I. LIP: Cap Increase & Waiver Extension. III. IGTs: a. Public Hospital - Protect Local Funds & IGTs b. Repeal Tiering Statute

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1 GRR MEETING & TELECONFERENCE Holland & Knight Law Firm 315 S. Calhoun Street (Bank of America Bldg), 6 th Floor Tuesday, March 4, :00 p.m. 1:00 p.m. EST CallIn: Conference ID: AGENDA Welcome I. LIP: Cap Increase & Waiver Extension II. DRG Comparison Report III. IGTs: a. Public Hospital Protect Local Funds & IGTs b. Repeal Tiering Statute IV. Restore DRG Cuts: a. IME Allocation on Top of DRG Base Rate b. Pediatric & Neonate High Volume DRG Adjuster V. Trauma: a. SB 1276 by Grimsley Grandfather & Validation of Rule b. New Proposed Need Rule Hearing February 25 VI. Other Issues Next Meeting/Teleconference: March 11, 2014 SNHAF Days in the Capitol: March 31 st April 1 st

2 INCREASE LOW INCOME POOL (LIP) CAP Request: Support AHCA s Request to Federal CMS to Increase the LIP Cap to $4.5 Billion. Justification: Increasing the LIP cap allows Florida to get its fair share of federal funding, protect IGTs and directly support hospital programs outside of capitated model. An increased cap allows Florida to:! Take Advantage of Untapped Local and Hospital Resources: Increase LIP fiscal cap to $4.5 billion per year to take full advantage of untapped fiscal resources at the local and hospital level to increase the numbers of citizens served.! Greater Emphasis on Quality and Health Care Delivery Invocations: Increase LIP funding and allow for expenditures or payments outside of a capitated model to support and reward providers with emphasis on programmatic and quality initiatives designed to improve the provision of health care services to uninsured and underinsured individuals.! Greater Emphasis on Physician Workforce Training: Increase LIP funds and allow for expenditures and payments for graduate medical education initiatives to support and reward enhancements and innovations in graduate medical education.! Soften the Impact of the Tiering Cuts: Effective July 2014, a new Florida hospital rate distribution model will impose large cuts on Safety Net Hospitals and those hospitals that are contributing local dollars to the Medicaid program. (SNHAF is recommending repeal of the tiering law). Specifically, the waiver request submitted in November:! Changes the name of LIP to Access Enhancement Pool. The Access Pool will continue to pay for utilization of services for those that are uninsured and underinsured. The Access Pool will be an expansion over LIP to maximize available room in hospitals Medicaid cost ceilings for a total of $3.8 B. The current LIP program utilizes about $2.8 in allowable hospital cost ceilings.! Adds a new program named System Transformation Awards to pay hospitals for performance outside of the hospitals Medicaid cost ceilings and increase flexibility of $675 M in IGTs. Florida s LIP allocation is much lower than other states. Florida s $1 billion LIP allotment is the same today as it was 8 years ago (2005) when the program was first created. Since that time, Florida has been significantly impacted by America s economic recession causing job and income losses, resulting in increased numbers of uninsured and Medicaid enrollees. Attachment: TX Cal FL Comparison bar charts. 2/14/14

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13 FY DRG Simulation Comparison By Provider GAA Simulation Compared to FINAL Implemented Simulation Effective July 1, 2013 County Provider Medicaid ID Provider Name GR and PMATF Automatic IGTs DRG Pricing Simulation GAA (used for initial DRG rate setting implemented 7/1/2013) IGTs Total DRG Payment GR and PMATF Automatic IGTs DRG Pricing Simulation FINAL (used for DRG rate setting implemented 11/1/2013, retrospective to 7/1/2013) IGTs Difference Between Simulations GAA and FINAL Total DRG Payment Dollars Percentage Automatic Full Annual IGT Distribution Used in Initial July 1, 2013 Rates (Before 10% of Federal Share Moved to Base Rate) Full Annual IGT Distribution Used in November 1, 2013 Rates Retro to July 1, 2013 (Before 10% of Federal Share Moved to Base Automatic Rate) Alachua North Florida Regional Hospital $ 9,337,535 $ $ $ 9,337,535 $ 9,394,467 $ $ $ 9,394,467 $ 56,932 Alachua Shands Teaching Hospital $ 66,924,777 $ 38,367,601 $ 36,786,328 $ 142,078,705 $ 66,675,314 $ 38,367,919 $ 42,473,567 $ 147,516,800 $ 5,438,095 4% $ 44,582,097 $ 45,408,854 $ 44,582,097 $ 52,428,706 $ 7,019,851 Alachua Specialty Hospital Gainesville $ 54,844 $ $ $ 54,844 $ 52,219 $ $ $ 52,219 $ (2,625) 5% $ $ $ $ $ Baker Ed Fraser Memorial Hospital $ $ $ $ $ $ $ $ $ 0% $ 489 $ $ 489 $ $ Bay Bay Medical Center $ 9,448,504 $ 1,347,215 $ 4,093,436 $ 14,889,155 $ 9,505,392 $ 1,347,151 $ 4,132,984 $ 14,985,527 $ 96,373 1% $ 2,007,005 $ 6,478,811 $ 2,007,005 $ 6,541,149 $ 62,338 Bay Gulf Coast Community Hospital $ 8,522,663 $ 2,988,862 $ $ 11,511,524 $ 8,577,243 $ 2,988,513 $ $ 11,565,756 $ 54,232 0% $ 3,550,923 $ $ 3,550,923 $ $ Bay Healthsouth Emerald Coast Hospital $ 713,266 $ $ $ 713,266 $ 713,104 $ $ $ 713,104 $ (162) 0% $ $ $ $ $ Bay Select Specialty Hospital Panama City $ 33,298 $ $ $ 33,298 $ 32,591 $ $ $ 32,591 $ (707) 2% $ $ $ $ $ Bradford Shands at Starke $ 648,670 $ 77,455 $ $ 726,125 $ 649,668 $ 76,611 $ $ 726,278 $ 153 0% $ 91,185 $ $ 91,185 $ $ Brevard Cape Canaveral Hospital $ 1,757,900 $ $ $ 1,757,900 $ 1,767,061 $ $ $ 1,767,061 $ 9,160 Brevard HealthSouth Rehab HospSea Pines $ 187,332 $ $ $ 187,332 $ 187,290 $ $ $ 187,290 $ (42) 0% $ $ $ $ $ Brevard Holmes Regional Medical Center $ 12,712,190 $ 5,235,830 $ $ 17,948,019 $ 12,776,275 $ 5,236,032 $ $ 18,012,307 $ 64,287 0% $ 6,255,064 $ $ 6,255,064 $ $ Brevard Kindred HospitalMelbourne $ 9,846 $ $ $ 9,846 $ 9,375 $ $ $ 9,375 $ (471) 5% $ $ $ $ $ Brevard Palm Bay Hospital $ 90,256 $ $ $ 90,256 $ 90,794 $ $ $ 90,794 $ 538 Brevard Parrish Medical Center $ 2,403,571 $ $ 3,182,183 $ 5,585,754 $ 2,407,405 $ $ 3,683,327 $ 6,090,732 $ 504,978 9% $ $ 4,100,417 $ $ 4,746,842 $ 646,426 Brevard Viera Hospital $ 86,179 $ $ $ 86,179 $ 86,447 $ $ $ 86,447 $ 268 0% $ $ $ $ $ Brevard Wuesthoff Medical Center Melbourne $ 1,666,636 $ $ $ 1,666,636 $ 1,676,279 $ $ $ 1,676,279 $ 9,643 Brevard Wuesthoff Memorial Hospital $ 3,355,769 $ $ $ 3,355,769 $ 3,378,069 $ $ $ 3,378,069 $ 22,300 Broward Broward General Hospital $ 43,512,642 $ 21,880,773 $ 25,032,401 $ 90,425,815 $ 43,842,194 $ 21,881,267 $ 23,770,163 $ 89,493,623 $ (932,192) 1% $ 25,714,364 $ 31,251,721 $ 25,714,364 $ 29,675,190 $ (1,576,531) Broward Cleveland Clinic Hospital $ 917,845 $ $ $ 917,845 $ 922,549 $ $ $ 922,549 $ 4,704 Broward Columbia Plantation General Hosp $ 12,942,721 $ 2,231,762 $ $ 15,174,483 $ 13,008,972 $ 2,231,742 $ $ 15,240,714 $ 66,231 0% $ 3,807,918 $ $ 3,807,918 $ $ Broward Coral Springs Medical Center $ 7,517,193 $ 3,076,997 $ 4,819,534 $ 15,413,725 $ 7,566,276 $ 3,077,140 $ 4,755,128 $ 15,398,543 $ (15,181) 0% $ 3,665,524 $ 6,099,110 $ 3,665,524 $ 6,017,414 $ (81,697) Broward HealthSouth Rehab HospSunrise $ 142,596 $ $ $ 142,596 $ 142,567 $ $ $ 142,567 $ (30) 0% $ $ $ $ $ Broward Holy Cross Hospital, Inc. $ 5,119,019 $ $ $ 5,119,019 $ 5,138,455 $ $ $ 5,138,455 $ 19,436 0% $ $ $ $ $ Broward Imperial Point Hospital $ 3,327,022 $ 1,750,922 $ 2,337,905 $ 7,415,848 $ 3,406,067 $ 1,750,842 $ 1,595,179 $ 6,752,089 $ (663,760) 9% $ 2,027,655 $ 2,876,158 $ 2,027,655 $ 1,963,637 $ (912,521) Broward Kindred Hospital Ft.Lauderdale $ 27,659 $ $ $ 27,659 $ 26,335 $ $ $ 26,335 $ (1,324) 5% $ $ $ $ $ Broward Kindred HospitalHollywood $ 98,512 $ $ $ 98,512 $ 95,463 $ $ $ 95,463 $ (3,049) 3% $ $ $ $ $ Broward Memorial Hospital $ 39,411,581 $ 17,889,227 $ 18,798,575 $ 76,099,382 $ 39,713,978 $ 17,890,126 $ 17,761,606 $ 75,365,710 $ (733,672) 1% $ 22,129,693 $ 24,703,972 $ 22,129,693 $ 23,340,070 $ (1,363,901) Broward Memorial Hospital West $ 10,349,070 $ 1,022,772 $ 8,886,622 $ 20,258,464 $ 10,269,990 $ 1,022,745 $ 11,306,973 $ 22,599,708 $ 2,341,244 12% $ 1,239,832 $ 11,444,658 $ 1,239,832 $ 14,561,338 $ 3,116,680 Broward Memorial Hospital Miramar $ 5,083,215 $ 1,568,311 $ 3,585,963 $ 10,237,490 $ 5,019,650 $ 1,568,302 $ 7,060,289 $ 13,648,241 $ 3,410,751 33% $ 1,931,633 $ 4,691,986 $ 1,931,633 $ 9,237,968 $ 4,545,982 Broward North Broward Medical Center $ 7,179,274 $ 4,614,927 $ 4,833,169 $ 16,627,369 $ 7,230,569 $ 4,615,074 $ 4,644,317 $ 16,489,959 $ (137,410) 1% $ 5,344,182 $ 5,945,745 $ 5,344,182 $ 5,713,240 $ (232,505) Broward Northwest Regional Hospital $ 4,619,131 $ $ $ 4,619,131 $ 4,644,744 $ $ $ 4,644,744 $ 25,613 Broward Pembroke Pines Hospital $ 2,656,739 $ 1,303,682 $ 1,878,585 $ 5,839,007 $ 2,635,083 $ 1,303,655 $ 2,638,370 $ 6,577,108 $ 738,101 13% $ 1,639,362 $ 2,509,527 $ 1,639,362 $ 3,524,566 $ 1,015,039 Broward St. John's Rehabilitation Hospital $ 282,424 $ $ $ 282,424 $ 282,360 $ $ $ 282,360 $ (64) 0% $ $ $ $ $ Broward University Hospital & Medical Center $ 2,357,623 $ $ $ 2,357,623 $ 2,371,203 $ $ $ 2,371,203 $ 13,580 Broward Westside Regional Medical Center $ 2,393,820 $ $ $ 2,393,820 $ 2,405,548 $ $ $ 2,405,548 $ 11,728 0% $ $ $ $ $ Calhoun Calhoun Liberty Hospital $ 209,791 $ 24,957 $ $ 234,748 $ 210,122 $ 24,431 $ $ 234,553 $ (195) 0% $ 35,866 $ $ 35,866 $ $ Charlotte Charlotte Regional Medical Center $ 2,403,443 $ $ $ 2,403,443 $ 2,415,674 $ $ $ 2,415,674 $ 12,231 Charlotte Fawcett Memorial Hospital $ 2,231,642 $ $ $ 2,231,642 $ 2,246,063 $ $ $ 2,246,063 $ 14,420 Charlotte Peace River Regional Medical Center $ 4,386,543 $ $ $ 4,386,543 $ 4,415,159 $ $ $ 4,415,159 $ 28,616 Citrus Citrus Memorial Hospital $ 3,127,180 $ $ 4,497,179 $ 7,624,359 $ 3,156,601 $ $ 2,557,341 $ 5,713,942 $ (1,910,417) 25% $ $ 4,763,744 $ $ 2,708,935 $ (2,054,809) Citrus Seven Rivers Community Hospital $ 2,460,552 $ $ $ 2,460,552 $ 2,476,864 $ $ $ 2,476,864 $ 16,311 Clay Orange Park Medical Center $ 6,826,821 $ $ $ 6,826,821 $ 6,869,397 $ $ $ 6,869,397 $ 42,577 Collier Cleveland Clinic FL Hospital Naples $ 2,893,185 $ $ 3,536,452 $ 6,429,637 $ 2,898,553 $ $ 4,259,243 $ 7,157,796 $ 728,159 11% $ $ 4,195,704 $ $ 5,053,223 $ 857,518 Difference

