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					Citizens Health Care Oversight                                             April 18, 2008
Committee Meeting Minutes

                 CITIZENS HEALTH CARE OVERSIGHT COMMITTEE
                                            Verbatim Minutes
                           (Because of the many comments by COC Members)

                                               April 18, 2008

Citizens Health Care Oversight Committee meeting was held in the County Commissioner’s Chambers, Neil
Combee Administration Building, Bartow.

The members present were as follows: Nancy Thompson, Dr. Nobo, Brian Hinton, Misilene Fulse, Stacy
Campbell Domineck, John McArthur, Ginger McNally, Andrea Gordon and Connie Kinnick.

COC Members Absent: Steve Henderson and Tonja Mosley

Other County Staff in attendance were as follows: Ed Smith, Jr., Larry Skidmore, Dr. Haight, Steve Yaskal,
Wilma Daniels, Gwen Hall, JoAnn Fioravanti, Debi Curry, and Michael Duclos

Other County Staff not in attendance: Joy Johnson and Fran Peek

The meeting was called to order by Nancy Thompson at 8:23:45 AM.

Nancy Thompson: Asked that all of the members introduce themselves and what group they represent.

Brian Hinton led the Pray and the Pledge of Allegiance.

N. Thompson: Requested a motion for approval of the minutes from March 13, 2008.

Motion: Brian Hinton made a motion for the approval of the minutes.

Second on the Motion: John McArthur.

Additions or corrections: hearing none; all those in favor of accepting the minutes as presented say AYE.

All members stated AYE.

Minutes approved.

N. Thompson: Stated that next on the Agenda would be Old Business and she called on Dr. Nobo who has
asked to discuss the issue of Chemotherapy and Radiation Therapy.

Dr. Nobo: He stated that a few months ago there was a vote from in this committee that we had funds to be
able to pay for some of the Chemo and Radiation. Most of our decisions fortunately the County
Commissioners have listened since that is why we were appointed for them. The institution such as
Lakeland Regional Medical Center and the Watson Clinic started to or continued to treat our patients. Paul
Powers the CFO of Lakeland Regional Medical Center came in last month and presented some numbers or
was going to present some numbers to see what the amount of it was. We talked of the importance of the

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Committee Meeting Minutes

Chemo; but we never voted to direct our Health Coalition, our Plan to look at the possibilities of what they
have requested. I have here some of the numbers so you can see the significant of this request.

                                             FISCAL YEAR 2007

Institutions Name               Expenditure Amount              Medicaid Rate
Watson Clinic                   $ 315,792.00                    $ 94,737.00


                                             FISCAL YEAR 2008

Institutions Name               Expenditure Amount              Medicaid Rate
Watson Clinic                   $ 18,455.00                     $ 5,500.00
Lakeland Regional               $ 390,000.00                    $ 25,211.00

Dr. Nobo stated that he feels that this was done in good faith, and that we are responsible members of this
committee should be concerned and request that Steve look at the possibility of at least paying for the 2008
to the Watson Clinic and Lakeland Regional Cancer Center; and look at the possibility of for the 2007. Just
about 5 weeks ago he saw a 36 year old woman who had not had a pap smear for 10 years; even though she
smoked a pack or a pack and a half a day she said she didn’t have any money for a pap smear. When she had
come to his office the cancer had eaten part of her vagina; I called the Watson Clinic knowing that the Plan
will not pay and they took her. She is taking radiation and chemo most likely it will be a tuff battle for her.
But it is very difficult for us physicians to see a patient like that and not have a place to turn. He stated that
he is not saying the Watson Clinic or Lakeland Regional will turn away a patient like that in the future, but I
am saying and requesting is that we in good faith voted to support these programs. We have had a change
and he said that he believes strongly even though I was criticized a few months ago when he asked that
things have changed we have a lot of doctors and he was pretty much told that we couldn’t change. But part
of no part of this plan is to look at the future and change as we go. He requested and if he had to make a
motion he will that we direct Steve to look at the feasibility of at least paying the 2008 and than looking
at the feasibility for the 2007, I so move.

N. Thompson: We have a motion do I have a second?

C. Kinnick: Second

N. Thompson: Open for discussion, questions, comments any discussion?

B. Hinton: Stated that he was looking at a slide that is in our packet the 3rd or 4th sheet back that says Cost of
Chemo:

Dr. Nobo: Stated that he is not quite sure these were the numbers given to me by those institutions. He said
he was not sure whether Steve received those through other payments. Since these are the number that he
had received from Mr. Powell who is the CFO and also, by the Medical Director of the Watson Clinic he
feels pretty strong that the numbers that he had presented are accurate.




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Steve Yaskal: He stated that the slide that Brian was referring to these are what we have received that have
been billed to us from Lakeland Regional, Winter Haven, Lakeland Regional Cancer Center and Radiation
and Oncology. We have not received bills from Watson probably because they knew we weren’t paying so
they haven’t billed us. Which this doesn’t mean that they are not out there; same things with these numbers
we are not sure that those are all the bills these are just the ones we have received as of about 2 weeks ago.
This is what our reimbursement would be, and as Dr. Nobo had stated, the amount of the charge is much
different that amount that we pay.

                              Cost of Chemo/Radiation
                                  Therapy to Date
                    HOSPITAL FEES

                    •   Lakeland Regional Medical Center                        $8,166
                    •   Winter Haven Hospital                                   $9,942
                    •   Lakeland Regional Cancer Center                         $7,503
                    •   Radiation Oncology                                      $1,261

                    Medicaid reimbursement to hospitals is based
                     on line items.

Dr. Nobo: If you add those numbers doesn’t almost come out to $25,000.00?

N. Thompson: $26,872.00 which is what she had come up with.

Dr. Nobo: Because Lakeland Regional Medical Center and Lakeland Regional Cancer Center would
probably be the same the only other one would be Winter Haven Hospital which I would not mind of course
adding that into his motion.

S. Yaskal: The radiation and oncology is basically the professional component for Winter Haven hospital.

Dr. Nobo: He did talk to Clark and Daughtrey and they said they had very few patients and those patients
they were fortunate enough to be able to request free medication from the pharmaceuticals but they do not
know who long that will continue but they will always try to do the same as Watson Clinic and other
institutions within the County.

S. Yaskal: In these charges there is very few bills for the chemo drug it self. We don’t know if they are using
the patient assistance program or they just haven’t billed us to date for those items.

Dr. Nobo: These numbers that he had received in the last few days; because he wanted to make sure that they
were accurate. So he can say again that these numbers were given to him by the CFO of Lakeland Regional
Medical Center and by the Medical Director of Watson Clinic and he did speak to the director of Clark and
Daughtrey and they told him they had none.


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N. Thompson: Well perhaps we could look at a cap and say if we wanted to go this route that we could
reimburse up to X, because we don’t know what the exact charges are. If I add up Steve’s numbers for
Winter Haven and Radiation and Oncology which are actually bills received and the number the numbers
that Dr. Nobo just gave the committee the number would be about $41,800.00, but we know that there might
be some other little pieces or parts out there. So we could say up to 50 or whatever, we think a good number
might be.

Dr. Nobo: He amended his motion to cap it at $50,000.00 and just look at the possibility of 2007 but he
is mainly directly by the 2008.

B. Hinton: I don’t think we ever

Dr. Nobo: That is why he is just suggesting 2008.

N. Thompson: It would be from the time they approved and voted to the addition of those services until the
last meeting when this committee made it clear that we were not going to be able. They provided services in
good faith based on an action that we took and we subsequently had to change that. She asked Steve from a
financial stand point is the 50 thousand going to send us to the poor house.

S. Yaskal: I hope not, we had a long discussion last month regarding the situation in the Plan and the
projections right now is to have an ending fund balance of about 3.5 million dollars assuming all of the
projections are correct. So the 50 thousand would just reduce the ending balance which would be in material
if you put a cap on it.

C. Kinnick: I did speak last month and say that we should go ahead and at least reimburse them for services
render thus far; because it was done on good faith. She knows that it is very difficult to start treatment on
someone and you have no place to send them. I think in good faith that we should go ahead at least pay the
2008 bills and if there is money left over in the budget at the end of the year than we could look at the 2007.

Ed Smith: He asked for a clarification, is the motion capping the payments for 2008 at $50,000.00?

Dr. Nobo: It is capping what they have billed from the moment we had voted to the moment that we
voted against it. Like Connie just said if we see that we are doing very well and we have some money
left over he is sure that he will bring back the possibility or the feasibility to look into what else we can
do. But at this moment it is for the time that is mentioned.

N. Thompson: And up to a maximum of $50,000.00.

Misilene Fulse: Asked about the agenda it looked like Steve and with the appearance of this slide that Steve
had some recommendations on this I would like to hear what his recommendation was on this and he had
already had this slide here so that we could hear the fiscal part of the story before we vote.

Dr. Nobo: He stated that he could tell you why he had the slide here because he told him he was going to
bring it up. He told him that he was contacting the institutions that are concerned about this issue and that he
was going to look to see what fees had come in; so that is why the slide is up there.



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S. Yaskal: So if you look in your minutes there were 3 questions and they are highlighted in yellow in your
minutes and we were asked to bring back that information at this month and that is why this slide is in there.
It is not intended for a recommendation or anything it is just for informative purposes.

Dr. Nobo: Thanked Steve for that.

N. Thompson: Other comments or questions? All of those in favor of the motion as stated say AYE.
(Entire committee stated AYE) MOTION CARRIED

N. Thompson: She thanked Dr. Nobo for bringing this back to the committee. Next item on the agenda is the
Action Items 0 3/18/2008 COC Meeting.

S. Yaskal: He explained about the action items and the slides that he was presenting in hopes to answer the
previous questions brought up by this committee. (Overtime, Co-Payments and Cost of Chemo/Radiation
Therapy to Date).

Dr. Nobo: And buy their cigarettes?

S. Yaskal: Stated that he didn’t want to go there!

Dr. Nobo: Stated that he can because he is doing a tabulation in his office and about 75% of A smoke.

S. Yaskal: the reality doctor he believes is that they are not going to give up the cigarettes and what they are
going to do is end up going to the Emergency Department rather than come up with $5.00 if they know that
they have to pay the physician.

N. Thompson: I can’t see someone missing a doctor’s appointment that they need for us saving $90,000.00 a
year on a 24 million dollar plan that just doesn’t make sense to me. This was good that you bring this to us
because there was a concern that perhaps we could serve a lot more people if we had or increased the co-pay
and I personally don’t see it when I look at this chart.

Dr. Nobo: No I don’t think so, I think what I brought up was never to talk about A, B, C, clases because I see
the patients. He stated that he sees quite a lot of these patients and that the $1.00 is perfect for the A,B, & C.
He said it is very frustrating when he sees those patients with COPD and oxygen and still smoking a pack or
2 a day. What he said was to look those between 150 and 175 increased to see if it was feasible for us to
continue. Now of course for one month he has been asking every single patient that has DNE that he has
seen would you consider a higher co-pay which will be deducted from the physicians because I think that we
all have to participate; and everyone of them not just half of one, every single one of them said doesn’t it
make sense that for 25 dollars I can see a doctor that otherwise I would have to go to an ER. Every one of
them said that they can come up with the 25 dollars. I did not ask A, B, & C and I know that they will not.

S. Yaskal: He stated that he knew that and that is why he highlighted the D & E because that is what the
question stated. This is for a 6 month period. He continued to explain the slide. He stated the savings would
be about 150 thousand dollars or maybe 300 thousand a year. It isn’t huge amount of money.

Dr. Nobo: He stated that the amount wasn’t enough of a saving; maybe we could even go higher but he
didn’t think even higher even at 160 thousand or 360 thousand that may not even. He is just trying to make

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sure that ever one of his ladies that I could see in his office and avoid what happened to that other patient that
I had talk to you about. That is why he volunteers on the We Care Plan, but we can not just see them all.

S. Yaskal: Continued on the slides.

Dr. Nobo: Asked if he could continue again, he stated that he sits with these ladies and he talks to them. He
wasn’t sure how many of you do that on a daily basis besides the people who work for this Plan. He stated
that 75% of them leave his office crying when they hear they will no longer have the Plan. A lot of them
haven’t even seen the paper and he informs them and he tells them that they should still go and keep
applying because maybe something will changed that you will be able to be.

S. Yaskal: The staff is very sad that we have to bring this to you. It is just the reality of the economy right
now. Hopefully things will improve.

B. Hinton: Since this is a partnership and you did bring that part up would the physicians accept a reduced
Medicare benefit to add more people to the Plan?

Dr. Nobo: He stated that he would ask them.

