Florida doctors, patients sue over Medicaid rates

Pediatric groups are seeking higher payment levels and monitoring of managed care plans.

By Amy Lynn Sorrel — Posted Dec. 19, 2005

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Florida's state health agencies have violated federal law by not ensuring that children on Medicaid have adequate access to primary and preventive health care.

That's what physicians and dentists allege in a federal class-action lawsuit taking on the state's Agency for Health Care Administration, the Dept. of Children and Family Services and the Dept. of Health.

The lawsuit was filed Nov. 21 in Miami by the Florida Pediatric Society/Florida Chapter of the American Academy of Pediatrics, the Florida Academy of Pediatric Dentistry and families of Medicaid-enrolled children.

The complaint accuses the system of "the endangerment of young lives" and failing to serve Florida's 1.6 million children on Medicaid by inadequately reimbursing physicians, failing to inform recipients of available medical services and abruptly referring them to HMOs with no room to accept them. "We were not happy to have to go the legal route but to no avail tried all legislative remedies available to us," said Louis St. Petery, MD, executive vice president of the Florida Pediatric Society.

Hundreds of fruitless meetings with the Legislature and Gov. Jeb Bush finally drove them to the courts, he said. Successful precedents in Oklahoma and Pennsylvania encouraged them to seek relief from the courts.

The plaintiffs are not seeking damages but reforms, such as adequate payment levels to attract enough physicians and dentists to the program, monitoring of managed care, and equal and regular access for Medicaid recipients to the same services as those available to children with commercial insurance.

"We have not seen an increase in state Medicaid rates in over 10 years, and they are significantly below what it actually costs to provide care," Dr. St. Petery said. He added that current rates do not take into consideration basic expenses, such as cost of living and medical liability premiums.

According to the complaint, more than 500,000 Medicaid-enrolled children in Florida received no preventive health care at all in 2004.

Officials declined comment for this story. In a statement, Alan Levine, AHCA secretary and a named defendant in the case, agreed that Florida's Medicaid program has problems. "Under the current system, there is not one single incentive to get children in the door for well-child checkups, and that's what the governor has proposed to change," Levine said.

He said Gov. Bush would address the issue in a special legislative session called to consider a Medicaid overhaul plan.

The governor's reforms include a more privatized approach to Medicaid. Under the proposal, Medicaid patients would choose a benefits package designed by health plans, or opt out and use state allocated dollars to join an employer-sponsored plan.

But physicians call those proposals unsatisfactory. They do not address the problems in the complaint, and the changes would make matters worse, Dr. St. Petery said.

"Reform proposes to push kids into managed care, and [health plans] do not get the job done," he said. "If you are going to push kids to managed care, then the state has to oversee it."

Some legal precedent supports the Florida doctors' arguments. In March, in OKAAP v. Fogarty, the U.S. District Court for the Northern District of Oklahoma ruled in a similar case that low reimbursement rates by the Oklahoma Health Care Authority prevented pediatricians from providing adequate medical services to children.

The Oklahoma Legislature since has authorized money to comply with the court's order to increase pediatric Medicaid rates to cover necessary physician services. The AMA/State Medical Societies Litigation Center filed a friend-of-the-court brief and contributed to plaintiffs' litigation costs.

A 1991 Pennsylvania lawsuit set the stage for the Oklahoma ruling. Judges in the U.S. District Court for the Eastern District of Pennsylvania found that the state's Medicaid program wasn't providing adequate access to care for children. The case, Scott v. Snider, was settled in 1995.

But in the 9th Circuit, the District Court for the Northern District of California ruled in another case that private doctors and patients cannot sue the state for a violation of federal law.

Doctors hope that is not the precedent the Florida court follows. Dr. St. Petery called the decision "crazy."

"If the federal government hasn't enforced Medicaid requirements, and the state doesn't enforce them, then who will do something about it?"

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External links

Florida Pediatric Society/Florida Chapter of the American Academy of Pediatrics, on its case against the Florida government (link)

Florida Agency for Health Care Administration on Medicaid reform (link)

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