As President of the Broward County Medical Association (BCMA) I continue to be reminded that South Florida and Broward County are the epicenters of Healthcare reform in the United Sates and by oneself being characteristically loquacious yet outspoken our voice united is reshaping local, state and national headlines.
One component of the Patient Protection and affordability Act is providing care for the uninsured through Medicaid. Medicaid payment rates to primary care doctors will increase to match Medicare rates and the Medicaid program will be expanded.
Florida Medicaid Reform was a demonstration looking to improve the value of the Medicaid delivery system operating under 1115 Research-Demonstration Waiver approved by the Centers for Medicare and Medicaid Services(CMS) in 2006 for 5 years. The program placed Medicaid patients into managed care organizations (MCO/HMO’s) and Provider Service Networks (PSN’s) in several counties in Florida. The Medicaid reform pilot expired June 30, 2011.
A letter of concern was written to CMS in March 2010, describing experiences regarding Florida’s Medicaid Reform Pilot. “There is decreased access to care, inaccurate information provided, higher costs, poorer care, fewer services, more forms, less satisfaction and no informed choice and Medicaid Reform must be immediately stopped and redirected.”
Since the inception of the Medicaid Reform Pilot in 2006, the Broward County Medical Association has maintained its position opposing Reform.
Broward doctors and hospitals are not blinded to the need to improve quality care while reducing the huge burden imposed on the state’s treasury ($20 Billion). Broward physicians are frustrated by delivery hurdles placed in their paths by the bureaucracy of MCO/PSN/HMOs models and suggest that delays receiving care are worse particularly when attempting to obtain specialty care. Doctors, besides tolerating delays waiting for authorizations are reimbursed a fraction of their usual fees under Medicaid being some of the lowest in the US (About 50% of Medicare rates).
The Florida Agency for Health Care Administration (AHCA) believes that the pilot project succeeded, basing conclusions on a relatively few number of complaints. While arguable, very few Medicaid patients complain even when confronted with multiple obstacles, ultimately grateful for the dedication of treating physicians. Indeed, patient satisfaction levels for doctors remains extraordinarily high.
The State’s argument for state-wide expansion rests on cost-savings. In reality, the Georgetown 2008 Study and University of Florida’s study (commissioned by the legislature) could not conclude whether any cost savings were derived from increased efficiencies or denial of care/ reimbursement. Improved quality and accessibility were never determined, relegated to a status of secondary importance.
Thereafter, BCMA’s voice for unfettered care by physicians promoted dialogue with State/Federal CMS Medicaid representatives to facilitate physicians’ concerns in a Medicaid workshop in Hollywood for physicians, patients, legislators, and hospital leaders. The BCMA’s voice was heard in state and national media.
Expansion of the Medicaid Reform Pilot Statewide
In 2011, the Florida Legislature passed legislation expanding Reform statewide and placing all Medicaid patients into MCO/PSN. Because of haste, these bills are flawed because they fail to safeguard and account for the availability of physicians-hospitals to provide quality care and access for patients, creating new financial implications and inherited bureaucracy. Among them, a complicated shared-savings with MCOs, obligating them to return to the state 50% of profit that exceeds 5-10%. At best, an imperfect attempt to compel MCOs to spend 90% of the dollars treating patients. There was no specificity defining the adequacy of patient care beyond a vague “establishing a health care quality improvement system for incorporating standards in care.”
Centers for Medicare and Medicaid Services-CMS
An April 2011 letter, from CMS to Florida’s AHCA, specified that CMS would NOT approve implementation of statewide expansion until specified criteria are met. “Such a plan will need to ensure that access to and quality of health care is ensured.
We have asked CMS not to extend the waiver nor allow the State to expand the program state-wide because Florida has failed and is still failing to address uncorrected concerns by patients, physicians, and hospitals alike.
Despite the reality that physicians consume only 5% of the Medicaid budget, there is no incentive for physicians to participate in this tortuous and patient hostile system. Given this dismal experience, the state should find better alternatives and safeguards. History is usually a predictor of the future.