N. Thompson: Maybe a combination of those 2 things.

Dr. Haight: Stated that he wanted to make a note that with the physician’s co-payment from the patients the
Health Department actually throughout the State of Florida we are unable to charge a payment to the patient.
There is no gate keeper fee at the Health Department, if the patients fall into that.

N. Thompson: So if we ever go to that we would have to have exclusions for the Health Department. Any
other comments or questions. She stated that the main objective for this meeting is to work on and look at the
FY 08/09 Preliminary Budget. Some of those who have not been through this process with us; we go
through this about this time of year. Our budget year aligns with the County’s budget year which October 1st
through September 30th. A fairly involved and protracted process that the BoCC uses to get a full budget
approved every year. The budget will actually be approved in August?

E. Smith: September

N. Thompson: For the October 1 start date. We are in the bringing stages of a process and the staff always
brings to us in the beginning of April every year the beginning recommendations based on the best available
information that we have today, what we think that budget will look like. One thing to remember if you
haven’t heard Steve say it 500 hundred times before is we are only allowed to budget at 95% of what we
expect our anticipated revenues to be that is a safe guard. I believe that all County programs are restricted by
its good business. So we have to abide by that rule at the same time. Steve we will let you start and if there
are questions please have Steve stop and ask your questions.

S. Yaskal: He started his budget presentation. He explained that this is the preliminary budget the initial
budget is due in by mid May. This is our last meeting before it is due so the staff wanted to bring it to the
COC. There will be changes for example the whole County General Funds is due in today. The rest of the
funds are due in about mid May. When they look at the total dollars they may have to make cuts, for
example in this budget there is a 3 ½ percent step plan increase for all employees plus a 2 percent cost of
living increase. The County has been going with an every other year cost of living increase, but the 3 ½ step
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every year. There is a possibility that when the see the total numbers cause the general fund is going to have
to cut several million dollars and they may have alter that and reduce the cost of living. What affects general
funds will affect us. So there will be number changed from time to time. This budget has not been seen by
any one so you are the first to see it. This budget will be in the system and it will not be reviewed for at least
another month. He started to explain the slides.

N. Thompson: asked about how much is in this budget for the software?

S. Yaskal: $500,000.00

N. Thompson: That will be a carry forward obligation into the next year.

S. Yaskal: There maybe some dollars spent this year, but the majority will be in next year now. Because by
the time the contract is signed and the software company can’t begin right away, it will be a month or two
before they start. So the whole $500,000.00 is in next year’s budget. He started to explain HCRA.

Dr. Nobo: He asked that he read the minutes and they were told last month he thought that it was Ms. Fulse
brought up that issue, that the patient had to be admitted.

S. Yaskal: No; the Health Care Responsibility Act is primarily is for emergency because it is usually
considered that your County can handle most services. So if someone is traveling out of County and ends up
in the Emergency Department however, there is a stipulation in the law that if you can’t get the service in
your County and you have to send them to another County we have to pay for that service.

Dr. Nobo: So it goes back to what Ms. Fulse said last month, so the minutes have to be corrected because I
believe that she said if they go to Moffat that we would have to pay for it anyway and she was corrected and
was told that no the patient had to be admitted and I made the comment well then they would just go ahead
and be admitted. From what you are telling me now; I just wanted to make sure that I understand it. So what
you are telling me that what Ms. Fulse said last month is correct. It is there, it is on the page.

S. Yaskal: Yes, but if it is a service and they can not get in Polk County than it will go under HCRA.

Dr. Nobo: Ms. Fulse you were correct.

N. Thompson: They just can’t go an self admit on anything, they had a car wreck, there had to be some other
reason you were in the other County to begin with you can’t just drive to Tampa and check yourself in.

Dr. Nobo: No, I am not saying that, they can drive and say I have some bleeding from your cervical cancer
and you have to be treated because you are bleeding. So there are issues that can be done. I just wanted it
corrected because I was a little confused. Thank You.

Dr. Haight: If services were to change in the area the Davenport, Haines City area and pregnant women on
Medicaid were getting more services across the boarder into Osceola, Lake and Orange County would that
factor in to more of a drain on HCRA?

S. Yaskal: Not if they can get the service in Polk County, we are not obligated to pay it if the services are
available in our County. We are only obligated if the service is not it can’t be the patients choice.

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Dr. Haight: If you are going into labor, they go to the nearest hospital which is outside of our County.

S. Yaskal: If it was an emergency admit, yes.

Dr. Haight: I think that maybe an issue as we are watching funds situation very closely and what the impact
would be locally to Public Health Services.

N. Thompson: Didn’t we see an increase in our HCRA payment from last year and you are budgeting for that
next year.

S. Yaskal: Historically we hardly ever went over 100 thousand dollars a year on HCRA and than it started to
slip up a little to 110, 115 thousand dollars we increase our budget to 150. Last year we went to 362
thousand and this year we are on target to hit close to 500 thousand so we are increasing the budget here.
We are recommending that the budget be increased from 150 to 500 thousand to cover this. But we are
seeing an increase in the amount of HCRA’s.

Dr. Haight: Is it possible to get diagnostic codes on this.

N. Thompson: I was just going to ask not to make more work if we could have a little more analysis of what
that increase is.

Dr. Haight: Because we would invest locally if it cost us less in the long run.

S. Yaskal: One of the big differences here is on in patient because our agreement with the hospitals we have
a 10 day maximum per stay. HCRA allows a 45 day maximum, so you get fairly large bills. We only see 40
or 50 HCRA’s a year.

N. Thompson: right but bills have gotten larger, if you have a wreck out of County and you stay there for 30
day or whatever.

Dr. Nobo: When does the patient no longer become someone from Polk County and the reason is he has seen
patients where they have needed care, because they do tend to move a lot. They move to another County and
than he heard through the grape vine that later when she came back that she had gone to a hospital in the
other County because she started having some pain, but she had moved to that County. How do you
differentiate when you are no longer a Polk County citizen?

Wilma Daniels: Basically can provide documentation according to the statute: the statute requires what we
can and can not use for eligibility. Once they provide us with that information we do have to utilize that for
determining eligibility. They have to bring in one proof that they live in Polk County, 4 weeks worth of
income, very similar to what we currently in our program. What happens though because these people, with
HCRA when they go to the facility at another hospital out of our County. We don’t have any ability to
manage those people. It could be a burn patient that gets air lift from Lakeland to Tampa, Orlando. It could
be a patient with a Neurological problem that really can’t be handled here in Polk County. So a lot of these
are really beyond the scope of the ability for the services that we have available to us in the County. That
hospital also has to declare when they send us the paperwork that it is a true emergency and the person had to
be admitted. So there are many steps that they have to go through and have to follow the state statute. But
unfortunately we can’t manage those people a head of time because we find out about them as they receive
the service or after they have already received the service. We do ask that everyone of those people that
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maybe Medicaid eligible we refer them to apply there we do not approve it until we find out if they are going
to be Medicaid eligible or not because we don’t pay if there is that possibility. The same we won’t pay with
our own program. So there are many factors that go into it, we do follow those state statutes, we log all of
those people and we do try to look at that.

B. Hinton: Understand too that this is a County liability it is not a Plan liability, it is just that the Plan is
budgeted to pay for the County liability.

W. Daniels: that is correct.

N. Thompson: Any other questions on HCRA, I do think that based on our experience and increase in the
budget make sense because of what we are learning. But I also think that anything that we can do to further
understand better the pool of folks that are being served by that.

B. Hinton: Steve on HCRA when they bill you what kind of discount do they typically give you a Medicaid
Rate?

S. Yaskal: They are paid at the Medicaid Rate.

J. McArthur: Other than that there is no wiggle room you get the bill it is the Medicaid Rate and you pay it.

S. Yaskal: Correct if they meet all of the criteria and the eligibility is confirmed and everything else than we
have to pay it.

N. Thompson: to elaborate on Dr. Nobo question if I move last week to Hillsborough County but I didn’t
receive services but I still have a Polk County address that I can prove than that would meet the criteria.

W. Daniels: If they truly move than they would no longer be a Polk County resident.

Dr. Nobo: Wanted to know who you would know if they truly moved? I know because they pick up the
records and said they are moving to Hillsborough.

W. Daniels: That is usually how we find out, we look at what address they give when they went to the
hospital. If they have moved they will usually give that address; even though we may have something prior
here and we will try to verify that and check that out. We have been known to check with that doctor’s
office that said; I have just had a patient that is on your Plan and they have moved; they just came and got
their records and they are moving to Hillsborough County. We will terminate them out of the program as
soon as we find that information out.

N. Thompson: Thank you, continuing on.

S. Yaskal: Started discussing the slides again beginning with Outreach Grants. He discussed the Budgeting
for Outcomes program.

B. Hinton: The $750,000 does include the dollars for LVIM and We Care?

S. Yaskal: that is our recommendation to include LVIM and We Care.

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N. Thompson: So that would basically leave about $290,000 for grant programs. Her concern about that is
she is involved with some other boards and some other groups who went through that process with the
County this last time; unsuccessfully she added. We already went through a competitive procurement
process to fund those grants so either we say we don’t have the money and don’t fund them or we have a
different re-procurement process. That is her concern; we are changing in the middle of the stream the way
that we fund things. We went out on bid we made commitments.

S. Yaskal: Our commitments are only for one year on any grant there is no commitment for a second year.
They are all one year grants and not promise of a second year. To correct one thing to say that there is only
$290,000 left for the grants that is making an assumption that LVIM and We Care would get purchased.
LVIM for example is getting 2 different programs one is $240,000 towards there operating costs at the
facility and they are getting another $120,000 for dental program.

Dr. Nobo: Please clarify one for me; you said $240,000 for operating budget? Cause I remember specifically
because that is very touchy with me as everyone can tell already and knows. The $240,000 was not to pay
for the interaction that they have with our patients?

S. Yaskal: Unfortunately; the $240,000 is a flat fee that we pay them.

Dr. Nobo: Ok than well than I can tell you that I want to know the number of patients that they have seen
(Our Patients) and I want to compare how much money they truly spent. Because if they truly only spent
$180,000 of our money for our patients than I will.

S. Yaskal: That is exactly what this committee would do they would have to come and show there outcomes
show what we are getting for our dollars, and we would see if this is a good program to spend our dollars on
or not. We may decide that we like the dental program and not the $240,000 program and give one program
to them or we may not give any to them. I am not saying we won’t I am just saying that it would be up to the
committee to rank them and see how LVIM or We Care and anybody else comes in the ranking. You may
like some of the out reach programs better than the accessing programs.

N. Thompson: Why would we limit it to what we have in that case; why not open the door and let everybody
come in and make a proposal. That is a concern I have.

S. Yaskal: We have done that historically and that is were the 1.1 million has come from because those are
the ones that have applied that the committee has chosen to give grants too. There has been other who
applied that the committee had chosen not to give grants too.

N. Thompson: She called on Dr. Haight for a comment, no.

J. McArthur: I am looking ahead about 3 pages on the handout on the full budget and I was looking at the
LVIM and I see a $264,000 grant in the 07/08 Projected Actual and than you were talking about 240 and 120
that is more like 360? Where am I missing something?

S. Yaskal: I am sorry I guess I miss spoke that it should have been $264,000 instead of $240,000 the
$120,000 program had not been in that because it actually has not started we do not have a final contract.
This committee has approved it but the contract has not been in place yet for the $120,000 therefore, it didn’t
show up in that column.

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N. Thompson: What is the hold up on that contract Steve?

Dr. Nobo: Have you notified LVIM and others that they are going to have to make presentations to see how
many patients they truly have seen of ours and how do we verify that.

S. Yaskal: we have not

N. Thompson: they would be waiting on us to decide who we would want to proceed.

S. Yaskal: We do get quarterly reports; I think that Gwen could answer that better than I can. They give us
some of that data.

Dr. Nobo: Also; where since LVIM and We Care are funds that we do where is the federally qualified clinics
here?

Ed Smith: On another page

S. Yaskal: When we get to the other slides you will see we have a separate line for the federally qualified
clinics; we were not including them in this Budgeting for Outcomes.

Dr. Nobo: And the reason.

S. Yaskal: Because we had basically voted to do those.

Dr. Nobo: We voted to LVIM and We Care

S. Yaskal: For last year there is no vote for next year, there is no guarantees it is a year to year thing.

Dr. Nobo: So ok we have already voted for next year on the federally qualified clinics? I thought we voted
every year for the following year. Isn’t that what we are doing voting for next year?

S. Yaskal: For next year’s budget.

Dr. Nobo: So why aren’t they here again, maybe I don’t understand you I apologize.

