Florida consumer-driven Medicaid reform in limbo

Washington -- A five-year pilot Medicaid reform in Florida designed to improve care access and quality has not yet lived up to its expectations, according to some physicians.

The project, which began in Broward and Duval counties in July 2006, financially rewards patients who access preventive care, provides varying benefit package options and offers counselors to assist enrollees in choosing a plan. Most pilot county enrollees must choose an HMO or a provider service network. PSNs are owned by hospitals and physicians.

But the reform brought new hassles with it, according to Arthur E. Palamara, MD, legislative chair of the Broward County Medical Assn., which has opposed the pilot project. He said it has become more difficult to receive approval for needed prescriptions and care in general, which is leading doctors to have second thoughts about treating Medicaid patients. "Many of these physicians do not plan to re-enroll in coming years," Dr. Palamara said.

Some Medicaid enrollees are having trouble finding doctors in the new networks who are willing to see them, said Aaron Elkin, MD, vice president of the Broward County Medical Assn. and chair of the ob-gyn department at Memorial Regional Hospital in Hollywood. "Patients are starting to get more and more restricted care."

Duval County physicians have not voiced as much frustration with the reform, said Jay Millson, executive vice president of the county's medical society. Duval County pilot enrollees are about half as likely as Broward County enrollees to be in an HMO as opposed to a PSN. While HMO reimbursement is on a capitated basis, the pilot has allowed PSNs to opt for fee-for-service pay. That will change in late 2009, when they must also switch to capitated pay.

Florida Medical Assn. members have mixed opinions on the Medicaid pilot, said Fred Whitson, FMA director of medical economics. The association is conducting a study on the reform and working on a formal position on it. Both will come out in February as the Florida Legislature begins its 2009 session. Some lawmakers are expected to push to expand the pilot to more counties or statewide, according to Laura Goodhue, executive director of Florida CHAIN, a network of consumer advocates.

As of Nov. 1, 2008, more than 138,000 people in the five pilot counties had enrolled, out of a total Florida Medicaid population of 2.26 million people. Medicaid enrollees in non-pilot counties continue to receive standard benefit packages in HMOs, provider service networks, a primary care case management program or traditional fee-for-service Medicaid.

Providing choices in benefits is a key goal of the project. But recent reports by the Florida Legislature's research office concluded that the state Medicaid agency should more closely examine plans' access to prescription drugs and their physician networks.

Pilot county enrollees should be able to receive the same prescription drugs as traditional Medicaid enrollees, but the Florida Agency for Health Care Administration does not compare HMOs' preferred drug lists with Medicaid's fee-for-service drug lists. The agency also does not review HMOs' prior authorization requirements for drugs to ensure they are reasonable, according to a September 2008 report by the Legislature's Office of Program Policy Analysis & Government Accountability.

Restrictive drug formularies have posed the biggest problem, Dr. Palamara said.

The Legislature's research office also cited difficulties assessing what drugs each pilot plan covers and comparing the coverage.

An October 2008 report by the Legislature's research office found that pilot plans' lists of participating doctors are not always accurate and can be difficult to search. The state health agency could establish a maximum patient-to-specialty-physician ratio to ensure adequate network capacity, the report said. Disenrollment data collected by state contractors between October 2006 and June 2008 found that 24% of enrollees left a plan because it did not feature a particular primary care or specialty physician.

Although the reform hasn't been as controversial in Duval County as in Broward County, "specialty access is a huge problem," Duval County Medical Society's Millson said.

Some physicians have treated patients only to discover they are not in a plan in which the doctor participates, Dr. Palamara said. Enrollees may have been overwhelmed by the choice of up to 18 pilot plans in Broward County. Duval County has fewer than half as many.

Florida Medicaid Director Dyke Snipes declined to comment on the reports, but he said the pilot needs more time before it can be judged fairly. Reports by the University of Florida, which has a state contract to evaluate the pilot, will guide the Legislature on how to improve the pilot, he said.

Enrollees might not have initially understood the enhanced benefits program. Those who receive recommended preventive care can earn up to $125 a year in credits good for over-the-counter medicine and other health-related products. Enrollees have spent only about $5 million of the $17 million they've earned. But in recent months they have been ramping up their credit usage, Snipes said.

The reform program does have encouraging trends, Snipes said. The percentage of enrollees who did not choose a plan and were automatically enrolled has decreased since 2006.

Florida Assn. of Health Plans did not return calls seeking comment.