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       Florida Senate - 2010                                    SB 1256
       By Senator Peaden
       2-00484-10                                            20101256__
    1                        A bill to be entitled                      
    2         An act relating to the physician workforce; repealing
    3         s. 381.0403, F.S., relating to the Community Hospital
    4         Education Act and the Community Hospital Education
    5         Council; amending s. 381.4018, F.S.; providing
    6         definitions; revising the list of governmental
    7         stakeholders that the Department of Health is required
    8         to work with regarding the state strategic plan and in
    9         assessing the state’s physician workforce; creating
   10         the Physician Workforce Advisory Council; providing
   11         membership of the council; providing for appointments
   12         to the council; providing terms of membership;
   13         providing for removal of a council member; providing
   14         for the chair and vice chair of the council; providing
   15         that council members are not entitled to receive
   16         compensation or reimbursement for per diem or travel
   17         expenses; providing the duties of the council;
   18         establishing the physician workforce graduate medical
   19         education innovation pilot projects under the
   20         department; providing the purposes of the pilot
   21         projects; providing for the appropriation of state
   22         funds for the pilot projects; requiring the pilot
   23         projects to meet certain policy needs of the physician
   24         workforce in this state; providing criteria for
   25         prioritizing proposals for pilot projects; requiring
   26         the department to adopt by rule appropriate
   27         performance measures; requiring participating pilot
   28         projects to submit an annual report to the department;
   29         requiring state funds to be used to supplement funds
   30         from other sources; requiring the department to adopt
   31         rules; amending ss. 458.3192 and 459.0082, F.S.;
   32         requiring the department to determine by geographic
   33         area and specialty the number of physicians and
   34         osteopathic physicians who plan to relocate outside
   35         the state, practice medicine in this state, and reduce
   36         or modify the scope of their practice; authorizing the
   37         department to report additional information in its
   38         findings to the Governor and the Legislature; amending
   39         s. 409.908, F.S.; conforming a cross-reference;
   40         providing an effective date.
   42  Be It Enacted by the Legislature of the State of Florida:
   44         Section 1. Section 381.0403, Florida Statutes, is repealed.
   45         Section 2. Section 381.4018, Florida Statutes, is amended
   46  to read:
   47         381.4018 Physician workforce assessment and development.—
   48         (1) DEFINITIONS.—As used in this section, the term:
   49         (a) “Consortium” or “consortia” means a combination of
   50  statutory teaching hospitals, statutory rural hospitals, other
   51  hospitals, accredited medical schools, clinics operated by the
   52  Department of Health, clinics operated by the Department of
   53  Veterans’ Affairs, area health education centers, community
   54  health centers, federally qualified health centers, prison
   55  clinics, local community clinics, or other programs. At least
   56  one member of the consortium shall be a sponsoring institution
   57  accredited or currently seeking accreditation by the
   58  Accreditation Council for Graduate Medical Education or the
   59  American Osteopathic Association.
   60         (b) “Council” means the Physician Workforce Advisory
   61  Council.
   62         (c) “Department” means the Department of Health.
   63         (d) “Graduate medical education program” means a program
   64  accredited by the Accreditation Council for Graduate Medical
   65  Education or the American Osteopathic Association.
   66         (e) “Primary care specialty” means emergency medicine,
   67  family practice, internal medicine, pediatrics, psychiatry,
   68  obstetrics and gynecology, and combined internal medicine and
   69  other specialties as determined by the Physician Workforce
   70  Advisory Council or the Department of Health.
   71         (2)(1) LEGISLATIVE INTENT.—The Legislature recognizes that
   72  physician workforce planning is an essential component of
   73  ensuring that there is an adequate and appropriate supply of
   74  well-trained physicians to meet this state’s future health care
   75  service needs as the general population and elderly population
   76  of the state increase. The Legislature finds that items to
   77  consider relative to assessing the physician workforce may
   78  include physician practice status; specialty mix; geographic
   79  distribution; demographic information, including, but not
   80  limited to, age, gender, race, and cultural considerations; and
   81  needs of current or projected medically underserved areas in the
   82  state. Long-term strategic planning is essential as the period
   83  from the time a medical student enters medical school to
   84  completion of graduate medical education may range from 7 to 10
   85  years or longer. The Legislature recognizes that strategies to
   86  provide for a well-trained supply of physicians must include
   87  ensuring the availability and capacity of quality graduate
   88  medical schools and graduate medical education programs in this
   89  state, as well as using new or existing state and federal
   90  programs providing incentives for physicians to practice in
   91  needed specialties and in underserved areas in a manner that
   92  addresses projected needs for physician manpower.