14 FY DRG Simulation Comparison By Provider GAA Simulation Compared to FINAL Implemented Simulation Effective July 1, 2013 County Provider Medicaid ID Provider Name GR and PMATF Automatic IGTs DRG Pricing Simulation GAA (used for initial DRG rate setting implemented 7/1/2013) IGTs Total DRG Payment GR and PMATF Automatic IGTs DRG Pricing Simulation FINAL (used for DRG rate setting implemented 11/1/2013, retrospective to 7/1/2013) IGTs Difference Between Simulations GAA and FINAL Total DRG Payment Dollars Percentage Automatic Full Annual IGT Distribution Used in Initial July 1, 2013 Rates (Before 10% of Federal Share Moved to Base Rate) Full Annual IGT Distribution Used in November 1, 2013 Rates Retro to July 1, 2013 (Before 10% of Federal Share Moved to Base Automatic Rate) Collier Naples Community Hospital $ 11,169,926 $ 3,911,179 $ 4,625,303 $ 19,706,408 $ 11,108,860 $ 3,910,958 $ 9,791,166 $ 24,810,984 $ 5,104,577 26% $ 4,081,877 $ 5,128,052 $ 4,081,877 $ 10,855,998 $ 5,727,946 Columbia Lake City Medical Center $ 1,224,682 $ $ $ 1,224,682 $ 1,232,945 $ $ $ 1,232,945 $ 8,263 Columbia Shands At Lake Shore $ 6,456,944 $ 871,608 $ 240,538 $ 7,569,091 $ 6,472,814 $ 871,361 $ $ 7,344,175 $ (224,916) 3% $ 984,792 $ 271,769 $ 984,792 $ $ (271,769) Dade Anne Bates Leach Eye Hospital $ 25,801 $ 2,955 $ 17,864 $ 46,621 $ 1,769 $ 116 $ 46,257 $ 48,142 $ 1,522 3% $ 3,807 $ 24,057 $ 3,807 $ 767,832 $ 743,775 Dade Aventura Hospital & Medical Center $ 6,149,230 $ $ $ 6,149,230 $ 6,182,045 $ $ $ 6,182,045 $ 32,816 Dade Baptist of Miami $ 26,214,725 $ 13,067,571 $ $ 39,282,296 $ 26,321,288 $ 13,067,424 $ $ 39,388,711 $ 106,415 0% $ 15,823,926 $ $ 15,823,926 $ $ Dade Cedars Medical Center, Inc. $ 11,111,142 $ 4,358,520 $ 2,373,956 $ 17,843,617 $ 10,647,324 $ 4,358,714 $ 11,487,034 $ 26,493,072 $ 8,649,455 48% $ 5,465,061 $ 3,162,224 $ 5,465,061 $ 15,300,404 $ 12,138,180 Dade Columbia Kendall Medical Center $ 10,351,849 $ 3,182,150 $ $ 13,533,998 $ 10,410,127 $ 3,182,043 $ $ 13,592,170 $ 58,172 0% $ 4,053,682 $ $ 4,053,682 $ $ Dade Coral Gables Hospital $ 1,635,676 $ 697,231 $ $ 2,332,907 $ 1,645,967 $ 697,231 $ $ 2,343,198 $ 10,292 0% $ 795,352 $ $ 795,352 $ $ Dade Doctors Hospital $ 2,339,621 $ $ $ 2,339,621 $ 2,347,669 $ $ $ 2,347,669 $ 8,047 0% $ $ $ $ $ Dade Healthsouth Larkin HospitalMiami $ 1,837,857 $ 1,032,020 $ $ 2,869,877 $ 1,849,771 $ 1,031,610 $ $ 2,881,382 $ 11,505 0% $ 1,252,285 $ $ 1,252,285 $ $ Dade HealthSouth Rehab Hosp Miami $ 429,138 $ $ $ 429,138 $ 429,056 $ $ $ 429,056 $ (82) 0% $ $ $ $ $ Dade Hialeah Hospital $ 8,649,657 $ 4,721,084 $ $ 13,370,741 $ 8,700,979 $ 4,721,038 $ $ 13,422,017 $ 51,276 0% $ 5,446,267 $ $ 5,446,267 $ $ Dade Homestead Hospital $ 8,646,632 $ 6,075,849 $ $ 14,722,481 $ 8,686,264 $ 6,075,818 $ $ 14,762,082 $ 39,601 0% $ 7,691,454 $ $ 7,691,454 $ $ Dade Jackson Memorial Hospital $ 118,811,226 $ 65,416,124 $ 90,412,764 $ 274,640,115 $ 118,309,832 $ 65,417,159 $ 97,992,313 $ 281,719,304 $ 7,079,190 3% $ 93,698,430 $ 137,573,635 $ 93,698,430 $ 149,104,500 $ 11,530,866 Dade Mercy Hospital, Inc. $ 3,921,314 $ $ $ 3,921,314 $ 3,944,286 $ $ $ 3,944,286 $ 22,972 Dade Metropolitan Hospital Miami $ 1,987,642 $ $ $ 1,987,642 $ 2,000,105 $ $ $ 2,000,105 $ 12,463 Dade Miami Childrens Hospital $ 62,868,488 $ 26,617,811 $ $ 89,486,299 $ 63,819,388 $ 26,617,296 $ $ 90,436,684 $ 950,385 1% $ 34,636,965 $ $ 34,636,965 $ $ Dade Mt. Sinai Medical Center $ 10,285,146 $ 3,663,623 $ 5,737,191 $ 19,685,961 $ 10,360,435 $ 4,092,067 $ 5,022,503 $ 19,475,005 $ (210,956) 1% $ 4,245,170 $ 7,062,206 $ 4,741,456 $ 6,182,262 $ (383,657) Dade Northshore Medical Center $ 14,880,846 $ 5,866,277 $ $ 20,747,123 $ 14,964,983 $ 5,866,481 $ $ 20,831,463 $ 84,340 0% $ 6,916,571 $ $ 6,916,571 $ $ Dade Palm Springs General Hospital $ 1,733,906 $ $ $ 1,733,906 $ 1,744,397 $ $ $ 1,744,397 $ 10,492 Dade Palmetto General Hospital $ 14,652,668 $ 5,928,599 $ $ 20,581,268 $ 14,739,136 $ 5,928,532 $ $ 20,667,667 $ 86,400 0% $ 6,785,342 $ $ 6,785,342 $ $ Dade Select Specialty Hospital Miami $ 30,840 $ $ $ 30,840 $ 30,487 $ $ $ 30,487 $ (353) Dade South Miami Hospital $ 17,601,189 $ $ $ 17,601,189 $ 17,658,462 $ $ $ 17,658,462 $ 57,273 0% $ $ $ $ $ Dade St.Catherine's Rehab Hosp $ 1,271,472 $ $ $ 1,271,472 $ 1,271,168 $ $ $ 1,271,168 $ (304) 0% $ $ $ $ $ Dade University of Miami Hospital $ 496,310 $ $ $ 496,310 $ 431,979 $ $ 952,069 $ 1,384,047 $ 887, % $ $ $ $ 2,862,352 $ 2,862,352 Dade West Gables Rehabilitation $ 532,407 $ $ $ 532,407 $ 532,297 $ $ $ 532,297 $ (110) 0% $ $ $ $ $ Dade West Kendall $ 207,771 $ $ $ 207,771 $ 208,781 $ $ $ 208,781 $ 1,010 0% $ $ $ $ $ Dade Westchester General Hospital $ 2,783,455 $ 1,234,453 $ $ 4,017,908 $ 2,800,879 $ 1,234,538 $ $ 4,035,417 $ 17,509 0% $ 1,387,463 $ $ 1,387,463 $ $ Desoto Desoto Memorial Hospital $ 3,445,494 $ 551,283 $ $ 3,996,777 $ 3,450,597 $ 551,161 $ $ 4,001,759 $ 4,982 0% $ 651,689 $ $ 651,689 $ $ Duval Baptist Hospital of Beaches $ 1,585,215 $ $ $ 1,585,215 $ 1,595,258 $ $ $ 1,595,258 $ 10,043 Duval Baptist Medical Center $ 25,973,844 $ 7,251,584 $ $ 33,225,428 $ 26,098,969 $ 7,251,865 $ $ 33,350,834 $ 125,406 0% $ 11,476,986 $ $ 11,476,986 $ $ Duval Genesis Rehabilitation Hospital $ 2,463,712 $ $ $ 2,463,712 $ 2,463,210 $ $ $ 2,463,210 $ (501) 0% $ $ $ $ $ Duval Mayo Clinic Florida $ 2,478,418 $ 182,344 $ $ 2,660,762 $ 2,484,148 $ 182,340 $ $ 2,666,488 $ 5,726 0% $ 201,553 $ $ 201,553 $ $ Duval Memorial Medical Center $ 8,719,832 $ $ $ 8,719,832 $ 8,769,888 $ $ $ 8,769,888 $ 50,056 Duval Shands Jacksonville Med Cntr $ 42,854,550 $ 17,800,721 $ 23,193,863 $ 83,849,133 $ 42,416,132 $ 17,801,045 $ 34,691,738 $ 94,908,914 $ 11,059,781 13% $ 20,924,042 $ 28,962,719 $ 20,924,042 $ 43,319,526 $ 14,356,806 Duval St. Lukes St. Vincent's Healthcare $ 2,106,137 $ $ $ 2,106,137 $ 2,119,608 $ $ $ 2,119,608 $ 13,471 Duval St. Vincent's Hospital $ 7,314,910 $ 2,159,643 $ $ 9,474,553 $ 7,358,471 $ 2,159,770 $ $ 9,518,241 $ 43,688 0% $ 2,535,587 $ $ 2,535,587 $ $ Escambia Baptist Hospital (Pensacola) $ 12,219,603 $ 4,185,494 $ 2,376,246 $ 18,781,343 $ 12,470,889 $ 4,185,596 $ $ 16,656,486 $ (2,124,857) 11% $ 5,366,339 $ 3,236,273 $ 5,366,339 $ $ (3,236,273) Escambia Sacred Heart Hospital $ 29,482,937 $ 10,754,331 $ 3,770,404 $ 44,007,672 $ 29,778,496 $ 10,754,988 $ 1,504,395 $ 42,037,880 $ (1,969,793) 4% $ 13,188,982 $ 4,912,199 $ 13,188,982 $ 1,959,835 $ (2,952,363) Escambia Specialty Hospital Pensacola $ 151,283 $ $ $ 151,283 $ 144,532 $ $ $ 144,532 $ (6,751) 4% $ $ $ $ $ Escambia West Florida Regional Med Cntr $ 5,173,553 $ $ $ 5,173,553 $ 5,205,219 $ $ $ 5,205,219 $ 31,666 Flagler Florida Hospital Flagler $ 2,787,709 $ 357,179 $ $ 3,144,887 $ 2,791,905 $ 357,145 $ $ 3,149,050 $ 4,163 0% $ 401,308 $ $ 401,308 $ $ Franklin George E. Weems Memorial Hosp $ 54,363 $ 17,960 $ $ 72,323 $ 54,460 $ 17,660 $ $ 72,120 $ (203) 0% $ 26,085 $ $ 26,085 $ $ Difference

