetic opioids similar to fentanyl but more powerful. “They understand it is a huge epidemic.”
Gov. Rick Scott declared the opioid epidemic a public health emergency last May. The Florida Department of Law Enforcement reported a 35 percent increase in opioid-related deaths from 2015 to 2016.
Twenty four states since 2016 have passed legislation that imposes some limits or guidelines on prescribing opioids. Only two — Kentucky and Minnesota — have statutory limits of three or four days.
State Sen. Lizbeth Benacquisto, a Republican from Fort Meyers, said discussions are continuing on allowing extended dosages for major procedures, such as heart surgery and hip replacements.
Florida Orthopedic Society Executive Director Fraser Cobb said he has offered suggestions to both Benaquisto and Boyd, but isn’t hopeful about a compromise. Besides transportation and mobility issues, especially with seniors, his organization’s concerns are about how pain can be defined in law.
Orthopedic surgeon Brandon Luskin of Boynton Beach echoes the same concerns, saying there isn’t any leeway when things are put into law.
“There are guidelines that allow doctors to tailor and modify plans for patients and not be under penalty,” he said. “When you put something into law either you are following it or breaking it.”
Both bills, each of which has one more committee stop before reaching the floor, contain tenants of Scott’s proposals. Besides the prescription limits, it includes a revamp of a statewide database to monitor prescriptions and to crack down on unlicensed pain management clinics.
Lauren Schenone, press secretary for Scott, said the governor has met with all parties for their input on the legislation.
“The Governor’s proposal is based on guidelines from the Centers for Disease Control and is applicable only to acute pain, not chronic pain such as cancer and hospice care,” she said.
“I really believe that everyone who has voiced their thoughts and concerns have one goal — to help stem the tide of new addiction,” Benaquisto said.
After telehealth providers offered up free services to victims of Hurricane Harvey last week, the telehealth community is replicating the same approach as Hurricane Irma churns through Florida.
In the wake of unprecedented devastation throughout Southeast Texas from Hurricane Harvey, telemedicine vendors like American Well, MDLive, Doctor on Demand and Teledoc offered free services for victims of the storm. Florida-based Nemours Children’s Health also chipped in with free care via the system’s CareConnect platform.
Now Florida is staring down its own disaster response with Hurricane Irma flooding parts of the states and those same vendors are again stepping in to provide support. American Well began offering services on Friday, expanding its reach from Texas and Louisiana to Florida, Georgia, North Carolina and South Carolina.
Nemours also began providing complimentary visits to families in Florida and Georgia on Friday, according to a release.
Others, like LiveHealth Online and Florida Hospital, are also offering free telehealth services. With locations in Orlando, Tampa and Daytona Beach, Florida Hospital is providing care through its eCare app that typically costs $49 per visit. MDLive, announced a partnership with AvMed, one of Florida’s largest health plans, to provide virtual visits to members in 30 counties across the state.
Meanwhile, Allscripts and Surescripts announced a collaboration to provide free access to patient-specific medication history data for pharmacists in Texas and Louisiana. Surescripts data showed a 93% decrease in prescription volume after the storm as medical providers shut down, in part because patients have trouble accessing their physician in the aftermath of a storm.
The partnership with Allscripts allows pharmacists to access a 12-month history of patient data, and a Texas state law allows pharmacists to dispense up to 30-days worth of prescriptions drugs without authorization from the prescribing practitioners.
For the first time, the American Red Cross is using drones to assess damage throughout areas of Texas and determine what geographic areas need the most aid. In a partnership with the UPS Foundation and drone manufacturer CyPhy Works, the Red Cross plans to test tethered drones as a way of prioritizing assistance to communities with the worst devastation. Officials said the pilot program will serve as a model for a rapid response team in the future that could be deployed in the aftermath of Irma.
Bud Stevens is an engineer for a big aerospace company who lives in Melbourne, on Florida’s Space Coast. When he moved back to the states from England, he wanted a proper U.S. physical.
It took four weeks to get that first appointment. The doctor saw what he thought was skin cancer, so he referred Stevens to a specialist. That was another four to five weeks.
“Since I hadn’t been in Florida very long, I really was not aware of if this was normal or exceedingly long,” Stevens said. “But it did seem like they were pretty full up. And it might have been because they were in the preferred network.”