   93         (3)(2) PURPOSE.—The Department of Health shall serve as a
   94  coordinating and strategic planning body to actively assess the
   95  state’s current and future physician workforce needs and work
   96  with multiple stakeholders to develop strategies and
   97  alternatives to address current and projected physician
   98  workforce needs.
   99         (4)(3) GENERAL FUNCTIONS.—The department shall maximize the
  100  use of existing programs under the jurisdiction of the
  101  department and other state agencies and coordinate governmental
  102  and nongovernmental stakeholders and resources in order to
  103  develop a state strategic plan and assess the implementation of
  104  such strategic plan. In developing the state strategic plan, the
  105  department shall:
  106         (a) Monitor, evaluate, and report on the supply and
  107  distribution of physicians licensed under chapter 458 or chapter
  108  459. The department shall maintain a database to serve as a
  109  statewide source of data concerning the physician workforce.
  110         (b) Develop a model and quantify, on an ongoing basis, the
  111  adequacy of the state’s current and future physician workforce
  112  as reliable data becomes available. Such model must take into
  113  account demographics, physician practice status, place of
  114  education and training, generational changes, population growth,
  115  economic indicators, and issues concerning the “pipeline” into
  116  medical education.
  117         (c) Develop and recommend strategies to determine whether
  118  the number of qualified medical school applicants who might
  119  become competent, practicing physicians in this state will be
  120  sufficient to meet the capacity of the state’s medical schools.
  121  If appropriate, the department shall, working with
  122  representatives of appropriate governmental and nongovernmental
  123  entities, develop strategies and recommendations and identify
  124  best practice programs that introduce health care as a
  125  profession and strengthen skills needed for medical school
  126  admission for elementary, middle, and high school students, and
  127  improve premedical education at the precollege and college level
  128  in order to increase this state’s potential pool of medical
  129  students.
  130         (d) Develop strategies to ensure that the number of
  131  graduates from the state’s public and private allopathic and
  132  osteopathic medical schools are adequate to meet physician
  133  workforce needs, based on the analysis of the physician
  134  workforce data, so as to provide a high-quality medical
  135  education to students in a manner that recognizes the uniqueness
  136  of each new and existing medical school in this state.
  137         (e) Pursue strategies and policies to create, expand, and
  138  maintain graduate medical education positions in the state based
  139  on the analysis of the physician workforce data. Such strategies
  140  and policies must take into account the effect of federal
  141  funding limitations on the expansion and creation of positions
  142  in graduate medical education. The department shall develop
  143  options to address such federal funding limitations. The
  144  department shall consider options to provide direct state
  145  funding for graduate medical education positions in a manner
  146  that addresses requirements and needs relative to accreditation
  147  of graduate medical education programs. The department shall
  148  consider funding residency positions as a means of addressing
  149  needed physician specialty areas, rural areas having a shortage
  150  of physicians, and areas of ongoing critical need, and as a
  151  means of addressing the state’s physician workforce needs based
  152  on an ongoing analysis of physician workforce data.
  153         (f) Develop strategies to maximize federal and state
  154  programs that provide for the use of incentives to attract
  155  physicians to this state or retain physicians within the state.
  156  Such strategies should explore and maximize federal-state
  157  partnerships that provide incentives for physicians to practice
  158  in federally designated shortage areas. Strategies shall also
  159  consider the use of state programs, such as the Florida Health
  160  Service Corps established pursuant to s. 381.0302 and the
  161  Medical Education Reimbursement and Loan Repayment Program
  162  pursuant to s. 1009.65, which provide for education loan
  163  repayment or loan forgiveness and provide monetary incentives
  164  for physicians to relocate to underserved areas of the state.
