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BCC Minutes 01/27/1987 W (B) - - ..... .. Naples, Florida, January 27, 1987 LET IT BE REMEMBERED, that the Board of County Commissioners in and for the County of Collier, and also acting as the Board of Zoning Appeals and as the gover·.ing board(s) of such special districts as have been created accor~lng to law and having conducted business .herein, met on this date at 2:45 P.M. i~ WORKSHOP SESSION in Building "F" of the Courthouse Complex, East Napl-3, Florida, with the ~ollowing members present: CHAI~MAN: Max A. Hasse, Jr. VICE--CHAIRMAN: Arnold Lee Glass i, .~ John A. Pistor Burt L. Saunders Anne Goodnight Maureen Kenyon, Deputy Clerk; Dr. Polkowski, ALSO PRESENT: Health Director; and Kevin O'Donnell, Public Services Administrator. AGENDA PRESENTATION ON DEVELOPMENT OF PLANS REGARDING THE HEALTH CARE DELIVERY SYSTEM IN COLLIER COUNTY PRESENTATION REGARDING HEALTH CARE DELIVERY SYSTEM IN COLLIER COUNTY Mr. Richard Akin, Director of Collier Health Services and Chairman of the Primary Care Services Group, stated that he would like to explain how the group was formed, adding that initially there were a number of health care providers in the community that became concerned when they began to hear humors regarding the citrus industry moving into Collier County. He stated that his primary business location is in Immokalee and he was routinely hearing that the citrus industry is , Page 1 :. . &OOK 101 PA~[ 122 ./-!J. f- 1DIPAcc12a : ~ ! J :.: ~} ,.. ~. _"t", I l ./, §; f.t :.~" January 27, 1987 coming. He stated that there was much concern over what this would do in terms of impacting the health care industry. He stated that the óitrus industry moving in would have an associated demand for labor which in turn will requjre health care. He noted that a group of pro- viders were put together and decided trat this problem should be discussed, adding that also in the grou, ~ere two commissioners, representatives from the League of Women Voters, representatives from the Redlands Christian Migrant Association as well as a couple of far- mers. He stated that it was decided that there seemed to be enough basis to the citrus industry coming in and the impact on the health care industry that an investigation needed to be done, adding that they determined that there would be a need of about $20,000 to con- duct a study of primary care in Collier County. He stated that the money was raised on a broad base community effort, adding that the County Commission donated $5,000; the farmers came up with around $2,000-$3,000; the Medical Society put in several thousandr the Redlands Christian people put in money; and the Hospitðl put in money. He stated that since the· County was a heavy participant in this and since there is an interest, it was felt that the County was owed a response as to what the money was contributed towards and what was found from this study. He stated that the immediate goal is to apply for and attract outside funding sources to help solve the problem, which most likely will be State funding. He stated that they are talking with people in private foundations and the Federal government. Page 2 - .,..-- _.. "-. - .. - .- .. - January 27, 1987 He stated that there is going to be a lot of competition for the dollars that will be appropriated and, therefore, they have to be ready and in line wait¡~g. He noted that the study was a Success but is only the first step, adding that the purpose of the study was to provide information anè rEcommendations upon which plans could be developed and actions taken regarding ". health care delivery system in Collier County. He stated that they wanted to determine the extent to which the anticipated expansion of the citrus industry, together with its associated demands for farmworkers, would impact the health care system. He indicated that they wanted to identify the current and projected need for additional health services, to assess the strength and weaknesses of the existir.g system, to provide recommendations upon - ,- which future actions could be taken, and to provide a preliminary data base upon which proposals for securing additional funding could be based. He reported that the conclusions were mostly what is known, but there were a few surprises, adding that they found that the poor people experience more difficulty receiving adequate and timely Care than the ones that have insurance and a method of payment, it was found that the problem was exacerbated by the fact that Collier County has a large concentration of migrants and seasonal farm workers, and it was found that the current and planned expansion of the citrus industry in and around Collier County will significantly increase the demand for additional farmworkers as early as 1990. He stated that since this study was completed, he has received information from &OOK 101 PAGE 124 Page 3 . '/' . f 101'Ar,r125 . ,{ -, i January 27, 1987 reliable sources that indicate the study that was done was very con- servative