Stevens said he’s been to a dermatologist before, so he wasn’t really concerned. But that waiting between appointments: “It was cause for concern,” he said. “But it wasn’t an unusually stressful cause for concern.”
In fact, 13 percent of Floridians had to wait three weeks or more to see a doctor when they’re sick, according to a national poll by the Robert Wood Johnson Foundation, NPR and the Harvard T.H. Chan School of Public Health. That’s a longer wait than the national average.
“The poll found that 1 in 5 Floridians needed health care in the last two years and reported they weren’t able to get it,” said Robert Blendon, Richard L. Menschel Professor of Health Policy and Political Analysis at Harvard T.H. Chan School of Public Health.
“That number is larger than the national average. So this issue of people having barriers to care – whether it’s financial, geographic or appointments – is larger in Florida than in most other spots in the U.S.”
There are a number of possible causes like patients not having primary care doctors, the distribution of doctors, patients in Florida being more elderly and having more issues as a group.
Blendon said the poll found 1 in 4 Floridians find the wait times to be unreasonable, which is also larger than the national average. And he said, taken together, the poll points to a bigger problem in Florida.
“I think what the poll provides is a sort of warning sign that there are things going on you should worry about,” Blendon said. “People without physicians, people having problems getting seen, people looking for alternatives because they can’t make the existing arrangements work. And it is sort of a call for people in leadership to take a stronger look.”
Halee Fisher-Wright, president of the Medical Group Management Association, which represents the people who run doctor practices, said access is a problem. But it also represents an opportunity – just look at apps like ZocDoc making appointments more convenient.
“Access has always been one of the most common complaints patients have,” Fisher-Wright said. “Access is probably the biggest opportunity medical practices have to enhance their functionality and operational success.”
Now, Bud Stevens, the Melbourne patient, has some interesting views on getting in to see a doctor because he spent long stretches of time using the National Health Service in England.
The wait times were, in some cases, quite a bit shorter in the U.K. One specialist he had to see had office hours until 8 p.m. two nights a week.
And for primary care, he was assigned to a clinic, and if he needed to see a general practitioner, they’d set up an appointment same day or next day. In the office, he’d tap in his credentials into a computer.
“And within five minutes of my appointment time, there would be somebody there to see me, sit down with me, and have a 15 to 20 minute conversation about any of my concerns regarding that appointment,” Stevens said.
Florida lawmakers Friday approved measures that would expand the drug-prescribing powers of advanced registered nurse practitioners and address a controversial health-insurance issue known as “balance billing.”
In a flurry of maneuvering at the end of the annual legislative session, lawmakers also approved an insurance change that will benefit people with Down syndrome — an issue dear to Senate President Andy Gardiner, whose son has Down syndrome. Gardiner has made helping people with developmental disabilities his signature issue while serving as president.
The drug-prescribing and insurance bills (HB 423 and HB 221) were among the final measures passed during the 60-day session, which ended at 6:45 p.m. Friday.
Advanced registered nurse practitioners have long lobbied for the authority to prescribe controlled substances. But the idea ran into the lobbying might of physician groups, which have opposed the proposals.
This year’s bill, spearheaded by Rep. Cary Pigman, R-Avon Park, and Sen. Denise Grimsley, R-Sebring, also would grant the power to prescribe controlled substances to physician assistants. The measure now goes to Gov. Rick Scott.
“It’s been a long battle, and well worth the fight,” Florida Nurses Association Executive Director Willa Fuller said in a prepared statement. “The passage of this bill is a huge victory for nurses and patients.”
The balance-billing issue also drew intense lobbying during the session, as it affects health insurers, doctors and hospitals.
The issue centers on patients who have preferred provider organization, or PPO, insurance coverage and go to hospitals for emergency treatment. Supporters of the legislation say those patients sometimes get unexpected bills because doctors in the hospitals are not part of the insurance plans’ networks.
The legislation, at least in part, would set up a dispute-resolution process that backers say would help shield patients from unexpected bills and leave it to health-care providers and insurers to work out payment issues. State Chief Financial Officer Jeff Atwater and the Florida Association of Health Plans pushed for the proposed changes, sponsored by Rep. Carlos Trujillo, R-Miami, and Sen. Rene Garcia, R-Hialeah.
But the Senate added a late twist to the balance-billing measure when it approved an amendment Friday to require insurance plans to cover such services as speech therapy, occupational therapy and physical therapy for people with Down syndrome. The change expands part of a law that took effect in 2009 for people with autism spectrum disorder.