N. Thompson: Because we voted to open 2 clinics in 2 years or whatever that actual process was.

Dr. Nobo: but he said we do one year at a time, we don’t.

B. Hinton: That was on special grants yeah. One suggested that I would make in the light of the economy
that we’ve got maybe it would be wiser not to do any additional outreach grants next year and focus all on
primary care and taking care of the existing patients if we can jack up our eligibility a little bit we might be
better off doing that than trying to reach out to a program that we don’t even know anything about.

C. Kinnick: Ok let me respond to that because I have been on the grant committee since its inception. A
number of the grants, well actually they are all beneficial. A couple of them are actually saving the Plan
money. There’s one with medical supplies, oxygen, crutches, I don’t know all that is included. But that is
money that is not coming out of the Plan per say cause this company is providing it. We have already shown
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an importance for the Teen Pregnancy Prevention Program and how that in the long run is saving us money.
So some of the grants all of the grants that we are funding are saving money in the long term. I would hate
to blanket say cut out these grants.

B. Hinton: Any new grants are what I meant to say, if I didn’t come across.

N. Thompson: Well we won’t have the money for any new ones under this scenario we would only be able to
fund probably a portion of those that are already funded.

C. Kinnick: What I would like to see the grants that we have in existence at least be able to come and present
there case and be considered for continuing funds.

S. Yaskal: that is the plan here is to take the existing and rank them and see which ones we would like to
fund next year.

Dr. Nobo: I apologize but I still did not get an answer or one that I would understand again when we make
our vote today which is on this preliminary budget it is for next year. You stated a few minutes ago that
everything we do it’s one year at a time, one year contract. I can go back to all of the minutes and find when
we made that statement before. So ago if we are voting to see if we are going to support LVIM and We Care
where are the clinics why are they not here?

S. Yaskal: I made a determination correctly or incorrectly; I felt that the intent was to have the clinics and
therefore we kept them in the budget just like we did the Health Department; we are not including the Health
Department in that Budgeting for Outcomes either. It is something we have done, you have every right I
suppose that they can vote against it if there is not funding and I guess it would go away. But that is why we
put it as a separate line item and not in this because we didn’t want to include everything.

Dr. Nobo: The issue that I bring up again, because I always bring it up we were told that on a quarterly basis
we were going to have a presentation on how many of our patients were being seen by these clinics to see if
it is cost effective. If we are looking at everything in fact one member already asked for the doctors to do a
discount or something like that, why would you exclude our largest expenditure that we may not need since
again I will go back and say we started with 68 doctors, Gwen correct me we have over 500 doctors almost
just about every doctor in this County so if you wanted to have access of care we have access of care. But if
the clinics show that they are seeing a large number of patients that would normally not have an appointment
with a doctor already well than maybe we even need to increase what we give them. But I just wanted to
know why they were excluded.

N. Thompson: My suggestion maybe would be we label this outreach grants and than you through in LVIM
and We Care maybe it needs to be just the outreach grants and whatever that dollar amount is and the LVIM,
We Care, Clinics and the Health Department all of that comes under a different category.

Dr. Nobo: I would agree with that.

C. Kinnick: Just to re-freshen everyone’s memory initially the clinics were presented to the Grant
Committee.

N. Thompson: that was another competitively procured contract.

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Dr. Nobo: I just wanted to know why are we differentiating when I think we need to be equal. I like what the
chairman said.

S. Yaskal: As I said I am not here to debut you doctor I just told you what I did I kept it as a separate thing; if
I did it incorrect I apologize but that is the way I felt that we were looking at it. We have the clinic open I
thought that our intent was to continue with that clinic and we have committed to wanting a clinic in Winter
Haven so I put the dollars on a separate line. I did not believe that was a negotiable item; but I could be
wrong.

Dr. Nobo: Sir; we had the intent of taking care those patient between 150 and 200 and we have just dropped
them, which I am very upset about that but there is nothing we could do. So we dropped them, so we do
change and that is so important we need to go and make changes.

S. Yaskal: Your question was why did I handle them differently and I have said if I did it incorrectly I
apologize there was not intent mentioned here.

Dr. Nobo: no need for apologizes

N. Thompson: I think Steve is putting things on the table for us to discuss that is his job, we can either accept
it or change it that is part of the process.

Dr. Nobo: I like your statement Chairman and that is that they came through a grant and if we; I would put
LVIM, We Care, Clinics and The Health Department as important factor in our Plan that needs to be
considered; perhaps and maybe this is not correct to say but Steve said he said something in the Outreach
grants and I just do not like this type of differentiation.

B. Hinton: The way I look at it and the way that I interrupt this sheet here all he has done is take the LVIM
and We Care and instead of making them a budget line item he is saying treat them like outreach grants next
year. That is the only thing different than we have been doing.

Dr. Nobo: I understand perfectly well I just want to know why that clinics are treated differently. When
LVIM does the same thing and We Care for 81 thousand dollars that is about a million dollars in service and
doesn’t that care and the clinic and the Health Department.

Dr. Haight: That is why I would suggest removing LVIM and We Care out of this budget and to profuse that
comment I am a board member of We Care but there are some programs that I thought that the Citizens
Oversight Committee would look at as significant and issues that were decided outside of the grants
committee process. A million dollars of free care done by 200 volunteer doctors that received its own line
item and didn’t need to go through this budgeting for outcomes process and be lumped into these outreach
grants. There could be discussions about LVIM and other things as separate. These are your bread and
butter issues the Health Department we provided an enormous amount of indigent care but we only get 1%
of the sales tax dollars. I am not complaining but I am saying that there are certain items within the sales tax
budget that are critically important; obviously important and you have already decided that and that is why
We Care sort of shows up as its own issue and I do have concerns about moving it into the grants process
and outcome for budget.

S. Campbell-Domineck: I just wanted to clarify that the clinics went through procurement process is that
right.
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N. Thompson: Yes

S. Campbell-Domineck: LVIM and We Care did not

N: Thompson: They did not.

S. Campbell-Domineck: In that procurement process was the plan for one year or to accomplish something
over a number of years.

N. Thompson: It was actually and staff can help me clarify, we let a RFP for 2 clinics and whatever that time
frame ending up being. Lakeland has been open and on the table is Winter Haven. John

Dr. Nobo: Every year it is one year.

J. McArthur: The other thing is did we not enter into a contract with the Clinic, with CFHC to run these 2
clinics one in Lakeland and one in Winter Haven. Don’t we have a contract for this quid pro quo, they do
something we pay them it works back and forth and we don’t have a contract with We Care or even the
Health Department as such.

S. Yaskal: we do have a contract with the Health Department; and we do have a contract with CFHC.

Dr. Nobo: We have contract with LVIM because I made sure that they would see every patient in the County
not just Lakeland.

N. Thompson: In all cases the intent is that they provide services to our Plan participates equal to or greater
to the amount of money that we are investing with that organization. Now Ed I am sorry.

E. Smith: Asked if he could make a recommendation that I think will help to clear this up make it a little
easier. We will take out; staff will take out LVIM and We Care and reinsert them as a line item and we will
reduce the outreach grant to $400 thousand.

C. Kinnick: Yes

B. Hinton: That’s fine.

E. Smith: That should accommodate everyone concern.

Dr. Haight: But that would lead to cutting already existing grant programs right.

E. Smith: No

Dr. Haight: Are these new grants you mean.

E. Smith: Existing grant programs are just exactly that they are year to year. They are year to year.

N. Thompson: Right; but Dr. Haights question is we prior had a budget of a million a year for outreach
grants now we are going to have a budget of $450 thousand.
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E. Smith: Obviously somebody will not be renewed, but it is a competitive anyway.

Dr. Haight: It is not that somebody is not going to get there is going to be a number, many of the grants
won’t be able to function with only a total number of only $400 thousand spread among multiple grant
recipients. If you just go back to those who were receiving grants at the million level and as Connie had
mentioned those grants are performing. As you already know one of ours that I oversee is the Teen
Pregnancy Grant; those grants won’t function for those amounts.

N. Thompson: did we actually award a million dollars worth of grants or some number short of that.

S. Yaskal: Right now there is 1 million 170 thousand dollars out on grants.

C. Kinnick: Wasn’t that because there was a carry over from delays from the year before. I don’t remember
every awarding more than 1 million dollars in grant monies in any one year. I think there is some carry over
and overlap.

S. Yaskal: There is some carry over and overlap, they are not all on the same fiscal year correct. But that is
how much in total grants we have outstanding.

C. Kinnick: And some of those will fall off as of October 1.

S. Yaskal: They will be up for renewal as of October 1, but we are recommending is that we would look at
all of the grants at one time even though there termination dates are different and stay within whatever dollar
figure that is if it is the 400 thousand.

N. Thompson: For an annual review. Right

M. Fulse: Her question for Steve and Ed if we only had 750 thousand dollars budgeted and you subtract the
480 for these 2 items, if we put 400 aren’t we changing the total? If 750 is what we needed to have than.

S. Yaskal: We would have to take dollars out of the healthcare plan; or dollars from somewhere else in the
budget to get that.

M. Fulse: Is that fine with you? Or are we going to end up short falling somewhere later. Or do we just need
to reduce the outreach grants.

S. Yaskal: whatever the committee

M. Fulse: to have the total at 750.

S. Yaskal: whatever the committee tells me is fine; and I understand as Connie said all of these grants are
good things. We won’t have given the money if we didn’t believe in what they are doing. But we are also
believed in 200% of the people should be serviced and unfortunately there just not money for everybody
anymore. So we have to cut back how many people we can serve and some of that is going to have to be the
outreach grants also. We just don’t have the funds to be the funder for everybody.


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C. Kinnick: One of the things is that some of these outreach grants did go to the 125%, 150% some of these
medical supply stuff, so the fact that we cut down to the 150% is going to decrease the amount that this
company is requesting or a company is requesting any how. Now it is not going to affect all grant recipients
but some of those when they come back to ask for renewal on the grant are they going to ask for less money
to begin with because the pool of people is smaller. I am ok with Ed Smith’s suggestion going to $400
thousand I would love to see it at a million but we have to be realistic. I think that we could go ahead with
the $400 thousand and still award the most highest of performing of those groups.

Dr. Nobo: Than I guess we are looking at how we can save so that we can take care of more patients and
when we do that we have to look at everything, not just one group of grants or not one group of people and I
think that We Care and LVIM have been doing a fantastic job for not just one year but for many, many,
many years and it just concerned me and maybe I am the only person who got concerned why they would be
separated from other issues such as the clinics.

N. Thompson: We are not suggesting that, I’m saying this is this issue we need to talk about outreach grants.
We are going to get to LVIM, Clinics.

Dr. Nobo: the problem is that it was done and I am glad that it has been corrected.

N. Thompson: that is part of why we come here that is part of the discussion.

S. Domineck-Campbell: Stated that she wanted to clarify for her purpose I understood about what Ed was
saying. We are talking about $345 thousand on that main budget $345,500 if you combine LVIM and We
Care and we are simply saying where we have $750 thousand budgeted for outreach grants we pull the $350
thousand out for LVIM and We Care and that leaves $400 thousand.

E. Smith: Correct

N. Thompson: Right, the math works a little better when you look at it that way. Than I would like to add a
point of clarification in the Counties process that they use the outcome based review process most of those
programs coming in like the museum and the children’s programs don’t have a Citizens Oversight
Committee that reviews those, so my clarification is we don’t need that process because we have this group
and it should either be this group or a sub-set of this group that does that review and makes those
recommendations. That’s my suggestion without benefit of adding other people who haven’t been involved
in the discussion and don’t understand what we do.

S. Yaskal: Our suggestion was that it would be members of the management team and members of the
Citizens Oversight Committee.

N. Thompson: Well you are our members of the management team.

S. Yaskal: we are not looking for outsiders who aren’t familiar with the program.

J. McArthur: How about those of us on the commission who have been on all of the discussion and still don’t
understand what we are doing.

N. Thompson: We will not vote on things as we go through we are make agreement on it, so if you don’t
agree with some decision or discussion that we are having you need speak up as we are going a long.
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Because at the end we will vote kind of on the whole package as we have made changes if that is ok with
everybody.

S. Yaskal: continued on with budget issues discussing the eligibility be brought down to 125%

B. Hinton: As of 10/01

S. Yaskal: as of 10/01

Dr. Nobo: I have a problem with that.

C. Kinnick: I have a big problem with that

S. Yaskal: I have a problem with that also, but I ran the numbers at 150, I ran the numbers at 125%, I ran the
number at 100%, 150% we weren’t going to be able to break even.

