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Position Statement Regarding the Proposed
Coal-Fired Power Plant in Taylor County

Board of Governors, Capital Medical Society
September 2006

The Florida Medical Association, the American Medical Association, the American Academy of Pediatrics and other medical organizations have adopted policies that support physician responsibility to respond to issues affecting the health of their patients. Both the Florida and Georgia Medical Associations have taken positions strongly in opposition to the use of coal for power generation.

Therefore, the Capital Medical Society is concerned about the medical risks associated with coal-fired power plants to our patients and fellow residents in the Big Bend area of Florida.

Mercury

Coal-fired power plants are the largest and only federally unregulated source of mercury pollution in the United States. Florida ranks 15th in the United States in the amount of air mercury emissions, accounting for over 2,500 lbs of mercury per year. Mercury is a developmental neurotoxin. The primary manmade sources of mercury pollution are coal-burning power plants and incinerators. Once released in to the atmosphere, mercury is deposited in bodies of water and ascends the aquatic food chain, making its way into fish, consumed by humans. The fetal brain is especially vulnerable to mercury because it is absorbed almost completely when ingested, and it crosses the placenta easily and is stored by the fetus. At high doses, fetal exposure can result in mental retardation, spastic paralysis and death.

Particulate Matter (PM)

PM10 are a heterogeneous mixture of solid or liquid particles of varying composition found in the atmosphere. Fine particles (PM2.5) are emitted from combustion processes, power plants and industrial activities. PM is small enough to reach the lower respiratory tract and has been associated with a wide range of serious health effects. Particle pollution contributes to excess mortality and hospitalization for cardiac and respiratory tract disease. In children, particulate pollution decreases lung function and lung growth.

Other Air Pollutants

Coal-fire power plants are a major source for the 6 “criteria air pollutants” and 188 pollutants and chemical groups known as HAP’s (Hazardous Air Pollutants.) The 6 “criteria air pollutants” include sulfur dioxide and nitrogen oxides, precursors of ozone. These air pollutants are known or suspected to cause serious health effects in adults and children, including cancer, birth defects, asthma exacerbations and respiratory tract and neurological illness. The exact connection between the epidemic of asthma experienced by our population and these pollutants has not been elucidated, but a strong connection is suspected.

From a healthcare point of view, we are opposed to a coal-fired power plant in our area because it will be detrimental to the health of our patients who have lung and cardiac diseases and because it increases the incidence of both respiratory conditions and neurologic developmental problems with children. The pollutants which result do not respect county or state lines or national boundaries. Much of the mercury polluting Florida apparently originates in coal-fired power plants in China, for instance.

We urge the City Commission to vote the NO COAL option, utilizing cleaner alternative power sources.

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Healthcare Tax – Committee Created to Promote Passage
October 2006

On September 20th, a political committee known as “Citizens for a Sound Health Plan” was formally opened to promote a YES vote on the proposed half-cent sales tax on the ballot this November. Dr. James Stockwell and Dr. A.D. Brickler are spearheading the committee. Dr. David Craig has agreed to lead the fundraising effort among physicians.

As you may know, the CMS Board of Governors reviewed the county’s proposed health plan and found it to be an effective means of dealing with the growing problem of uninsured in our community. The County intends to primarily employ a “money follows the patient” model, which will ensure the best use of dollars. Taxpayers only pay for care that is delivered and only when it is delivered.

Doctors in this community see both the emotional and economic toll on working families who do not have health insurance. As physicians we not only understand our moral obligation but also are acutely aware of the economic consequences facing our community and that is why we strongly support the efforts to bring reason and sanity to our local healthcare solutions.

The time to execute this campaign is short; we ask that you send campaign donations to the following address:

Citizens for a Sound Health Plan
122 South Calhoun Street
Second Floor
Tallahassee, FL 32301

(Click here for a Contribution Form)

Frequently Asked Questions About the
Leon County Community Healthcare Plan

For more information go to http://www.co.leon.fl.us/HHS/healthcarereport.asp

What is the Leon County Community Healthcare Plan?

