dumping patients – part 6

Today’s Times Picayune writes a piece on the shortcomings of the Florida Medicaid program. Louisiana’s DHH director Alan Levine, who pushed the Florida Medicaid program through their legislature, is modeling the current Louisiana Medicaid pilot program after the Florida plan.

Florida Medicaid program criticized; Jindal plan built on similar principles
by Jan Moller, Capital bureau, The Times-Picayune
Sunday February 15, 2009, 8:33 PM

BATON ROUGE — The Medicaid pilot program Alan Levine helped push through the Florida Legislature in late 2005 was certainly ambitious: a bold bet that commercial managed-care companies, given enough flexibility, could run that state’s health care program for the poor at a lower cost and produce better outcomes than state government.

Three years later, Levine has moved on to become secretary of the Health and Hospitals Department in Louisiana, where he has designed a Medicaid pilot program that’s built on many of the same principles. But while Louisiana waits to learn whether its plan will pass muster with federal authorities, the Florida program remains a work in progress that, according to some critics, has failed to live up to its promises.

Doctors complain about excessive paperwork and rationing of care. Policy analysts question whether the savings will materialize. A recent analysis by The Associated Press found that the number of primary-care providers seeing Medicaid patients in the two largest counties in the program has dropped by 25 percent in the past 18 months.

And last month, one of the largest Medicaid insurers announced that it was pulling out of the pilot program because of low reimbursement rates, leaving 78,000 beneficiaries to find other coverage.

A survey of 210 Florida doctors by the Georgetown University Health Policy Institute found that only 8 percent thought the changes have improved the Medicaid program, while 47 percent said things have gotten worse and 47 percent reported no change. Plans to expand the pilot program beyond the five counties where it is now operating were put on hold last year, but they are expected to be considered by the Florida Legislature this spring.

“To the extent that change has occurred, it appears to be moving in the wrong direction,” the October 2008 report concluded. “The complexity of the program has grown, causing confusion and increased administrative burdens for consumers and providers. Access to needed services appears to be worsening according to both physicians and beneficiaries, and provider participation is declining.”

Levine said the Georgetown study and The Associated Press analysis are deeply flawed, and he cites figures from Florida’s top health care agency showing that Medicaid beneficiaries in that state have more access to specialists and that per-patient costs have declined since the pilot program started in July 2006. He said statistics from Florida and around the country bear out his claim that managed care produces better health outcomes than the fee-for-service model being used in Louisiana.

He attributed the complaints about the program to entrenched interest groups trying to protect their bottom line. “The financial interests committed to health care are strong, powerful and resistant to change,” Levine said.

Former Florida Gov. Jeb Bush also has defended the program and has noted that participants now have access to services, such as dental coverage and free over-the-counter drugs, that were unavailable before.

‘Coordinated care’ focus

Levine added that the Louisiana plan, dubbed Louisiana Health First, differs in key ways from the Florida plan. Among other things, the Louisiana model, which aims to cover 380,000 people in four metropolitan areas starting in 2010, would not rely on health-maintenance organizations to deliver care. Instead, it would instead steer people into “coordinated care networks” controlled by health care providers such as hospitals, doctors or clinics.

While some details differ, the fundamental change Levine wants to make in Louisiana is the same as what was done in Florida: Instead of having Medicaid operate as a “fee-for-service” system, in which doctors and hospitals are paid a set rate for each service they provide, the managed-care networks would get a fixed, per-patient fee to take care of patients. The fee would vary based on the health of the patient, giving the care networks an incentive to take on patients with chronic illnesses that HMOs often try to exclude in favor of healthier clients.

Joan Alker, a researcher who conducted the Georgetown University study, said Louisiana is at a further disadvantage to Florida because the state has no previous experience with managed care in its Medicaid program. In Florida, about half of all Medicaid recipients were enrolled in HMOs before the pilot program was launched in July 2006.

The complaints from Florida doctors echo the objections raised by physicians in Louisiana, who have argued that introducing commercial managed care into Medicaid ends up siphoning off dollars to those companies’ profit margins that otherwise would be spent on patient care.

Difficulties in access

Dr. Aaron Elkin, an obstetrician in Hollywood, Fla., said the increased use of managed-care organizations has led to more paperwork and less income and has made it harder for poor patients to access prenatal services. “I see so many patients that used to be able to see me in the first trimester now see me in the second trimester because they just can’t access (care),” said Elkin, who is a director of the Broward County Medical Association.

Paul Duncan, a research professor at the University of Florida who has conducted a series of evaluation of the pilot program, said he suspects the doctors’ frustration has more to do with a general dislike of managed care and the low rates paid under Medicaid than any specific complaints about the pilot program.

“They don’t like Medicaid period,” Duncan said. “They don’t like HMOs, and they particularly don’t like Medicaid HMOs.”

He said that although problems remain with the Florida program, it has shown some notable successes. Among other things, it has proved that managed-care companies are willing to enroll unhealthy patients if given a proper financial incentive.

For now, Louisiana’s plans are on hold pending a federal review of the state’s waiver request. Because Medicaid costs are shared between states and the federal government, the U.S. Department of Health and Human Services must sign off on any major changes to the program.

The Jindal administration had hoped to have its plan approved in time for the spring session of the state Legislature. But Levine said last week that the original timetable was too optimistic and that the change of administrations in Washington means the state’s waiver application might not get considered until later this year. </em>

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~ by maringouin on Monday, February 16, 2009.