15 FY DRG Simulation Comparison By Provider GAA Simulation Compared to FINAL Implemented Simulation Effective July 1, 2013 County Provider Medicaid ID Provider Name GR and PMATF Automatic IGTs DRG Pricing Simulation GAA (used for initial DRG rate setting implemented 7/1/2013) IGTs Total DRG Payment GR and PMATF Automatic IGTs DRG Pricing Simulation FINAL (used for DRG rate setting implemented 11/1/2013, retrospective to 7/1/2013) IGTs Difference Between Simulations GAA and FINAL Total DRG Payment Dollars Percentage Automatic Full Annual IGT Distribution Used in Initial July 1, 2013 Rates (Before 10% of Federal Share Moved to Base Rate) Full Annual IGT Distribution Used in November 1, 2013 Rates Retro to July 1, 2013 (Before 10% of Federal Share Moved to Base Automatic Rate) Gulf Sacred Heart Hosp. Gulf $ 420,857 $ 35,748 $ $ 456,606 $ 421,405 $ 35,709 $ $ 457,113 $ 508 0% $ 44,315 $ $ 44,315 $ $ Hardee Florida Hospital Wauchula $ 57,335 $ 18,786 $ $ 76,121 $ 57,422 $ 18,786 $ $ 76,209 $ 88 0% $ 21,396 $ $ 21,396 $ $ Hendry Hendry Regional Medical Center $ 655,029 $ 98,382 $ $ 753,412 $ 656,016 $ 97,595 $ $ 753,611 $ 200 0% $ 91,679 $ $ 91,679 $ $ Hernando Brooksville Regional Hospital $ 5,857,799 $ 1,499,932 $ 3,938,433 $ 11,296,165 $ 5,899,863 $ 1,499,900 $ 2,738,243 $ 10,138,006 $ (1,158,158) 10% $ 1,711,980 $ 4,775,406 $ 1,711,980 $ 3,320,220 $ (1,455,186) Hernando Healthsouth Hospital of Spring Hill $ 75,536 $ $ $ 75,536 $ 75,518 $ $ $ 75,518 $ (18) 0% $ $ $ $ $ Hernando Oak Hill Community Hospital $ 2,195,332 $ $ $ 2,195,332 $ 2,208,373 $ $ $ 2,208,373 $ 13,041 Highlands Florida Hospital Heartland Med Cntr $ 4,769,808 $ $ $ 4,769,808 $ 4,757,678 $ $ 1,170,633 $ 5,928,311 $ 1,158,503 24% $ $ $ $ 1,646,126 $ 1,646,126 Highlands Highlands Regional Medical Center $ 1,669,220 $ $ 2,093,802 $ 3,763,022 $ 1,680,112 $ $ 2,084,071 $ 3,764,183 $ 1,161 0% $ $ 2,644,372 $ $ 2,631,919 $ (12,453) Hillsborough Brandon Regional Medical Center $ 9,882,783 $ 3,195,056 $ 3,805,206 $ 16,883,044 $ 9,975,230 $ 3,194,974 $ 3,019,751 $ 16,189,954 $ (693,090) 4% $ 3,872,046 $ 4,898,881 $ 3,872,046 $ 3,887,781 $ (1,011,099) Hillsborough H L Moffitt Cancer Center $ 7,882,576 $ 1,148,882 $ 4,858,779 $ 13,890,237 $ 7,560,389 $ 1,148,162 $ 7,242,869 $ 15,951,421 $ 2,061,184 15% $ 1,256,818 $ 5,647,687 $ 1,256,818 $ 8,418,589 $ 2,770,902 Hillsborough Kindred Hospital (Tampa) $ 7,653 $ $ $ 7,653 $ 7,287 $ $ $ 7,287 $ (366) 5% $ $ $ $ $ Hillsborough Kindred Hospital Central Tampa $ 19,280 $ $ $ 19,280 $ 18,357 $ $ $ 18,357 $ (923) 5% $ $ $ $ $ Hillsborough Memorial Hospital of Tampa $ 702,121 $ $ $ 702,121 $ 705,956 $ $ $ 705,956 $ 3,835 Hillsborough Shriners Hospital for Children $ 156,837 $ 21,045 $ $ 177,882 $ 157,658 $ 21,043 $ $ 178,701 $ 819 0% $ 340,761 $ $ 340,761 $ $ Hillsborough South Bay Hospital $ 727,421 $ $ 459,863 $ 1,187,284 $ 732,329 $ $ 426,403 $ 1,158,731 $ (28,553) 2% $ $ 576,948 $ $ 535,016 $ (41,932) Hillsborough South Florida Baptist $ 2,633,085 $ 1,455,504 $ 2,623,077 $ 6,711,666 $ 2,691,182 $ 1,455,370 $ 1,427,084 $ 5,573,637 $ (1,138,029) 17% $ 1,760,061 $ 3,370,050 $ 1,760,061 $ 1,833,421 $ (1,536,629) Hillsborough St. Joseph's Hospital $ 37,276,002 $ 15,817,941 $ 26,279,844 $ 79,373,787 $ 37,870,340 $ 15,818,528 $ 20,420,895 $ 74,109,763 $ (5,264,024) 7% $ 20,350,893 $ 35,918,204 $ 20,350,893 $ 27,909,402 $ (8,008,802) Hillsborough Tampa General Hospital $ 50,228,900 $ 31,849,851 $ 39,699,846 $ 121,778,596 $ 51,329,104 $ 31,850,231 $ 32,015,440 $ 115,194,775 $ (6,583,821) 5% $ 39,747,702 $ 52,632,209 $ 39,747,702 $ 42,444,060 $ (10,188,149) Hillsborough Town and Country Hospital $ 1,140,801 $ $ 700,508 $ 1,841,309 $ 1,150,314 $ $ 603,141 $ 1,753,455 $ (87,854) 5% $ $ 821,389 $ $ 707,929 $ (113,460) Hillsborough Univ Community Hosp Carrollwood $ 929,187 $ $ 1,078,186 $ 2,007,374 $ 953,212 $ $ 448,757 $ 1,401,969 $ (605,404) 30% $ $ 1,848,519 $ $ 769,419 $ (1,079,100) Hillsborough Univ Community HospTampa $ 6,657,017 $ $ 1,873,667 $ 8,530,684 $ 6,705,190 $ $ 1,682,586 $ 8,387,776 $ (142,908) 2% $ $ 3,425,212 $ $ 3,077,677 $ (347,534) Holmes Doctors Memorial Hospital $ 1,084,343 $ 125,544 $ $ 1,209,886 $ 1,085,683 $ 125,520 $ $ 1,211,204 $ 1,317 0% $ 141,280 $ $ 141,280 $ $ Indian River HealthSouth Rehab HospTreasure Coast $ 326,853 $ $ $ 326,853 $ 326,780 $ $ $ 326,780 $ (73) 0% $ $ $ $ $ Indian River Indian River Memorial Hospital $ 5,489,632 $ $ 5,959,447 $ 11,449,079 $ 5,566,312 $ $ 4,784,213 $ 10,350,526 $ (1,098,553) 10% $ $ 7,371,990 $ $ 5,917,905 $ (1,454,085) Indian River Sebastian Hospital $ 939,586 $ $ $ 939,586 $ 945,295 $ $ $ 945,295 $ 5,708 Jackson CampbelltonGraceville Hospital $ 38,812 $ 9,717 $ $ 48,529 $ 38,866 $ 9,716 $ $ 48,583 $ 54 0% $ 11,103 $ $ 11,103 $ $ Jackson Jackson Hospital $ 4,049,307 $ 760,549 $ $ 4,809,855 $ 4,054,472 $ 760,289 $ 10,291 $ 4,825,052 $ 15,197 0% $ 837,261 $ $ 837,261 $ 11,536 $ 11,536 Lake Florida Hospital Waterman $ 4,486,328 $ $ 5,510,704 $ 9,997,031 $ 4,540,963 $ $ 3,853,980 $ 8,394,943 $ (1,602,089) 16% $ $ 8,230,506 $ $ 5,756,071 $ (2,474,435) Lake Leesburg Regional Medical Center $ 5,740,545 $ $ 4,811,726 $ 10,552,271 $ 5,776,829 $ $ 4,820,242 $ 10,597,070 $ 44,799 0% $ $ 7,081,394 $ $ 7,093,818 $ 12,424 Lake South Lake Memorial Hospital $ 2,182,496 $ $ 3,498,284 $ 5,680,781 $ 2,197,605 $ $ 3,452,085 $ 5,649,690 $ (31,090) 1% $ $ 3,968,552 $ $ 3,916,291 $ (52,262) Lee Cape Coral Hospital $ 4,497,260 $ $ 6,729,584 $ 11,226,844 $ 4,554,492 $ $ 5,385,312 $ 9,939,804 $ (1,287,040) 11% $ $ 8,083,279 $ $ 6,468,398 $ (1,614,880) Lee Lee Memorial Hospital $ 26,049,384 $ 14,883,700 $ 20,858,302 $ 61,791,387 $ 26,673,627 $ 14,884,070 $ 14,385,819 $ 55,943,516 $ (5,847,871) 9% $ 16,527,784 $ 24,605,991 $ 16,527,784 $ 16,970,148 $ (7,635,843) Lee Lehigh Regional Medical Center $ 1,321,305 $ $ $ 1,321,305 $ 1,330,220 $ $ $ 1,330,220 $ 8,915 Lee Southwest Florida Regional Medical $ 7,323,157 $ $ 12,525,502 $ 19,848,659 $ 7,474,745 $ $ 9,565,418 $ 17,040,163 $ (2,808,496) 14% $ $ 15,019,541 $ $ 11,469,552 $ (3,549,988) Leon Capital Regional Medical Center $ 5,487,525 $ $ 762,690 $ 6,250,214 $ 5,522,302 $ $ 692,011 $ 6,214,313 $ (35,902) 1% $ $ 924,649 $ $ 838,960 $ (85,689) Leon HealthSouth Rehab HospTallahassee $ 122,545 $ $ $ 122,545 $ 122,522 $ $ $ 122,522 $ (23) 0% $ $ $ $ $ Leon Specialty Hospital Tallahassee $ 21,897 $ $ $ 21,897 $ 20,849 $ $ $ 20,849 $ (1,048) 5% $ $ $ $ $ Leon Tallahassee Memorial Rgnl Med Cntr $ 15,889,590 $ 4,121,205 $ $ 20,010,796 $ 15,974,289 $ 4,121,088 $ $ 20,095,377 $ 84,582 0% $ 6,930,746 $ $ 6,930,746 $ $ Levy TriCounty Hospital Williston $ 673,494 $ 60,020 $ $ 733,514 $ 674,313 $ 59,947 $ $ 734,260 $ 745 0% $ 69,520 $ $ 69,520 $ $ Madison Madison County Memorial Hospital $ 61,661 $ 8,067 $ $ 69,727 $ 61,778 $ 7,696 $ $ 69,474 $ (253) 0% $ 9,285 $ $ 9,285 $ $ Manatee L.W. Blake Memorial Hospital $ 1,331,135 $ $ 1,350,242 $ 2,681,376 $ 1,338,598 $ $ 1,401,624 $ 2,740,222 $ 58,846 2% $ $ 1,770,290 $ $ 1,837,658 $ 67,368 Manatee Lakewood Ranch Medical Center $ 762,647 $ $ $ 762,647 $ 766,562 $ $ $ 766,562 $ 3,914 Manatee Manatee Memorial Hospital $ 10,546,301 $ 3,534,034 $ 7,301,354 $ 21,381,690 $ 10,679,685 $ 3,534,180 $ 6,078,893 $ 20,292,759 $ (1,088,932) 5% $ 4,652,285 $ 10,210,731 $ 4,652,285 $ 8,500,808 $ (1,709,923) Marion Kindred Hospital Ocala $ 15,686 $ $ $ 15,686 $ 14,935 $ $ $ 14,935 $ (751) 5% $ $ $ $ $ Difference