  165         (g) Coordinate and enhance activities relative to physician
  166  workforce needs, undergraduate medical education, and graduate
  167  medical education provided by the Division of Medical Quality
  168  Assurance, the Community Hospital Education Program and the
  169  Graduate Medical Education Committee established pursuant to s.
  170  381.0403, area health education center networks established
  171  pursuant to s. 381.0402, and other offices and programs within
  172  the Department of Health as designated by the State Surgeon
  173  General.
  174         (h) Work in conjunction with and act as a coordinating body
  175  for governmental and nongovernmental stakeholders to address
  176  matters relating to the state’s physician workforce assessment
  177  and development for the purpose of ensuring an adequate supply
  178  of well-trained physicians to meet the state’s future needs.
  179  Such governmental stakeholders shall include, but need not be
  180  limited to, the State Surgeon General or his or her designee,
  181  the Commissioner of Education or his or her designee, the
  182  Secretary of Health Care Administration or his or her designee,
  183  and the Chancellor of the State University System or his or her
  184  designee from the Board of Governors of the State University
  185  System, and, at the discretion of the department, other
  186  representatives of state and local agencies that are involved in
  187  assessing, educating, or training the state’s current or future
  188  physicians. Other stakeholders shall include, but need not be
  189  limited to, organizations representing the state’s public and
  190  private allopathic and osteopathic medical schools;
  191  organizations representing hospitals and other institutions
  192  providing health care, particularly those that have an interest
  193  in providing accredited medical education and graduate medical
  194  education to medical students and medical residents;
  195  organizations representing allopathic and osteopathic practicing
  196  physicians; and, at the discretion of the department,
  197  representatives of other organizations or entities involved in
  198  assessing, educating, or training the state’s current or future
  199  physicians.
  200         (i) Serve as a liaison with other states and federal
  201  agencies and programs in order to enhance resources available to
  202  the state’s physician workforce and medical education continuum.
  203         (j) Act as a clearinghouse for collecting and disseminating
  204  information concerning the physician workforce and medical
  205  education continuum in this state.
  206         (5) PHYSICIAN WORKFORCE ADVISORY COUNCIL.—There is created
  207  in the Department of Health the Physician Workforce Advisory
  208  Council, an advisory council as defined in s. 20.03. The council
  209  shall comply with the requirements of s. 20.052, except as
  210  otherwise provided in this section.
  211         (a) The council shall consist of 23 members, appointed by
  212  the State Surgeon General, which shall include:
  213         1. A designee from the department.
  214         2. An individual recommended by the Area Health Education
  215  Center Network.
  216         3. Two individuals recommended by the Council of Florida
  217  Medical School Deans, one representing a college of allopathic
  218  medicine and one representing a college of osteopathic medicine.
  219         4. Two individuals recommended by the Florida Hospital
  220  Association, one representing a statutory teaching hospital and
  221  one representing a hospital that is licensed under chapter 395,
  222  has an accredited graduate medical education program, and is not
  223  a statutory teaching hospital.
  224         5. Two individuals recommended by the Florida Medical
  225  Association, one representing a primary care specialty and one
  226  representing a nonprimary care specialty.
  227         6. Two individuals recommended by the Florida Osteopathic
  228  Medical Association, one representing a primary care specialty
  229  and one representing a nonprimary care specialty.
  230         7. Two individuals who are program directors of accredited
  231  graduate medical education programs, one representing a program
  232  that is accredited by the Accreditation Council for Graduate
  233  Medical Education and one representing a program that is
  234  accredited by the American Osteopathic Association.
  235         8. An individual recommended by the Florida Justice
  236  Association.
  237         9. An individual representing a profession in the field of
  238  health services administration.
  239         10. The Commissioner of Education or his or her designee.
  240         11. The Chancellor of the State University System or his or
  241  her designee.
  242         12. The Secretary of Health Care Administration or his or
  243  her designee.
  244         13. The executive director of the Department of Veterans’
  245  Affairs or his or her designee.
  246         14. The Secretary of Elderly Affairs or his or her
  247  designee.
  248         15. The President of the Senate or his or her designee.
  249         16. The Speaker of the House of Representatives or his or
  250  her designee.
  251         17. A layperson member as determined by the State Surgeon
  252  General.
  253         18. A designee of Florida’s Congressional Delegation.
  255  Appointments to the council shall be made by the State Surgeon
  256  General, except that representatives from a state agency and
  257  legislative representatives shall be appointed by the respective
  258  agency head, legislative presiding officer, or congressional
  259  delegation. Each entity authorized to make recommendations under
  260  this subsection shall make at least two recommendations to the
  261  State Surgeon General for each appointment to the council. The
  262  State Surgeon General shall name one appointee for each position
  263  from the recommendations made by each authorized entity.
