Medicaid Reform in Florida
Apr 10, 2008
This morning, I wrote a letter to Speaker Marco Rubio about the proposed expansion of Medicaid reform. I thought you might find this interesting.
We are still debating the budget. As soon as we finish, I will provide a detailed update about the proposed spending plan.
Honorable Marco Rubio
Speaker of the Florida House
Dear Speaker Rubio:
For the reasons more specifically set forth in the attachment, I am extremely concerned by the apparent desire of the Florida House to prematurely expand Medicaid "reform" by 2010. In brief, the project is still largely untested, and all early indicators suggest that it is not improving care or saving money in its current state. Further, using our own Miami-Dade as the next expansion site is even more problematic and disturbing. The Medicaid budget cuts being contemplated by both Chambers will likely hurt our County much more than others given our high concentration of poverty and large Medicaid population. Unlike Broward (the home of the current pilot project), Miami-Dade's delivery system is extremely asymmetrical and its population more difficult to serve. I believe the horror stories many patients are raising in Broward will only be amplified in Miami-Dade. In short, we will be doing nothing to enhance the care provided our most vulnerable citizens and, in the best light, be advancing a policy that only seeks to diminish the health care funds spent on Miami-Dade residents. I don't know why we would support these goals.
Finally, delaying its implementation to 2010 is hardly a compromise that provides any solace to what, I believe, is a potentially devastating and unwise policy expansion. As you know, in the legislative process it is always harder to reach agreement to undo policies once they have been enacted - this is exactly the scenario that has allowed the district cost differential to permanently deprive education funds to Miam-Dade schools. I believe that if the legislature votes to expand Medicaid "reform" to Miami-Dade that it will be exceedingly difficult to alter that course in the intervening years.
Ultimately, we must delay expansion of Medicaid "reform," until the problems are fixed and there is strong evidence that it is cost effective and improves care. Absent clear evidence this is the case, premature expansion of this program to the people of Miami-Dade is unwarranted and wrongheaded.
Thanks for considering this request,
POLICY BRIEF: Medicaid "reform" is untested and unproved and any expansion would be premature and dangerous.
The Medicaid Reform Evaluation is currently being conducted by the University of Florida's Department of Health Service Research, Management and Policy. The stated purpose of that study is to determine if Medicaid Reform meets its objectives of delivering quality healthcare services while achieving better health outcomes and enrollee satisfaction at a lower cost. That determination will not be made until the study is completed June 30, 2010. Yet results concerning patient and provider satisfaction, and indicators of quality of care, are already in from other studies, and the reports are not good. Dr. Andrew Agwunobi, the recently resigned AHCA Secretary, and AHCA's Inspector General Linda Keen, both concluded that any expansion of Florida's Medicaid Reform ought to be delayed until improvements are met and cost effectiveness can be proven. No study has ever confirmed that Florida will see the purported cost savings. If that weren't enough, the Government Accounting Office has notified Congress of its concerns regarding Florida's Medicaid Waiver.
Georgetown University Health Policy Institute was the first to sound the alarm, which has continued in 4 separate briefings. In May 2007 Dr. Alker reported that provider participation was declining among doctors who had previously accepted Medicaid Reform patients. Some complained of reimbursement, but most were frustrated with excessive paperwork and that patients were changed to plans they didn't understand and doctors they didn't know. Perhaps worst of all, more than half said it was harder to provide medically necessary care to children, largely due to plan limits and requirements.
In July 2007 the Georgetown researchers reported that patients, especially those with disabilities were having trouble getting the medicines they needed. The Choice Counselors could not tell them if their prescriptions were covered, referring them back to the plans that were confusing. It seems many patients didn't know their medicines weren't covered until they tried to fill prescriptions. The delay in getting those medicines (which may be lengthy when the patient must get back in touch with a doctor and check what is covered on the plan) and the possible complications that can occur if the medicine must be switched (different dose response, side effects) can have serious negative health outcomes.
In their most recent report, released December 2007, the researchers found evidence that the Medicaid Reform plans have become more restrictive, lowering limits of needed services and requiring higher co-pays. Such needed services include respiratory therapy and physical therapy. Limits on such services can raise the risk of infection, slow recovery times and reduce independent functioning.
In September 2007 AHCA released its Inspector General Review of the Medicaid Reform pilot. More than a dozen issues of concern were raised, many relating, at least in part, to the rapid implementation and expansion of Medicaid Reform. Areas needing remedy included that for most providers, no list of covered prescriptions was available either on-line or from service telephone contact; no system for patient complaints was in place; and most concerning, transition to Medicaid Reform was more challenging for the medically complex and mentally ill. In addition, the IG study found a high error rate in Provider Network reports, issues of incomplete data collection and internal communication.
Though the UF study will not be completed until mid-year 2010, the research team did provide and update and shared preliminary data in Miami-Dade in January 11,2008. The team's lead researchers agreed that it is too soon to tell if Medicaid Reform is working. Further, they shared some data confirming concerns about access and quality of care. From patient interviews they learned that some patients had to leave their regular doctor, and others had been assigned to doctors that were no longer in their plan. Patients were also unhappy with Choice Counselors, had trouble getting needed referrals and couldn't stay on medicines that had been working for them.
Medicaid Reform is not yet proven to be working for patients or doctors, as reported by the Inspector General, and researchers from Georgetown University and UF. Patients may have more choice of plans, but they lose choice when they are forced to change their doctors or must go off a medicine that works. The system is large and inflexible; in some families each of the children was assigned to a different pediatrician. The elderly and disabled are being restricted from necessary services, and these restrictions progressed from the first year to the second.
The Inspector General's 2007 report declares that Medicaid Reform was implemented too quickly, that AHCA staffing was inadequate to handle the changes, that performance, quality, encounter and cost data are lacking. The current session's proposed budget cuts will sharply affect AHCA, meaning more appropriate staffing is highly unlikely. The incompleteness of available data will call into question the conclusiveness of the evaluation still pending from UF. Everything points to a prudent slow down, and yet in the face of contradictory intelligence, the Florida House wants to move the clock ahead and force Medicaid Reform on Miami-Dade by 2010.
Everyone agrees that health care costs must be dealt with. Yet, there is no real world proof that Medicaid Reform as currently implemented in Florida will save money. The IG report was unable to show a savings and commented that the data is not available to determine cost effectiveness. Preliminary data from UF may show a marginal decrease, but the researchers themselves acknowledge that may be due to barriers to health care access. Further, there is evidence that Medicaid Reform could increase costs and do some damage along the way. Traditional Medicaid is rather efficient in its administration, accounting for only 3-7% of costs, while private insurance administrative fees average 13.6%. Adding a middle-man-HMO into Medicaid adds the need for profit—making. Taking these costs out of the state expenditures means either patients must get less services, less patients get services, or doctors get less reimbursement, which again translates as less patient services. MediPass, the state's non-HMO version of Medicaid for children, costs $10 per member per month less than the HMO version. Further, Miami-Dade has a version of Medicaid Reform in the private administration of its children's dental services, which has resulted in less preventative care, less visits per child, and an increase in state cost.
The IG report also cautions that expansion of Medicaid Reform threatens the fiscal viability of county health departments. We've had enough natural and man made disasters to make us appreciate the need for strong county health departments. The report also notes that fraud, a major contributor to Medicaid costs, still exists under Medicaid Reform, albeit in different forms.