16 FY DRG Simulation Comparison By Provider GAA Simulation Compared to FINAL Implemented Simulation Effective July 1, 2013 County Provider Medicaid ID Provider Name GR and PMATF Automatic IGTs DRG Pricing Simulation GAA (used for initial DRG rate setting implemented 7/1/2013) IGTs Total DRG Payment GR and PMATF Automatic IGTs DRG Pricing Simulation FINAL (used for DRG rate setting implemented 11/1/2013, retrospective to 7/1/2013) IGTs Difference Between Simulations GAA and FINAL Total DRG Payment Dollars Percentage Automatic Full Annual IGT Distribution Used in Initial July 1, 2013 Rates (Before 10% of Federal Share Moved to Base Rate) Full Annual IGT Distribution Used in November 1, 2013 Rates Retro to July 1, 2013 (Before 10% of Federal Share Moved to Base Automatic Rate) Marion Munroe Regional Medical Center $ 8,920,576 $ $ 10,774,555 $ 19,695,131 $ 9,008,256 $ $ 8,923,383 $ 17,931,639 $ (1,763,492) 9% $ $ 15,006,730 $ $ 12,427,755 $ (2,578,975) Marion Ocala Regional Medical Center $ 4,935,298 $ $ 1,209,837 $ 6,145,135 $ 4,963,085 $ $ 1,544,373 $ 6,507,458 $ 362,323 6% $ $ 1,467,271 $ $ 1,873,576 $ 406,305 Martin Martin Memorial Hospital $ 5,193,441 $ $ 1,879,308 $ 7,072,748 $ 5,220,285 $ $ 1,932,957 $ 7,153,242 $ 80,494 1% $ $ 2,295,540 $ $ 2,361,161 $ 65,621 Monroe Fishermen's Hospital $ 207,701 $ 32,642 $ $ 240,343 $ 208,006 $ 32,320 $ $ 240,326 $ (17) 0% $ 42,011 $ $ 42,011 $ $ Monroe Lower Florida Keys Hospital $ 2,517,236 $ 1,305,302 $ $ 3,822,538 $ 2,531,088 $ 1,304,520 $ $ 3,835,607 $ 13,070 0% $ 1,521,187 $ $ 1,521,187 $ $ Monroe Mariners Hospital $ 289,670 $ 43,926 $ $ 333,596 $ 289,949 $ 43,926 $ $ 333,875 $ 279 0% $ 52,960 $ $ 52,960 $ $ Nassau Baptist Medical Center Nassau $ 1,764,670 $ 285,681 $ $ 2,050,351 $ 1,767,330 $ 285,634 $ $ 2,052,963 $ 2,612 0% $ 358,242 $ $ 358,242 $ $ Okaloosa Columbia Twin Cities Hospital $ 520,741 $ $ $ 520,741 $ 524,110 $ $ $ 524,110 $ 3,369 Okaloosa Ft. Walton Beach Medical Center $ 6,940,111 $ $ $ 6,940,111 $ 6,980,532 $ $ $ 6,980,532 $ 40,421 Okaloosa North Okaloosa Medical Center $ 2,545,323 $ $ $ 2,545,323 $ 2,562,188 $ $ $ 2,562,188 $ 16,866 Okeechobee H.H. Raulerson $ 2,967,508 $ 433,455 $ $ 3,400,963 $ 2,972,008 $ 433,432 $ $ 3,405,440 $ 4,476 0% $ 493,495 $ $ 493,495 $ $ OOS_Part Archbold Memorial Hospital $ 16,227 $ $ $ 16,227 $ 16,337 $ $ $ 16,337 $ 109 OOS_Part Atmore Community Hospital $ 59,401 $ $ $ 59,401 $ 59,802 $ $ $ 59,802 $ 401 OOS_Part Charlton Memorial Hospital $ 4,809 $ $ $ 4,809 $ 4,824 $ $ $ 4,824 $ 15 0% $ $ $ $ $ OOS_Part D.W.Mcmillan Memorial $ 17,265 $ $ $ 17,265 $ 17,381 $ $ $ 17,381 $ 116 OOS_Part Flowers Hospital $ 240,885 $ $ $ 240,885 $ 242,511 $ $ $ 242,511 $ 1,625 OOS_Part Mizell Memorial Hospital $ 7,110 $ $ $ 7,110 $ 7,158 $ $ $ 7,158 $ 48 OOS_Part Smith Hospital $ 3,900 $ $ $ 3,900 $ 3,927 $ $ $ 3,927 $ 26 OOS_Part South Baldwin Hospital $ 40,688 $ $ $ 40,688 $ 40,749 $ $ $ 40,749 $ 61 0% $ $ $ $ $ OOS_Part South Georgia Medical Center $ 76,631 $ $ $ 76,631 $ 77,148 $ $ $ 77,148 $ 517 OOS_Part Southeast Alabama General $ 708,272 $ $ $ 708,272 $ 713,051 $ $ $ 713,051 $ 4,779 OOS_Part Southeast Georgia Medical Center $ 11,840 $ $ $ 11,840 $ 11,920 $ $ $ 11,920 $ 80 OOS_Part U.S.A Children's & Women's Hospital $ 78,285 $ $ $ 78,285 $ 78,813 $ $ $ 78,813 $ 528 OOS_Part University of South AL Med Cntr $ 116,211 $ $ $ 116,211 $ 116,834 $ $ $ 116,834 $ 623 OOS_Part Wiregrass Hospital $ 101,563 $ $ $ 101,563 $ 102,216 $ $ $ 102,216 $ 654 Orange Florida Hospital $ 69,652,303 $ 34,276,766 $ 9,980,961 $ 113,910,030 $ 70,097,532 $ 34,277,151 $ 8,760,983 $ 113,135,665 $ (774,365) 1% $ 42,656,169 $ 13,195,059 $ 42,656,169 $ 11,582,153 $ (1,612,905) Orange Health Central $ 4,795,200 $ 881,572 $ 3,568,968 $ 9,245,741 $ 4,810,267 $ 881,502 $ 4,248,952 $ 9,940,721 $ 694,981 8% $ 1,029,883 $ 4,429,787 $ 1,029,883 $ 5,273,552 $ 843,765 Orange Nemours Children's Hospital $ $ $ $ $ $ $ $ $ 0% $ 9,128,686 $ $ 9,128,686 $ $ Orange Orlando Regional Medical Center $ 78,250,368 $ 30,684,417 $ 13,127,977 $ 122,062,762 $ 78,524,399 $ 30,684,821 $ 14,048,623 $ 123,257,843 $ 1,195,081 1% $ 33,940,452 $ 15,426,061 $ 33,940,452 $ 16,506,939 $ 1,080,878 Orange Select Specialty Hospital Orlando $ 126,591 $ $ $ 126,591 $ 122,306 $ $ $ 122,306 $ (4,285) 3% $ $ $ $ $ Osceola Columbia Medical CenterOsceola $ 8,347,617 $ 3,481,883 $ $ 11,829,501 $ 8,399,012 $ 3,481,181 $ $ 11,880,193 $ 50,692 0% $ 3,821,759 $ $ 3,821,759 $ $ Osceola St. Cloud Regional Center $ 886,252 $ $ $ 886,252 $ 891,540 $ $ $ 891,540 $ 5,288 Palm Beach A.G. Holley State Hospital $ 842,731 $ $ $ 842,731 $ 842,783 $ $ $ 842,783 $ 52 0% $ $ $ $ $ Palm Beach Bethesda Mem. Hosp. $ 13,314,073 $ 3,346,118 $ 7,312,425 $ 23,972,616 $ 13,491,005 $ 3,345,831 $ 4,748,914 $ 21,585,750 $ (2,386,866) 10% $ 3,814,307 $ 8,855,108 $ 3,814,307 $ 5,751,270 $ (3,103,838) Palm Beach Boca Raton Community Hospital $ 2,011,206 $ $ 724,096 $ 2,735,302 $ 1,990,424 $ $ 1,014,108 $ 3,004,531 $ 269,230 10% $ $ 797,695 $ $ 1,117,232 $ 319,537 Palm Beach Columbia Hospital $ 2,701,701 $ 918,816 $ 2,129,242 $ 5,749,759 $ 2,722,838 $ 918,790 $ 1,943,780 $ 5,585,408 $ (164,352) 3% $ 1,026,237 $ 2,526,409 $ 1,026,237 $ 2,306,414 $ (219,994) Palm Beach Columbia JFK Medical Center $ 11,334,399 $ 4,040,839 $ 8,100,218 $ 23,475,456 $ 11,423,129 $ 4,040,969 $ 7,621,188 $ 23,085,285 $ (390,170) 2% $ 4,846,806 $ 10,321,408 $ 4,846,806 $ 9,710,707 $ (610,702) Palm Beach Columbia Palms West Hospital $ 7,057,432 $ 2,358,736 $ 5,678,052 $ 15,094,220 $ 7,100,221 $ 2,358,579 $ 5,751,236 $ 15,210,036 $ 115,816 1% $ 2,753,255 $ 7,041,487 $ 2,753,255 $ 7,132,064 $ 90,577 Palm Beach Delray Comm. Hospital $ 3,442,642 $ 82,123 $ 2,660,837 $ 6,185,601 $ 3,456,456 $ 82,120 $ 2,789,730 $ 6,328,307 $ 142,705 2% $ 93,719 $ 3,224,523 $ 93,719 $ 3,380,752 $ 156,230 Palm Beach Glades General Hospital $ 6,244,841 $ 669,136 $ 39,451 $ 6,953,429 $ 6,185,344 $ 668,661 $ 1,723,029 $ 8,577,034 $ 1,623,605 23% $ 771,274 $ 45,473 $ 771,274 $ 1,987,445 $ 1,941,972 Palm Beach Good Samaritan Hospital $ 2,988,974 $ $ 3,386,643 $ 6,375,617 $ 3,017,769 $ $ 2,885,979 $ 5,903,748 $ (471,869) 7% $ $ 4,114,805 $ $ 3,506,482 $ (608,323) Palm Beach Jupiter Hospital $ 1,593,200 $ $ 838,183 $ 2,431,382 $ 1,603,573 $ $ 880,211 $ 2,483,784 $ 52,402 2% $ $ 1,060,597 $ $ 1,113,830 $ 53,233 Palm Beach Kindred Hospital Palm Beaches $ 109,416 $ $ $ 109,416 $ 104,179 $ $ $ 104,179 $ (5,237) 5% $ $ $ $ $ Palm Beach Palm Beach Gardens Medical Center $ 1,534,447 $ $ 2,182,401 $ 3,716,848 $ 1,616,402 $ $ 1,424,519 $ 3,040,921 $ (675,927) 18% $ $ 2,711,765 $ $ 1,770,051 $ (941,714) Difference

