Fla. Medicaid reform pilot: More efficiency or less care?
■ Other questions surround the state's consumer-driven reform, but patient satisfaction remains high.
By Doug Trapp — Posted Aug. 10, 2009
New evaluations of Florida's Medicaid reform program found that it reduced or held spending in check during its first two years. But it's not clear if the program improved efficiency or simply reduced the amount of care provided.
Florida is in the middle of a five-year Medicaid pilot project designed to encourage enrollees to take a more active role in their health care and to achieve more predictable cost increases. Qualifying enrollees in five counties are offered a choice of health plans with varying benefits. These plans include HMOs and provider service networks, which are owned by physicians and hospitals. More than 200,000 people had enrolled in pilot plans as of June 1.
A series of evaluations have criticized the implementation and structure of the Medicaid pilot. In June, the Florida Office of Program Policy Analysis & Government Accountability -- the Legislature's watchdog agency -- advised lawmakers not to expand the pilot until data demonstrate that it has improved both access to and quality of care.
But two recently finalized state-commissioned reports by the University of Florida begin to answer some questions about the effectiveness of the Medicaid pilot.
The initiative has been shown to limit or reduce spending. The university authors compared Medicaid spending in the two largest pilot counties -- Broward and Duval -- from the two years preceding reform with spending from the first 22 months of the project. The authors found that the pilot reduced monthly spending on Medicaid enrollees who are disabled or chronically ill. The growth reduction was sharper for PSN enrollees and more modest for HMOs.
But the preliminary report has its limits, said Aaron Elkin, MD, vice president of the Broward County Medical Assn. "There are way too many variables, and they can't tell you with this information if there is really cost reduction."
R. Paul Duncan, PhD, co-author and chair of the University of Florida Dept. of Health Services, said the spending report is not comprehensive. The researchers did not have access to detailed health plan spending on services and could not say if the reform simply reduced access, or if some spending was excluded.
Duncan said the reports may not satisfy those looking for final word on the state's Medicaid pilot program, which has been controversial. "People want it to be horribly, horribly bad, or spectacularly good, but it really isn't either."
A second university report examined Medicaid enrollees' satisfaction with their health plans, physicians, and other aspects of the health system. It found few significant post-reform changes, with continued high satisfaction ratings for physicians.
Some doctors, however, are dissatisfied with the Medicaid pilot health plans' authorization process.
Marvin Schiff, MD, a family physician in solo practice in Pompano Beach, said he was forced to hire a part-time clerk to help navigate the more rigorous referral process. Seventy percent of his patients are enrolled in Medicaid. "We have to work hard to make sure that the patients get the care that's available to them," Dr. Schiff said.
In addition, the pilot reform still offers low pay for physicians, said Tad Fisher, executive vice president of the Florida Academy of Family Physicians. "I think there's a general frustration that the reforms didn't really reform at all."
The pilot project also has been complicated by Medicaid health plans limiting enrollment or dropping out. But Holly Benson, secretary of the Florida Agency for Health Care Administration, noted in a June 3 letter that Medicaid enrollees in pilot counties have more health plan choices now than before the project.
The Florida Medical Assn. opposes expansion of the Medicaid pilot, said FMA Executive Vice President Tim Stapleton. The association's board recently adopted a report critical of the Medicaid pilot reform by Arthur Palamara, MD, an FMA delegate and surgeon in Broward County. The association plans to share the report with the state lawmakers during the next legislative session, Stapleton said.
Fisher said he would like to see Florida adopt North Carolina's community care model, where physicians have input in the management of Medicaid case-management networks with medical homes.