  264         (b) Each council member shall be appointed to a 4-year
  265  term. An individual may not serve more than two terms. Any
  266  council member may be removed from office for malfeasance;
  267  misfeasance; neglect of duty; incompetence; permanent inability
  268  to perform official duties; or pleading guilty or nolo
  269  contendere to, or being found guilty of, a felony. Any council
  270  member who meets the criteria for removal, or who is otherwise
  271  unwilling or unable to properly fulfill the duties of the
  272  office, shall be succeeded by an individual chosen by the State
  273  Surgeon General to serve out the remainder of the council
  274  member’s term. If the remainder of the replaced council member’s
  275  term is less than 18 months, notwithstanding the provisions of
  276  this paragraph, the succeeding council member may be reappointed
  277  twice by the State Surgeon General.
  278         (c) The chair of the council is the State Surgeon General,
  279  who shall designate a vice chair to serve in the absence of the
  280  State Surgeon General. A vacancy shall be filled for the
  281  remainder of the unexpired term in the same manner as the
  282  original appointment.
  283         (d) Council members are not entitled to receive
  284  compensation or reimbursement for per diem or travel expenses.
  285         (e) The council shall meet twice a year in person or by
  286  teleconference.
  287         (f) The council shall:
  288         1. Advise the State Surgeon General and the department on
  289  matters concerning current and future physician workforce needs
  290  in this state;
  291         2. Review survey materials and the compilation of survey
  292  information;
  293         3. Provide recommendations to the department for the
  294  development of additional items to be incorporated in the survey
  295  completed by physicians licensed under chapter 458 or chapter
  296  459;
  297         4. Assist the department in preparing the annual report to
  298  the Legislature pursuant to ss. 458.3192 and 459.0082;
  299         5. Assist the department in preparing an initial strategic
  300  plan, conduct ongoing strategic planning in accordance with this
  301  section, and provide ongoing advice on implementing the
  302  recommendations;
  303         6. Monitor the need for an increased number of primary care
  304  physicians to provide the necessary current and projected health
  305  and medical services for the state; and
  306         7. Monitor the status of graduate medical education in this
  307  state, including, but not limited to, as considered appropriate:
  308         a. The effectiveness of graduate medical education pilot
  309  projects funded pursuant to subsection (6).
  310         b. The role of residents and medical faculty in the
  311  provision of health care.
  312         c. The relationship of graduate medical education to the
  313  state’s physician workforce.
  314         d. The availability and use of state and federal
  315  appropriated funds for graduate medical education.
  318         (a) The Legislature finds that:
  319         1. In order to ensure a physician workforce that is
  320  adequate to meet the needs of this state’s residents and its
  321  health care system, policymakers must consider the training of
  322  future generations of well-trained health care providers.
  323         2. Physicians are likely to practice in the state where
  324  they complete their graduate medical education. The instate
  325  retention rate following graduate medical education for
  326  physicians in this state is more than 61 percent.
  327         3. It can directly affect the makeup of the physician
  328  workforce by selectively funding graduate medical education
  329  programs to provide needed specialists in geographic areas of
  330  the state which have a deficient number of such specialists.
  331         4. Developing additional positions in graduate medical
  332  education programs is essential to the future of this state’s
  333  health care system.
  334         5. It was necessary in 2007 to pass legislation that
  335  provided for an assessment of the status of this state’s current
  336  and future physician workforce. The department is collecting and
  337  analyzing information on an ongoing basis to assess this state’s
  338  physician workforce needs, and such assessment can serve as a
  339  basis for determining graduate medical education needs and
  340  strategies for the state.
  341         (b) There is established under the department a program to
  342  foster innovative graduate medical education pilot projects that
  343  are designed to promote the expansion of graduate medical
  344  education programs or positions to prepare physicians to
  345  practice in needed specialties and underserved areas or settings
  346  and to provide demographic and cultural representation in a
  347  manner that addresses projected needs for this state’s physician
  348  workforce. Funds appropriated annually by the Legislature for
  349  this purpose shall be distributed to participating hospitals,
  350  medical schools, other sponsors of graduate medical education
  351  programs, consortia engaged in developing new graduate medical
  352  education programs or positions in those programs, or pilot
  353  projects providing innovative graduate medical education in
  354  community-based clinical settings. Pilot projects shall be
  355  selected on a competitive grant basis, subject to available
  356  funds.