17 FY DRG Simulation Comparison By Provider GAA Simulation Compared to FINAL Implemented Simulation Effective July 1, 2013 County Provider Medicaid ID Provider Name GR and PMATF Automatic IGTs DRG Pricing Simulation GAA (used for initial DRG rate setting implemented 7/1/2013) IGTs Total DRG Payment GR and PMATF Automatic IGTs DRG Pricing Simulation FINAL (used for DRG rate setting implemented 11/1/2013, retrospective to 7/1/2013) IGTs Difference Between Simulations GAA and FINAL Total DRG Payment Dollars Percentage Automatic Full Annual IGT Distribution Used in Initial July 1, 2013 Rates (Before 10% of Federal Share Moved to Base Rate) Full Annual IGT Distribution Used in November 1, 2013 Rates Retro to July 1, 2013 (Before 10% of Federal Share Moved to Base Automatic Rate) Palm Beach Specialty Hospital Palm Beach $ 11,149 $ $ $ 11,149 $ 10,615 $ $ $ 10,615 $ (534) 5% $ $ $ $ $ Palm Beach St. Mary's Hospital $ 26,982,359 $ 9,511,191 $ 13,694,436 $ 50,187,986 $ 26,955,539 $ 9,511,374 $ 16,025,706 $ 52,492,619 $ 2,304,633 5% $ 11,259,187 $ 17,221,610 $ 11,259,187 $ 20,152,937 $ 2,931,327 Palm Beach Wellington Regional Medical Center $ 6,371,859 $ 848,165 $ 3,005,395 $ 10,225,419 $ 6,416,451 $ 848,184 $ 2,827,114 $ 10,091,749 $ (133,670) 1% $ 1,199,941 $ 4,515,590 $ 1,199,941 $ 4,248,839 $ (266,751) Palm Beach West Boca Medical Center $ 6,220,265 $ $ $ 6,220,265 $ 5,532,753 $ $ 4,833,007 $ 10,365,760 $ 4,145,496 67% $ $ $ $ 6,020,772 $ 6,020,772 Pasco Bayonet Point/Hudso $ 3,476,489 $ $ $ 3,476,489 $ 3,497,762 $ $ $ 3,497,762 $ 21,273 Pasco Columbia New Port Richey Hospital $ 3,361,246 $ $ $ 3,361,246 $ 3,382,148 $ $ $ 3,382,148 $ 20,902 Pasco Florida Hospital Zephyrhills $ 2,985,612 $ $ $ 2,985,612 $ 3,004,504 $ $ $ 3,004,504 $ 18,893 Pasco North Bay Medical Center $ 2,215,349 $ $ $ 2,215,349 $ 2,228,353 $ $ $ 2,228,353 $ 13,004 Pasco Pasco Community Hospital $ 1,250,421 $ $ $ 1,250,421 $ 1,258,413 $ $ $ 1,258,413 $ 7,992 Pasco UCHLTACH at Connerton $ 31,132 $ $ $ 31,132 $ 29,642 $ $ $ 29,642 $ (1,490) 5% $ $ $ $ $ Pinellas All Children's Hospital $ 77,876,870 $ 21,282,398 $ 1,753,644 $ 100,912,912 $ 77,303,423 $ 21,281,880 $ 13,878,074 $ 112,463,377 $ 11,550,465 11% $ 29,748,824 $ 2,451,271 $ 29,748,824 $ 19,399,434 $ 16,948,163 Pinellas BayCare Alliant Hospital $ 563,511 $ $ 264,266 $ 827,777 $ 599,438 $ $ $ 599,438 $ (228,339) 28% $ $ 407,695 $ $ $ (407,695) Pinellas Bayfront Medical Center $ 13,896,422 $ 4,425,357 $ 8,063,381 $ 26,385,160 $ 14,051,670 $ 4,425,253 $ 6,626,630 $ 25,103,552 $ (1,281,608) 5% $ 5,575,051 $ 10,791,773 $ 5,575,051 $ 8,868,725 $ (1,923,048) Pinellas Edward White Hospital $ 1,117,132 $ $ $ 1,117,132 $ 1,124,126 $ $ $ 1,124,126 $ 6,994 Pinellas HealthSouth Rehab HospLargo $ 749,460 $ $ $ 749,460 $ 749,321 $ $ $ 749,321 $ (139) 0% $ $ $ $ $ Pinellas Helen Ellis Memorial Hospital $ 1,639,275 $ $ $ 1,639,275 $ 1,649,285 $ $ $ 1,649,285 $ 10,010 Pinellas Kindred HospitalSt. Petersburg $ 8,857 $ $ $ 8,857 $ 8,433 $ $ $ 8,433 $ (424) 5% $ $ $ $ $ Pinellas Largo Medical Center $ 3,370,831 $ 755,389 $ $ 4,126,220 $ 3,391,567 $ 755,389 $ $ 4,146,957 $ 20,737 1% $ 851,478 $ $ 851,478 $ $ Pinellas Mease Hospital Clinic $ 1,744,511 $ $ 1,590,012 $ 3,334,522 $ 1,801,397 $ $ 487,985 $ 2,289,382 $ (1,045,141) 31% $ $ 2,065,561 $ $ 633,951 $ (1,431,610) Pinellas Mease Hospital Countryside $ 4,781,324 $ $ 4,531,406 $ 9,312,730 $ 4,779,879 $ $ 5,366,643 $ 10,146,522 $ 833,792 9% $ $ 6,003,563 $ $ 7,110,305 $ 1,106,742 Pinellas Morton F. Plant Hospital $ 8,097,868 $ 5,013,931 $ 6,630,045 $ 19,741,845 $ 8,220,308 $ 5,013,796 $ 3,989,600 $ 17,223,704 $ (2,518,141) 13% $ 6,161,970 $ 8,656,425 $ 6,161,970 $ 5,208,834 $ (3,447,591) Pinellas Northside Hospital $ 3,524,663 $ 967,083 $ $ 4,491,747 $ 3,543,502 $ 967,083 $ $ 4,510,585 $ 18,838 0% $ 1,875,802 $ $ 1,875,802 $ $ Pinellas Palms of Pasadena Hospital $ 928,611 $ $ $ 928,611 $ 932,809 $ $ $ 932,809 $ 4,199 0% $ $ $ $ $ Pinellas St Anthonys Hospital $ 4,104,042 $ 1,724,683 $ $ 5,828,725 $ 4,052,506 $ 1,724,687 $ 1,983,310 $ 7,760,503 $ 1,931,778 33% $ 2,698,871 $ $ 2,698,871 $ 3,297,014 $ 3,297,014 Pinellas St. Petersburg General Hospital $ 3,906,898 $ 1,427,718 $ $ 5,334,616 $ 3,926,941 $ 1,427,696 $ $ 5,354,637 $ 20,021 0% $ 1,714,334 $ $ 1,714,334 $ $ Polk Bartow Memorial Hospital $ 1,381,537 $ 154,858 $ 707,530 $ 2,243,925 $ 1,395,269 $ 154,898 $ 370,856 $ 1,921,023 $ (322,902) 14% $ 340,957 $ 1,653,851 $ 340,957 $ 867,196 $ (786,656) Polk Heart of Florida Hospital $ 4,546,969 $ 2,673,834 $ 3,469,595 $ 10,690,397 $ 4,627,185 $ 2,673,765 $ 1,060,065 $ 8,361,014 $ (2,329,383) 22% $ 2,675,195 $ 3,687,720 $ 2,675,195 $ 1,127,341 $ (2,560,379) Polk Lake Wales Hospital Association $ 1,273,773 $ $ 598,226 $ 1,871,999 $ 1,282,049 $ $ 1,276,746 $ 2,558,795 $ 686,796 37% $ $ 690,975 $ $ 1,475,057 $ 784,082 Polk Lakeland Regional Medical Center $ 14,327,925 $ 5,537,009 $ 10,180,394 $ 30,045,328 $ 14,452,316 $ 5,537,065 $ 8,845,886 $ 28,835,266 $ (1,210,062) 4% $ 6,614,048 $ 12,919,073 $ 6,614,048 $ 11,225,011 $ (1,694,062) Polk Winter Haven Hospital $ 5,488,211 $ 3,070,348 $ 5,175,331 $ 13,733,890 $ 5,552,194 $ 3,070,282 $ 3,951,073 $ 12,573,549 $ (1,160,341) 8% $ 3,214,902 $ 5,756,724 $ 3,214,902 $ 4,395,038 $ (1,361,686) Putnam Putnam Community Hospital $ 5,109,999 $ 684,352 $ $ 5,794,351 $ 5,117,508 $ 684,255 $ $ 5,801,762 $ 7,412 0% $ 747,266 $ $ 747,266 $ $ Santa Rosa Jay Hospital $ 494,720 $ 73,691 $ $ 568,411 $ 495,474 $ 73,021 $ $ 568,494 $ 83 0% $ 84,750 $ $ 84,750 $ $ Santa Rosa Santa Rosa Hospital $ 2,018,195 $ $ 1,745,126 $ 3,763,321 $ 2,030,715 $ $ 2,112,107 $ 4,142,822 $ 379,501 10% $ $ 2,110,828 $ $ 2,554,733 $ 443,905 Sarasota Columbia Englewood Community Hosp $ 510,660 $ $ $ 510,660 $ 513,933 $ $ $ 513,933 $ 3,274 Sarasota Doctors Hospital of Sarasota $ 687,212 $ $ $ 687,212 $ 691,473 $ $ $ 691,473 $ 4,261 Sarasota HealthSouth Rehab Hosp Sarasota $ 290,217 $ $ $ 290,217 $ 290,166 $ $ $ 290,166 $ (51) 0% $ $ $ $ $ Sarasota Healthsouth Ridgelake Hospital $ 162,056 $ $ $ 162,056 $ 156,337 $ $ $ 156,337 $ (5,719) 4% $ $ $ $ $ Sarasota Memorial Hospital $ 11,243,278 $ $ 15,417,370 $ 26,660,649 $ 11,407,724 $ $ 13,047,500 $ 24,455,224 $ (2,205,424) 8% $ $ 19,001,665 $ $ 16,080,518 $ (2,921,147) Sarasota Venice Hospital $ 1,970,567 $ $ $ 1,970,567 $ 1,979,674 $ $ $ 1,979,674 $ 9,107 0% $ $ $ $ $ Seminole Central Florida Regional Hospital $ 3,713,693 $ $ $ 3,713,693 $ 3,735,563 $ $ $ 3,735,563 $ 21,870 St. Johns Flagler Hospital $ 4,233,541 $ $ 1,710,986 $ 5,944,527 $ 4,261,844 $ $ 1,650,510 $ 5,912,354 $ (32,173) 1% $ $ 2,060,706 $ $ 1,988,556 $ (72,151) St. Lucie Lawnwood Regional Medical Center $ 11,469,429 $ 3,771,963 $ $ 15,241,393 $ 11,536,122 $ 3,771,963 $ $ 15,308,086 $ 66,693 0% $ 5,606,828 $ $ 5,606,828 $ $ St. Lucie St.Lucie Medical Center $ 3,591,373 $ 1,755,070 $ $ 5,346,443 $ 3,614,149 $ 1,755,070 $ $ 5,369,219 $ 22,776 0% $ 2,153,546 $ $ 2,153,546 $ $ Sumter The Villages Regional Hospital $ 1,406,860 $ $ $ 1,406,860 $ 1,415,409 $ $ $ 1,415,409 $ 8,549 Difference

18 FY DRG Simulation Comparison By Provider GAA Simulation Compared to FINAL Implemented Simulation Effective July 1, 2013 County Provider Medicaid ID Provider Name GR and PMATF Automatic IGTs DRG Pricing Simulation GAA (used for initial DRG rate setting implemented 7/1/2013) IGTs Total DRG Payment GR and PMATF Automatic IGTs DRG Pricing Simulation FINAL (used for DRG rate setting implemented 11/1/2013, retrospective to 7/1/2013) IGTs Difference Between Simulations GAA and FINAL Total DRG Payment Dollars Percentage Automatic Full Annual IGT Distribution Used in Initial July 1, 2013 Rates (Before 10% of Federal Share Moved to Base Rate) Full Annual IGT Distribution Used in November 1, 2013 Rates Retro to July 1, 2013 (Before 10% of Federal Share Moved to Base Automatic Rate) Suwannee Shands at Live Oak $ 354,671 $ 29,692 $ 2,942 $ 387,305 $ 355,318 $ 29,330 $ $ 384,647 $ (2,658) 1% $ 29,847 $ 2,995 $ 29,847 $ $ (2,995) Taylor Doctor's Memorial Hospital $ 1,100,308 $ 124,177 $ $ 1,224,485 $ 1,101,830 $ 123,324 $ $ 1,225,154 $ 669 0% $ 173,640 $ $ 173,640 $ $ Union Lake Butler Hospital $ 40,647 $ 3,402 $ $ 44,049 $ 40,703 $ 3,401 $ $ 44,104 $ 55 0% $ 15,171 $ $ 15,171 $ $ Volusia Bert Fish Memorial Hospital $ 988,231 $ $ 1,201,440 $ 2,189,671 $ 1,002,190 $ $ 1,006,459 $ 2,008,649 $ (181,022) 8% $ $ 1,780,863 $ $ 1,491,967 $ (288,896) Volusia Halifax Medical Center $ 12,823,642 $ 5,340,343 $ 8,437,317 $ 26,601,302 $ 12,607,118 $ 5,340,503 $ 12,132,624 $ 30,080,245 $ 3,478,944 13% $ 6,121,525 $ 10,274,331 $ 6,121,525 $ 14,773,753 $ 4,499,422 Volusia Memorial Hospital West Volusia $ 3,242,250 $ $ 4,258,901 $ 7,501,151 $ 3,270,295 $ $ 3,727,759 $ 6,998,054 $ (503,097) 7% $ $ 5,388,485 $ $ 4,716,676 $ (671,809) Volusia Ormond Beach Memorial Hospital $ 4,784,427 $ $ $ 4,784,427 $ 4,810,720 $ $ $ 4,810,720 $ 26,293 Volusia Volusia Medical Center $ 2,525,598 $ $ 2,723,378 $ 5,248,976 $ 2,562,439 $ $ 1,390,132 $ 3,952,572 $ (1,296,404) 25% $ $ 4,184,634 $ $ 2,135,974 $ (2,048,660) Walton Healthmark Regional Medical Center $ 994,383 $ 75,594 $ $ 1,069,977 $ 995,750 $ 75,526 $ $ 1,071,275 $ 1,298 0% $ 77,166 $ $ 77,166 $ $ Walton Sacred Heart Hosp Emerald Coast $ 3,726,749 $ 455,217 $ $ 4,181,966 $ 3,732,357 $ 454,830 $ $ 4,187,187 $ 5,222 0% $ 532,427 $ $ 532,427 $ $ Washington Northwest Community Hospital $ 311,480 $ 40,942 $ $ 352,422 $ 311,939 $ 40,940 $ $ 352,879 $ 457 0% $ 45,334 $ $ 45,334 $ $ Totals $ 1,555,483,180 $ 524,520,668 $ 580,489,783 $ 2,660,493,630 $ 1,561,514,586 $ 524,941,264 $ 596,667,477 $ 2,683,123,327 $ 22,629,696 1% $ 666,309,227 $ 762,775,396 $ 666,805,513 $ 787,401,703 $ 25,122,593 Difference

19 Who benefits from local public safety net hospital funds? Florida state legislators are reallocating $655.6 million in local public money and matching federal funds from six public safety net hospitals and using it to pay for patient care at other hospitals in every corner of Florida. Here s a look at the funds reallocated from each public hospital and the regions around the state that benefit from their contributions. REGION 1 IMPORTS $26.9 MILLION Pensacola REGION 2 IMPORTS $9.8 MILLION Tallahassee Jacksonville Panama City Gainesville REGION 4 IMPORTS $77.8 MILLION REGION 3 IMPORTS $47.6 MILLION Daytona Beach REGION 5 IMPORTS $63.8 MILLION Orlando REGION 7 IMPORTS $107 MILLION The six SNHAF public hospitals export: TOTAL $655.6 MILLION St. Petersburg Sarasota Tampa REGION 6 IMPORTS $100 MILLION REGION 9 IMPORTS $18.2 MILLION Jackson Health System $336.5 million Miami Dade County Broward Health $165 million Broward County Memorial Healthcare System $107 million Broward County Sarasota Memorial Healthcare System $26.6 million Sarasota County Halifax Health $17.4 million Volusia County Lee Memorial Health System $2.5 million Lee County Fort Myers REGION 8 IMPORTS $6 MILLION REGION 10 IMPORTS $4.9 MILLION REGION 11 IMPORTS $131.5 MILLION Miami 11 Regions denoted are the state s Medicaid managed care regions.