by a factor of two to three. He stated that he is pre- dicting that this will effect the industry as early as 1990 and there are people in the business that are indicating that it will be 1988 or 1989. He indicated thet the current demand is outstripping the capa- .city for the delivery ~ystem and the citrus industry is on top of all of it. He noted that in addition to the problem that is coming to Immokalee, there is àlso a problem in the Naples area with the poor. He stated that there are a large numbe:· of people that have no insurance whjch is something that needs further investigation and planning, adding that the current sources of financing the system are not adequate to meet the expanding needs. He stated that further planning needs to be conducted fer all areas of the county, adding that the citrus industry is important and needs to be considered, but it is only one'compooent of the picture. He noted that the group -"- ..' decided that it was important to establish an on-going planning group comprised of representatives of the major health care providers that provide help for the poor; specifically, they should develop a joint ~roposal for additional funding and deliver improvements and to deve- lop an annual plan ad~ressing the critical problem related to mater- nity and 08 care, prioritizing health care needs and recommending the allocation of funds. He stated that it was also recommended that health be included as an element in the Comprehensive Plan scheduled for September, 1988, snd if this is not realistic maybe it can be l; ~~ ' Page 4 - .,..-- - ". - .. - - - January 27, 1987 added as an element at a later point in time. He s~ated that they plan on pursuing efforts with the Federal Government to expand the Florida Agriculture He'11th Plan which is an area that the County could help with. He stated that the Florida Agriculture Health Plan is an insurance plan that is offered through Collier Health Services in Immokalee and is Federally funded. He noted that until recently $2 million has been received to provide Care in Collier County for the migrant workers, but last year the prt~ram was cut to $800,000. He stated that he would recommend that a 19ional planning effort with ¡the surrounding counties be initiated, adding that the group has invited representatives from surrounding counties to meet with them to develop a regional planning effort. . He stated that they would like to . .. prepare and submit a proposal for state funding under the Health Care Access Act, as there will be more funds available by the end of the summer under this Act to offset some of the needs. He stated that they looked at the feasibility of locating a hospital base services multi-base facility in Immokalee, adding that some property has been identified and they are in the process of having a firm come to Immokalee to do a specific study which would indicate what is most . likely to make the most sense. He stated that the group could utilize the County help in supporting State-wide efforts to increase Medicaid reimbursement rates for physician services. He noted that there are a number of changes in the 'Medicaid Law that have been approved by the Federal Legislature, most of which are left to State option. He Page 5 &OOX 101 PAr.[ 126 ~'ç, ' , t ~ i ~ ~ i ~-~--,.."",.__.."_..".~.,..~.,, '/-r-, , f 101 'lCE 127 January 27, 1987 - ¡ noted that Collier Cour, ~y is on~ JC;;f the lowest counties in the State in terms of return in Medicaid dollars. He staled that Collier County receives an average of 5.6\ and the average county receives around 20\. He stated that with regards to a Medicaid contract for prepaid eårvices in Immokalee, it would not be feasible because only 5.6\ of the people living there are eligible f'r Medicaid and, therefore, this would not work. He stated that more P~')le need to be Qualified. He stated that fcr relief at the State level, both the House and Senate have subcommittees that are meeting to address health care for the indigent and there is talk of tort reform and specific hearings are coming up on indigent care. He noted that the Florida Medical Association has appeared to support a half cent increase in sales tax in the State to SUPPOët health care for the indigent, adding that these are things that look promising and may put some money back into the County that would enable the County to address some of these -problems. He stated that in order to apply for any of these funds that become available,' they have to get in line and be ready and this is only the first step. He stated that in order to continue this planning process, th~ County is needed as a þartner. In answer to Commissioner Hasse, Mr. Akin stated that in order to Qualify for Medicaid, one has to be a resident and establishment of residency for most of the people in Immdkalee has been difficult. He noted that Medicaid is a complex Subject, but there are things that could b~ done if the State would cooperate. ... bì.. ','1' . Page 6 - .,..