Florida has no data 3 years into Medicaid trial


Published: Monday, June 1, 2009 at 10:59 a.m.
Last Modified: Monday, June 1, 2009 at 10:59 a.m.

MIAMI Nearly three years into a Medicaid privatization program former Gov. Jeb Bush said could be a national model, state officials say they do not have crucial data to measure the program's effectiveness, including how many patients' treatments and prescriptions have been approved or denied.

Patients and health care advocates have complained they can't get doctors appointments and medications under the program, which began in October 2006. An Associated Press study found nearly 25 percent of doctors in Broward and Duval counties, the two biggest counties in the pilot program, have dropped out because of red tape and an inability to treat patients as they see fit.

The complaints have led to an outcry for accountability from the state's health care agency, especially after WellCare, the program's largest private health care provider, has admitted to stealing more than $35 million from the state under another program.

There's also been little evidence to show that the pilot, operating in five counties, has improved health care or saved the state money.

"How could you even think you could get away with not measuring?" said state Rep. Elaine Schwartz, D-Hollywood, who hears horror stories from sick residents complaining they aren't getter proper care under the program. "The people who put this (program) in didn't really want to know whether our vulnerable population was really being served because they were in bed with the HMOs that were looking at the bottom line and the dollars."

Amy Silverman, 52, calls the pilot program a "horror" after trying to get treatment for her atypical bipolar, severe depression, heart and kidney problems. Silverman says many of the doctors and specialists listed in her plan have either dropped out or aren't taking new patients. She's had such trouble getting appointments that she's gone to the emergency room, instead, for minor things that could have been handled by a doctor. The plan also denied a medication she's been using for years.

"I fear that my only hope for decent health care will be to move out of state and away from family," said Silverman, a Broward County resident.

The Agency for Health Care Administration, which oversees the pilot, said in an e-mail it is overhauling its computer system and is "in the process of collecting encounter data from all Medicaid health plans"....but "we do not have usable data at this time."

AHCA paid the University of Florida $2.5 million in 2005 to conduct an independent study of the program, but Paul Duncan, who is heading the study said he had not yet received the data.

Various groups, including Georgetown University, the health care advocacy group Florida CHAIN and the AP, have asked for the encounter data for nearly a year, but have not received it. The data should include patient diagnoses, what treatments and prescriptions doctors have prescribed and whether they were paid, denied or delayed. The data would also show how many specialist appointments have been paid or denied a chief complaint among patients.

"There's definitely a question of accountability," said Joan Alker, research associate professor at Georgetown University Health Policy Institute, who has studied the pilot program. She said Florida's Medicaid reform is unique because it gives HMOs "unprecedented power to define the benefits package."

"HMOs have a bottom line and that bottom line is to their shareholders and not necessarily to the health of the people they're serving," she said.

Under the pilot, the government pays private companies a set amount for handling a specific number of residents in the counties similar to an HMO in the private sector. The companies, in turn, decide how to care for people, including which doctors they can see and what medicines and treatments can be prescribed.

Proponents say the plans offer patients more customized benefits. However, patients complain they often have to pick between plans that cover either their doctors or medicines not both. Studies echo those complaints putting the program even more under fire.

Roughly 202,000 of Florida's 2.1 million Medicaid beneficiaries were enrolled in a reform plan. About 84 percent are children and parents; 16 percent are disabled individuals receiving Social Security.

WellCare, the largest HMO in the pilot, stopped caring for about 80,000 reform patients in May, saying state budget cuts made it economically unfeasible to offer quality health care. WellCare said it owes Florida and Illinois about $46.5 million for overcharging the states and overstating its profits due to accounting errors from 2004-2007. The company avoided criminal prosecution for health care fraud by agreeing to pay $80 million in restitution under an agreement with the U.S. Attorney's Office last month.

National health care experts say there should be some benchmark data made public after the first year of any experimental program.

"Especially when you're instituting something new and you're experimenting, it's core responsibility to evaluate how that experiment is doing," said Richard Sorian, vice president of the National Committee for Quality Assurance, a Washington-based health plan accreditation organization.

Schwartz says she continues to hear from patients and frustrated doctors about compromised care. She helped Broward County commissioners draft a resolution in February to repeal the program in Broward and oppose expanding it into other counties. It's unclear what effect, if any, the resolution will have.

One of the main flaws of the program, Schwartz says, is allowing private companies like WellCare to determine the benefits because they cut back on patient care to make a profit. That often leads to a mound of paperwork and prior authorizations for doctors, which ultimately delays patient care.

Dr. Aaron Elkin, a longtime Broward obstetrician, says the state should not "experiment on the most vulnerable population" with little accountability, inaccurate information and decreased access to care.

He used to treat patients in their first trimester of pregnancy, which is the best time to initiate prenatal care. Since the pilot, Elkin says most of his Medicaid patients aren't able to see him until well into their second trimesters.

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