20 Where does the money go? Here s a look at each of the 11 regions and the counties within them, and the amount of money they import from public hospitals. Region Counties Imports Other* Totals Escambia, Okaloosa, Santa Rosa, Walton Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon, Liberty, Madison, Taylor, Wakulla, Washington Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, Union Baker, Clay, Duval, Flagler, Nassau, St. Johns, Volusia Pasco, Pinellas Hardee, Highlands, Hillsborough, Manatee, Polk Brevard, Orange, Osceola, Seminole Charlotte, Collier, Desoto, Glades, Hendry, Lee, Sarasota Indian River, Martin, Okeechobee, Palm Beach, St. Lucie Broward Miami Dade, Monroe $26,894,089 $9,838,724 $47,597,923 $77,792,487 $63,790,532 $99,969,512 $106,939,421 $6,009,600 $18,209,379 $4,941,295 $131,569,740 $62,034,499 $655,587,201 *Other statewide hospital payments, not calculated by region.

21 New tiering formula hurts teaching and children s hospitals Buried in the 2011 managed care reform act was a revised payment formula for hospitals which will become effective July 1, This reimbursement formula, which arbitrarily places every Florida hospital within one of three tiers, especially hurts teaching and children s hospitals across the state. Under this formula, the six largest teaching hospitals will be cut $293.3 million, two standalone children s hospitals will be cut $17.6 million and a regional perinatal hospital will be cut nearly $11 million. That s a total of $321.6 million in cuts to nine safety net hospitals due to the unnecessary, arbitrary provisions passed into law three years ago. Jackson Memorial Hospital, the largest contributor of local public health funds to the state, will be cut $142.8 million under the formula. In all, Dade County s teaching and children s hospitals will be cut $159.7 million. SACRED HEART $10.7 MILLION Pensacola Panama City Tallahassee SHANDS JACKSONVILLE $38 MILLION Jacksonville Gainesville SHANDS GAINESVILLE $59.5 MILLION Daytona Beach TOTAL $(321.6) MILLION Tiering hurts teaching hospitals, standalone children s hospitals and a regional perinatal hospital ALL CHILDREN S $4.8 MILLION St. Petersburg Sarasota Tampa Orlando TAMPA GENERAL $43.3 MILLION ORLANDO REGIONAL $5.6 MILLION STATUTORY TEACHING HOSPITALS Jackson Memorial $ (142.8) million Tampa General $ (43.3) million Shands Gainesville $ (59.5) million Shands Jacksonville $ (38.0) million Orlando Regional $ (5.6) million Mt. Sinai $ (4.10) million $ (293.3) million STANDALONE CHILDREN S HOSPITALS All Children s Hospital $ (4.8) million Miami Children s Hospital $ (12.8) million $ (17.6) million REGIONAL PERINATAL HOSPITAL Sacred Heart $ (10.7) million Fort Myers JACKSON MEMORIAL $142.8 MILLION MIAMI CHILDREN S $12.8 MILLION MT. SINAI $4.1 MILLION Miami

22 New tiering formula hurts children s hospitals In 2011, the Florida Legislature passed a measure that redesigned a Medicaid reimbursement payment formula for hospitals. As a result, on July 1 every Florida hospital will be arbitrarily placed in one of three tiers, causing the state s 11 children s hospitals to be cut by $123 million. Under the new formula, most of the state s freestanding and imbedded children s hospitals in the Florida Association of Children s Hospitals face unnecessary cuts. As shown below, that could amount to cuts of $12.8 million at Miami Children s Hospital, $22.1 million at Shands Children s Hospital, $14.0 million at St. Joseph s Children s Hospital and $30.7 million at Holtz Children s Hospital at Jackson Memorial. This Legislative Session, lawmakers must address and fix this seriously flawed tiered reimbursement scheme. SACRED HEART CHILDREN S $4.8 MILLION Pensacola Panama City Tallahassee WOLFSON CHILDREN S $4.1 MILLION Jacksonville Tiering hurts children s hospitals FACH: STANDALONE CHILDREN S HOSPITALS All Children s $ 4.8 million Miami Children s $ 12.8 million FACH: IMBEDDED CHILDREN S HOSPITALS Arnold Palmer Children s at Orlando Regional Medical Center $ 2.1 million Holtz Children s at Jackson Memorial $ 30.7 million Shands Children s $ 22.1 million Chris Evert Children s at North Broward Hospital $ +4.1 million Joe DiMaggio Children s at Memorial Hospital $ +7.8 million Sacred Heart Children s $ 4.8 million Golisano Children s at Lee Memorial Hospital $ +3.1 million St. Joseph s Children s $ 14.0 million Florida Hospital for Children $ 2.6 million Wolfson Children s at Baptist Hospital $ 4.1 million Baptist Children s $ 4.4 million OTHER CHILDREN S HOSPITALS Tampa General $ 9.5 million Palm Beach Children s Hospital at St. Mary s Medical Center $ 10.2 million TOTAL TOTAL $ MILLION $ MILLION Tampa St. Petersburg Gainesville SHANDS CHILDREN S GAINESVILLE $22.1 MILLION ST. JOSEPH S CHILDREN S $14.0 MILLION Sarasota Fort Myers Orlando TAMPA GENERAL* $9.5 MILLION ALL CHILDREN S $4.8 MILLION Daytona Beach FLA HOSPITAL FOR CHILDREN $2.6 MILLION ARNOLD PALMER CHILDREN S $2.1 MILLION ST. MARY S CHILDREN S $10.2 MILLION HOLTZ CHILDREN S $30.7 MILLION MIAMI CHILDREN S $12.8 MILLION BAPTIST CHILDREN S $4.4 MILLION Miami

23 Children s Hospitals Cut Under New Tiering Formula In 2011, the Florida Legislature passed a measure buried in the managed care reform act that redesigned a Medicaid reimbursement payment formula for hospitals. As a result, on July 1 every Florida hospital will be arbitrarily placed in one of three tiers, causing 11 of the state s children s hospitals to be cut by $123 million. Under this new formula, the state s two specialtylicensed, freestanding hospitals All Children s Hospital in St. Petersburg and Miami Children s Hospital will see a loss of $18 million, nearly $5 million and $13 million respectively. Hospitals with imbedded children s hospitals will also face unnecessary cuts as a result, including: $ 30.7 million at Holtz Children s at Jackson Memorial in Miami $ 22.1 million at Shands Children s Hospital in Gainesville $ 14.0 million at St. Joseph s Children s of Tampa $ 2.6 million at Florida Hospital for Children in Orlando $ 4.4 million at Baptist Children s in Miami $ 4.8 million at Sacred Heart Children s in Pensacola $ 4.1 million at Wolfson Children s at Baptist Hospital in Jacksonville $ 2.1 million at Arnold Palmer Children s at Orlando Regional Medical Center $ 9.5 million at Tampa General Hospital $ 10.2 million at Palm Beach Children s Hospital at St. Mary s Medical Center The Florida Association of Children s Hospitals and Safety Net Hospital Alliance of Florida children s hospitals provide care to the state s chronically ill and severely injured kids. These hospitals experience high Medicaid caseloads, with an average of nearly two out of three kids treated in these hospitals enrolled in Medicaid. Additionally, for all pediatric and neonatal patients statewide (Medicaid, charity and commercially insured children), these 14 hospitals provide nearly 60 percent of the care, while the other 40 percent is provided by the remaining 230 hospitals. The types of patients these hospitals treat are traditionally more medically complex and expensive to care for than children in other Florida hospitals. For example, this sicker patient population is illustrated by the DRG payment codes, which show that FACH hospitals are treating kids with an average case mix that is 60 percent higher than children and neonates in other hospitals. This arbitrary payment formula, passed three years ago into law, was developed with no analysis of the impact of implementing the threetiered system. If realized, these cuts could jeopardize access to care for Florida s sick and injured children. Losses from these hospitals will be redistributed to other hospitals across Florida that may not offer the highly specialized, expensive, lowreimbursement services that these hospitals offer, such as organ transplants, pediatric specialty trauma care and behavioral health services. This Legislative Session, lawmakers must repeal this seriously flawed tiered reimbursement scheme.

24 Comparison of State, Local and Federal Funds used for the Low Income Pool and Supplemental Hospital Rates SFY and SFY SFY Funding of Low Income Pool and Hospital Rates (1) (2) (3) (4) State Funds Local Funds Federal Funds Total All Funds 1. Low Income Pool Special LIP 700,000 47,386,313 67,906, ,992,349 LIP 4 (Return of IGT plus Alloca9on) 316,969, ,954, ,924,062 Primary Care Programs 8,508,487 39,985,485 68,839, ,333,588 Total Low Income Pool 9,208, ,341, ,700,000 1,000,250, Supplemental Rates Funded with Shared Local Revenue C,E 10,056, ,471, ,459, ,986, Supplemental Rates for Hospital Specific Contributors A,F 398,136, ,174, ,311,207 Total Funds All Programs 19,264,487 1,125,949,737 1,625,333,920 2,770,548,144 SFY Funding of Low Income Pool and Hospital Rates per the SSEC for FY State Funds Local Funds Federal Funds Total All Funds 1. Low Income Pool B Special LIP 700,000 46,877,047 68,415, ,992,349 LIP 4 (Return of IGT plus Alloca9on) 313,595, ,328, ,924,062 Primary Care Programs 8,443,115 39,486,839 69,403, ,333,589 Total Low Income Pool 9,143, ,959, ,147,750 1,000,250, Supplemental Rates Funded with Shared Local Revenue E Supplemental Rates for Hospital Specific Contributors F New Tier Pament Methodology B Tier 1 35% Rural, Teaching, Children c 10,056, ,104, ,740, ,901,228 Tier 2 35% 9% Medicaid & Charity with LIP contribu9on 114,098, ,870, ,969,227 Tier 3 30% All Hospitals 97,798, ,317, ,116,482 Total Tiers 10,056, ,001, ,929, ,986,937 Total Funds All Programs 19,199, ,960,792 1,068,077,030 1,807,236,937 Loss in Local & Federal Funds in SFY Compared to SFY (65,372) (405,988,945) (557,256,890) (963,311,207)

25 Notes: A Local funds for the self funded rates Bed to the schedule of executed LOA's provided by the Agency. B State, local and federal funds are from the detailed G&DTF schedule in the December 2013 SSEC book. C Included in IP/OP rates and Tier 1 is the LIP funded liver program of $9,932,000. D The general consensus of the esbmabng conference was to eliminate the self funded rates due to the conversion to managed care. E. Commonly known as exempbon/buyback program. Sixty seven (67) Hospitals qualify for supplemental rates irrespecbve of their lack of contribubon to local public funds. 93% of financing is provided by six public hsopitals. F. Commonly referred to as self funded rates. Nearly all of the benefits for this program goes back to specific hospitals providing local public funds.

