1

Manuscript Title:

Practitioner or Pretender? Unlicensed Activity Regulation in Florida

Word Count:

3,698

2

Author(s):

Scott Flowers is Program Administrator for the Florida Department of Health, Unlicensed Activity (ULA)

program; Contribution: acquisition of data and critical revision of the manuscript for important

intellectual content

Jamie G. McNease, MSW, is a Strategy Manager for the Florida Department of Health, Division of

Medical Quality Assurance; Contribution: drafting of the manuscript, analysis and interpretation of data

and critical revision of the manuscript for important intellectual content

Nick Van Der Linden is a Strategy Manager for the Florida Department of Health, Division of Medical

Quality Assurance; Contribution: critical revision of the manuscript for important intellectual content

3

ABSTRACT: The unlicensed practice of health care professions is becoming an increasingly popular topic

for media outlets nationwide. Unlicensed activity, or practicing medicine or other professions without a

license, is prohibited according to medical practice acts in most states. This places the task of protecting

consumers from the potentially harmful and unsafe practices of unauthorized practitioners on medical

and health care regulators. The Florida Legislature deemed the issue of unlicensed activity a state

priority and subsequently empowered the Florida Department of Health and health care regulators to

enforce vigorously the licensure regulations. As a result, Florida has developed a strategic program with

several initiatives to combat unlicensed activity. Through these initiatives, Florida is making positive

strides in protecting, promoting and improving the health of residents and visitors. This article outlines

program components, discusses lessons learned, and provides recommendations to states looking to

launch similar initiatives.

4

Introduction

Unlicensed activity is generally defined as the provision of medical or health care services by an

individual whose professional education, training and other relevant qualifications have not been

approved through the issuance of a license by the appropriate regulatory authority.1 The overarching

purpose of professional licensure, and the statutes that regulate those licenses, is to protect and

promote the health, safety and general well-being of the public by ensuring that only individuals

qualified by education and experience are able to practice certain professions. Current regulations not

only set the professional standards for those who are licensed health care practitioners, but also give

consumers more confidence in knowing what licensed practitioners can and cannot do. State licensing

laws also protect the public by establishing penalties for practicing a health care profession without first

obtaining appropriate licensure.

The recognition of unlicensed activity as a problem in the United States dates back to 1760

when the city of New York enacted the first medical licensing laws. These laws were minimal and lacked

the capacity to fully protect the public from dangerous practitioners. As Kenneth De Ville explains, the

statutes “did not forbid unlicensed practice but merely provided certificates of legitimacy to ‘qualified’

doctors.”2 Over time, licensing laws were changed and developed into medical practice acts, which were

designed to “eliminate charlatans, incompetents or frauds”3 and better protect consumers from the

potentially injurious health care services delivered by unqualified providers.

Since most states do not maintain records of unlicensed health care providers, quantifying the

problem of unlicensed activity in the United States is a difficult task. Although there is limited data

available, the full size and scope of unlicensed activity remains unclear at this time. What is clear and

established as fact is that when an unlicensed and unregulated individual practices a health care

profession, the consequences of receiving health care services from these individuals can be grave. This

5

article provides an overview of what is known about the problem of unlicensed activity in Florida and

throughout the United States, both past and present. It also describes Florida’s Unlicensed Activity (ULA)

program and outreach initiatives implemented in Florida to combat the unlicensed practice of health

care professions. Finally, the article summarizes the education initiatives implemented to address this

issue, emphasizing the important role health care practitioners and consumers play in eliminating

unlicensed activity.

Hurricane Andrew: The Straw that Broke the Camel’s Back

Although unlicensed activity has been around for many years, it has not necessarily been at the

forefront of professional regulation. In Florida, the problem of unlicensed activity was not fully

recognized or acknowledged until 1992—in the aftermath of Hurricane Andrew. On August 24, 1992,

Andrew, a Category 5 hurricane, barreled through South Florida, leaving hundreds of thousands of

individuals with devastating damage to person and property. During the days and weeks following the

hurricane, when vulnerable and desperate homeowners were beginning to pick up the pieces of their

broken lives and rebuild their homes, unlicensed contractors offered the allure of immediate assistance.

These individuals were not bound by the standards and regulations of licensure in Florida, and many

provided sub-standard work and/or received sizeable deposits from homeowners for repairs that were

never completed.

