In previous Hospital News columns I’ve discussed the plans currently underway to move the Medicaid-eligible population into private HMO-style managed care plans. A pilot version of the program is currently underway in Broward County. Yet another managed care plan, Florida Senior Care, proposes to do the same thing with the age 60 and older Medicaid-eligible population. As I write this, the federal government is nearing the end of the 90-day period it has to review Florida’s application and to decide whether to permit the plan to go forward. If it approves, the Florida legislature will then have the final say as to if, how and when it will begin implementation.

Now comes word that Gov. Jeb Bush may call a special session of the legislature, possibly as early as October, to deal with the state’s property insurance crisis brought about by eight hurricanes in two years. Should the federal approval be received for Florida Senior Care, it’s entirely possible that Gov. Jeb Bush could add this issue to the legislative call, even though a different legislature would be sitting a month later, and two months later, a different governor.

I have long urged all health care providers and legislators to examine Florida Senior Care very closely before climbing aboard the bandwagon and that we need to know and fully discuss the operational details of FSC. So far, very little is known, so serious questions remain:

• Health care provider reimbursement rates are already inadequate. How can the private HMO cover its administrative costs and make its guaranteed profit without cutting provider rates further?
• How do providers maintain quality improvement when their lifeblood funding is restricted?
• How long will it take for providers to get paid?
• Under FSC, there will be multiple payor sources and multiple methods of billing. Who reimburses the providers for this extra administrative cost?
• Will HMO quality and provider credentialing programs duplicate existing state regulation, adding still more administrative cost?
• Will cost considerations tempt the HMO to place the person in the least expensive setting versus the setting that is most appropriate to his or her need?
• What happens if the health care provider doesn’t agree to the HMO’s low-ball reimbursement rate? Is it frozen out of the provider network? Remember the “any willing provider” struggles of the early 1990s?
• What happens if a condition of the health facility’s license is that it serve a defined percentage of Medicaid patients and the HMO doesn’t send it enough?
• Who will compensate the provider if the person receiving care is later deemed ineligible for Medicaid?

That last question should be of particular interest to hospitals because it will be they who will have to care for elderly patients while Medicaid eligibility is being determined. Under FSC, I’m doubtful any nursing home would admit a person if there’s even a chance of not being compensated for the care it provides.

As a nursing home operator, I’m all for a special legislative session because the legislature can do something about the property insurance crisis that profoundly affects nursing homes too. If the call is expanded as described above, it could finally bring us the answers to key FSC questions. And who knows, the legislature in its wisdom could also consider an override of Gov. Bush’s May veto of $91 million in Medicaid funding for nursing homes. That would be a real and welcome “October Surprise.”

It’s certainly shaping up to be an interesting Fall!