On May 23, 2006, the Leon County Board of County Commissioners voted to place the issue of a ½ cent sales tax before the voters of Leon County to provide essential healthcare services to the uninsured, working poor and medically needy residents of our community in the most cost-effective manner. This was the latest in a series of steps the Board has taken over the past several years to address healthcare for the uninsured, including collaboration with the CareNet partners and implementing the Primary Healthcare Program in 2001 and funded it through a property tax.

The proposed Community Healthcare Plan would operate like an HMO to provide basic health coverage for qualified Leon County residents. The plan will offer significantly less health coverage than commercially available insurance like that provided by an employer or purchased by an individual. However, the plan would provide appropriate and cost-effective care to those who would otherwise seek healthcare alternatives of last resort – like that rendered in emergency rooms – which come with the highest costs and result in worse health outcomes for the individual and the entire community.

What are the program goals and desired outcomes?

• To improve the quality of life and health outcomes of the County’s most needy and vulnerable residents
• To interrupt or reverse the trend of increasing uninsured in our community
• To reduce inappropriate Emergency Room visits
• To slow the escalation of health care costs and the invisible tax of cost shifting to the overall community
• To increase productivity, efficiency and overall health of the workforce
• To realize highest quality of life and healthiest community for Leon County

Who’s eligible to participate in the Leon County Community Healthcare Plan?

Qualified participants must:

• Be a Leon County resident;
• Be uninsured for one year;
• Be between 18 and 64 years of age;
• Have a household income which falls below 200% of the Federal Poverty Level (FPL);
• Not be eligible for any other state or federal program or having medical needs that are not covered by any such program (i.e. Medicaid, Medicare, etc.)
• Not have insurance offered by employer.

This Plan contemplates a phased enrollment of qualified residents. Under the phased enrollment, individuals with incomes up to 150% FPL will enroll under phase one of enrollment, with individuals with incomes up to 200% FPL to follow in enrollment in phase two. The Plan anticipates an estimated 9,000 enrollees. Under the plan, co-pays are also based on a sliding scale fee schedule based on income (see following table).

2006 Poverty Guidelines

Is it true that Leon County has the lowest number of uninsured people in Florida?

Yes, there are between 22,300 and 31,000 Leon County residents who are uninsured. However, the Mercer report warns that “a cycle has been set in motion in Leon County…and without corrective action to break this cycle, the number of uninsured residents in Leon County will continue to grow and the amount of uncompensated costs (the “Invisible Tax”) of medical care will continue to grow.”

What is the funding source / How much will this cost?

It is important to note that Leon County property owners have been paying for the existing healthcare program through a special property tax. This property tax has been eliminated by the Board of County Commissioners for fiscal year 2006-2007. It is also important to note that each insured person in Leon County currently pays inflated medical costs and insurance premiums due to uncompensated medical care provided to the uninsured.

If approved by the voters in November, the Community Healthcare Plan would be funded primarily through the imposition of the ½ cent Voter-Approved Indigent Care Surtax. This funding source was approved by the Florida Legislature for those counties that develop a plan to address the problems associated lack of access and affordability of healthcare to indigent and uninsured persons in their county in a cost-effective manner. If approved, the sales tax would begin generating an estimated $18 million annually. Between 22% and 30% of the tax would be paid for by visitors to Leon County. The estimated cost of the ½ cent sales tax to the average consumer is approximately $52 to $59 per year, or between 14 and 16 cents a day. The maximum amount of additional tax on any transaction is $25 because the tax can only be levied on the first $5,000 of any sale.

The estimated cost of the ½ cent sales tax was calculated using two approaches:

1. Per the Department of Revenue, the total taxable sales in Leon County in 2005 was approximately $3.5 billion. Based on information contained in the “Estimates of the Economic Impact of Visitors on Tallahassee/Leon County,” presented by Dr. Mark A. Bonn, College of Business, FSU, approximately 22% of all taxable transactions are paid for by tourists. Reducing the $3.5 billion by 22%, results in Leon County residents accounting for $2.7 billion. The $2.7 billion was then divided by the total number of residents, 262,121. This division results in total taxable sales per capita per year of $10,382. A ½ percent tax on the per capita taxable sales of $10,382 is $51.91 - rounded to $52.
2. The second method looked at the total estimated revenue being generated from the tax at $19.4 million. Again, assuming 22% of the revenue is paid for by tourists, Leon County residents would pay approximately $15.2 million. Dividing the $15.2 million by the population (262,121) equals approximately $58 per resident per year.