According to the Spring Term A.D. 1992 Final Report of the Dade County Grand Jury, there were

1,600 citizens’ complaints reviewed by Dade county investigators in November 1992 and 1,300 of those

complaints were related to unlicensed contractors.4 The number of complaints for one month alone

almost doubled the number of complaints involving unlicensed construction contractors in fiscal year

1990-1991.5 Annual report data shows that complaints against unlicensed construction contractors and

workers increased drastically from 890 in fiscal year 1991-1992, prior to Hurricane Andrew, to 1,307 in

6

fiscal year 1992-1993.6 Although construction-related unlicensed activity complaints had the most

dramatic increase, other professions—electrical contractors, land surveyors, real estate agents and

architecture—also had a noticeable rise in unlicensed activity complaints.

The criminal actions of unlicensed contractors in 1992 brought attention to a broader problem—

the unlicensed practice of other occupations, including health care professions. Though complaints

against unlicensed health care practitioners were not nearly as prevalent as the construction industry, it

was recognized that the consequences of receiving health care services from unlicensed providers were

potentially more serious, even deadly. In 1992, the Florida Legislature began a series of targeted

activities aimed at reducing and preventing the unlicensed practice of a profession. In December 1998,

the Division of Medical Quality Assurance (MQA) opened its first ULA program office in Fort Lauderdale

with a staff of four.

Florida’s Unlicensed Activity Program

The Florida Legislature has made the vigorous enforcement of licensure requirements and

prevention of unlicensed activity a state priority. Section 456.065, Florida Statutes, states that the

unlicensed practice of a health care profession is strictly prohibited. This statute also gives the Florida

Department of Health the authority to investigate unlicensed activity allegations, issue and deliver

notices to cease and desist to violators, and impose citations and administrative penalties of up to

$5,000 per incident. The statute also details the civil and criminal penalties for unlicensed activity.

To implement the law and meet legislative intent, the Department of Health developed a

statewide program within MQA to combat unlicensed activity in Florida. The goal of the ULA program is

to pursue aggressively any and all allegations of unlicensed practice in the health care professions, and

to eradicate unlicensed activity. Currently, there are 18 ULA investigators working at 11 field offices

throughout the state. Maintaining such a vigorous program requires continuous funding sources to

7

cover program expenditures. Expenses, such as personnel costs, enforcement activities and outreach

efforts, are approximately $1 million each year (see Table 1). In fiscal year 2014-2015, the annual

expenditures were over $1.2 million. The program is statutorily funded through a special fee of $5.00

per licensee upon initial licensure and at each renewal. In addition to the licensure fee, the ULA program

is also given statutory authority to collect fines and to recover the costs of investigations and

prosecutions. These funding sources allow the Department to maintain its unlicensed activity

enforcement and outreach initiatives throughout the year.

Enforcement

Practicing health care without a license is a crime in Florida that can result in misdemeanor or

felony penalties including fines and incarceration. Pursuant to section 456.065, Florida Statutes,

investigations involving the unlicensed practice of a health care profession are criminal in nature and

require a finding of probable cause to present to law enforcement or to file charges with the state

attorney in the county of occurrence. If the unlicensed activity allegations can be substantiated, the ULA

investigation will conclude with one or more of the following outcomes: (1) the arrest of the subject(s)

by law enforcement; (2) the issuance of a Uniform Unlicensed Activity Citation and; (3) a fine and/or the

issuance of a Cease and Desist Order. If the investigation results in the determination that the alleged

acts were lawful and proper or did not occur, the investigation is closed as unfounded. In the event that

the investigation determines that the allegation cannot be proved or disproved, the case is closed as

unsubstantiated.

In all cases, the ULA investigator prepares a detailed investigative report supporting the

conclusions reached by the investigation. Investigative records made or received by ULA investigators

are not exempt from public record laws; however, if the ULA investigative record involves a licensed

health care practitioner or licensure applicant, the record is protected under section 456.073, Florida

8

Statutes. Certain documents within ULA investigative records may also be confidential, such as patient

medical records. The confidential portions of ULA investigative records must be redacted prior to public

inspection.