26 Net Impact due to Tiering Law State Fiscal Year SFY 1314 Impact of the Elimina6on of Self Funded Rates SFY 1314 GAA LIP Statewide / LIP Rate NET Redistribute column B Tiering Law NET Gain / <Loss> (GAA vs Tiering) Full Impact (Gain / <Loss>) of Tiering Law A B C D = C B E = D + A Statutory Teaching Jackson Memorial (99,523,942) 138,211,519 94,974,323 (43,237,196) (142,761,139) Tampa General (28,147,683) 56,599,400 41,479,140 (15,120,260) (43,267,943) Shands Gainesville (39,843,000) 64,691,160 45,014,022 (19,677,138) (59,520,138) Shands Jacksonville (30,526,738) 63,419,090 55,931,765 (7,487,325) (38,014,063) Orlando Regional Medical Center (11,940,400) 42,631,493 48,987,645 6,356,152 (5,584,247) Mt. Sinai (4,732,780) 11,423,125 12,025, ,662 (4,130,118) Total Statutory Teaching (214,714,542) 376,975, ,412,682 (78,563,106) (293,277,648) Public Hospitals Broward Health Broward General (21,128,533) 41,470,623 75,663,081 34,192,458 13,063,925 Coral Springs (4,735,238) 5,083,376 13,571,898 8,488,522 3,753,284 Imperial Point (1,410,627) 5,638,220 7,483,315 1,845, ,469 N. Broward Medical Center (4,296,663) 8,704,754 12,457,454 3,752,700 (543,963) Total Broward Health (31,571,061) 60,896, ,175,748 48,278,775 16,707,714 Memorial Healthcare System Memorial Hollywood (19,096,385) 43,257,726 79,363,880 36,106,154 17,009,769 Memorial Miramar (7,508,526) 4,016,983 7,834,671 3,817,688 (3,690,839) Memorial Pembroke Pines (2,975,076) 3,941,972 4,187, ,220 (2,729,855) Memorial West (13,761,726) 2,400,244 18,383,980 15,983,736 2,222,010 Total Memorial Healthcare System (43,341,714) 53,616, ,769,724 56,152,799 12,811,085 Lee Health System Lee Memorial (12,227,640) 22,829,819 42,976,562 20,146,742 7,919,102 Cape Coral Hospital (4,906,853) 617, ,631 (4,289,222) HealthPark Medical Center Gulf Coast Medical Center (7,309,816) 1,015,955 1,015,955 (6,293,861) Total Lee Health System (24,444,310) 22,829,819 44,610,148 21,780,329 (2,663,981) Halifax Medical Center (10,293,216) 9,143,579 21,274,439 12,130,860 1,837,644 Sarasota Memorial (10,485,607) 1,634,797 3,351,361 1,716,564 (8,769,042) Children's Hospitals All Children's Hospital (12,250,272) 43,113,514 50,539,974 7,426,460 (4,823,811) Miami Children's Hospital 51,452,437 38,636,962 (12,815,475) (12,815,475) Total Children's Hospitals (12,250,272) 94,565,951 89,176,936 (5,389,015) (17,639,287) Sacred Heart Hospital (1,149,835) 18,009,874 7,207,929 (10,801,946) (11,951,781) Sacred Heart Gulf 115, ,986 97,352 97,352 Sacred Heart Hospital on the Emerald Coast 908,087 2,093,490 1,185,404 1,185,404 Total Sacred Heart System (1,149,835) 19,033,595 9,514,404 (9,519,190) (10,669,026) Safety Net Hospitals (348,250,557) 638,697, ,285,443 46,588,016 (301,662,541) Not for Profit Less Safety Net (146,273,739) 219,825, ,357,128 (41,468,734) (187,742,472) For Profit Totals (70,278,451) 115,813, ,689,114 (7,124,233) (77,402,684) Grand Total (564,802,746) 974,336, ,331,686 (2,004,951) (566,807,697) 3/4/14 12_SNHAF_Net GainLoss Tiering.xlsx e _ lt

27 IGTs (Today) & Medicaid Hospital Reimbursement Beginning in 2007 the Legislature dramatically reduced Medicaid hospital rates resulting in an increased dependence on locally levied revenues (Intergovernmental Transfers IGTs) to supplement the state portion of Medicaid hospital rates. Through letters of agreement between local entities and the Agency for Health Care Administration (AHCA), IGTs were added to the state s match portion and used to draw down federal funds in support of three Medicaid distribution programs: 1. Low Income Pool (LIP) IGTs sent to AHCA were used to draw down federal dollars to fund the $1.0 billion LIP Program as authorized under an 1115 Medicaid waiver. IGT contributing entities receive a return on investment (a percentage determined by the Legislature) that is in addition to the LIP program wide benefits of the IGT supported federal earnings. LIP funds were distributed to hospitals through a variety of categories Special LIP, Safety net LIP, Primary Care, and demonstration projects. Many hospitals received benefits from LIP funding without contributing any IGTs. 2. Low Income Pool Exemptions IGTs were also used to draw down federal dollars to supplement hospital Medicaid rate shortfalls for hospitals providing a specific percentage of Medicaid and charity care. These payments were provided under the LIP Exemption program. The local IGTs sent to AHCA matched with federal funds, allowed for $800 million to address some of the Medicaid rate shortfall to qualified hospitals. 3. Self Funded Buy Backs Each hospital in the state with access to local public funds is allowed to work through AHCA to draw down federal dollars to supplement their Medicaid rates up to their Medicaid cost cap. Under this program the local entity that raised the IGTs were eligible for the full benefit of the federal match (this is in addition of the LIP Exemption program). Last session, the Legislation diverted 10% of the federal portion to all hospitals in the state. February

28 Tiering Law (this Summer) & Medicaid Hospital Reimbursement The 2011 Legislature passed the Medicaid Managed Assistance law (MMA or Medicaid Reform) that will go into affect July 1, This bill places most Medicaid patients in a managed care setting and creates an Access to Care Partner (ACP) to manage the administration of all IGTs. The legislation included substantial changes to the distribution of these IGTs through a new tiering model. 1. Tiering Impact on the Low Income Pool The basic LIP program is unchanged under the tiering law. However, the 1115 waiver that provides federal authorization for the LIP program expires on June 30, Florida is currently in negotiations for an extension of the waiver and requesting an increase in the cap from $1 billion to $4.5 billion. 2. Tiering Impact on Low Income Pool Exemption Program The MMA tiering law redirects all IGTs and related federal match used today in the LIP Exemptions program to be redistributed under a new three tiered formula: Tier 1 35% Rural, Teaching and Children Hospitals Tier 2 35% Hospitals must have greater than 9% Medicaid & Charity as well as provide an IGT in LIP Tier 3 30% All Hospitals 3. Tiering Impact on Self Funded Buy Backs The MMA makes no provision for supplementing rates with these funds. Tiering Law should be repealed The loss will reduce Medicaid funding to FACH hospitals by $311.5 million. The tiering methodology used to distribute these funds is arbitrary. There was no underlying policy or analysis that arrived at these categories or percentages. February

29 Tier 2 eligibility is very unpredictable and therefore creates increased risk for any local government contributing local public funds. The application of the Tiering formula redirects exemption and buy back funding to an arbitrary designation of hospitals. The net impact of this redirection increases the export of IGTs and their benefits by shifts funds from the local entities that generated these funds. Buy Back Program Should be Reauthorized The MMA law made no provisions for the distribution of IGTs and IGTs generated benefits. The official Social Service Estimating Conference indicated that the uncertainty, disincentives and increased risk caused with the Tiering Law, and the pending movement to managed care would cause local entities to lower their IGTs contribution. The loss of these local funds will decrease total available funding in the Medicaid program by $963,311,207. February

30 Statewide Managed Care (this Summer) & Medicaid Hospital Reimbursement The 2011 Legislature passed the Medicaid Managed Assistance law (MMA or Medicaid Reform) that will go into affect July 1, This bill places most Medicaid patients in a managed care setting and creates an Access to Care Partner (ACP) to manage the administration of all IGTs. The legislation included substantial changes to the distribution of these IGTs as described above, but did not address IGT supported rates to be reimbursed by managed care organizations (MCO). MMA Impact on IGTs The law makes no provisions to track or ensure the return of IGT supported MCO payments to hospitals. Legislation Must Be Passed to Ensure IGT Supported MCO Hospital Payments are Tracked and Returned to Contributing Entity If IGTs are to be buried within the managed care capitated fee it will be impossible to evaluate the benefits to the contributing entity. This results in a disincentive for IGT contributors to continue to contribute. The state Social Services Estimating Conference recognized this disincentive and lowered the estimated IGT contributions in their FY forecast. Further complicating matters, the Medicaid caseload associated with the shift from FFS to managed care is uncertain. As a result the state Social Services Estimating Conference did not forecast the Medicaid Managed Care expenditures for FY February

31 Restore Cuts to Teaching Hospitals & Imbedded Children s Hospitals Position: SNHAF supports funding for hospitals with indirect medical education costs and high pediatric services/days costs. Problem: o Last sessions Medicaid reimbursement system conversion from cost based fee for service to diagnosis related group (DRG) resulted in severe cuts to hospitals. o Hardest hit were teaching hospitals and imbedded children s hospitals. o The 2013 Legislature recognized the DRG resulting cuts and appropriated $65 million as transition funding. Solution: o The 2014 Legislature should reallocate the $65 million transition funding to the hardest hit hospitals. o Teaching and children s hospitals should receive the $65 million via an indirect medical education allocation formula on top of the DRG base rate, and a new DRG adjuster for hospitals with more than 28,000 pediatric and neonate days. Justification: o Indirect & direct medical education and high volume pediatric hospitals were all reimbursed in the old cost based Medicaid FFS system. o DRG s by design do not account for costs associated with GME (DME or IME). o Florida s DRG model does not account for higher costs associated with high volume pediatric hospitals services (28,000 pediatric days) IME and pediatric adjuster options are attached. 3/4/14

32 Indirect Medical Education (IME) Value of IME for SFY1314 using Medicare IME multiplier applied to FY1314 IP DRG base payments Rank Order $65,000,000 $32,978,858 $16,489,429 A B C D Shands Gainesville* $16,798,341 $12,379,977 $6,281,193 $3,140,596 Jackson Memorial* $15,395,051 $11,345,786 $5,756,478 $2,878,239 Miami Children's Hospital $10,276,743 $7,573,715 $3,842,653 $1,921,327 Shands Jacksonville* $8,826,114 $6,504,636 $3,300,238 $1,650,119 Tampa General* $5,789,357 $4,266,618 $2,164,741 $1,082,371 All Children's $5,715,929 $4,212,503 $2,137,285 $1,068,643 Orlando Regional Medical Center* $4,935,043 $3,637,009 $1,845,298 $922,649 Broward General $2,422,078 $1,785,014 $905,657 $452,829 Florida Hospital Orlando* $2,040,970 $1,504,146 $763,154 $381,577 Sacred Heart Hospital $1,626,922 $1,199,003 $608,335 $304,167 H L Moffitt Cancer Center* $1,428,018 $1,052,415 $533,961 $266,980 Palmetto General Hospital $1,323,165 $975,141 $494,755 $247,377 Mt. Sinai* $1,286,519 $948,134 $481,052 $240,526 University of Miami Hospital (Cedars)* $1,138,747 $839,229 $425,797 $212,899 Larkin Community Hospital Miami* $1,039,299 $765,939 $388,612 $194,306 Tallahassee Memorial Regional Medical Center $1,016,088 $748,832 $379,933 $189,966 JFK Medical Center $690,858 $509,146 $258,324 $129,162 Manatee Memorial Hospital $689,628 $508,240 $257,864 $128,932 Baptist Medical Center $646,819 $476,690 $241,857 $120,928 Largo Medical Center* $565,033 $416,416 $211,276 $105,638 Bayfront Medical Center $463,022 $341,236 $173,132 $86,566 Palms West Hospital $396,159 $291,960 $148,131 $74,065 Mayo Clinic* $379,259 $279,505 $141,811 $70,906 Wellington Regional Medical Center $376,183 $277,238 $140,661 $70,331 Halifax Medical Center $335,184 $247,023 $125,331 $62,666 Memorial Hollywood $327,327 $241,232 $122,393 $61,197 St. Lucie Medical Center $324,477 $239,132 $121,328 $60,664 St. Petersburg General Hospital $310,244 $228,642 $116,005 $58,003 Westchester General Hospital $308,204 $227,139 $115,243 $57,621 Northside Hospital and Heart Institute $250,404 $184,542 $93,630 $46,815 University of Miami Hospital/Clinics $222,968 $164,322 $83,372 $41,686 Cleveland Clinic Hospital $220,622 $162,593 $82,494 $41,247 St. Vincent's Medical Center $215,531 $158,841 $80,591 $40,295 Morton Plant Hospital $212,657 $156,723 $79,516 $39,758 Columbia Hospital (aka W Palm Hospital) $143,429 $105,704 $53,631 $26,815 University Community HospitalMedical Center $43,022 $31,706 $16,087 $8,043 Memorial Hospital Jacksonville $13,254 $9,768 $4,956 $2,478 University Community HospitalCarrollwood $4,683 $3,452 $1,751 $876 Bascom Palmer Eye Inst/Anne Bates Leach Eye Hos $887 $654 $332 $166 Broward Health Coral Springs $0 $0 $0 $0 Bethesda Mem. Hosp. $0 $0 $0 $0 Kendall Regional Medical Center $0 $0 $0 $0 Mercy Hospital a Campus of Plantation General $0 $0 $0 $0 NE Florida State Hospital $0 $0 $0 $0 Northwest Medical Center $0 $0 $0 $0 Plantation General Hospital $0 $0 $0 $0 Univ Hospital & Medical Ctr (Broward Co) $0 $0 $0 $0 West Kendall Baptist $0 $0 $0 $0 Westside Regional Medical Center $0 $0 $0 $0 Total $88,198,238 $65,000,000 $32,978,858 $16,489,429 General Revenue (40.99%) $36,152,458 $26,643,500 $13,518,034 $6,759,017 Federal Match (59.01%) $52,045,780 $38,356,500 $19,460,824 $9,730,412 Macintosh HD:Users:sfagg:Desktop:Documents:GRR:2014:3/4/14 H&K GRR Mtg.:13_SNHAF_IME_653316_ xlsx