Isn’t a sales tax regressive and will it actually hurt the people the program is trying to help?

Sales taxes are often considered to be regressive. Regressive by definition means that the tax takes a larger percentage of the income of low-income people than of high-income people. To avoid this occurring, the State of Florida does not tax food or medicines, nor are services taxed. In addition, according to the IRS, sales tax payments increase as your income increases. For example, the annual IRS deduction of the additional tax to an individual making less than $20,000 is $16; while the impact to someone making $50,000 to $60,000 is $45. The current method of supporting the healthcare program is through a property tax. Property taxes are also sometimes considered regressive because lower income people spend a larger percentage of their income on housing than wealthier people.

If the sales tax is approved, will Leon County have the highest sales tax in Florida?

Yes, Leon County would be the first community in the state with an 8% tax rate. Under Florida Law, Leon County is one of a number of Florida counties that has the authority to levy a ½ sales tax to fund indigent healthcare. It’s important to note that historically, Leon County voters have supported additional sales tax referendums for quality of life initiatives, including a ½ cent for schools and a penny for storm water and transportation improvements, bringing Leon County’s sales tax rate to 7.5%. Additionally, Leon County ranks the 5th lowest out of Florida’s 67 counties in spending per citizen. This essentially means, Leon County collects less tax and delivers more quality services at a lower cost. Most other counties are paying for healthcare services through higher property taxes, taxing hospital districts, and other special property taxes.

Will the ½ cent sales tax hurt the local economy?

No. The Mercer report and other studies show that consumers are not likely to trade retail quality and diversity for a ½ cent savings because the savings is negated by transportation costs. Also, businesses are dependent on a customer base and are not likely to locate or relocate based on a ½ cent. Additionally, the ½ cent sales tax will benefit the economy by adding millions of dollars needed to provide essential healthcare services and also result in immeasurable economic benefits from a more healthy and productive workforce.

How will the money be spent?

The proposed Community Healthcare Plan seeks to leverage all existing community and provider resources with the “funds following the patient” based on services rendered by local physicians, hospitals and clinics. The proposed plan avoids high infrastructure costs, taking advantage of Medicaid and Medicare pricing and leveraging of local dollars. The proposed healthcare plan features a strong emphasis on cost containment by:

• Focusing on preventative services which ensures appropriate and timely medical care and avoids health deterioration which requires the most expensive and inefficient treatment;
• Requiring a generic drug formulary;
• Incorporating a strong medical management component to ensure the coordination of care by all of the providers in the local healthcare system

To meet its obligation to the taxpayers, the County will maintain strong accountability, oversight and control of the plan, which will be accomplished in part by employing an Administrative Services Only (ASO) vendor (a Third Party Administrator or TPA) to provide numerous professional managed care services critical to ensuring the cost-benefit of the plan. The ASO model is an arrangement whereby the County hires an outside firm to provide specific administrative services. These services include, but are not limited to the following:

• Enrollment and eligibility determinations
• Accurate claims adjudication and responsive support to participants backed by robust technological capability
• Reporting and strategic services to project claims cost, track trends, minimize liability, and measure performance.
• Coordinated care and utilization management on a case-by-case basis to increase quality while reducing expenditures on inappropriate care and inaccurate billing practices.
• Account management for everyday services in managing plans
• Comprehensive health management and disease management programs for conditions ranging from cardiovascular disease to asthma and diabetes.
• Nurse telephone and on-line contact services.

The ASO will function very much like an HMO as it pertains to the management of the medical provider system and as it would appear to the clients of the program.

Who will benefit from the proposed healthcare plan?