Outreach and Education

While enforcement remains a top priority, community outreach, marketing and education have

become critical components of the program’s efforts to eliminate current unlicensed activity and

prevent future occurrences. The ULA program’s prevention strategy includes a campaign to increase the

public’s awareness of unlicensed activity and promote prevention. To support the campaign, the

Department has a dedicated ULA hotline (1-877-HALT-ULA) where individuals can report suspected

unlicensed health care practice. Other avenues of reporting include a designated email address

(HALTULA@FLHealth.gov) and a complaint form that can be printed from the program’s website and

mailed. Key to the program is educating health care consumers of the importance of and how to verify

the license of their health care provider through the MQA License Verification website. The program

also has a designated Unlicensed Activity Liaison whose primary function is public outreach, law

enforcement collaboration and training.

Marketing of ULA resources is accomplished through various means, including public service

announcement movie trailers, online digital campaigns, billboards and bilingual gas pump toppers

located in specific regions of the state (see Figure 1). A digital video campaign during March and April of

2015 garnered nearly 930,000 impressions from movie goers in the Tallahassee, Jacksonville and

Panama City markets. Additionally, the ULA program partners with the Department’s Bureau of

Environmental Health, Migrant Farmworker Housing Program to conduct outreach within migrant

communities. Bilingual presentations are designed to educate migrant farmworkers about the dangers

of unlicensed health care providers and to share information on making informed health care decisions.

9

Finally, the ULA program sends educational and training materials to law enforcement agencies and

private medical providers to increase awareness and recognition of unlicensed activity.

Collaboration

Florida law establishes that the unlicensed practice of a health care profession is a criminal

offense; however, the Department does not have jurisdiction to criminally prosecute unlicensed activity

cases.7 The statutory authority given to the Department allows for the issuance of civil citations and

orders to cease and desist all unlicensed activity. Collaboration with local law enforcement agencies and

state attorney offices is critical to the success of the ULA program. The program works in conjunction

with law enforcement and state attorneys to investigate, arrest and prosecute individuals practicing

health care professions without a license.

Although non-sworn, many ULA investigators have law enforcement experience from prior

careers as detectives or police officers. This experience allows investigators to develop strong

relationships within the law enforcement community and work cooperatively with local law

enforcement agencies on joint investigations of unlicensed activity in Florida. These collaborative

investigations have produced many notable successes in protecting the public.

Collaboration Success

In 2005, the ULA program produced a ten-minute educational video highlighting the positive

results from the program’s collaborative efforts with law enforcement agencies. The video showcased

high-profile arrests and operations along with the benefits of inter-agency cooperation. It was presented

at trade shows, conferences and inter-agency meetings to reinforce existing relationships and

encourage new partnerships.

A Collaborative Case

10

Johnnie and Christine felt that they had nowhere else to turn. By early 2013, Johnnie was

diagnosed with stage-4 lung cancer and received a grim prognosis. Lynnette Blake—a wife, mother and

proclaimed survivor of cancer—pretended to be a licensed medical doctor who performed various

medical procedures, claiming she could cure terminally ill patients from cancer. At her clinic, Back To

Eden Wellness Center, Blake treated Johnnie, professing that she could cure his cancer through

alternative medicine.8

Christine watched as her husband of 15 years grew more and more ill. The alternative, unproven

treatments seemed to be doing more damage than good. Over the course of his eight treatments with

Blake, Johnnie was placed on a 21-day diet and received a series of unknown drugs through intravenous

injections. In June 2013, shortly after completing his treatments with Blake, Johnnie passed away.9

On August 6, 2013, Blake was arrested on 12 counts of criminal conduct: five for the unlicensed

practice of a health care profession, five for the unlicensed practice of naturopathy and two counts for

the unlicensed practice of dentistry. Interviews conducted with several patients revealed that Blake had

placed tooth bleaching substances into the patients’ mouths. Upon arrest, Blake told investigators that,

as a naturopathic doctor and member of the Pastoral Medical Association, she was exempt from Florida

laws requiring licensing for health care professions.10

After being convicted of all counts charged, Lynnette Blake appeared repentant at the

sentencing hearing on August 1, 2014. According to Blake, her intentions were “to help people, never

hurt.”11 The Martin County Judge allowed Blake to make her statements and apologies to the victims of

her admitted scheme. Witnesses and surviving family members of Blake’s victims gave emotional

accounts of their experiences and losses. The judge sentenced her to 15 years in prison.

During the joint operation between the West Palm Beach ULA unit and the Martin County

Sheriff’s Office (MCSO), it was discovered that Lynnette Blake had gone to great lengths to pose as a

11

medical doctor at the Back To Eden Wellness Center. Many of her patients had terminal cancer

diagnoses and hoping to live beyond the scope of their disease, sought her alternative health care

services. In the investigation by ULA and MCSO, it was determined that Blake created fake transcripts

and medical school diplomas to deceive people.