Dr. Nobo: Well I need to see those numbers, maybe we can go 140, no, no, can we go to 140% does it have
to go a whole 25 point.

B. Hinton: Well last month when we were looking at it we were looking at a 3.1 million dollars sales tax
reduction, he is projecting a 5.8 that is basically where it is coming from isn’t it Steve.

S. Yaskal: Right; if we could get into the budget and than maybe come back to that discussion cause I think
you will see the numbers it little bit more when we get into the budget.

Dr. Nobo: Asked if there was anyone else that would like to discuss this subject.

M. Fulse: Said she had a question on the eligibility? Her question is how many people at 125% will be
eligible for Medicaid or some other means and whether they will be able to get healthcare anywhere else, or
is this going to be a population of people that is just not going to be served by anyone.

S. Yaskal: For the most part most of the people, if you are at 125% you are employed obviously you have a
source of income. Most people not all but a lot of people do have insurance available to them it is just a
question of affordable. Unfortunately; what happens with a lot of these people is they have insurance
available at their employment but because of there income and by the time they make their payments for
house payments, utilities, food, clothing there is not enough left for the amount of insurance. What is
happening today the employers are putting more and more a burden on the employee, there is going to be
people who will have a tuff time getting insurance at that rate.

Dr. Haight: Stated a follow up to maybe answer your question further I think we would have to look closely
at the Legislative session that is currently going on and ask have there within all of the laws that are being
passed have there been there a change in the eligibility for Medicaid. For example; if there was a change to
say a pregnant woman is eligible at 185% of poverty and that was lower than you have raised a very good
point. Now these women are no longer eligible for Medicaid if that were to happen, I don’t have what is
currently happening right now in the Legislative session but we would have to find that information out to
get to that answer too.


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Dr. Nobo: I can tell you a little bit with the budget there are going to be a lot of cuts to the Health
Department and to other issues. The governor just – it is flying through the Senate but not quite flying
through the house the governors idea of increasing accessibility but the FMA is working very hard and we
are not even sure that we will be able to endorse the Plan even though the chambers have already has
endorsed it there is a lot of issues going on and I don’t have all of the specifics at this time and it just passed
in the last couple of days. But I do know that the house is having some issues even though they are saying
that they want to increase even more accessibility. So who knows what is going to happen to tell you the
truth.

J. McArthur: Talk about sitting in all of the discussions and not having an idea what is going on look at
Tallahassee.

Dr. Nobo: Well because what happens in Tallahassee affects us.

J. McArthur: Absolutely

N. Thompson: Remember that Medicaid has to be matched by the State from general revenue funds and they
do anything they can to reduce Medicaid expenditures causes than that reduces the State general revenue
expenditures.

J. McArthur: It also reduces the Federal matching part too. A double hit.

Dr. Nobo: the State of Florida it is one of the least under Medicaid payments they are one of the least,
Mississippi pays a lot more, most other States pay more than the State of Florida. So we are going to bring
this back as you had suggested.

S. Yaskal: I will bring it back.

N. Thompson: We are not making that decision today that is a suggestion for that budget that Steve is giving
us.

S. Yaskal: Continued on the budget presentation.

N. Thompson: Asked about the Annual Budget figure is from last year, all County agencies do 2 year
budgets.

S. Yaskal: Right, but these are the budgets that we have and this year we had budgeted $35,500,000 because
the trend had been an increase each year. All of a sudden we are not seeing the increases. Remember our
budgets are at 95%. Nancy has already mentioned that.

N. Thompson: If we project revenue of $31,653,700 we can’t budget all of that we have to budget 95%.

S. Yaskal: Which we will see coming up on the slides. Continuing on the slide presentation.

Dr. Haight: Explained about the County Health Department line in the Budget; he stated that part of the
problem is because of the different fiscal years we don’t receive the data that we need to plan our budget at
the time that the County is needing there data. So it is difficult to project ahead. Adding to that there is a
proposed cut from the State to the Health Departments which could even total at worst case scenario 3
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million dollars plus $900 thousand from general revenue from the State, that is worse case scenario we are
waiting for the decisions. In addition we did lose $250 thousand from the County government even though
we by State Statute are in a contract between the County and the Health Department and the reason that laws
in there is to recognize the unique partnership between the County and the State and meeting public health
needs and to strengthen that partnership we have that contract. Part of those monies funded general public
health, school nurses, disease out break, safe drinking water, and that has been eliminated. So really
although we are not only an indigent health operation that is where we are receiving our funds from right
know from local investments even though there is suppose to be this really strong partnership. It is a good
deal by the way, because right now we get about 11 cents of sales tax dollars for every dollar we spend, we
are taking care of eligible patients.

N. Thompson: Excellent

S. Yaskal: continued on the budget slides. He stated that Mental Health; we do provide them $55 thousand
for Domestic Violence that have requested that go to $60 thousand and $24 thousand for short term
residential, those 2 are not mandated. The $55 thousand they have received the same amount for about 8 or
9 years ever since we started funding Domestic Violence.

N. Thompson: But they are not mandated are they or are they not in this budget?

S. Yaskal: They are in that number, they are included in that mandated services but they are really not
mandated; and I wanted to be sure that was understood.

C. Kinnick: So what was that it was $55 thousand?

S. Yaskal: Well they are asking to go from $55 thousand to $60 thousand there is $5 thousand more in it for
Domestic Violence and the short term residential is the same it is $24 thousand but there is no change, it has
always been $24 thousand.

C. Kinnick: That is $84 thousand of that figure is not mandated.

S. Yaskal: Correct

B. Hinton: What about that grant or was it a grant or a contract that we entered into with Peace River for the
match for the State.

S. Yaskal: that would come out of the Polk HealthCare Plan dollars that is $283 thousand a year for the next
3 years.

B. Hinton: That is out of the Plan

S. Yaskal: Yes that would come out of that. He explained that is why you would see an increase in the
Mandated Services from $1.2 million to $1.667 million.

N. Thompson: Almost all of that is the HCRA? Right

S. Yaskal: Majority of that is all but $80 thousand dollars there was an increase in the Mental Health portion.
He continued on the budget slides. He stated that the ending fund balance would be $1.4 million dollars; this
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is where his concern goes back to the 125% that is not a comfortable reserve. Having said that if we look at
the projected actual he is projecting in reality we would end up with an ending balance of 3.2 million
because he believes that the sales tax revenues will be greater than what we are budgeting and there are a few
places where the expenses might be a little less than what we budgeted. Last month we talked about who
much reserves would we really like to have and this is still not getting up to the numbers we would like to
have. But over the next couple of years I don’t think we can afford to have reserves.

Dr. Nobo: But if we go and add like we decided a few minutes ago add the LVIM and the We Care than in
reality your ending fund balance will be less than a million.

S. Yaskal: Either that or I am going to have to adjust something like up in Polk HealthCare Plan for less
claims or something.

Dr. Nobo: And again I go back again I do not object to the clinics I think that the clinics do a fabulous job if
we could have one just like a McDonalds at ever corner it would be fantastic. But I need to know is of that
$1.4 million how many of our patients are being seen? And if the clinics come and they show that they are
seeing more than $1.4 million than I move to increase whatever number that is. If they come here and they
say we have seen 2000 patients which would equate to $2.5 million I would be the first one to amend this
budget for them to get $2 million dollars because they have seen that many of our patients. But on a tight
budget that we have right now and at a yearly contract we have to be really careful to have them build from
the ground up a clinic that we may not be able to support it. The State is going through a crisis and the State
is stopping to do building clinics, they are stopping to pay the Health Departments and here we are already
looking at a decrease and are willing to take the risk to have a clinic come up from the ground up. When and
if you notice everything in this line has been decreased except one. We are even going to decrease perhaps
our members to a 125% of Medicare. I need that number and I can’t image why the newspapers are not
asking for that number, I need to know how many of our patients these clinics are seeing; and I will repeat it
again if someone doesn’t understand it I can even say it in Spanish. If they see more patients of ours than we
are giving them than they deserve a lot more, if they are seeing $2 million of our members than they don’t
deserve $1.4 million they deserve $2 millions. But I need to know how many of our members are being seen
to equate to what we are giving them. Is that such a?

S. Yaskal; The only thing that I can say for that is both Gaye Williams and Bernard could not be here today
because they are currently going under a Federal Survey which they needed to be too. One of the things they
are hoping as an outcome of the Federal Survey is that they will be able to get more Federal Funds to help to
pay for these clinics. But again there is no guarantees, they will be here at the next meeting and can make
that presentation and give you those numbers. Last month they were here but we didn’t make a presentation
because the focus was on the cuts in the program. There plan is to make a presentation at the next meeting.

Dr. Nobo: How long has that clinic been open now?

N. Thompson; Since November

Dr. Nobo: I though that we said that they had to come her and present how many patients they were seeing
every 3 month? I can look at the minutes because I know that it is there.

S. Yaskal: It is and they planned on doing it we asked them not to last month and they couldn’t be here this
month, they will be ready at the next meeting.

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N. Thompson: They did provide us with some numbers a few months into it.

Dr. Nobo: No precise numbers

N. Thompson: but they weren’t broken out, Stacy you had a question.

S. Domineck-Campbell: the LVIM I am going back up on the chart, she stated that she had misinterpreted
something the $120 thousand in Dental that you had mentioned at the very beginning is not included in the
previous years $264 thousand?

S. Yaskal: It is not because again that contract has not started yet it should be fairly soon. That was
something that this committee approved as well as the BoCC approved because just as a reminder there is a
volunteer Dental network and the Polk County Dental Association had requested us to fund a full time
dentist, I shouldn’t say a full time dentist but a dentist and an assistant so that they could do the triaging if
you will at LVIM and than they will assign that patient to a physician somewhere around the County. So
that is what was decided to spend that $125 thousand for that purpose. As of right now will we see some
dollars this year probably before the year isn”t over but I don’t know when that will get started.

B. Hinton: One of the questions back on the clinics for a second, the structure of the payment plan for them
was basically because there are start ups. Right, in the future they are going to come back be just another
provider under the Plan and they will get paid based on patients that they see. But in this initial period of
time we are funding them the way we are to help them get started and get in place. While I agree we need to
know the number of the patients that are being seen; the intent was to get the clinics open and productive so
that they become a big part of Community. That is no different than how a hospital would recruit a doctor
whether it is an orthopedic, or an OB/GYN they do it through income guarantees or collection guarantees, it
is the same kind of deal.

Dr. Nobo: The difference is they are not using tax payer’s money

B. Hinton: They are bringing in (Inaudible)

Dr. Nobo: Also, they are not using tax payer’s money and the issue is no the issue is I thought it was to
increase access to care and we felt that the clinics were going to do that because we only had 69 doctors.
That was, and believe me one of the newspapers when they were interviewing me the other day he said that I
have too much time to kill because I have gone through all of the minutes for the last three years and I have;
and I can tell you exactly what we all said pretty much verbatim because that is what the minutes says and
that is not what our intent was. Our intent was to take care of those patients that are unfortunate that they can
not afford insurance. It was not to build clinic, it wasn’t for bricks and mortar and I know that I can go back
to the minutes where that was explained to us. Remember for those of you who don’t know and the new
member here the original 5 we met every week to barely understand how to do this Plan. Every week we
met for how long I can’t even remember.

N. Thompson: Forever.

C. Kinnick: Forever.

Dr. Nobo: Forever and we are still some what confused our biggest concern than was the perception by the
tax payers of this County that once they donated this money. I am sorry not donated but once this money
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was available that it was not going to be used for the purpose that what we said and that was to take care of
the citizens of Polk County. That’s it.

N. Thompson: Connie

C. Kinnick: I want to say that I completely support Dr. Nobo in this I think that it is a hard decision we are
going to have to make on this budget, it is no ones fault it is the economy this is the way, this is the reality of
life and I think that every program every dollar spent needs to be looked at critically. The clinics are a
wonderful thing, LVIM is a wonderful thing, we can list, The Health Department is a wonderful thing we can
list all of these wonderful things that are being done for the Citizens of Polk County. But the money is a fine
eyed thing and every program when we do this budget must be looked at on the basis of a decreasing
economy at least for the next year. I don’t think we can blindly say well that budgeted dollars are in there for
the clinics so we are going to open the Winter Haven Clinic, no I think we need to look at it and re-evaluate
everything in this budget.

N. Thompson: Ok thank you other comments, no John

S. Yaskal: Just one more last thing if I may the County does a 2 year budget so you will also see the
2009/2010 on here. I am not going to go into detail over it pretty much all I have basically done is looked at
expenses going up about 3%, administrative fees will go down because again we will not have the $500
thousand in there for the computer system, once the computer system is up and running we will be able to
reduce some temporary staff that we currently have so there will be some significant savings once we get the
computer up and running.