  357         (c) Pilot projects shall be designed to meet one or more of
  358  this state’s physician workforce needs, as determined pursuant
  359  to this section, including, but not limited to:
  360         1. Increasing the number of residencies or fellowships in
  361  primary care or other needed specialties.
  362         2. Enhancing the retention of primary care physicians or
  363  other needed specialties in this state.
  364         3. Promoting practice in rural or medically underserved
  365  areas of the state.
  366         4. Encouraging racial and ethnic diversity within the
  367  state’s physician workforce.
  368         5. Encouraging practice in community health care or other
  369  ambulatory care settings.
  370         6. Encouraging practice in clinics operated by the
  371  Department of Health, clinics operated by the Department of
  372  Veterans’ Affairs, prison clinics, or similar settings of need.
  373         7. Encouraging the increased production of geriatricians.
  374         (d) Priority shall be given to a proposal for a pilot
  375  project that:
  376         1. Demonstrates a collaboration of federal, state, and
  377  local entities that are public or private.
  378         2. Obtains funding from multiple sources.
  379         3. Focuses on enhancing graduate medical education in rural
  380  or underserved areas.
  381         4. Focuses on enhancing graduate medical education in
  382  ambulatory or community-based settings other than a hospital
  383  environment.
  384         5. Includes the use of technology, such as electronic
  385  medical records, distance consultation, and telemedicine, to
  386  ensure that residents are better prepared to care for patients
  387  in this state, regardless of the community in which the
  388  residents practice.
  389         6. Is designed to meet multiple policy needs as enumerated
  390  in subsection (3).
  391         7. Uses a consortium to provide for graduate medical
  392  education experiences.
  393         (e) The department shall adopt by rule appropriate
  394  performance measures to use in order to consistently evaluate
  395  the effectiveness, safety, and quality of the programs, as well
  396  as the impact of each program on meeting this state’s physician
  397  workforce needs.
  398         (f) Participating pilot projects shall submit to the
  399  department an annual report on the project in a manner required
  400  by the department.
  401         (g) Funding provided to a pilot project may be used only
  402  for the direct costs of providing graduate medical education.
  403  Accounting of such costs and expenditures shall be documented in
  404  the annual report.
  405         (h) State funds shall be used to supplement funds from any
  406  local government, community, or private source. The state may
  407  provide up to 50 percent of the funds, and local governmental
  408  grants or community or private sources shall provide the
  409  remainder of the funds.
  410         (7) RULEMAKING.—The department shall adopt rules as
  411  necessary to administer this section.
  412         Section 3. Section 458.3192, Florida Statutes, is amended
  413  to read:
  414         458.3192 Analysis of survey results; report.—
  415         (1) Each year, the Department of Health shall analyze the
  416  results of the physician survey required by s. 458.3191 and
  417  determine by geographic area and specialty the number of
  418  physicians who:
  419         (a) Perform deliveries of children in this state Florida.
  420         (b) Read mammograms and perform breast-imaging-guided
  421  procedures in Florida.
  422         (c) Perform emergency care on an on-call basis for a
  423  hospital emergency department.
  424         (d) Plan to reduce or increase emergency on-call hours in a
  425  hospital emergency department.
  426         (e) Plan to relocate their allopathic or osteopathic
  427  practice outside the state.
  428         (f) Practice medicine in this state.
  429         (g) Reduce or modify the scope of their practice.
  430         (2) The Department of Health must report its findings to
  431  the Governor, the President of the Senate, and the Speaker of
  432  the House of Representatives by November 1 each year. The
  433  department may also include in its report findings,
  434  recommendations, or other information requested by the council.
  435         Section 4. Section 459.0082, Florida Statutes, is amended
  436  to read:
  437         459.0082 Analysis of survey results; report.—
  438         (1) Each year, the Department of Health shall analyze the
  439  results of the physician survey required by s. 459.0081 and
  440  determine by geographic area and specialty the number of
  441  physicians who:
  442         (a) Perform deliveries of children in this state Florida.
  443         (b) Read mammograms and perform breast-imaging-guided
  444  procedures in this state Florida.