The Program’s Impact

As is the case with other states, Florida does not have a mechanism for tracking the total

number of unlicensed health care practitioners that are still at-large. This makes it difficult to fully

measure the impact of the program on reducing unlicensed activity in Florida. To ensure that the

program is meeting its objectives and goals, the Department measures the program’s impact based on

certain metrics which are listed in the MQA annual report each year. The metrics include: complaints

received, complaints referred for investigations, completed inquiries, completed investigations, cease

and desists issued, and investigations referred to law enforcement. The data sets in the annual report

are also used to inform program administration of the geographic regions and specific professions with

high numbers of unlicensed activity cases so more targeted communication and marketing can be

implemented.

Florida is home to large immigrant and minority populations. According to the 2010 Census

data, minority groups make up almost half of Florida’s total population (see Table 2). Individuals from all

demographic categories can become victims of unlicensed activity; however, there are high instances of

unlicensed health care in areas with large minority and immigrant populations in Florida and other

states, such as Nevada and California.12,13 U.S. Census data indicates there are larger concentrations of

minority and immigrant populations in the south and central regions of Florida. Similarly, from fiscal

year 2011-2012 to fiscal year 2014-2015, there were greater numbers of unlicensed activity cases in

these regions than there were in north Florida (see Table 3).

12

The prevalence of unlicensed activity in these population groups is influenced by many complex

factors, including sociocultural differences, communication barriers between physicians and patients,

high rates of poverty or unemployment and lack of access to services from licensed health care

practitioners. Cultural and linguistic barriers between patients and health care providers can have

negative effects on health outcomes and patients who experience such barriers are less likely than

others to have an established source of medical care.14,15 In certain regions of Florida, a large

percentage of the population over five years of age do not speak English (see Figure 2).16 To address

these factors and barriers, many of the public resources provided by the ULA program are strategically

designed to reach a broad range of demographic categories.

In addition to the prevalence of unlicensed activity within immigrant and minority populations

in Florida, certain professions have significantly greater numbers of unlicensed activity cases than others

(see Table 4). Massage therapy and medicine are professions that have consistently high numbers of

unlicensed activity cases. In fiscal year 2013-2014, unlicensed activity cases involving the practice of

massage therapy and medicine combined were almost half (48%) of the total number of cases (see

Figure 3). The professions of dentistry and opticianry, which include dental laboratories and optical

establishments, also attract unlicensed practice. In fiscal year 2014-2015, a majority (73%) of the

unlicensed activity cases involved the practice of massage therapy, medicine, dentistry or opticianry (see

Figure 4). Based on the demographic composition of Florida and the high number of unlicensed activity

cases in particular regions, the ULA program has created public service announcements and bilingual

educational materials to target these diverse groups.

Lessons Learned and Recommendations

Florida combats the enduring problem of unlicensed activity through its ULA program, which has

several key components:

13

1. State legislation provides a critical backbone

Legislative activities over the years have allowed the program to grow and more effectively

enforce the law. Any state-run initiative requires a statutory basis on which to stand. As evidenced in the

history of the ULA program in Florida, legislative support and statutory authority to take action against

unlicensed practitioners is a foundational program component. Without the legislative authority to issue

cease and desist orders and citations, the ULA program would be less effective.

2. Secure a reliable funding source

Continuous funding is critical to initiating and maintaining a robust unlicensed activity program.

Florida’s ULA program is funded through both licensure/renewal fees and collection of fines and

investigative costs, which are credited to a specific ULA fund. The fees are collected from all initial health

care license applicants and licensees who are renewing a license. The fines are assessed from unlicensed

health care practitioners, who may also be required to pay the cost of the ULA investigation and any

further prosecution. The ULA program received approximately $2.5 million in licensure fees and

$150,000 in fines and investigative costs in fiscal year 2014-2015. Although the annual revenues

fluctuate slightly from year to year, the continual collection of these fees and fines provides consistent

funding to carry out investigations and enforcement operations.

3. Develop reliable data collection methods to assess performance

Reliable performance metrics are critical to assessing the program’s impact and progress toward

accomplishing goals and objectives. The ULA program has measures impacting its performance with a

clearly defined and consistent method for collecting data—something that has not always been in place.