N. Thompson: As we are learning now that budgets is made in magic ink anyway because we will have to
revisit it this time next year.

S. Yaskal; It is just pure crystal ball work and there is no rhyme or reason for it we do the best we can, but I
just did want to put it in here just because we do present a two year budget to the Board.

N. Thompson: Other questions on the budget, we want to go through the next slides and we will go through
our in depth discussion. More in depth we are going to stay here until we are sick about hearing about it.

Dr. Nobo: Steve can I just say something looking at this it is extremely impressive how you guys can do the
great work that you do and only take 15% of the money that is fabulous, I congratulate you.

S. Yaskal: Thank you and again there is some things in that 15% that are there like the $500 thousand for the
software and if those were out it would be down to 13%. We do not like it being has high as 15%, but that is
what the graph is showing that 68% of the dollar is going to the patients for the HealthCare Plan and you see
the other items up there. (he continued on going over the last 2 slides). He explained that historically the
administrative cost we were able to keep that under 10% but with the sales tax going down and the amount
that we can pay for claims going down that is changing that percentage.

Dr. Nobo: You also had a lot of over time trying to do the work of 10 people with 3.

N. Thompson: Right


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S. Yaskal: Went over the last slide showing that the administrative costs come down to 13.9% and the Plan
increase to 68.9%. He explained that when the economy increases the sales tax comes back to where we
expect to come back all these numbers will change we will be happy to go back up.

N. Thompson: Explained that we have been through the budget presentation and now discuss.

Dr. Nobo: I would like to go back to the 125%, we need to does it have to be a whole quarter can it be a
140% can it be 145% I just want to make sure. Cause let me tell you these patients are going to go back to
the E/R but you know something, you know what I learned and the ladies can do it. The ladies are welcome
in this and you will know why in a minute what I am going to say, the women come to my office and spend a
couple of hours and be in the room with me when I am talking to these ladies who have had no care at all for
years and years, and how if we could have seen them just a few years before the savings in and coldly say in
our finances would be so great but most importantly in their health. So I invite any of your ladies, because it
is so critical to take care of these patients and being a gynecologist I only see woman but I am sure the same
way would go with the man. We would have to see how in the world we can increase our eligibility to at
least to attempt to see that extra patient that needs us.

N. Thompson: The recommendation here and make sure that I understand it, is would move towards 125%
with this budget year on 10/1?

S. Yaskal: Correct

N. Thompson: Through the same process that we just adopted which would mean there would be a period of
time where people of the longer term eligibility or of the higher level of income eligibility are going to
continue in the Plan until their card expires.

S. Yaskal: Correct however; I would probably recommend that new people coming into the Plan now for the
rest of the year that their expiration dates would probably be 9/30. They wouldn’t be; we won’t give them a
year card knowing that they are going past October 1st.

Dr. Nobo: Again does it have to be a whole 25%?

S. Yaskal: No there is no magic to that my concern like I said doctor I don’t disagree with anything that you
say. We don’t want to cut these things anymore.

Dr. Nobo: I know that Steve

S. Yaskal: Anymore than anyone else, my concern is that ending fund balance. There’s a lot of crystal ball
work in budgeting especially in medical care. There is always a concern that the expenses are going to be
greater than what we are projecting based on prior years. There is a concern now that our sales taxes may
not even hit the numbers that we are projecting even though they are low. There are so many unknowns and
we just don’t have a lot of fund balance to play with right here.

N. Thompson: I have a question do we have to decide this today? I mean we just made some major changes
at our last meeting, we don’t even know what the impact of that is really going to be yet. I mean we crystal
balled it right but we don’t know what the real impact is going to be if it could be a couple of months of data
looking at the new world order and than relook at.

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S. Yaskal: I think that is fine; like I said this is the preliminary budget if we see that the projections are
looking better than what we went with we may say lets go back up. It is just that.

N. Thompson: So we could go ahead and issue those cards to 9/30 as a precautionary measure so if we have
to implement this Wilma’s staff will have an easier time of it. But if we can change our mind and say no we
think we can leave it at 150% or whatever they can just issue continuation cards.

Larry Skidmore: (Mostly inaudible no microphone was used) October 1st, so that will give us just a little
time to see how this thing is going to fluctuate, the bottom line for me is and my responsibility is to not go
over budget and end up in the red.

N. Thompson: Not an option.

L. Skidmore: They are not going to call Dr. Nobo or you they are going to call me. That is my
responsibility, if we say 125 and if we see that it is getting better by October 1st; we can readjust that or if we
have to stay at 125 and during the year it gets better hopefully; it will get better, we will readjust it.

E. Smith: A few comments if I could you will recall when we had our 20 plus million dollar surplus and
people wanted to do this and they wanted to do that, and they wanted to do something else and they wanted
to Chemo and Radiation. I said let’s be careful on what we are doing here the Plan is still maturing the
numbers aren’t in yet, we don’t know what the impact, no let’s do this, well we saw the results of that. We
had to come back and reduce to the 150% of poverty. Now the staff and I spend everyday working in this
Plan; this is not a part time job for us. Steve and I talk at length about this recommendation; this is not
something that was decided on the spur of the moment. I did not want to do it he can tell you that, but I also
have a responsibility the County Manager looks to Mr. Skidmore and I to balance the budget they are not
interested in excuses or anything else. They are just interested in the bottom line. When we came in here
with this recommendation it wasn’t with happy faces. The other thing is if the sales tax goes back up there is
nothing in the world to prevent us from coming back in and saying hay let’s bump that back up again. We
can very easily do that.

N. Thompson: Right

E. Smith: But as a budget for next year; this is what we’ve got to recommend at this time, as you look at a
picture at this point in time. Cause like Steve said this is a lot of crystal balling we don’t know what the
sales tax revenue is going to be for the rest of the year, what we are having to do is take October and
November in other words this year and extrapolate an number for the remaining months to come up with
what we think it’s going to be.

N. Thompson: And at the same token Ed it could go down. Because the economy could get worse we are
seeing a lot of people getting laid off; we are seeing a lot of people reduce there expenses.

E. Smith: Absolutely; Hillsborough County it is at 100% of poverty and has been that way for many years. I
don’t want to go there; I don’t want to go there at all. But we’ve got to look at our core services at our vital
core services which are primary care, specialty care, in patient, ER, drugs our vital core services. No we
don’t like it either but to be fiscally responsible at this juncture today at this point in time this is what we are
recommending.


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J. McArthur: If I could say something; I was getting ready to say these numbers are not craved in granite
somewhere and a long the way you can adjust from one to the other. But Ed while you where talking I was
looking here and I don’t see too many places up there that we could cut to transfer funds that are running
short.

Dr. Nobo: I do

J. McArthur: I know you do, we use to have a Chatty Cathy doll and you pull her string and she would say
the say thing over and over again. I can’t see it not many of them, there are a few might be a dollar here and
dollar there but very few.

Dr. Nobo: Nancy

N. Thompson: Yes

Dr. Nobo: I am not going to get personal but I will use the fiscally responsible statement that Mr. Smith said
and I can not physically responsibility vote on a budget saying that another clinic will be opened in Winter
Haven from the ground up when we’re possibility cutting down the number of patients that we will be seeing
in our Plan. I am also concerned that last month it was the magic number was 150 now this month it is 125.
What happened in those 28 days or 30 days that dropped it by 25% and my other question is how high can
we go? Meaning 130, 135 it that expectable or is the magic number 125?

E. Smith: What happen between last month and this month is I just explained that we are doing an
extrapolation for next year. We are assuming that the average of the months that we just received will
continue for the rest of the year. That is the magic that just happen.

S. Yaskal: And again last month I believe that we said that as we watch these numbers we may have to come
back to you with more changes. Now we are looking at next years numbers at that time we were only
looking at the rest of this year and now we are looking at next years numbers and that is the purpose of going
to 125%. To answer your other question there is no magic to 125 it could be 130 it could be 127 it could be
132 I have not run the number other than what I said I did it at 100, 150 and I did it at 125. Be honest with
you I would have been more comfortable going to 100, but we just don’t want to do that. That would have
given us enough reserves that I would have been comfortable with. These are tight reserves I would be
uncomfortable going anymore but that is not to say that if this committee tells me that they want me to come
back I’ll come back with what ever your tell me that you want. We don’t break down the numbers currently
exact by what we showed you the 125, 150, so I don’t really have a way of saying how many people are in
our Plan.

N. Thompson: At those different levels.

S. Yaskal: At 140 or 130, it would be even more guess work. But if that is what the committee wishes.

M. Fulse: She stated that she had a couple of comments; one of the comments that I have is not in rebuttal
first of all let’s be perfectly clear. As a practicing pharmacist in the community I see numbers of people who
don’t go to the doctor at all, they avoid the doctor’s office completely. We spend a lot of time as community
practitioners telling people how important it is to go to the doctor, to have their mammograms, to have their
pap smears, etc., I see a large number of people who have health insurance who refuse to go to the doctor to
get there regular exams even though they have health insurance. I have people in my circle of people that I
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work directly with who haven’t had a mammogram in 20 years and found out that they have massive cancer
and they had health insurance the whole time. So a lot of women and men are not going and getting the
health care that they need and it is unfortunate whether they have 125% or whether they are wealthy, they
just avoid the doctor until they are sick and that is a sad state of affairs. But in terms of the clinics as a clinic
representative it would not be right for me to say that we don’t need the clinics because they cost too much.
In the time when people are losing jobs and we don’t know what is going to happen in terms of finances,
those clinics are supported not only by the health plan $700 thousand or whatever won’t build a clinic.
Lakeland Regional put in just as much money last year to put that clinic in place as we did. They see the
need for it, they have even asked for increased services in that Clinic and that Clinic like the pharmacy and
different things that were not approved by Polk Health Plan, because Polk Health Plan said you’re going to
make it work until we give you any more than this. I think that budgeting Steve and them I think that they
were very careful not to over extend the Polk Health Plan in the Clinic and I think that Lakeland Regional
and Winter Haven Hospital and the people who are in the health care business their saying we need these
clinics, just like Polk Health Plan and the Community has said we need these clinics. Another thing if a
person is at a 100%, 125% or 150% if they present at a clinic they are put on a sliding scale for payment, but
if they don’t pay they are still seen. They are taken care of their immediate primary care needs so the clinics
do operate in a different way than the rest of these numerous practitioners that we have now signed on the
Plan. But in terms of education we don’t have a line item for education the only line item for education we
had is the teen pregnancy thing that we have that they were going to educate the teens, but there is nobody
education 35 year old woman telling them to go to the doctor. There is nobody offering that kind of help and
we have a serious need in Polk County to educate people. I appreciate everything that everybody has said
but I think that the clinics have a place and I think that the clinics like the primary care clinic in Lakeland
they have a big community room they can be doing education programs, they can be working with the
churches having programs to try to get these women in before they have lesions and things that are causing
them to go to the doctor after 20 years of even having health insurance, because a lot of them do have health
insurance and they still won’t go to the doctor until something catastrophic happens and that is Polk County
and you can check with the hospitals and everybody on that. They present when there is a problem, or
present when they are having a baby and the man present when something goes wrong with the things that
make them happy and that is when they present. So we have got to educate our people so we don’t have a
line item up there for education but that would be the most important line item up there.

J. McArthur: Amen

N. Thompson: Thank you other comments down here.

J. McArthur: Just one she Misilene that Lakeland Regional helped to establish the clinic and set it up in
Lakeland, Winter Haven Hospital is doing the same thing with the one that is going to go up in Winter
Haven, so the hospitals are to be commended for that.

N. Thompson: Dr. Nobo

Dr. Nobo: Ms. Fulse because your husband is the Chief Financial Officer of these clinics I can not begin to
compare your knowledge to these clinics, but I can tell you a couple of things, I can tell you that the people
who come to my office of course which could be the difference, the people who come to my office do not
want to go to the clinic and perhaps the people that go to your clinic do not want to go to the doctor. But I
thought correct me if I am wrong that the clinics have doctors in there and that they are going to be seen by a
doctor so I don’t understand why someone would say I don’t want to go to the doctor but go to a clinic to be
seen by a doctor.
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N. Thompson: I think she was talking about people she sees through her pharmacy business.