-' , - - - -.... .. .. J8nua:y 27, 1987 Commissioner Pist~r questioned what is expected of the County as a partner, to which Mr. Akin stated that he is expecting the County to participate in the planning process, to assist them by writing letters to get things established for the County that would be of little or no cost to the County, but would bring in significant amounts of money, adding that there is a problem arisin\" and he wants the Commission to be aware of it. Commissi~ner Glass questioned what percentage of the people that the group is dealing with are illegal aliens, to which Mr. Akin stated that it is very high, adding that it is in excess of 50\. Mr. Akin stated that by the Federal grant of the Public Health Service, they are not allowed to contact the Immigration or Naturalization Depart- ment. . ~ Public Services Administrator O'Donnell stated that health care for indigents is a problem and will continue to grow in magnitude, but it is not a problem that has a solution that can be decided only by the Board. He stated that it is up to the State and Federal govern- ment as well as the private sector to get involved. He noted that in 1986, the Board appropriated $2 million in various means for indigent health care and over the last five years, the Social Service budget for client assistance alone went up 120\, adding that there is a defi- nite nee~ being met by the County, maybe not at lOa\, but Collier County is definitely already a partner. He noted that the impact from the agriculture industry is sketchy, adding that there is concern that ðOOK 101 PACE 128' Page 7 "!" , nl. , . . , oJ~; ~/!J~ 101 pm 129 January 27, 1987 within the next 3 to 5 ~ears"with the new Immigration Law passing, that the traditional labor force utilized by agriculture will move into othar areas and agriculture may actually have a difficult time getting sufficient workers or they may have to invoke a particular section of the Immigration Law known as 30lH-2A,- which would allow for them to import workers from foreign countries and then send them home when the work is done. He noted that· 1riculture is sensitive to the fact that they do not want to have the whole indigent health care problem placed exclusively on their doorstep. He stated that the Board can definitely support the efforts of the committee through seeking legislation through 'the Florida Agriculture Health Plan as was recommended by Mr. Akin. He stat~d that this type of action would be beneficial to everyone involved. He stated that it is necessary to contact the adjacent counties to review this whole matter on a part- nership level. He indicated that the Board should proceed cautiously .. . until it is known what everyone's ròle is with regards to the hospital facility for Immokalee. He noted that he cannot support proceeding to include the Healt~ Element in the Comprehensive Plan at this time, adding that health as a major concern should be supported and the encouragement of the Health Element could be done after'the County submits the plan because at the present time, the County is mandated to do 11 elements and it is going to be difficult to fund all these elements. He stated that the timetable is extremely tight and addi- tional elements could not be added at this time and staff is not ;J Page 8 - .,..-. -, -. - - January 27, 1987 available either. He ¡nd~cated that no one knows how the State or Regional Planning Cour.~il will react to the plans that are being sub- mitted by the municipali~ies and until there is a track record set, -the County should proce'.-,j wi th only what hu been mandated by the State. He noted that after the plan has been submitted, it could be amended bt a future time if the County so desires. He stated that the County should continue to pðrticipate with the group, but it is not a county problem, it is a regional, state and world national problem which has not been emphasized enough. He stated that he would strongly suggest that the Board direct Jff to put together resolu- tions that would support the increase in the Medicaid program which is one of the biggest factors that would help improve indigent health care. ... Commissioner Hasse questioned if illegal aliens are entitled to Medicaid, to which Mr. Akin stated that as of October, the State can no longer utilize residence or an address as criteria, adding that they have to come up with some other criteria that eliminates that status. Mr. Reggie Brown, Agriculture Director, stated that there is new legislation that was enacted late in 1986 which was the Federal Immigration Reform and Control Act and under that Act, there is a spe- cial provision that states that any illegal alien that performed field labor type tasks in production of perishable commodities in the United States for a period of 90 days or longer between May l, 1985, and May aDOK 101 PAr,r 130 Page 9 , ~'<>~ l' :.... , . lOOK 101 pm 131 ¡ ,1\1 January 27, 1987 ... I " ., 1, 1986, will be eligible to make application through the Immigration and NaturaliZ3tion Service for temporary resident alien status which '. ~': . ~I. , ~ :«. '.