According to the Mercer Report, providing health insurance coverage to the previously uninsured has great potential benefits to the entire community, including:

Businesses Benefit

• Insurance premiums have been rising much faster than inflation – this forces the employer to make tough choices about the amount of coverage they can afford to provide and the amount they can contribute to the cost of the plan.
• To make matters worse, these responsible businesses are paying a hidden “premium tax” to pay for uncompensated care. In essence, they are subsidizing those employers who choose not to provide health insurance to their employees.
• Businesses have a much greater chance to see relief from increased insurance premiums if providers are reimbursed for care which was once uncompensated.
• Businesses benefit from a healthy and insured workforce. Businesses experience higher productivity, less absenteeism and less turn-over when the workforce has access to affordable healthcare, including preventative healthcare.
• Eye Opener: National research indicates that for every 1% increase in insurance costs, .084% of the population loses their health insurance. Applying this ratio to Leon County suggests that the 13.5% increase in health insurance costs in 2005 alone may have resulted in an estimated 2,452 Leon County residents losing their health insurance.

Insured Residents Benefit

• When hospitals and other health-care providers experience revenue shortfalls which result from uncompensated care, they must look to other payers to make up the loss. Because these providers cannot generally shift these cost to governmental payers, they must look to private insurers to pay higher rates through higher premiums.
• Eye Opener: In Leon County, the above translates to less than 65% of the population bearing the costs of all uncompensated care that is not supported by government or philanthropic programs.

Healthcare Providers Benefit

• Providers recover only about 35% of the cost of providing care to patients who have been uninsured for over one year. As such, over 60% of the cost of the care for these uninsured patients is uncompensated and must be absorbed or shifted to another payer.
• Eye Opener: Leon County hospitals reported over $20 million in uncompensated charity care in 2004.

Uninsured Residents Benefit

• Uninsured residents of Leon County are most directly impacted by the lack of health insurance. These residents experience poorer health outcomes in every category. Poor health is directly related to lower workforce participation and personal income.
• Eye Opener: National research indicates that an estimated one in three personal bankruptcies is a result of medical debt.

What are the covered benefits under this plan?

This Community Healthcare Plan will offer significantly less health coverage than commercially available insurance like that provided by an employer or purchased by an individual. However, the plan would provide appropriate and cost-effective care to those who would otherwise seek healthcare alternatives of last resort – like that rendered in emergency rooms – which come with the highest costs and worst health outcomes for the individual and the entire community. Healthcare services covered under this plan “at a glance” include the following:

Case Management Services

• Medical management of patients with chronic diseases, such as diabetes and hypertension;
• Referrals to other public programs as appropriate;
• Referrals to physician specialists for evaluation and consultation;
• Patient education on disease and health management.

Primary Care Services

Periodic health assessment, including:

• Health Examinations
• Necessary Laboratory Services
• Up Front Medical Management
• Chronic Disease Management
• Episodic Outpatient Care
• Emergency Care / Urgent Care

Specialty Care Services

Limited consultations, examinations, and treatment specialties covered:

• Cardiology; ENT, Gastroenterology, General Surgery, Gynecology, Nephrology, Neurology/Neurosurgery, Oncology, Ophthalmology, Optometry, Orthopedic, Surgery, Podiatry (for diabetics only), Psychiatry/Mental Health, Pulmonary, Urology.
• Outpatient Surgical Services at Specialists Offices
• Inpatient Hospital Services – 8 day Annual Limit
• Outpatient Diagnostic Services – including services such as Hematology, Chemistry, Cytopathology, MRI, Eye Exam, Cardiac Stress Test, CT, EKG, Endoscopies and colonoscopies
• Mammography Screenings
• Hospital Based Physician Services
• Outpatient Therapies
• Physical and Respiratory Therapies (provided at PCP Office only)
• Family Planning (limited to physician services for consultation)
• Basic Dental Services for Adults

Pharmaceutical Services

• Generic Only Formulary

Exclusions

Again, this Community Healthcare Plan is not comparable in benefit level to a commercial insurance product by design. As such, there are many excluded services under this plan including, but not limited to:

• Dialysis (Chronic)
• Reconstructive Surgery
• Blood Disease
• Infertility Services
• Prosthetic Devises/Braces
• Oral Surgical Services
• Organ Transplants
• Cosmetic/Plastic Surgery
• Orthodontia
• Out-of-County Services
• Termination of Pregnancy
• Services for the treatment of any kind of addiction
• Services for the treatment of sexual dysfunction
• Advance Oncology
• Chiropractic Services
• Elective Vascular Surgery
• Contraception
• Hearing Aids/Testing
• Inpatient Rehabilitation Services
• Joint Replacements
• Procedures for the treatment of obesity
• Durable Medical Equipment
• And All Not Medically Necessary Services

* Please note this benefit package is currently undergoing a medical peer review and is subject to modification.

Will this be a free healthcare plan for all eligible participants?

No. The proposed plan includes a sliding scale co-pay fee structure for medical and pharmaceutical services as seen in Table 2 (below). It is estimated that at full enrollment (9,000 participants), participants will pay $3.2 million into the program through revenue generated by co-pays.

Table 2

Who will provide oversight to ensure the success of the proposed healthcare plan?

The Board of County Commissioners has established the Primary Healthcare Implementation Advisory Board (PHIAB) to oversee the current Primary Healthcare Program and would use this Advisory Board to oversee the future program. This Advisory Board is made up of the CEOs of both local hospitals, the President of the Chamber of Commerce, the present and past administrators of the Leon County Health Department, and prominent local doctors in the community who have experience in serving the uninsured population. The PHIAB will oversee the Community Healthcare Plan and report annually to the Board of County Commissioners on the progress of the program.

How will the County prevent people and employers from dropping commercial insurance and enrolling in the County’s Plan?

The Community Healthcare Plan has very strict eligibility criteria for enrollment into the Program, such as income limits. In addition, certain features will be incorporated into the Plan to prevent what the industry titles “crowd out”. These include the following:

• A “Leaner” benefit set than exists in the marketplace, to decrease the incentive for employees to leave existing insurance for the County program;
• Funding providers at appropriate reimbursement levels – typically below commercial rates; and
• Implementing eligibility requirements (e.g., a “bare provision” of 1 year).

How will the County measure the success of the Program?

The County will measure the success of the program through a series of industry standard measurements, common to all healthcare providers. The program will heavily focus on qualitative and quantitative measures, built into each vendor/provider contract, to measure performance standards designed to meet these goals and objectives. Performance standards will be developed using measures outlined by the American Medical Association (AMA), National Committee for Quality Assurance (NCQA), Health Plan Employer Data Information Set (HEDIS), Healthy People 2010 and monitoring, reporting and penalties for non-compliance will be established in each of the following areas:

• Financial performance (efficient expenditure of funding on quality healthcare services);
• Administration (claims payment, customer service, credentialing, etc);
• Case Management (patient assessment, identification of problems, creation of care plans, coordination of medical and home-health services, referrals to community resources and programs, and provision of education); and,
• Clinical performance (quality of care).

The County and the ASO will be responsible for monitoring the program vendors to ensure program goals are obtained.

How will the County ensure that the Program will not grow out of control?

The Program will be limited to the amount of funding raised through the ½ cent sales tax. One of the many benefits of the ASO model is the County’s ability to maintain control over the financial and benefit structure of the program. The Plan includes “levers” that can be accessed if needed for the County to minimize financial risk. These “levers” include the following:

• Change or limit program eligibility
• Change or limit the benefits offered by the plan
• Reimburse providers using budgeted funding where possible

The County will strive to maximize tax payer dollars in the most efficient means possible to provide quality healthcare to qualified residents of this County.

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Dr. A.D. Brickler Presented Lifetime Leadership Award

At its annual Distinguished Leadership Awards Dinner, Leadership Tallahassee honored Dr. Alexander D. Brickler, Jr. with its 2006 Lifetime Leadership Award. The immensely popular event was held on September 19th, at the Tallahassee-Leon County Civic Center. Leadership Tallahassee is a program of the Greater Tallahassee Chamber of Commerce.