Dr. Nobo: Also

M. Fulse: Wait a minute, wait a minute, before we go any further let me explain to the community and the
community watching this. I have been a practicing pharmacist for 27 years, I have been volunteering in
healthcare for 27 years my husband has been the CFO in medical practice for 3 years. I have been on
healthcare band wagon educating, going to elementary schools, going to middle schools and high schools
talking to children about their healthcare and the importance of healthcare for 27 years. I was a volunteer in
Tallahassee community for 5 years as a pharmacy student. So my husband is the chief financial officer in
healthcare for the past 3 years but he doesn’t even begin to know what I know about what this community
needs and I would appreciate your leaving that part out. The story is I care about people my community that
I work in here in Bartow I am sure that we can get a whole bunch of them in here to tell you I care about
people, I care about healthcare, I care about community. I am not paid, my salary as a pharmacist takes care
of me, I am not paid to represent my husband or his interests as a financial officer. He does not need me to
help him be a financial officer he has been a CPA and practicing financial person for 30 years. 3 years in
healthcare, 30 years in the community ok. So going into that in such a political way is wasting everyone’s
time, my records speaks for itself.

Dr. Nobo: I, when I was a member of We Care I had to sign a piece of paper saying that because I was a
member of the Board of We Care when I spoke in favor of We Care. When Dr. Haight spoke about it, he
said it, every time my name has been mentioned here it starts with a doctor so that everyone knows exactly
where I stand. So I don’t know why you took this comment the way, I presume you did because what I said
was I will not try to compare your knowledge of these clinics because your husband works for them that was
my comment. Now if we had the whole morning here I could tell you want I have done in my 27 years of
doctor and all of the people that I have saved and all of this that I have done but I don’t want to bore you.
But believe me I could probably spend easy 2 hours of telling you what I have done in this community and
what I have done but I am not going to waste your time. What I am trying to say is we do need a lot of
education and patients need to be educated to come to the doctor’s offices. I see it everyday I am the only
person on this panel unless she (Connie Kinnick) goes back to work who spends hours yes hours everyday
talking to these patients for example I always ask them why are you going to the ER, they go to the ER
because that is what they are accustom to unfortunately, they go to the ER because that is what they have
done all of there lives, so you have to educate them. I have seen a patient for a pelvic problem and even
though I am her doctor and I tell her I am accessible she’ll come back 3 weeks later after being to the ER. I
have asked them why did you go to the ER and they simply said I am just use to it. So education is
extremely important and I think that the Plan is doing a good job trying to educate and it may take a whole
generation to educate these members of this Plan because that is what they are accustom too. What we are
trying to see is how we can get the most patients being seen and yes I have a physically responsible problem
to vote or to even say that we need to just approve everyone of these numbers when we are not sure where
our money is going to go and to decrease the patients that we are seeing to open another clinic that may not
be necessary I am concerned. My goal is to try to use the tax payers money do what was meant for and the
tax payers voted and I go back and I will ask the Ledger to get back all of the articles when we were voting
about this that the biggest concern that people had that when the money was going to be given it wasn’t
going to be used for what the people voted and that is to take care of those unfortunate working class of Polk
County that did not have enough money to have insurance, that is the issue that I am making physically
responsibly.

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N. Thompson: Ok, I have a comment and than if there are other members who want to speak to this issue, I
am assuming we have narrowed our budget issues to the clinic issue and unless there are other items that
people want to talk about. My comment is going to be and Dr. Haight and I have sat side by side at all of
these meetings and had the same discussion; I’m sorry I mean Dr. Nobo, but Dr. Haight was here too. I
continue to support the expenditure for clinics and one of the reasons is even more so now we are cutting
eligibility for the Plan. When we are no longer able to serve people that are at 125, 150, 200% of poverty
that capacity that we have built through the clinics, it is about building health capacity in the community, it is
still going to be there. So as we have to cut those folks who miss the cut now they can still go to the clinic
and be seen on a sliding scale on the extent that they can pay. I know that is not the intent of I spend a dollar
to get this dollar of service but and again I agree with you we need to see the numbers, we need to make sure
that the return on that investment is as great as we had hoped it would be, but I do think that the capacity
issue continues even more to concern me. Other comments from the committee.

B. Hinton: Again a lot of us has been on this for a long time and seen some of these numbers, there was a
study that was presented to us about 2 years ago I believe that talked about the shortage of physicians in Polk
County, primary in particular and I think that came from Lakeland Regional Medical Center. Lance
Anastasio showed up here a couple of months ago saying that his clinics didn’t have the capability of taking
on any more patients and so again I am a strong advocate for clinics I make no secret about it I think that is
where we need to be spending as much money as we possibility can, whether it is only with Central Florida
Health Care or other partners, but in every case we have another partner coming to the table whether it is
Federal funds, Lakeland Regional Medical Center, Winter Haven Hospital they are throwing in huge sums of
money. So our dollars get doubled, tripled and quadrupled in some cases to make these things happen.
Again I support them.

N. Thompson: Misilene

M. Fulse: That was one of the issues; what I was bringing forth was that when we do give a dollar to a clinic
that is also getting money, Federally, State and who have opportunity to asked for other grant opportunities
you know for healthy community money and all of that it is a major investment, it is a different type of
investment, than when you pay because a patient went to a doctors office. The dollar is a different dollar if
that dollar if that dollar can attract more dollars.

C. Kinnick: Nancy

N. Thompson: Yes

C. Kinnick: But we still don’t know how many patients the clinics are seeing.

N. Thompson: Well I think that any approval that goes forward needs to as Dr. Nobo has asked needs to
include that information. That would be my take on it, we should be looking at that. Stacy

S. Domineck-Campbell: I just want to share that if we can get those numbers, which I think is really
important, how many they have seen since November. But even when a new doctor comes to the area it
takes a moment for people to find out about them, and find out about the quality of care they prove and
before the word gets out that you actually need to go to this doctor. So you may see a few at the beginning
and it increases over a number of years. So you are talking about a clinic that has been opened since
November and it is April and that is six months. Some outreach has been done, certainly not at the level that
we are all satisfied with, to do even more outreach so that people will be aware of that the clinics are
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available to them, and an additional explanation, so people clearly understand it that I can go to the clinic.
More education is needed, I might go but what does that mean and they may not know what it means to have
a clinic in the area and I am sure that it is going to increase as word of mouth gets out or more information,
education is provided. So while I think that those numbers are important I won’t base my decision on a
clinic that has been open 6 or 7 months and see that we need to do away with it.

C. Kinnick: If it was a new clinic to the County or the State I would agree 100%, but the Federally Qualified
Health Centers have a very good reputation and people know that one comes to town they are going to get
the same quality of service if they went to Georgia and went to one of those clinics. So what I am saying and
you are right about physician when they come to town it takes time to build up their practice. But if a
physician goes to Geisler Clinic they are kind all ready cause people assume that Geisler Clinic won’t hire
someone who wasn’t a qualified physician. So they already got something going for them so their practice
builds up a little quicker than someone in private practice. So the Federal Qualified Health Center even
though it is new has or should have a little higher number because it does have a good reputation, it is
building on a previous reputation. So it shouldn’t take quite as long to get the ball rolling.

N. Thompson: Right somewhere in between.

M. Fulse; But it does, it does, because of our education level and because of our complete intent on the
Emergency Room not handing. We went through a think that we were making sure that the Emergency
Room wasn’t endorsing the clinic any higher than the rest of the physicians and all of this stuff. Like
Lakeland Regional has to give the patient a whole list of all of these places to go they can’t just say that there
is a clinic over there. So there are a lot of things that we as a committee have done that even limits the
advertising and stuff of the clinic. The Lakeland community hasn’t had any Federally Qualified Clinics so
they do have to get use to the idea, they do have to be educated, a lot of the Lakeland People they don’t even
go to the Health Department because they are not completely aware of what is available there. They are not
in tune with what a clinic means in the Lakeland area.

N. Thompson: I think once we see numbers and this discussion will be more pertinent to look at, to what
extent the market penetration has been. I can say that people in Lakeland are a little more elitist and there
have been clinics in Frostproof and Davenport but they don’t know about them and they don’t care about
them. Now we have one gee never heard of it before.

J. McArthur: I was there and I had never heard of a Federally Qualified Health Clinic until I started 6 or 7
years stepping up to the microphone over there and talking to the County commission about indigent health
care as a result that is why I am sitting here I think. I have always had insurance of some kind or another so I
haven’t needed to go searching for this. So the education is an important part of it. There is one little
bookkeeping thing I think that I should bring up. Misilene mentioned that her husband is a Chief Financial
Officer with Central Florida HealthCare anytime that we vote on something affecting the FQHC she abstains
and fills out the form that the State requires so that she doesn’t swing the vote one way or another. We are
legal.

N. Thompson: Ok, yes thank you for that.

B. Hinton: Question, what do we need to vote on here, what does Ed or what does Larry need from us today
in regards to this proposed budget.


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E. Smith: Steve when is the, when do we have too, I thought we had to get this to the Board by May this
budget, general fund is due now.

S. Yaskal: Right general fund was due today, Human Services I think it is the 18th of May, I am not sure of
the exact date but it is the middle of May that we have to turn the budget in. That is a preliminary budget; it
is not to say that it won’t be changed after that but Human Services Department has to have their budgets in
mid May.

E. Smith: Well I think where I am going with this is do we have to have a vote today? Isn’t that the
question?

B. Hinton: Yeah that is my question, cause if so I would make a motion to do it. But we are debating a lot of
things on here and it is a good debut but if we have something to take action on then we need to do it.

N. Thompson: I thought we could whatever action we take with the amendments than Steve will redo that
and submit that. Now normally we do Public Comment at the end of the meeting, but because I assume that
the Public Comment would have to do with this budget vote if there is no strong objection from the members
I would like to move that up as part of our decision rather than we vote on something than we listen to the
public comment about it. It doesn’t seem very logical to me.

J. McArthur: That is great thinking

N. Thompson: Dr. Nobo as a not public comment than we will go to public comment.

Dr. Nobo: Stacy you are correct that is why I said at the beginning since this clinic was beginning and I will
give you an example that I gave, part of their budget included more than one person to do medical records
and I said that if you are starting and you are going to start slow why do you need more than one person to
do medical records? I am sure that your secretary could do it. Cause I was trying to make the budget
efficient, so you see that you are correct and I was told that no that they needed that many numbers because
that they were quickly going to get that high number. So I agree with you but that is not what was presented
to us. Also, I would appreciate if no words were put into my mouth because I have never spoken against the
clinics so when someone says we believe in the clinics we believe in this you can add that Dr. Nobo, or
Ralph Nobo whatever you want to call me I agree with you I don’t have an issue with the clinic. My issue is
simple the Citizens of Polk County voted a tax on themselves so that that money would go directly for those
who could not have any other insurance that has always been my watchful eye, I will call it. The tax payer’s
money spend it properly. I think that the clinics and I think I have said it 2 or 3 times every meeting because
those people on this committee keep saying we like the clinics we like the clinics but don’t see why I am
perhaps, and Connie and knows what the bill says and it says that it had to go for specific purpose, that is all,
and I will say it again I wish there were more clinics. Remember these clinics don’t only depend on our
money, which is why they are called Federally Qualified Clinics, they get money from the Federal
Government and they get paid a lot more than doctors do. Mr. Hinton said well maybe the docs will get paid
less, well the Federally Qualified Clinics and I have said it before I use to get paid $52.00 every time I saw a
pregnant women the Federally Qualified Clinic gets over $130.00 and let’s not talk about sovereign
immunity that I have to pay $60 thousand dollars and they pay zero and the other doctor in the room will
probably testify that believe me there is a lot of stress. So please don’t say I am 100% for the clinics because
I am 100% for the clinics what I am not in favor of is giving them a blank check not knowing the number of
patients that they are going to see and perhaps starting another clinic where you have the Bond and Geisler
Clinics which we, I hope they are in the plan and if they are not I have always offered which my offer was
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never taken. I had offered to go and speak to the Administrator of Winter Haven Hospital and I am going to
go to their Board because I know some of the board members, because I really don’t understand how Winter
Haven would not be willing the County by having some of our patients going to their clinics. I think maybe
I miss understood the Administrator, but because let me tell you there is one here in Bartow and I have
spoken to Dr. Balea and he has never told me that he is so full that he can’t see people, he is an excellent
doctor who sees a lot of patients but I have a feeling that he can see one or 2 more. So please anyone who is
listening today, when you hear Nancy or Brian saying they are 100% for the clinics add my name to it,
because I am 100% for the clinics what I am not is giving them tax payer’s money that may not go to take
care of our patients.