In the waning hours of the 2016 legislative session, Florida lawmakers Friday approved wide-ranging reforms to the state’s mental-health and substance-abuse treatment systems.
House members voted 118-1 to approve the proposal (SB 12) after it had bounced back and forth between the chambers throughout the week. A similar bill died last spring during the chaotic end of the 2015 legislative session.
“It’s been a long, hard road,” said House Children, Families and Seniors Chairwoman Gayle Harrell, a Stuart Republican who was heavily involved in developing the measures.
Mark Fontaine, executive director of the Florida Alcohol and Drug Abuse Association, she he thinks policymakers “are beginning to really understand the impact of mental health and substance abuse on the entire system.”
“They’re understanding the impact on the courts … the child welfare system … and the health care system,” Fontaine said.
The focus of this year’s bill is a “no wrong door” policy, so that people who need mental-health or substance-abuse treatment can get it no matter how they enter the systems — whether through criminal offenses or personal crises.
To do that, the bill would create central receiving facilities to function as single points of access to emergency care and intervention services.
The bill also would “align” the Baker Act and the Marchman Act, two state laws dealing with involuntary commitment.
The Baker Act allows for involuntary examination or commitment if people are likely to have mental illnesses that pose harm to themselves or to others. The process must be initiated by judges, law enforcement officers, physicians or mental-health professionals. The Marchman Act allows for the involuntary commitment of Floridians undergoing substance-abuse crises.
Last year, Senate sponsor Rene Garcia, R-Hialeah, tried for a flat-out merger of the Baker and Marchman acts, but the House would not go along.
The Baker and Marchman acts differ in terms of which facilities may receive people in crisis, who can provide assessments and evaluations, the time permitted to conduct involuntary examinations and the authority to release people after they are stabilized.
Crucially, the two acts also differ widely in terms of funding.
This year’s bill doesn’t create a merger, Garcia said, but an alignment of the timelines and legal processes for assessment, evaluation, and receipt of available services under the Baker and Marchman acts to help people in recovery and keep them from returning to the system.
“Our main goal is to ensure that individuals, when they are picked up on the street, are taken to a facility,” he said. “And that facility is where the triage happens, and they can walk out with a treatment plan or a referral to another system.”
However, he said, there isn’t enough money to ensure that “they would walk out and be able to go to a treatment facility” — especially under the Marchman Act.
Florida ranks 49th of the 50 states in per capita funding for mental health services.
Still, Harrell and Garcia say they expect this year’s bill — by streamlining the systems — will save money and pave the way for future expenditures.
For instance, the bill directs the Agency for Health Care Administration and the Department of Children and Families to develop a plan to increase federal funding for behavioral health care.
Fontaine, of the Florida Alcohol and Drug Abuse Association, said money set aside in 2015 and 2016 will allow about a dozen communities to put into effect the bill’s call for a single point of access. That money totals $20 million over the two years.
Among other things, the bill would tighten performance measures for what are known as behavioral health “managing entities,” which oversee mental-health and substance-abuse treatment services by region.
Garcia said the bill will help to remove the stigma faced by people struggling with addiction and mental illness.
“The first thing is to make sure that we as a state identify that there is a problem,” he said. “The problem is making sure that we get people out of the shadows, and into treatment. Let’s not treat mental health as a separate disease, but as a disease like any other disease.”
A former Sarasota, Florida doctor whose license to practice was revoked by the state was found guilty Thursday of four counts of practicing without a license. The charge could mean at least seven years in prison if the judge does not stray from sentencing guidelines.
Leonard Rubinstein, who advertised specialties in allergy treatment and cosmetic surgery and kept treating patients even after losing his license in 2012, was arrested in December 2013 after undercover officers posed as a married couple seeking a breast augmentation for the wife.
During the consultation, Rubinstein eventually told them he would have to do the surgery in Mexico, but did not explain that it was because his license in Florida had been revoked after twice previously being on probation.
Rubinstein did ask to examine the woman’s breast during the Sarasota consultation.
Sarasota Police then used a search warrant to access other recent medical records, which led to more charges, involving treatment of several other patients. The charges alleged Rubinstein did allergy testing and treatment and other medical procedures as well as offering breast augmentation surgery.
At his four-day trial this week, the defense insisted Rubinstein was working only as an assistant to a licensed doctor who was not always at the office.