One measure that has changed, for example, is the number of arrests resulting from unlicensed activity

cases. This data was listed in the MQA annual report until fiscal year 2013-2014. After evaluation, arrest

14

data is no longer reported because arrests are made by law enforcement agencies and, therefore, are

not a direct reflection of the ULA program’s performance. Current measures, such as the number of

complaints received and cease and desists issued, are internal to the ULA program and can more

accurately reflect the performance of the program over time. In 2014-2015, the ULA program had a 72

percent increase in cease and desists issued compared to the previous fiscal year. The fluctuation in data

collection methods and measures of program performance over nearly 20 years of program operations

has resulted in some limitations in the assessment of the ULA program’s impact.

4. Develop strategic partnerships with law enforcement and state attorneys

Florida law grants the ULA program authority to issue civil citations and cease and desists to

violators. Because of this limited authority, collaborative relationships with law enforcement agencies

and state attorneys are essential to ensuring that violators are criminally prosecuted in accordance with

the law. Developing strategic partnerships with other state and local agencies, like law enforcement, is a

major component of any program of this nature.

5. Build strong investigations for criminal prosecution

In the early years of the ULA program, most cases were referred to state attorney offices for

further prosecution. Due to factors such as lack of resources, knowledge and legal sufficiency to pursue

the case in a criminal capacity, many of the unlicensed practitioners were never prosecuted once the

investigation was transferred to the state attorney. Over the years, investigators have been trained to

build complete investigative reports with legally sufficient information to present to the state attorneys.

Today, the ULA program’s investigative files are often the backbone of criminal investigations resulting

in misdemeanor and felony arrests. The program is constantly evaluating its investigative reporting

process.

15

6. Take a preventative approach

Since the first program office opened in Fort Lauderdale in 1998, the ULA program has

continued to combine reactive efforts in investigating complaints received with proactive efforts to

prevent future unlicensed activity by educating the community through outreach and targeted

messaging. Over time, the program’s administration learned that consumers were unaware of the scope

and dangers of unlicensed practice. From this, the program developed its outreach campaign ensuring

educational materials were in English and Spanish. Various educational and outreach efforts include

profession-specific public service announcements, billboards, brochures and gas pump toppers.

Education has increased public awareness and provided a platform to find, investigate and prosecute

violators.

Conclusion

In the aftermath of Hurricane Andrew, unlicensed contractors preyed upon victims of the

devastation. This prompted state and local officials to begin taking steps to protect consumers from all

unlicensed activity. Today, Florida’s ULA program works diligently to enforce licensure regulations and

prevent unlicensed activity. Florida was the first state with a separate, designated program specifically

designed to combat unlicensed activity. Florida’s ULA program has been recognized for its unique and

proactive approach in addressing this national issue and due to its success, other states have used

Florida’s program model to fight against unlicensed activity.17

Although there are limitations to evaluating the scope of the problem nationally, most states

have enacted laws through medical and health care practice acts to prevent the unlicensed practice of a

health care profession. Both prevention and enforcement are important components in the fight against

unlicensed activity at a state and national level. Prevention requires a combination of outreach to

promote public awareness of the issue and encouraging licensed health care practitioners and

16

consumers to report any and all suspected unlicensed activity. Enforcement requires statutory authority

to investigate and prosecute violators, and partnerships with state regulators and law enforcement

agencies.

After an analysis of program results and refinement of performance measures, the focus has

been shifted from a primary emphasis on enforcement to a broader prevention campaign that includes

outreach and education efforts. The results of this shift show an increase in unlicensed activity

reporting, allowing for the ULA program to conduct better investigations and issue more cease and

desist orders to violators. Initiatives like Florida’s ULA program are long-term and require continuous

evaluation to guide evidence-based strategies and direct program activities.

17

References

1. This general definition was derived from a compilation of definitions listed in each state’s medical

practice act. Some states also include advertisement and the act of holding oneself out as a licensed

health care practitioner in the definition of unlicensed activity. For a list of medical practice acts by

state, see: Nevada Division of Public and Behavioral Health, Unlicensed Healthcare Task Force. Table

of Medical Practice Acts.

http://www.health.nv.gov/PDFs/unlicensedMedicalActivity/Table_of_Medical_Practice_Acts.pdf

Accessed June 2015.

2. De Ville KA. Medical Malpractice in Nineteenth-Century America: Origins and Legacy. New York, NY:

New York University Press; 1990.