N. Thompson: Thank you do we have Public Comment on this issue or anything else related to the budget?
What I will ask you to do, we didn’t do a sign in did we Debi? If you would just come over to this side and
to the podium one at a time, first we have Sandy yes. Introduce yourself for the record and we will try to
keep the comments to a couple of 3 minutes for you to, Debi has a sheet for you to sign in. Come to the
lectern not the podium thank you John.

Sandy Swanson she is the Executive Director of We Care Polk County and I just wanted to tell you all for
some of you who don’t know because you are fairly new on this board. That for 9 years from 1998/1999
fiscal year We Care has been funded by the Polk County Commission as a line item. We certainly owe a
great deal of thanks to Ed Smith because he had the vision to realize what a volunteer network would have in
healthcare in Polk County. He actually rescued us at one point as we were failing. We started in 1998 with
42 doctors we now have a little over 200 volunteer doctors and we expect to be at 225 doctors by mid
summer, which is tremendous. We are the largest group of volunteer doctors in Polk County and we are the
sixth largest group of volunteer doctors in the State of Florida so that says a whole lot for us. We do provide
over 1 million dollars in free medical care each year. The discussion about moving us into the out reach
grants I only wanted to make a couple of comments on that and there are a lot of funds available Statewide
and Countywide for free clinics but we are not a free clinic. We are what is called nationally a free clinic
without walls, because our physicians use their own office to see the patients because we do specialty care
only. We do a lot of surgeries, thyroid care, eye care, Gynecology care; Dr. Nobo of course knows that. The
money that comes from you all and from the County to We Care is for our Core Funding, we have very low
overhead costs because we do not have a clinic. We have me and a part time person, we have asked for an
increase next year in our budget unfortunately as the HealthCare Plan has to reduce eligibility limits a lot
more of those patients are going to be coming to us and we are going to need more assistance in our office
for that. But I also wanted to let you know that just recently We Care was awarded the first every Susan G.
Komen for the cure grant for $100,000 to establish free screening mammograms and other breast diagnostics
in Polk County. Without the core support from this group we will fold our rent is provided by the Polk
County Medical Association, the money that comes from this group is strictly salaries, telephone expenses,
consumable supplies and that is our overhead. But without that than we wouldn’t be able to apply for that
$100,000 from the Komen foundation or the $72,000 from the Blue Foundation of Florida, so we hope that
you will take that into consideration. Thank you very much.

N. Thompson: Thank you

Dr. Haight: Stated he wanted to add that without that kind of funding for the mammograms those are
programs that the Health Department use to do in the past and because cut backs in the past are not as
available. The Health Department does give sovereign immunity to all of those volunteer doctors so we sign
off on that so in their own office they do have the extension of the State’s sovereign immunity for seeing that
patient.
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N. Thompson: Seeing that group of patients, I thought that I remembered hearing about that it is wonderful.
Other Comments, yes sir.

Pastor Earl Brown he is representing the P.E.A.C.E. organization and the more than 20 congregations across
Polk County. He stated that they are extremely excited and they are thrilled about the open of the Lakeland
Clinic and the citizens who are being cared for and who indeed will be cared for. As I have sat and listened
one of the crucial situations in my faith text it says for lack of knowledge people parish. I am one of those
pastors who get out on the streets and goes into peoples homes and one of the things that I found is that there
are dozens and dozens of people everyday who say to me that they have no idea about this particular clinic
and others have mentioned I meet people who have no idea about what services they maybe able to get at the
Health Department. So education is in deed a crucial issue. When it comes to the Winter Haven clinic there
still well over 125,000 uninsured or under insured citizens in our County, we must be judged as a County not
by the virtue of wealth but by the wealth of our virtue and the wealth of our virtues must say that we are
going to take care of the last, the least and the lost. It is imperative that we continue to move forward with
the Winter Haven Clinic as others have already said we have a situation where Lakeland Regional Medical
Center, Winter Haven Hospital is willing to invest substantial funds into this process and the tax payers
dollars is very minimal in this so we are here as the P.E.A.C.E group to encourage the leadership here to
move forward and vote a very affirmative in this process. As representatives of P.E.A.C.E. of more that 20
congregations here in Polk County we have worked very diligently to get the tax passed and so we are here
to say simply to the leadership here we want you to keep the commitment, keep the promises that have been
made so that we can continue to serve the citizens of our County particularly the last, the least and the lost
many of which have no idea about these particular clinics or even other healthcare resources that are being
provided. I am personally taking on the challenge of 4 communities in the Lakeland area where we believe
there is a great need for education and we are putting on our tennis shoes and we are going to go door to door
and begin to education people on certain things that are vitally important them in their health. We just thank
you for the time.

N. Thompson: Thank you Pastor

Betsy Grizzary she is from First United Methodist Church, Lakeland (Justice Ministry) one thing that has not
been addressed by this wonderful group has been the hours that the clinic is open they are open from 8AM to
8PM; they are open on Saturday and Sundays. She stated that she did know the details of the private
physicians who are seeing some of the patients that we have had discussions about. But my guess is that
they are not working Saturday and Sundays, just a guess. Something that is exciting to me is the fact that it
is bi-lingual. I don’t know how many doctors have patients and they make sure that the staff is bi-lingual.
When I got involved in Justice Ministry and P.E.A.C.E I was interested in the education and something that
was brought forward was some of the kids are pulled out of school to go with their parents to the doctor so
the children can translate. Well when we have people who literally speak the same language it makes a more
complete bond. I appreciate and I have listen carefully to all of the speakers everyone’s heart is in the same
place, we are just going at it in different ways we are going to end up serving the folks of Polk County and
that is what we are after.

N. Thompson: Thank you

Dr. Nobo: To clarify a few things some doctors are open in the evening and I am one of them. Many
pediatricians are open some Saturdays and Sundays and also we the 3 of us here ask when did you start
opening on Sunday at the Lakeland Clinic we were not aware of that.
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Betsy Grizzary: (inaudible)

Dr. Nobo: very good thank you

N. Thompson: I didn’t recall that.

C. Kinnick: I didn’t recall it being open on Sundays

J. McArthur: Yeah, it is, not the full hours but it is open some hours. Also, Dr. Nobo forgot to point out that
he is bi-lingual so as well.

Dr. Nobo: Thank you John, I am glad you brought that up. The State law is that a doctor office has to have
accessible to whatever language which the FMA has worked very hard because some people wanted to be
sure that they were certified, translators which that would be almost impossible for every language we have
here in Polk County, but yes most doctors have to have someone and even though I have seen them come in
with friends and some of their children, yes and I can say everything I am saying in Spanish.

C. Kinnick: There is a telephone line when I worked at the Health Department it’s fairly easy to cover the
Spanish speaking population. But if you get someone in that speaks Vietnamese or Creole or something like
that there is a telephone line as far as I know any one doctor’s office anyone could call. I have sat there with
the telephone and the person trying to do Creole and having the translator. So any facility has that ability but
it is expensive but it does have that ability.

Dr. Haight: The advantage of it helps protect confidentiality too. That is good.

N. Thompson: Ok we have another speaker.

Harry Pettit he is a member of the First Presbyterian Church in Lakeland also involved with the P.E.A.C.E
organization our church is a member congregation one of the 20. We have been involved with this issue for
a number of years since before the ½ percent sales tax and as been mentioned we were very supportive of
that. The reason we were supported of it was because as it has been stated was our understanding as tax
payers and voters it was our understanding that the money would be used for indigent healthcare, for those
who were uninsured or underinsured. It is our belief that possible the most efficient or one of the most
efficient ways to deliver healthcare to under insured and uninsured is through these clinics. It has been
explained today that the money that the County puts in through the ½ cent sales tax is multiplied several fold
as a result of other funding that is available. I don’t believe that there is any competition here between
physicians, clinics or the Health Department or anything else. I think that the problem is larger than all of us,
way larger than all of us. I think that if we have 5 clinics which is the long term goal and we have all of the
doctors that Dr. Nobo speaks of seeing patients and we have the Health Department doing everything they
can. I don’t believe we will still cover it all. So I think that it is important to look at this in a broader picture
and to say that the clinics are a very essential part of it, and we have it started and it would be very sad to put
the brakes on that and to break promises that have been made. Thank You

J. McArthur: Mr. Pettit, before you leave P.E.A.C.E. had it’s big annual meeting a week ago this past
Monday I believe.

H. Pettit: Yes the Action Meeting
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J. McArthur: Just for general information would you tell us how many people were attending that meeting?

H. Pettit: I believe it was 13, 12, 13 hundred

J. McArthur: 13 hundred on a Monday evening in Winter Haven.

H. Pettit: Monday night in the Cypress Cathedral we had 3 of the County Commissioners, we had Mr. Smith,
and we had a wonderful meeting. The sense of that meeting that we are moving forward together, we
understand constraints in budgeting. There will always be constraints in budgeting; I think that the
wonderful thing is to look at the projections they are not that horrible. There is a reduction obviously but I
don’t see it certainly as the glass half full at this point. I think that the glass is about 90 or 95% full; I think
we should be talking about as had been said several times the best way of using the money. I think that there
are ways of looking at this that show that the healthcare clinic are an excellent way to use the money.

J. McArthur: I don’t think you would get 12 or 13 hundred people out to see Miley Cyrus let a lone come.

E. Smith: I would just like to add that the County Manager was also at that meeting.

H. Pettit: Sorry, yes, thank you.

N. Thompson: Ok, thank you all for comments. Where we are we had a lot of discussion we have had some
consensus on some things that we want to change in the budget that has been presented to us and we have
heard from the Public on their issues and concerns and I think we are ready to entertain some sort of a
motion if someone will make one.

S. Domineck-Campbell: Move to approve the proposed or preliminary budget with the amendments
that were requested.

B. Hinton: Second

N. Thompson: Those amendments are if we could clarify the changes on the first page, I just want to
make sure that we all know that we are voting on the same thing.

B. Hinton: That Lakeland Volunteers in Medicine and We Care get rolled over and the outreach
grants get reduced pretty much by that amount.

N. Thompson: Ok, further discussion on the motion.

Dr. Nobo: I still have a concern with cutting just about everything and not knowing the number of patients
that are being seen that belong to the Plan and I personally would rather look at the possibility of, you know
we have one clinic running already, let’s make sure that clinic stays running. We are cutting everything, we
have been told by Steve about a 5 million dollar down fall approximately and I just think that it is physically
irresponsible to even to give more money for another clinic when we don’t know if we are going to have
money. So I will have to inform that when I vote no on this budget it is only because I think that we have
one clinic going we started it even though I have my issues with it we need to more or less support that one
and to already add 600 thousand dollars when everything else is being cut, without know the exact number
and perhaps saying we may need to delay just the way Steve said, we are going to cut now to a 125% of
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poverty line until we can see what happens during the summer. Well I think that we should do the same I
think we should put the Winter Haven Clinic on hold until we know exactly if we are going to be able to
support it or not. So when you hear my no vote I wanted to explain why it is.

N. Thompson: Thank you, Connie

C. Kinnick: I just have one question to make my vote AYE or NAY comfortable is what is best going to
serve the largest number of people in Polk County. Is it going to be to open a second clinic or is it going to
be to keep that poverty level at 150% without knowing how many people are being seen in the Lakeland
Clinic and not knowing how many are going to be effected by decrease from 150% to 125% I don’t know
what is going to help Polk County people more the clinic or keeping it at 150%.

Dr. Haight: Can the Federally Qualified Health Centers still maintain revenue from the Medicare patients
that they see and Blue Cross Blue Shield patients that they see? I just don’t know.

N. Thompson: Oh absolutely yeah

Dr. Haight: I am not sure; I think that is part of what is involved with the data is; Gaye Williams does a very
good job explaining the financial budget issue with her staff to describe what is there budget that keeps the
doors open. I think that if you change those numbers well what the impact is if they are going to change by a
few dollars what is the impact.

N. Thompson: I think regardless of what we vote here today that is information that we need at our next
meeting and Steve and Ed heard that they wouldn’t be under going a review and they will be here with us.

B. Hinton: One comment and that is that this is a planning document for next year, it is 5 months away so
nothing is going to be done with the new clinic for that amount I would not anticipate even in the next few
months while all of you are going through the budget process.

E. Smith: That clinic is going to have to be constructed anyway, so there is going to be some construction
time. That is your answer.

N. Thompson: Lots of time to revisit and relook at it because this is a 10/1 budget anyway nothing is
happening now; nothing would happen until after 10/1 and as Dr. Nobo has pointed out we change things
before we can change things again.

Dr. Nobo: I know Nancy but do you know how many times it has been thrown at me that we voted already
and that is why we need to do it already. That is why I have a concern to give the impression that everyone
here agreed to do this because I am sure that someone will bring it up again saying well you already voted on
April the 18th.