·,'.,'·....i . ~.- ~, :íI'~ I~<t:, ,- ........'. ~ /!-, ~ ,':~~... . 't·· makes them legal and then after a certain period of time, they can 2~pplY for permanent resident alien status and then in turn, they can ~uÜimatelY b'~come citizens of this cour."ry. He stated that provision . is in the Act to address the issue of th tremendous number of illegal aliens that are employed in agriculture throughout the United States and it will bring them into a legalized st~tus. In answer to Commissioner Hasse, Mr. Brown stated that there is mandatory financial penalties to employers for employing illegal aliens after they have received a 6 month education period, at which time the Federal Immigration Service will start imposing these penalties on employers with the premise being to slow down bringing illegal aliens into the United States. He noted that ey~ry employer will require proof of residency and ptoof of right to work prior to being able to employing anyone in this country. He stated that bas!- oally what is needed,is a United States Passport to prove that one is ð U.S. citizen or a U.S; birth certificate and a picture I.D. or a Social Security number, and a driVers license. He noted that in the the provision that allows these people to become legal resident aliens, they would no longer be bound to agriculture for employment once they have become legal, they will migrate into other jobs like washing dishes, flipping hamburgers or making beds. He stated that C~ngress had another provision written into this particular immigra- . I:! I· , . . ,. Page lO - - .. ... ',~ .. -. -..... .. .. January 27, 1987 tion bill that allows agriculture under certain circumstances the opportuni~y to bring in offshore labor, adding that in five or six years it is felt thðt becausp. of the displacement of the illegal aliens and the stopping of the flow of illegal aliens into this country, agriculture may be faced with the task of recruiting offshore labor and bringing it into the country ~ d using it as an agriculture labor force and then exporting that labor ~ack into the country of origin and being responsible for that labor forces health, shelter, and well-being during that period of time. Dr. Polkowski, Health Director, referred to an overhead chart stating that the health care syste~ can be depicted by a pyramid, adding that the base of the pyramid is the basic preventive ønd cura- tive and least sp~cialized care. SMe noted that this service is pro- vided by the private sector as well as the two public funded facilities which is the Health Department and CHSI. She stated that as one climbs the pyramid there is the smaller portion of health care which is the more specialized, highly complex care, which is hospi- talization and specialists. She stated that if one continues the climb up the pyramid there is increased complexity, skills, and cost along with the risk of having complications, the increase in malprac- tice insurance and the risk of lawsuits. She stated that the base of the pyramid is where the people need to be, which is the preventive and well maintenance, the immunization, pre-natal care, post-natal care, well-child health screening. She stated that all people should Page 11 &OOK 101 P'~r 132 w~,~ lU~ . t··' ; ;f t.' \ ) '/- f aOOK 10fpAr.r 133' January 27, 1987 be at the bottom of the pyramid but thete has to be referrals to the higher levelp. of care and th~n back down for the continuing care, .ad~ing that access to the health care system is largely governed by the ability to pay, whether it is third party payers, Medicaid insurance, out-of -pocket, or through p'Jblic funded programs. She ", reported that health care costs money:., the staff, the facilities, the equipment, and the materials. She stated that the Collier County Public Health Unit has a legal statutory responsibility to protect the public's health so it does service the entire population of Collier County. She stated that for certain services, the Public Health Unit is limited to those who qualify financially. She stated that there are continuing year round increases in the population which also means year round increases in needed health services. She stated that according to the 1980 Census, Collier County had people at less or equal to 100\ of the poverty level in every single census tract but it vðried greatly in terms of percentage within census trðcts, adding that it went up to 60\ in one, and one-third of the tracts had over 10\ of the population in those tcactè as being at or less than lOOt of poverty level. She stated that the County serves the medically indigent who are those with little or no health insurance and who are without sufficient resources to pay for essential health care. She stated that a survey was done from the people that come to the Health Department one survey was done on the pre-natal patients and the other survey was done for the rest of the patients. She stated that -, , ,{:... nt'~ ,'" , Page 12 - .,..