Doctors in Medicaid Reform cite roadblocks to care

 By Carol Gentry
10/16/2008 © Florida Health News

TAMPA – Two-thirds of Jacksonville and Broward County doctors surveyed recently about how Florida’s Medicaid “Reform” experiment is going say their patients are having trouble getting treatments they need.

That assertion, which emerged from a report by a team from the Georgetown University Health Policy Institute, is striking because improving patients’ access to care was one of the main reasons that Florida officials gave for launching the Reform program two years ago.

Created by former Gov. Jeb Bush with permission from federal health authorities, the project requires Medicaid patients in pilot counties to be enrolled in a managed-care plan and allows plans to alter the benefits traditionally offered. The idea was to tailor benefits to the needs of patients, but critics objected to the state’s willingness to leave it up to private companies to decide what patients need.

Currently the program is active in five counties – Duval, Broward, Nassau, Baker and Clay – but some legislators want to spread it statewide.

The Georgetown report, released Wednesday at a public forum in Tampa, said it’s too early to tell yet whether the project is accomplishing some of its other goals, such as saving money and cutting down on fraud and waste.

“To proclaim Medicaid reform either a success or a failure would be premature,” the team concluded. “But, to the extent change has occurred, it appears to be moving in the wrong direction. The complexity of the program has grown, causing confusion and increased administrative burdens for consumers and providers.”

Paul Duncan, a University of Florida professor who studies the Reform program on contract with the state, said he can’t draw any conclusions yet. It’s just the end of the second year, he said, and his team hasn’t even finished analyzing patient attitude surveys; the data that would indicate whether patients’ health is better or worse is years away, he said.

In the absence of hard evidence, Duncan said, the doubters refuse to believe that patients are okay and proponents refuse to believe the program is flawed. “There are no unequivocal answers,” he said.

The state Medicaid program, which receives federal funds and must abide by federal rules, covers certain very low-income groups: mothers and children, most of whom are healthy and inexpensive to cover; and the frail elderly and disabled, whose care is expensive and difficult to manage.

The for-profit HMOs that accept financial risk for enrollees under the project have a relatively small share of the expensive patients, the Georgetown report said. Sicker beneficiaries tend to stay in treatment settings they’re familiar with, like the provider-service networks, or PSN’s, headed by public or non-profit hospitals. They are paid a flat fee for each service.

Several speakers at Wednesday’s forum, “Looking Back, Looking Ahead: Medicaid Reform in Florida,” were advocates for the poor who strongly oppose any attempt to expand the program to other counties.

Anne Swerlick, deputy director of Florida Legal Services, said she has Medicaid clients in reform counties who end up in the hospital because they can’t get authorization for appropriate outpatient care. “People are getting hurt,” she said..

But Joseph Rogers of Broward Health’s PSN, South Florida Community Care Network, told the audience of patient advocates that they need to take a broader view. The same for-profit HMOs that dominate the scene in Reform counties are quietly enrolling Medicaid beneficiaries in other counties, but it’s less noticeable because no one’s studying it, he said.

“The recipients get a better package of benefits in Broward than in Dade and Palm Beach,” Rogers said. In non-reform counties, he said, “there’s no transparency at all.”

Patients told the researchers that they had a difficult time finding out which doctors and drugs were covered under which plans, since many of the lists were inaccurate. The inaccuracy of the lists was noted in a report last fall by the Inspector General of the Agency for Health Care Administration.

Doctors told the researchers that they’re overwhelmed with paperwork and the time wasted in trying to obtain clearance from the HMOs to refer patients to appropriate treatment. Sixty-two percent said their experience with the reform plans was worse than with traditional Medicaid.

The report calculated that there’s been a net decrease of 10 percent in the number of doctors treating Medicaid patients in Broward and Duval. More than two-thirds of those who left are specialists.

Of the 210 physicians surveyed earlier this year, 47 percent said Medicaid was worse than before the onset of reform, and an equal percentage said it was about the same. Only 8 percent said it was better.

Sponsors of the forum included Florida Health Policy Center and the Jessie Ball duPont Fund. Both provide monetary support to Florida Health News.

--Carol Gentry can be reached at 727-410-3266 or Carol.Gentry@FloridaHealthNews.org.