33 Increase Pediatric and Neonate Adjustors for High Volume Hosp:als Hospital Op:on 1 Op:on 50% of Target Op:on 2 Op:on 50% of Target Shands Teaching Hospital $ 4,052,759 $ 2,026,380 $ 3,165,602 $ 1,582, Broward General Hospital $ 1,978,825 $ 989,412 $ 2,354,924 $ 1,177, Memorial Hospital $ 2,862,698 $ 1,431,349 $ 2,643,187 $ 1,321, BapDst of Miami $ 846,802 $ 423,401 $ 1,040,924 $ 520, Jackson Memorial Hospital $ 3,472,178 $ 1,736,089 $ 2,909,733 $ 1,454, BapDst Medical Center $ 2,027,430 $ 1,013,715 $ 2,559,672 $ 1,279, Sacred Heart Hospital $ 2,312,596 $ 1,156,298 $ 2,541,077 $ 1,270, St. Joseph's Hospital $ 2,894,559 $ 1,447,280 $ 3,029,720 $ 1,514, Tampa General Hospital $ 2,257,051 $ 1,128,526 $ 1,749,255 $ 874, Lee Memorial Hospital $ 1,354,615 $ 677,307 $ 2,106,928 $ 1,053, Florida Hospital $ 1,305,731 $ 652,865 $ 2,313,693 $ 1,156, Orlando Regional Medical Center $ 4,900,188 $ 2,450,094 $ 4,753,230 $ 2,376, St. Mary's Hospital $ 2,617,458 $ 1,308,729 $ 2,282,119 $ 1,141,059 Total $ 32,882,889 $ 16,441,445 $ 33,450,061 $ 16,725,031 Target Funding $ 33,051,430 $ 16,525,715 $ 33,051,430 $ 16,525,715 Includes hospitals with more than 28,000 pediatric days (excluding rehab and normal newborn). Free standing children's hospitals are excluded. Op:on Descrip:ons Op#on 1 For the hospitals idendfied the adjustor was increased from 1.3 to 1.8 for all pediatric and neonate claims with a APR DRG Severity Level of 3 or 4. At 50% of target the adjustor approximates 1.55 Op#on 2 For the hospitals idendfied the adjustor was increased to 1.4 for all pediatric and neonate claims regardless of the APR DRG Severity Level. At 50% of target the adjustor approximates 1.35.

34 Medicaid Hospital Appropriations FY1314: Last Year v DRG Current Year plus Residency Program plus Transition FFS Appropriated Payments FY1213 DRG Appropriated Payments FY1314 DRG Conversion IMPACT FY 1314 Residency Program Payments FY 1314 BEGINNING BASE FY 1415 FY1213 v. FY 1314 OneTime Transitional Payments FY 1314 OneTime Transition Payments IMPACT FY 1314 A B C = B A D E = C + D F G = E + F Statutory Teaching Jackson Memorial $321,103,775 $275,387,398 ($45,716,377) $13,158,393 ($32,557,984) $23,316,724 ($9,241,260) Tampa General $129,243,409 $122,198,171 ($7,045,238) $5,100,639 ($1,944,599) $2,184,177 $239,578 Shands Gainesville $165,977,128 $142,460,030 ($23,517,098) $9,968,558 ($13,548,540) $11,994,425 ($1,554,115) Shands Jacksonville $91,953,207 $84,029,179 ($7,924,028) $5,047,419 ($2,876,609) $2,456,621 ($419,988) Orlando Regional Medical Center $126,362,820 $122,419,603 ($3,943,217) $4,784,488 $841,271 $1,222,483 $2,063,754 Mt. Sinai $21,538,528 $20,142,538 ($1,395,990) $2,783,643 $1,387,653 $432,787 $1,820,440 Total Statutory Teaching $856,178,867 $766,636,919 ($89,541,948) $40,843,139 ($48,698,809) $41,607,217 ($7,091,592) Public Hospitals Broward Health Broward General $93,456,218 $90,661,297 ($2,794,921) $2,051,879 ($743,042) $866,486 $123,444 Coral Springs $16,729,460 $15,453,162 ($1,276,298) $70,000 ($1,206,298) $395,680 ($810,618) Imperial Point $7,367,530 $7,437,652 $70,122 $70,122 $70,122 N. Broward Medical Center $16,660,833 $16,683,118 $22,285 $22,285 $22,285 Total Broward Health $134,214,041 $130,235,229 ($3,978,812) $2,121,879 ($1,856,933) $1,262,166 ($594,767) Memorial Healthcare System Memorial Hollywood $78,716,034 $76,269,818 ($2,446,216) $693,002 ($1,753,214) $758,380 ($994,834) Memorial Miramar $10,525,410 $10,253,571 ($271,839) ($271,839) ($271,839) Memorial Pembroke Pines $6,291,824 $5,564,424 ($727,400) ($727,400) $370,996 ($356,404) Memorial West $19,789,942 $20,258,810 $468,868 $468,868 $468,868 Total Memorial Healthcare System $115,323,210 $112,346,623 ($2,976,587) $693,002 ($2,283,585) $1,129,376 ($1,154,209) Lee Health System Lee Memorial $63,946,292 $61,985,522 ($1,960,770) ($1,960,770) $607,881 ($1,352,889) Cape Coral Hospital $11,926,902 $11,226,857 ($700,045) ($700,045) $217,029 ($483,016) HealthPark Medical Center $0 $0 Gulf Coast Medical Center (fka SW FL Regional) $20,562,814 $19,848,677 ($714,137) ($714,137) $221,398 ($492,739) Total Lee Health System $96,436,008 $93,061,056 ($3,374,952) $0 ($3,374,952) $1,046,308 ($2,328,644) Halifax Medical Center $26,784,313 $26,673,190 ($111,123) $662,264 $551,141 $551,141 Sarasota Memorial $25,392,020 $26,660,664 $1,268,644 $1,268,644 $1,268,644 $0 Children's Hospitals $0 All Children's Hospital $99,224,989 $101,075,639 $1,850,650 $1,330,888 $3,181,538 $3,181,538 Miami Children's Hospital $83,279,937 $89,706,440 $6,426,503 $2,641,036 $9,067,539 $9,067,539 Total Children's Hospitals $182,504,926 $190,782,079 $8,277,153 $3,971,924 $12,249,077 $0 $12,249,077 Sacred Heart Hospital $39,896,445 $44,158,066 $4,261,621 $1,116,099 $5,377,720 $5,377,720 Sacred Heart Gulf $781,417 $456,604 ($324,813) ($324,813) $324,813 $0 Sacred Heart Hospital on the Emerald Coast $4,469,983 $4,181,587 ($288,396) ($288,396) $288,396 $0 Total Sacred Heart System $45,147,845 $48,796,257 $3,648,412 $1,116,099 $4,764,511 $613,209 $5,377,720 Safety Net Hospitals $1,481,981,230 $1,395,192,017 ($86,789,213) $49,408,306 ($37,380,907) $45,658,276 $8,277,369 NotforProfit Less SafetyNet $732,162,964 $736,665,344 $4,502,380 $15,474,384 $19,976,764 $12,831,168 $32,807,932 ForProfit Totals $504,332,649 $534,487,929 $30,155,280 $15,023,205 $45,178,485 $6,522,952 $51,701,437 Grand Total $2,718,476,843 $2,666,345,290 ($52,131,553) $79,905,896 $27,774,343 $65,012,396 $92,786,739 1 / 8 FINAL 2012 v 2013 v 2014 base.xls 3/4/14

35 SNHA Safety Net Hospital Alliance of Florida February 25, 2014 Teaching Hospitals Jackson Health System Mount Sinai Medical Center Orlando Health Shands HealthCare John H. Armstrong, MD, FACS State Surgeon General and Secretary Florida Department of Health 4052 Bald Cypress Way, Bin #A00 Tallahassee, FL Shands Jacksonville Medical Center Tampa General Hospital Public Hospitals Halifax Health Lee Memorial Health System Memorial Healthcare System Broward Health Sarasota Memorial Healthcare System Children s Hospitals All Children s Hospital Miami Children s Hospital Regional Perinatal Intensive Care Center Sacred Heart Health System Anthony Carvalho President Dear Surgeon General Armstrong: I am writing to submit comments regarding the Department of Health (DOH) Office of Trauma proposed draft Trauma Center Apportionment rule 64J 2.010, titled Apportionment of Trauma Centers within Trauma Service Areas. These comments are submitted on behalf of the Safety Net Hospital Alliance of Florida (SNHAF) members. The SNHAF membership represents Florida s largest teaching, public, and children s hospitals, as well as regional perinatal intensive care centers. Our 14 safety net hospital systems are located in the most densely populated areas of Florida but provide services to all Floridians, coast to coast, including Florida s rural communities. The Safety Net Hospital Alliance of Florida (SNHAF) members operate 7 of the 8 verified Level I trauma centers; 100% of all ICU burn care; 70% of all organ transplants; 48% of all pediatric ICU days; 41% of all charity care days; and 40% of all Medicaid days in the State. They provide 68% of all medical training for physicians. Trauma center apportionment has enormous consequences for the citizens of Florida and requires valid data and collaborative thoughtful planning. We share a common goal of ensuring Florida has a sustainable high quality trauma system for our citizens. The current proposed draft Trauma Center Apportionment rule 64J 2.010, titled Apportionment of Trauma Centers within Trauma Service Areas fails to further our shared goal. The current proposed trauma center apportionment rule: Fails to re align trauma service areas (TSAs), basing the proposed rule on the 1990 TSAs, ignoring the significant population growth, Florida has experienced in the subsequent 23 years. Fails to prepare comprehensive needs assessment as required by Florida Statute. Fails to consider the shortage of physician specialist and subspecialist essential to a strong trauma system. Fails to consider impact variations in capacity and capabilities of the

36 pre hospital emergency services available within TSAs have on transport time and patient outcomes. Fails to consider nationally recognized trauma caseload requirements for clinical competence, specifically in relation to training tomorrows Trauma Surgeons. Fails by the use of total population to consider the impact population specific characteristics have on trauma service needs or the incidents of traumatic injury within the specific populations of each TSA. Fails to consider existing trauma center available capacity when determining allocation of new trauma centers Fails to provide protection of trauma care in the event of a natural disaster by designating a minimum distance between trauma centers within TSAs. Fails to incorporate the recommendations of the 2005 DOH Trauma Assessment Study, the American College of Surgeons, February 2013 report and to consider specific language related to Trauma. Fails to incorporate the consensus items from the January, 2014 Negotiated Rule Workshop Therefore, we respectfully request the DOH to work with Trauma System Stakeholders to revamp the proposed trauma rule in a more holistic approach. An approach that reviews and considers all sections of the trauma rules (64J through 64J F.A.C.); reassesses the 19 designated TSAs in recognition of the significant population growth Florida has experienced over the past 23 years; the capacity of existing trauma centers in determining the need for new trauma centers in a TSAs availability of limited physician resources in required trauma specialties; assesses the pre hospital EMS capacity and capabilities within each TSA; case load volumes for training future trauma physicians; population characteristics by TSA; and uses data driven metrics based on statistically valid data interpreted using nationally recognized definitions and formulas. The SNHAF membership has enjoyed a long and effective working relationship with the DOH and we wish to continue. The SNHAF membership hopes DOH will accept our offer to work collaboratively with DOH in an effort to move forward in strengthening Florida Trauma System for the citizens of Florida. Sincerely, Anthony P. Carvalho President