-.. ." ".. - - "~,,. ~.~,.,.~.".., ..qq.".....--.-.--.,---- " - .. ......... - - January 27, 1987 similar findings were diacovered, adding that most of them were either employed or were dependent on a household member that was employed. She reportej that the farmworkers are at a disadvantage because very few have insurance, but this is also reflected in other low paying jobs. She stated that among non-farm industries those with the least group health insurance coverage are tho construction, retail and ser- vice industries. She stated that 3/4 0." the people employed in those occupations have no group health insurance. She stated that another thing that was found among the Health Department patients is that they tend to have higher rates of medical problems and are more likely to develop complications due to delays in getting medical care and lack of preventive practices. She stated that some of these people have difficulty in aè;es~ing medical care and a big problem is financial ability, adding that Medicaid is reimbursing at a rate that is less than cost and to qualify you have to be at one-third or less of the poverty level. She stated that if an individual is employed and has no group health insurance for him or his family, it would cost about $3,000 a year which includes pre-natal care and without pre-natal care it would cost about $1,800 a year. She stated that another problem for some people is transportation, adding that over 42t of the people had to get to the Health Department by means other than their own vehicles. She indicated that there is also a problem of clinic ser- vice availability in terms of hours, distance and the range of ser- vices. She noted that the Health Department has a large group of &ODK 101 PAGr 134 Page l3 r,i' Hl1'· 1:L.) . 1/' " am 101 PAr.r 135 January 27, 1987 people that speak other languages and have different cultures, which sometimes creatês com~~:,ication difficulties, and there is also a need for health education in this ~roup of patients. She noted that most of thes~ individuals or housp.hold members who are employed are directly impacting on the growth of the local economy and help make everyones lives easier and more enjoyable. She.stated that there are delays that occur in a~quiring medical care which leads to complica- tions and higher medical and long-tern care sU9Port costs. She stated that preventing disease and complicati~..s is far less costly and these patients' children will become Collier County's future residents. She indicated that a healthy population is better for the economy as there are fewer bed days and a greater ability to provide more work days, which effects the quality and quantity of work and service provided. She noted that Collier Coun~y should be concerned because of our own human values and concerns for one another. She indicated that there is a need to work together as partners and action in the State of Florida takes place ~t several leve~s, including the state level, individual counties, counties working together, and a regional level. She stated that th~ population of Collier County will continue to grow which will mean an increase of the medically indigent, which include the non-farm workerS in additio~ to the agriculture and citrus industry. She noted that Collier County ranks in the top four 'in Florida in per capita income, a substantial portion of the society is at.th.e ~ower end of the economic scale. She reported that there is , Page, 14 .. '. ¡ - -or- - - "'.""'."...."._~".,,,....,....'".,,......_........___^"',,_.,'...., ,..,..~."....~_,·~...'~.'M"~.....'_'"'"..~_.__·_·_-·_·""' ... .. .. - - ...... .. '/', , '1 January 27, 1987 need for cooperative __'~orts between the health care agencies and the government to adequately address the problems and some of the coopera- tive effnrts include improving the coordination between the existing agencies, pushing for legislation in terms of money and helping the doctors with malpractice and insurance, increasing the accessibility of medical vervices through financial meana, and improving the accessibility through transportation. ..... Commissioner Olass left the ..utinq at this ti........ Dr. Eytel stated that the Board is responsible for those that can- not be responsible, adding that there are a certain number of people that do not take the responsibility of taking care of themselves and they should be made to be aware of that. He stated that the physi- cians have been fúÌfilling t~eir responsibility to the County for many years. He stated that medical care reimbursement is changing and because of the changes that are occurring, the physicians are beginning to feel it. He noted that third party reimbursement plans did not start until after World War II and as a result of Medicare and Medicaid there has been drastic increases in demands and services and the establishment of usual and customary fees are now standard and the practice of the physicians of charging the rich to pay for the poor is no longer operative and that is a fact. He stated that the private physicians of this County provided over $2 million last yeer of free health care to those who could not afford it. He indicated that the private physicians for the most part have been taking care of the top &OOK 101 Plr,f 136 Page 15 ";'" .,.,="._"'--_...".","'"'''''.