I was very interested to see our Gov. Jeb Bush proclaimed the best governor in the nation in a recent Weekly Standard article (“Governor in Chief”). The author wrote that one of the things that makes Jeb tops is his bold reform plan for Florida’s Medicaid system. Gov. Bush says his program will improve system efficiency and patient outcomes while slowing the rate of increase in Medicaid spending. His plan relies on private HMOs and other managed care entities to provide services to some 200,000 people in the Ft. Lauderdale and Jacksonville pilot areas beginning this month. Plans are also in place for a separate elder care (age 60+) version to begin on a pilot basis in Pensacola and the Orlando-Melbourne area. In addition, legislation recently passed by Congress made major changes in Medicaid eligibility. All such reforms have potential, but they also have the potential to further strain the already underfunded health care system.

Unintended consequences

I’ve been around long enough to have developed a healthy skepticism whenever I hear bold pronouncements about a better, brighter tomorrow from elected officials. Too often, the Law of Unintended Consequences comes into play. Let’s look at some potential “land mines” amid all this change as it relates to hospital-nursing home interaction:

Citizenship: The Deficit Reduction Act passed by Congress now requires the states to determine with certainty the citizenship of the Medicaid applicant, and it specifies the documents it will accept as proof. What happens if the person’s documents aren’t on that list and he/she is deemed ineligible? Who will pay for their care? Nursing homes may eventually require more information on the hospital patient prior to his or her transfer to the nursing home.

Medicaid eligibility, lookback period: The DRA also lengthened the look-back period for determining financial eligibility for Medicaid. The eligibility process already takes a long time, but providers know they will be paid retroactively for the care they provided during the determination period. The new Bush managed care programs may not make retroactive payments to providers, so if eligibility is denied, somebody will be stung with uncompensated care. Nursing homes would likely move to a higher level of diligence in screening before admitting. Thus, the hospital could become a “waiting room” for the nursing home and/or the assisted living facility.

Criminal histories, sex offenders: In the name of protecting the public, some local jurisdictions have passed ordinances restricting where those with criminal/sex offender histories may live or work. The Florida legislature has considered other laws requiring the pre-screening of all prospective ALF and nursing home patients for criminal/sex offender backgrounds. Background screening currently takes about seven-ten days. Add half a million or more people a year to the existing caseload (with longer periods of time to scrutinize) and you are sure to have an even longer delay. Where would these prospective patients wait and where would they ultimately go if a criminal/sex offender history were found?

Bobby Rosenthal
President, 21st Century Health Group, Inc.
Past President Florida Health Care Association

Hospitals may soon see it becoming harder and harder to promptly discharge their patients to local nursing homes and ALFs, and this could produce frustration and anger. But the anger should be directed at the well-intentioned government that creates the system and its problems, refuses to adequately fund it and then wonders why providers want more details before jumping on the latest “reform” bandwagon.

Working together

Nursing homes and hospitals are both essential parts of the health care continuum that serves Florida’s elders. Instead of pursuing our separate interests, we ought to be working together more closely, both in Washington, DC and in Tallahassee. As for the proposed Medicaid managed elder care pilot programs, we insist on full advance disclosure of all operational aspects of the program, and so should legislators.

As for me, I’m not feeling quite so warm toward our Gov. Bush these days. His veto in May of $91 million in Medicaid funding for nursing homes is certain to have a negative effect on both nursing homes and hospitals. So his reform plans are doomed if they don’t recognize the first law of health care: Adequacy of provider funding is what ultimately determines access and quality.