http://www.palmbeachpost.com/health/grading-hmos-medicaid-test-the-state-prepares-to-1360961.html?viewAsSinglePage=true
TALLAHASSEE — Amy Silverman said she feels like a refugee - lucky to have escaped from a frightening place, but at a very high cost.
Silverman, 55, of suburban Delray Beach, fled Broward County last year to break free of Florida's 5-year-old experiment, which placed most Medicaid patients there in managed care.
One county north, helped by aging parents who emptied retirement accounts to ease her move, Silverman said her health has improved.
In Palm Beach County, she's back in conventional Medicaid coverage, which provides her access to the same doctor on a regular basis and to medication the doctor prescribes.
But she worries: The experiment is poised to go statewide.
"I am horrified that the legislature is even considering spreading Medicaid reform to the rest of Florida," said Silverman, who is covered by the program for a psychiatric disability. "This will be horrible and I don't want anyone to go through what I did."
In a bid to squeeze $1 billion out of a recession-wracked state budget, Florida lawmakers are set to push most of the state's 2.9 million Medicaid patients into HMO-style health coverage plans, similar to those launched in Broward, Baker, Clay, Nassau and Duval counties, beginning in 2006.
Republican Gov. Rick Scott and the GOP-led legislature say the statewide effort will inject private-sector efficiency into a government-run system plagued by skyrocketing costs, fraud and poor management.
Others say it will only magnify problems that marred the five-county pilot program.
"We've seen plenty of red flags raised in the pilot counties, like Broward," said Joan Alker, a professor at Georgetown University Health Policy Institute, who has been studying Florida's overhaul. "This is a very vulnerable population. And the more barriers you put up to them receiving care, the more likely that they will not get care or just wind up in emergency rooms."
Silverman said that was her experience.
Enrolled in Broward HMOs for four years, Silverman said she rarely saw the same doctor twice, was placed on different medication by her plan to save money and saw her condition worsen - in part, because of the emotional toll the program took on her.
"It was hell," Silverman said.
"This program doesn't save money," she said. "This was all about making money. The managed care companies just pocketed what they could. Decent doctors dropped out, and the patients were left holding the bag."
Costs rising quickly
The state, though, has learned from these missteps, supporters said.
"We've gone out and heard from people," said Sen. Joe Negron, R-Stuart, the Senate's Health and Human Services budget chief. "We've heard the stories about people bouncing from plan to plan. We've heard about people not being able to see specialists. But we've also heard that the current system is irretrievably broken, and we're starting a new program."
Florida's Medicaid spending is on track to reach $22 billion next year - almost one-third of the state's depleted budget, although the federal government will pay about $12 billion .
Medicaid costs are stoked by the state's prolonged economic slump, with patient rolls climbing, as Floridians losing jobs find themselves without health coverage.
But with state lawmakers struggling to close an almost $3.8 billion budget shortfall, Medicaid has been targeted as a fat, wasteful program in need of a fix.
The House and Senate are advancing different Medicaid overhauls, but both are anchored on managed care.
The House dealt with two dozen proposed amendments to its plan (CS/HB 7107, CS/HB 7109) Tuesday, before giving it preliminary approval, with a final vote expected Thursday. The Senate holds the first hearing on its bill (SB 1972) today, in the Health Regulation Committee.
Scott, who built his $218 million net worth in the health care industry, backs the change.
"The biggest driver in our budget right now is the cost of Medicaid," Scott said. "We need to have a viable safety net for the poor. We've got to come up with a better way to make sure the dollars are spent better."
Supporters point to the success of other states, where more modest overhauls of Medicaid have cut rising costs. Arizona, Georgia and Texas have all reported saving hundreds of millions of dollars through managed care, compared with traditional fee-for-service Medicaid programs.
The underlying premise of the Medicaid revamp is to improve health care services by giving managed care plans authority to design programs that meet the specific needs of patients, improve preventive health services and promote cost-saving competition between plans.
Instead of sick or injured patients showing up in doctor's offices or emergency rooms seeking treatment, with bills paid directly by Medicaid, health management organizations would guide patients into health plans and manage the dollars.
Patients would have to use doctors within a plan's network, and prescriptions would be limited to those on formulary lists approved by the managed care plan.
Most analysts agree for-profit HMOs will dominate the new system, but neither the House nor Senate would require health care providers to be HMOs. Provider service networks operated by hospitals or doctors' groups also are envisioned, along with other forms of managed care.
How much profit?
The House and Senate disagree, for now, on how to divide the state into managed care regions. They also differ on how to hold HMOs and other types of plans accountable for serving patients.
The Senate would force plans to spend 90 percent of the money they receive on care - known in the insurance industry as a "medical loss ratio." The House proposes a profit-sharing formula that would require plans to reimburse the state if they make more than 5 percent in profits.
Michael Garner, president of the Florida Association of Health Plans, said HMOs prefer the House proposal, fearing the Senate approach would add heavy administrative costs.
HMOs work on a modest profit margin, anywhere from 1 percent to 3 percent, he said. But the legislative proposals are built in a way that competition will yield lower cost and better quality, Garner said.
"I think we've all learned from the pilot program," he said.
The five-county experiment prompted a revolving door of managed care plans, patients and doctors said.
Patients, who are predominantly low income, complained of being shuffled from one to another, with HMOs or provider service networks cutting costs by denying or delaying care, and restricting access to medications.
"It was like our names were just tossed into a lottery," said Kendra Garcia, of Miramar, whose three young children receive treatment for emotional and developmental issues. "I've been put into so many different plans, I probably have five different cards right now in my purse."
Obstacles and complexity
Health care providers also struggled. Dr. Lydia Reid, a Broward speech and language pathologist, said patients she treated had to find another doctor when HMOs declined to include her in their networks.
"I was told by the plans, they had enough, they didn't need anyone else in my specialty," Reid said. "But I've also had patients tell me the doctors they're assigned are far away. And they can't get there by bus."
But Rep. Ronald Renuart, R-Ponte Vedra Beach, a doctor, said a reworked Medicaid system holds promise in Florida - if done right.
"The costs go up when the doctor isn't preventing illness, trying to get the patient out of the hospital, isn't managing the patient," Renuart said. "That's uncoordinated care. And that's what we have now in Florida."
Renuart said he hopes that provider service networks run by doctor groups or hospitals emerge as potent competitors to HMOs in the new Florida system. He thinks they can better coordinate a patient's complete care.
Still, he acknowledged a lingering fear: that state Medicaid costs will decline only because the poor, elderly or disabled aren't seeking care in a system that proves too complex to navigate, or denies easy access to treatment.
"I would hope it doesn't come to that," Renuart said.
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