  445         (c) Perform emergency care on an on-call basis for a
  446  hospital emergency department.
  447         (d) Plan to reduce or increase emergency on-call hours in a
  448  hospital emergency department.
  449         (e) Plan to relocate their allopathic or osteopathic
  450  practice outside the state.
  451         (f) Practice medicine in this state.
  452         (2) The Department of Health must report its findings to
  453  the Governor, the President of the Senate, and the Speaker of
  454  the House of Representatives by November 1 each year. The
  455  department may also include in its report findings,
  456  recommendations, or other information requested by the council.
  457         Section 5. Paragraph (a) of subsection (1) of section
  458  409.908, Florida Statutes, is amended to read:
  459         409.908 Reimbursement of Medicaid providers.—Subject to
  460  specific appropriations, the agency shall reimburse Medicaid
  461  providers, in accordance with state and federal law, according
  462  to methodologies set forth in the rules of the agency and in
  463  policy manuals and handbooks incorporated by reference therein.
  464  These methodologies may include fee schedules, reimbursement
  465  methods based on cost reporting, negotiated fees, competitive
  466  bidding pursuant to s. 287.057, and other mechanisms the agency
  467  considers efficient and effective for purchasing services or
  468  goods on behalf of recipients. If a provider is reimbursed based
  469  on cost reporting and submits a cost report late and that cost
  470  report would have been used to set a lower reimbursement rate
  471  for a rate semester, then the provider’s rate for that semester
  472  shall be retroactively calculated using the new cost report, and
  473  full payment at the recalculated rate shall be effected
  474  retroactively. Medicare-granted extensions for filing cost
  475  reports, if applicable, shall also apply to Medicaid cost
  476  reports. Payment for Medicaid compensable services made on
  477  behalf of Medicaid eligible persons is subject to the
  478  availability of moneys and any limitations or directions
  479  provided for in the General Appropriations Act or chapter 216.
  480  Further, nothing in this section shall be construed to prevent
  481  or limit the agency from adjusting fees, reimbursement rates,
  482  lengths of stay, number of visits, or number of services, or
  483  making any other adjustments necessary to comply with the
  484  availability of moneys and any limitations or directions
  485  provided for in the General Appropriations Act, provided the
  486  adjustment is consistent with legislative intent.
  487         (1) Reimbursement to hospitals licensed under part I of
  488  chapter 395 must be made prospectively or on the basis of
  489  negotiation.
  490         (a) Reimbursement for inpatient care is limited as provided
  491  for in s. 409.905(5), except for:
  492         1. The raising of rate reimbursement caps, excluding rural
  493  hospitals.
  494         2. Recognition of the costs of graduate medical education.
  495         3. Other methodologies recognized in the General
  496  Appropriations Act.
  498  During the years funds are transferred from the Department of
  499  Health, any reimbursement supported by such funds shall be
  500  subject to certification by the Department of Health that the
  501  hospital has complied with s. 381.4018 s. 381.0403. The agency
  502  may is authorized to receive funds from state entities,
  503  including, but not limited to, the Department of Health, local
  504  governments, and other local political subdivisions, for the
  505  purpose of making special exception payments, including federal
  506  matching funds, through the Medicaid inpatient reimbursement
  507  methodologies. Funds received from state entities or local
  508  governments for this purpose shall be separately accounted for
  509  and shall not be commingled with other state or local funds in
  510  any manner. The agency may certify all local governmental funds
  511  used as state match under Title XIX of the Social Security Act,
  512  to the extent that the identified local health care provider
  513  that is otherwise entitled to and is contracted to receive such
  514  local funds is the benefactor under the state’s Medicaid program
  515  as determined under the General Appropriations Act and pursuant
  516  to an agreement between the Agency for Health Care
  517  Administration and the local governmental entity. The local
  518  governmental entity shall use a certification form prescribed by
  519  the agency. At a minimum, the certification form shall identify
  520  the amount being certified and describe the relationship between
  521  the certifying local governmental entity and the local health
  522  care provider. The agency shall prepare an annual statement of
  523  impact which documents the specific activities undertaken during
  524  the previous fiscal year pursuant to this paragraph, to be
  525  submitted to the Legislature no later than January 1, annually.
  526         Section 6. This act shall take effect July 1, 2010.

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