3. Council of State Governments. Occupational Licensing Legislation in the States. Chicago, IL. Council

of State Governments; 1952.

4. The Circuit Court of the Eleventh Judicial Circuit of Florida in and for the County of Dade. Spring

Term A.D. 1992: Final Report Of The Dade County Grand Jury. Miami, FL; 1992.

5. Florida Department of Professional Regulation. Fiscal Year 1990-1991 Statistical Charts.

http://www.floridahealth.gov/licensing-and-regulation/reports-and-publications/_documents/90-

91doh-ar.pdf. Accessed May 27, 2015.

6. Florida Department of Professional Regulation. Fiscal Year 1993-1994 Annual Report.

http://www.floridahealth.gov/licensing-and-regulation/reports-and-publications/_documents/93-

94mqa-ar.pdf. Accessed May 27, 2015.

7. FS (Florida Statutes) 456.065.

8. This story is based on the case of Johnnie Hughes who died in June 2013 of lung cancer that was

accelerated by alternative, unproven treatments prescribed by Lynette Blake. The story received

18

media coverage in Florida, and both online newspaper articles and Florida Department of Health

press releases were used to assemble this fact pattern.

9. LaGrone K. Cases highlight problem in med spa industry. WPTV Contact 5. February 24, 2014.

http://www.wptv.com/news/local-news/investigations/cases-highlight-problem-in-med-spa-

industry. Accessed May 2015.

10. The Florida Department of Health, Office of Communications. Joint Investigation Leads to Arrest and

Conviction in Martin County, Press Release. August 4, 2014.

http://www.floridahealth.gov/newsroom/2014/08/080414-ula-actions-martin-county.html.

Accessed May 2015.

11. LaGrone K. Lynnette Blake: Woman sentenced to 15 years for posing as a doctor. WPTV Contact 5.

August 4, 2014. http://www.wptv.com/news/local-news/investigations/lynnette-blake-woman-

sentenced-to-15-years-for-posing-as-a-doctor. Accessed May 2015.

12. Latino Research Center. !NO A Los Médicos Clandestinos! – Public Awareness Campaign. University

of Nevada, Reno; 2012. Available at:

http://www.health.nv.gov/PDFs/unlicensedMedicalActivity/LatinoResearchCenterFinalReport.pdf.

Accessed June 4, 2015.

13. Medical Board of California. Operation Safe Medicine Returns July 2009. Medical Board of California

Newsletter--July 2009. Available at:

http://www.mbc.ca.gov/publications/newsletters/newsletter_2009_07.pdf. Accessed June 4, 2015.

14. The Sullivan Commission. Missing Persons: Minorities In The Health Professions, A Report Of The

Sullivan Commission On Diversity In The Healthcare Workforce. 2004. Available at: http://health-

equity.pitt.edu/40/1/Sullivan_Final_Report_000.pdf. Accessed June 19, 2015.

15. Flores G. Language Barriers to Health Care in the United States. N Engl J Med. 2006;355(3):229-231.

DOI:10.1056/nejmp058316.

19

16. Floridacharts.com. Florida CHARTS Population Characteristics Data. 2015. Available at:

http://www.floridacharts.com/charts/PopulationCharacteristics/. Accessed June 24, 2015.

17. Del Papa FS. Responding to Unlicensed Health Care in Nevada: A Plan for Action.

http://www.health.nv.gov/PDFs/unlicensedMedicalActivity/RespondingToUnlicensedHealthCareNV-

ActionPlanFinal.pdf. Published June 2012. Accessed June 1, 2015.

20

Tables:

Table 1. Annual Program Revenues and Expenditures from 2012-2015

Fiscal Year Total

Revenues1 License

Fees Fines Total

Expenditures2 Personnel

Costs Outreach

Costs3

2012-2013 $2,234,339 $2,125,122 $109,217 $1,043,930 $930,708 $113,222

2013-2014 $2,422,574 $2,314,458 $108,116 $956,216 $861,789 $94,427

2014-2015 $2,516,334 $2,361,686 $154,648 $1,258,581 $964,195 $294,386 1 Total revenues include monies received from both licensure/renewal fees collected and fines and investigative costs collected. 2 Total expenditures include expenses for personnel, outreach and enforcement. Both outreach and personnel expenses also include enforcement expenses since enforcement requires investigative personnel time and travel. 3 Outreach costs include expenses related to advertising, communications, travel, equipment and vehicle rentals, educational and training supplies, research services, printing and postage costs, and general outreach commodities (i.e. conference vendor booth registrations).