Criteria for the award: An individual who has made “significant, tangible leadership contributions to the Tallahassee community for more than 25 years.”

Dr. A.D. Brickler is indeed a candidate for this recognition!

His medical colleagues repeatedly voice admiration for his dedication to all patients, and his commitment to providing care to indigent patients is one of his trademarks.

He opened his private practice in family medicine and obstetrics in Tallahassee in 1957, with his father-in-law, Dr. Russell Anderson. They used the former FAMU Hospital. Dr. Brickler was the pioneer for integrating medicine in Tallahassee and was one of the first two African-American physicians on staff at TMH.

He served as Associate Director of the Family Medicine Residency Program at TMH. Many times he was voted “outstanding teacher” by the residents. From the early 70’s to the early 90’s he was the key physician supervising the obstetrics program at the residency program.

Dr. Brickler also served FAMU as Director of the Student Health Center, part-time for over 25 years. He also served as Chair of the medical staff of Florida A & M University Hospital in Tallahassee.
He was the 1999 Recipient of the I. B. Harrison, M.D. Humanitarian Award, presented by the Capital Medical Society and Capital Health Plan.

Established in 1997, this award is presented every March, in association with Doctors’ Day to recognize and honor a local physician for his/her dedication and commitment to the values associated with Dr. I. B. Harrison: Compassion, service, respect, wisdom and integrity.

In 1982, Dr. A.D. Bricker was named “Family Doctor of the Year” by Dr. C. Everett Koop, Surgeon General of the U.S. The award was jointly sponsored by the American Academy of Family Physicians and the editors of Good Housekeeping magazine. He has been a Diplomat of the American Board of Family Practice since 1973.

He served as Chair of the TMH Executive Committee, among other leadership roles at TMH.

In 1996, he was awarded a Life Membership from the Florida Medical Association, in recognition of 35 years of dedicated active membership and devoted service to mankind in the practice of the medicine.
He served as Community Columnist for the Tallahassee Democrat in the early 80’s for 6 years. He wrote many controversial and brave columns during this time.

Dr. Brickler has influenced many lives in Tallahassee, including his son, Dr. A.J. Brickler and his daughter, Dr. Celeste Brickler-Hart, both physicians in Tallahassee today.

Editor’s Note: The Tallahassee Democrat Editorial Board wrote the following salute to Dr. A.D. Brickler - Originally published September 21, 2006 in the Tallahassee Democrat. Reprinted with permission.

What a lifetime. Dr. Brickler a lifelong leader

Physician Alex Brickler Jr., honored Tuesday for a lifetime of leadership, came into the public eye more than 25 years ago when he was writing a column for the Tallahassee Democrat. Some of his most compassionate and yet clearly stated messages were those urging young women - and young men - to be careful with their reproductive lives; to grow up themselves before they began raising families they might not be equipped to raise adequately.

Dr. Brickler was saying this in the early 1980s, long before celebrity Bill Cosby and others were approaching the black community in particular, but the youth of our culture in general, in such candid ways about personal responsibility.

“ These babies have such a slim chance of escaping (poverty),” he said again in 1989 before a legislative committee on teen pregnancy. “That’s the tragedy of it all. The great majority are stuck. I get awfully weary and discouraged.”

Over the years, as he continued a thriving obstetrics practice, his fearless willingness to confront social issues made him far more controversial and significant an influence in this area than his warm, country-doctor demeanor would suggest.

The Greater Tallahassee Chamber of Commerce has honored Dr. Brickler with its 2006 Lifetime Leadership Award, its highest honor and one reserved for an individual who has made “significant, tangible leadership contributions to the Tallahassee community for more than 25 years.”

No doubt it was a privilege for Tuesday’s other impressive leadership honorees — businessman Kim B. Williams, Tallahassee Memorial CEO Mark O’Bryant, former Superintendent of Schools Bill Montford and marketing executive Gil Ziffer — to share the stage with such an extraordinary, passionate and gentle giant in our community.

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