N. Thompson: Got you, other comments or questions hearing none all of those in favor of the motion as
stated say AYE.

AYE VOTE: Hinton, Domineck-Campbell, Gordon, Fulse, McArthur, McNally, and Thompson

NAY VOTE: Nobo and Kinnick

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Dr. Nobo: Shouldn’t Ms. Fulse abstain.

M. Fulse: I don’t have to abstain to the total budget I only abstain when it is the vote on the exact clinic.

Dr. Nobo: I don’t know, so what is the difference?

N. Thompson: The attorney said that is the correct interruption.

B. Hinton: You are voting on a contract and one is not.

Dr. Nobo: I just want to learn because I never voted for We Care now I can, because I am not on the board I
just wanted to learn.

N. Thompson: But you did vote for the budget right

M. Fulse: I just voted for the budget

N. Thompson: yes and I had to sign a piece of paper saying that I am a member and my vote was taken out,
that is correct. Yes, I have a copy.

M. Fulse: Not on the budget that is what I am talking about.

Dr. Nobo: Anyway it doesn’t matter.

N. Thompson: We will have the attorney clarify that for us we don’t want to be out of compliance with
whatever it is. Yes.

Dr. Nobo: On other matters I have a couple of things the reason that I know this is because the State of
Florida it is very concerned that we are one of the lowest States with most uninsured, one of the highest
States with uninsured so the Secretary of Health did ask Lakeland Regional to give us an idea exactly the
benefits that were occurring. Lakeland Regional is such a great hospital because it is run very well and the
generosity to help everyone else but to also decrease the ER visits. Well unfortunately I hate to tell you that
it is not happening. That is a concern that we have at the State level and also at here. It is very difficult to
assess it when we are not sure when we requested those numbers compared to the year before it wasn’t at the
time that we saw a high influx of migrate workers. We are not sure whether it is repeat but I don’t have the
exact numbers so I don’t want to be quoted, but I can tell you right now it is not working the numbers were
higher. So that is going to have to be something that we are going to have to work on. Also, I have met
multiple times with Wilma and again even though my services were not asked to increase the number of
doctors I will again tell you that I have spoken to Wilma and I have found 2 doctors to be in a PNT
committee. A P&T committee sits and discusses what type of drugs is best for the patients that are most cost
effective. I think that everyone should have a P&T committee and one of the issues is she had no doctors.
Well not only had I found 2 doctors 1 of them is the chairman of the P&T committee at Lakeland Regional
so I am hoping that it will not take 3 and 4 months to form this committee, which I believe that Mr. Smith
has to ok it. So that they can start reviewing it because if I understand correctly in the very, very near future
they will give out the contracts for the next management Wilma. So I found 2 doctors already I will
volunteer myself and we can find other doctors and also we can find a pharmacist. Wilma had a great idea to
have someone come once we have the committee set but if we wait 3 or 4 months to do it than the purpose
would be very limited since you already have a contract so I am hoping that will be done, and this is just to
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show you more of what the physicians are willing to do for the Plan. Also, I strongly believe that you need a
Utilization Review Committee I have talked to Wilma about an issue that I believe there is ways we
physicians can save by educating the patients and the Plan. For example, let me give you a simple example
you can save a lot of money. When a healthy woman goes to the Plan she gets an appointment with usually a
Family Physician she goes to the Family Physician who immediately may find something gynecological than
she comes to the Gynecologist that is 2 visits already, that is 2 expenses and sometime the Family Physician,
like I would not want to treat a heart condition because I may order a test that maybe good but not exactly
necessary at that time. Those patients come to me with some tests that are fine no harm done give me a lot
of information. But possible but as a gynecologist I might have been able to maybe order a different test that
might have been a little more cost effective. So I have been talking to Wilma and I am willing to offer my
services again which have never been requested to help there. Because that could be a huge savings because
as a Gynecologist seeing 3, 4 or 5 woman a day from your Plan a day at least that will show you that their
maybe a cost in savings by directing those healthy women, I am not talking about the chronic obstructed
pulmonary disease, I am not talking about the diabetic, I am talking about some of these ladies who there
issues may not be related to heart condition. So again we doctors are willing to help the Plan you just need
to ask for it. Wilma said she needs 2 or 3 doctors for the P&T I’ve got that I hope Mr. Smith will do it
expeditiously and the utilization review committee we can also do that, we doctors want to help the Plan as
much as we can.

J. McArthur: Dr. Nobo just for information what is a PNT committee?

Dr. Nobo: Pharmacy and Therapeutic.

J. McArthur: P N T

Dr. Nobo P & T

E. Smith: I think that the staff has some comments on that, Wilma would you like to step up.

W. Daniels: What I have been doing is a little bit of research on the P & T Committees and what I have
found is that most P & T Committees are strictly hospital related. Most health plans do not have P & T
committees and as I was researching for instance employee health plans don’t have P & T committees
because as we contract out with a Pharmacy Benefits Manager that is one of the services that they do proved
to us, that is what we have been utilizing in the past. So at this juncture we’re not sure that would be the
most effective use of our time because we do have that available to us through the Pharmacy Benefits
Manager that we have contracted with and that is a service that they fully provided for us.

Dr. Nobo: But, valuable time, I think if you have physicians that are willing to sit with you and discuss what
they feel is best for the citizens of Polk County at a free charge I can’t imagine that can’t be valuable.

W. Daniels: Well except that most therapeutic committees are related to hospital settings verse Plan settings.

Dr. Nobo: The reason is because is because when the patient gets admitted the hospital wants to have the
most cost effective, but we want to do is try to have the best way for our patient, for example our patients
have a lot of medications and sometimes, because the Plan that is maybe occurring in another state cause you
are dealing with a National Committee.

W. Daniels: Yes
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Dr. Nobo: May not be what is best for Polk County. When you have volunteer physicians I do not
understand why spending one hour or maybe a month or maybe every 2 months it is not valuable to you.

W. Daniels: I am not saying it is not valuable at all it is just that it is already a service that we have available
to us through our pharmacy benefits manager and that is why we contract with a pharmacy company to
provide part of that service to us.

Dr. Nobo: But again this is a Federal and these, it just floors me every time that you have a group of
physicians who are willing to work with you and sit with you to see if something is going to work it may not
work. You may have one meeting and those physicians that are knowledgeable about this will say, you
know Wilma this is not necessary and I am just flabbergasted that you guys would not think that it is a value
that is all.

W. Daniels; Oh I did not say that it is not a value

Dr. Nobo: You are not having a committee

W. Daniels: I do get input from several physicians I have physicians that will call me and send me letters and
talk to me about this type of services quite often.

N. Thompson: We have other comments I have members that needs to leave for other meetings and Dr.
Nobo has patients waiting for him.

E. Smith: just a footnote to Dr. Nobo’s comments and maybe this will make you a little happier Dr. Nobo we
are going to set up a Medical Review committee and that will be happening within 3 or 4 months.

M. Fulse: As prior member of a P & T committee and pharmacy directorship and all I might add we might be
able look at having a form where the physicians can fill out the form for additions or deletions and they
submit the form to the Plan that way the provider that you are using could actually get an idea of some of the
things that is bothering the physicians in the area. I know that at the hospital level and at the clinic level we
do use a form and it will say I doctor so and so feel like this drug needs to be added for this patient, this
patient population because it does this, this and this. Or I doctor so and so feel like this medication should be
deleted because I found many, many side effects related to this or this and that could be submitted to the
company that is handling it and that P & T committee were ever they are will get a better idea of what our
community needs. At the hospital level at Lakeland Regional level we use a form and we have a doctor or 2
on the committee but the committee is comprised of a pharmacist, a quality assurance nurses and different
profession other than just physicians. The physicians do have a voice but that voice is done in a manner of a
form a document that is turned in and it can be reviewed.

Dr. Nobo: That is why you need a committee, pharmacist, physicians

N. Thompson: Right

M. Fusle: I am just offering it as an avenue for input.

Gwen Hall: I don’t want to lead on to this I just want to dove tail on what Wilma said so that others can
leave. This whole service as far as the pharmacy and therapeutics review committee when Wilma is talking
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about our pharmacy benefits manager that whole process is already being done. It is a part of the service that
we purchased for our pharmacy program which does consist of physicians, pharmacist, utilization review
nurses and everyone. We have to remember we are running a business here and we purchase drugs within
certain drug classes that A) give us the best benefit to the Plan for our customers within all drug classes. But
also they go out and shop what is going to give us the best rebate for the Plan. So this is not just we are
going to pick the cheapest drugs they have to cover all drug classes that are within our prescribed drug
formulary but again Wilma does receive as our liaison with in the division she does receive those requests
she sends them to her liaison who is a pharmacist at Pharma Care that does go in they do look at it and we do
make modifications to our Plan on a regular basis. So there has been a very much open line of
communication for flexibility on our Plan we will reprint those things. From an external stand point to
reestablish another committee for staff to have another obligation to have another external committee to do
what a service is already being provided for us is just a redundancy of work. That is just kind of our point
but what Mr. Smith is saying from a holistic stand point on a review committee that is something that is in
the works right now to get participation from our medical providers in the community to be involved with
the health Plan operations for us. Some of those pharmacy things may come into it with some quality of care
issues will come into it as well.

Dr. Nobo: I disagree completely, first did you say that you pay for that service?

G. Hall: It is a part of our contract for services.

Dr. Nobo: So not something you can carve out and save money on it by having our own?

G. Hall: No sir it is part of the service delivery when you purchase drugs through a Pharmacy benefits
manager

Dr. Nobo: So it is globally, the reason why P&T committees are important at hospitals and probably else
where it is because each community is different, but anyway.

G. Hall: But as a Health Plan it doesn’t fit this model.

N. Thompson: We completely skip over the HealthCare Alliance Update, Connie. We jump from budget to
other matters and once again even though you are right here on the agenda did you have an update for us.

C. Kinnick: The Polk HealthCare Alliance met this month last Thursday, and it was a 4 hour session.
Basically from well 3 ½ hours, from 8:30 AM to 12:00 first thing we did was accept the new revised by laws
that was voted on and passed by the membership. Than secondly we met in our 2 primary small groups
looking at Federal Policy making, Federal and State Policy making, what is going on in Tallahassee and in
D.C. and the other group looked at the physical health portion of HealthCare in Polk County. We finally
except for a couple of little tweaking things we came up with our completed Action Plans with our strategies
and our goals to meet the needs of the people of Polk County. So on our next meeting next month we will
continue to look at these plans but hopefully, we are going to start taking some action and going out and
completing the education and the recruitment and the first items that are on the plan.

N. Thompson: Thank you

Dr. Haight: Nancy and I think when every thing settles down from the budget issues and I think we have to
for this group set a side a block of time to go into detail over this community health improvement plan.
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Because the Polk HealthCare Alliance really is one arm for this group to provide a lot of guidance and input
because it is were the hospitals, the healthcare providers those who are interested in both the academics or
out in private sector are sitting down at this HealthCare Alliance and you can go to the web site Polk
HealthCare Alliance.Com and see all of the documents there but I think we really should set a side a time to
present now that we are at this point of the action plans and taking action.

N. Thompson: It sounds like it to me too. So Mr. Smith can take note of that, I don’t know when the right
time for that would be the next meeting or meeting after that but we need to have a presentation.

C. Kinnick: I would say at least a couple of months to let us get this thing

N. Thompson: The earliest!

C. Kinnick: One of the things we are coming up with is brochures we are trying to recruit new membership
and we want to get this brochure packet information available and I would like to wait for the presentation
here to have that packet available and than have our chair person or probably Dr. Saddler even come in and
present.

E. Smith: Do you want to let us know when you want to be on the agenda?

Dr. Haight: Yes, because I think that there needs to be some time because there are summits coming up
JoAnn Fioravanti and other efforts that I think that are really something to be proud of what this HealthCare
Alliance has been able to do. We could line up a very healthy update for you and provide you that input.
Then we need all of your input because this is the entity outside of what you are working with that could
provide information do research and gather that data that you need. That is part of their action plan is to
gather that data and educate not only themselves but you too as far as what is most important in HealthCare
in Polk County.

N. Thompson: Good excellent, other comments or questions. Hearing none I will entertain a motion to
adjourn.

B. Hinton: So move.

Dr. Nobo: Second

N. Thompson: Second, all in favor AYE, (the entire committee responded AYE) we are adjourned. Thank
you.

Meeting Adjourned at 11:02:21 AM
Transcribed by: Debi Curry; Office Manager, IV
                Community Health & Social Services Division




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