-...'''--<....''',-~......'''<~-"-''"' aoa~ 101 P1Ct 137 , . January 27, 1987 of Dr. Polkowski's triangle, the complex health care problems. He stated that most of the physicians in the County serve in the emergency room of the hospital and when an indigent patient arrives and needs hospital carp., they are automatically taken care of by the on-call physician for that specific pt~blem. He stated that a lot of this care in being provided without an~ cost to the taxpayer of Collier County and the physicians or hospital have never been given recognition for this nor is he sure that anyone wants such recogni- tion, but there are things that are beginning to happen that the Board should be made aware of. He noted that the tort problems in this state are becoming so hercndous tnat the physicians can no longer pro- vide the kind of health care that has been provided the indigents without some kind of compensation. He stated that physicians are not being paid for 40\ of the babies that are delivered. He noted that in the past two years Collier County has lost 9 OB physi~JÞns and there are only three left because these physicians cannot afford to pay $140,000 a year for insurance without delivering a lot of babies that can be paid for. He stated that they are willing to participate in the effort that has been started because the problem needs to be addressed as it will be increasing and there must be solutions forth- coming, adding that it has to be a cooperative effort. He stated that he feels that there is going to be significant State legislation - . addressed to the indigent health care issue in this State. He stated that there are going to be chahges in the tax structure of the State l"('" Page 16 - -'.' - - . _~""'_,""".T .~ "..".,~ ,."," -.--.,..,-.-.-----...---- - - .. ,j"".' . ~c~ ' lrf'~ I'~"~': oJ· , ~~..; '; J't' ~.'1j.""..t. 2~f: f:',: ,1. #r.. ;n~;' }?'·t: ~N' ~"".~~ ~:'1 :'~'. h~ ~ .... , January 27, 1987, is going to result in more money being allocated to the indigent health care questions and the County has to be ready to participate. that the gap between the Medicaid patient and the medi- cally indigent is a significant number, adding that some of them can afford to b~y their own insurance but they have elected not to because they do not want that responsibility. He stated that when they become ill, they sliek help through the County \f they can. He stated that this whole problem is a society problem ðnd it has to be addressed from multiple points of view and solutions are going to come forth. He stated that he envisions that the Medicaid system will become a capitated system and there will be capltated systems that can take care of that indigent population for a fixed dollar per year for a recipient. He stated that Collier County has to be ready to take on such a plan when it becomes a legislative fiat. Commissioner Pistor stated that he agrees with Dr. Eytel, adding that there needs to be an education and an acceptance of that educa- tion. He stated that the responsibility has to be accepted for what i~ going on around everyone, adding that the doctors contribute, the hospital contributes and taxes cannot constantly be increased unless there is a certain amount of citizen acceptance that the need is really ~here. ..... Commi.sioner Saun4ers left the meeting at this time...... Mr. Cecil stated that the citrus industry will be moving into Collier County and that was the main goal of this study, adding that &OOK 101PAGt138 Page l7 ".~--",......,.-,-_.'_--""""'~;'_"'~.",_",-,",, , /-P' , f :1 101,Ar,t 139 ~ i j ~ 1 ,.. l t)(. January 27, 1987 , ;$..'¡< ª:::f:; .~"",,:,. ·1'··~~t;...;.'1 -4:"'$: a. } ì\ "J~': :'Jt; .~;-; ~,-~;) ¡3 recently it was found th~t some of the timetables may be out of line. . He noted that when this industry moves to Collier County somebody will be harv~sting that citrus. He stated that this needed to be presented for the Board's consideration for the total health care system in Collier County. He stated that the p' 4tical acts are being changed , Y'-i ....,,,,, f.....,....~...,~.v,.·"l. ': . ¡''''oj í~'"" ~,i¡' ~. ,;,. ~ ~.¡,~,~. \' ,,0/1'111-1 everyday and no one knows what is going to happen, but the medical .problems.are a real problem and have to be looked at. Commissioner Hasse stated that he would like to thank everyone for all that has been contributed to society. There being no further busin~ss, the meeting was adjourned by Order of the Chair - Time: 4:05 P.M. .. \,1 ',,: J t \ ~-"...1 I '} 11 : 1\. ~;, ~: r . 'j f':J, 'f"., l t ;.: t 1: ;r: : 'I. (I ,.of ,'_ II t,,, 9 ~. ;" .... < '''j ~ . ~:( ~ ":f: ',{ ~. ' .. i".. . ,¡, . " . , \ .' i' , . ~ I· ,""" '. , .\: r , . . , "'\ ::.;: ~! \ I ~'. " i.. : " - -. - - , . Page 18