Table 2. Majority and Immigrant and Minority Populations in Florida and Selected Counties1

Place Total

Population Majority % of Total Population

Immigrant and Minority

% of Total Population

Florida 18,801,310 10,884,722 57.9% 7,916,588 42.1%

Miami-Dade County 2,496,435 383,551 15.4% 2,112,884 84.6%

Broward County 1,748,066 760,817 43.5% 987,249 56.5%

Palm Beach County 1,320,134 793,571 60.1% 526,563 39.9%

Hillsborough County 1,229,226 660,565 53.7% 568,661 46.3%

Orange County 1,145,856 526,754 46.0% 619,102 54.0%

Osceola County 268,685 108,292 40.3% 160,393 59.7% 1 Florida Legislative Office of Economic and Demographic Research, 2010 Census Redistricting Data (Public Law 94-171) Summary File, Generated on March 17, 2011.

Table 3. ULA Cases in Florida by Geographical Region from 2011-2015

Fiscal Year Total No. of

Cases1 No. of Cases in South

Florida2 No. of Cases in Central

Florida3 No. of Cases in North

Florida4

2011-2012 165 55 61 49

2012-2013 190 69 65 56

2013-2014 238 79 85 74

2014-2015 398 130 175 87 1 Total number of cases is based on legally sufficient investigations resulting in the issuance of a cease and desist order and/or a civil citation. 2 The counties in South Florida include Martin, Palm Beach, Broward, Miami-Dade, Monroe, Charlotte, Glades, Lee, Hendry and Collier. 3 The counties in Central Florida include Marion, Sumter, Lake, Seminole, Orange, Osceola, Polk, Hardee, Highlands, Volusia, Brevard, Indian River, Okeechobee, Saint Lucie, Citrus, Hernando, Pasco, Pinellas, Hillsborough, Manatee, Sarasota and DeSoto. 4 The counties in North Florida include Gadsden, Leon, Wakulla, Jefferson, Madison, Taylor, Hamilton, Suwannee, Lafayette, Dixie, Columbia, Union, Bradford, Gilchrist, Alachua, Levy, Baker, Nassau, Duval, Clay, Saint Johns, Putnam, Flagler, Escambia, Santa Rosa, Okaloosa, Walton, Holmes, Washington, Bay, Jackson, Calhoun, Liberty, Gulf and Franklin.

21

Table 4. Most Represented Professions in Annual ULA Cases from 2011-2015

Fiscal Year Total Cases

Massage Therapy Medicine Dentistry Opticianry Other1

2011-2012 165 37 15 17 22 74

2012-2013 190 29 39 21 46 55

2013-2014 238 78 36 26 21 77

2014-2015 398 179 37 17 56 109 1 Other professions are listed in the Division of Medical Quality Assurance Annual Report for the fiscal years listed.

22

Figures:

Figure 1. Location of ULA Program Bilingual Gas Pump Toppers as of December 2014

23

Figure 2. Percentage of Individuals Over 5 That Do Not Speak English by Region1 as of 2010

Census2

1 Values for the Number of Persons Over 5 that Do Not Speak English are the sum of all counties in each region. Regional values for the Percent of Persons Over 5 that Do Not Speak English were calculated by dividing the Number of Persons Over 5 that Do Not Speak English by the regional total number of persons over 5 (from 2010 Census data), expressed as a percentage. 2 Data source: Florida Department of Health, Bureau of Vital Statistics. County-specific data can be retrieved from http://www.floridacharts.com/charts/OtherIndicators/NonVitalIndRateOnlyDataViewer.aspx?cid=0299.

24

Figure 3. Percent of ULA Cases by Profession1 in Fiscal Year 2013-2014

1 Other professions are listed in the Division of Medical Quality Assurance Annual Report for the fiscal years listed.

Figure 4. Number of ULA Cases by Profession1 for Fiscal Year 2014-2015

1 Other professions are listed in the Division of Medical Quality Assurance Annual Report for the fiscal years listed.

33%

15%11%

9%

32%

Massage Therapy Medicine Dentistry Opticianry Other

Other27%

Massage Therapy, Medicine, Dentistry

and Opticianry73%

0 20 40 60 80 100 120 140 160