http://noewait.blogspot.com/p/about-waiting-lists.html
Until the 1960’s, people with developmental disabilities received services in large institutions or their family provided care with little in the way of government support. Class action law suits and intense scrutiny of the horrifying conditions in institutions led to public outcry and change. The Community Mental Health Act of 1963 began the deinstitutionalization of people with developmental disabilities (and mental health issues). Medicaid was created in 1965 to provide care for this population and others. In 1972, Title XIX of Medicaid program added a new benefit called Intermediate Care Facilities (ICF/MR) Most ICF’s are large congregate care facilities focused on intensive medical or behavioral intervention, and they are both public and privately operated. The Americans With Disabilities Act of 1990 contained an 'integration mandate' that requires public agencies to provide services "in the most integrated setting appropriate to the needs of qualified individuals with disabilities." In 1999, the Olmstead decision of the Supreme Court upheld the ADA’s integration mandate when the state of Georgia appealed to enforce institutionalization.
Approximately 4 million Americans have developmental disabilities. These individuals attend school, usually until they are 21 years old. At that point, they move into the adult services category and should receive services through “Home and Community-based Waivers.” Because Waivers are not an entitlement, in almost all states they are not fully funded to meet the need and involve variations in the types and intensity of services and supports that are offered. This results in waiting lists and lack of portability of services from one state to another and one county to another. The time periods people can be left waiting for help obtaining job services, a community-based program, or a secure home in which to live can be anywhere from five to twenty years long, depending upon the state and the type of service needed.
Tens of thousands of people are on waiting lists for Waiver services. Few families can afford to pay out-of-pocket for these services (an average of $35,000 - $75,000) per year for host or group home placements because parents have had to leave careers to care for their children and pay for large medical bills.
The result of this lack of access to services is that people with developmental disabilities sit at home with their parents with nothing to do and nowhere to go. Most often one of their parents must leave their employment to stay at home to take care of them. And as the parents age, older adults with disabilities – especially those in the “baby boom” generation often have no one to care for them and the entire family is in crisis. We know many parents in their 70’s and 80’s needing care themselves who continue to care-give for their sons and daughters in very difficult situations. There are many cases where parents have passed away, leaving their adult child without a place to live. In cases where parents have found their adult children cannot be managed at home because of severe behavioral issues, or physical problems – they, too, wait for disaster to strike. When these families do not even have access to long-term care for their loved ones or choices for that care near their homes, the rights of these individuals are denied. Families are even unable to move to other states or counties to accept better jobs, for example, because the price they may pay for doing so would be that their adult child will lose all of their services and go to the end of the line in their new state home. Parents and sometimes siblings who have been left to care for these individuals are strained to their limits – having to advocate daily in their communities, through their legislators and others just to obtain these basic human services.
Essentially, were have regressed back to the 1960’s, when parents and families had no support in taking care of their loved ones with developmental disabilities.
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Tuesday, April 5, 2011
Monday, April 4, 2011
Sun Sentinel Article on Medicaid Cuts
http://www.sun-sentinel.com/health/fl-hk-state-health-cuts-20110404,0,2079968.story
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Saturday, April 2, 2011
NY Times article on Medicaid Cuts
nyti.ms
Under last year’s overhaul, Medicaid rolls are expected to grow drastically, but budget woes have states reducing payments to caregivers.
LAFAYETTE, La. — Eight-year-old Draven Smith was expelled from school last year for disruptive behavior, and he is being expelled again this year. But his mother and his pediatrician cannot find a mental health specialist to treat him because he is on Medicaid, and the program, which provides health coverage for the poor, pays doctors so little that many refuse to take its patients.
LAFAYETTE, La. — Eight-year-old Draven Smith was expelled from school last year for disruptive behavior, and he is being expelled again this year. But his mother and his pediatrician cannot find a mental health specialist to treat him because he is on Medicaid, and the program, which provides health coverage for the poor, pays doctors so little that many refuse to take its patients.
Michael Stravato for The New York Times
Dr. Rachel Chatters, right, with Ana Smith, says she begs specialists to see Medicaid patients.
Related
Arizona Asks to Set Fines for Health Risks (April 2, 2011)
Michael Stravato for The New York Times
Ms. Smith said she has tried for more than a year to find a psychiatrist to treat her son Draven, 8, who is on Medicaid.
The problem is common here and across the country, especially as states, scrambling to balance their budgets, look for cuts in Medicaid, which is one of their biggest expenditures. And it presents the Obama administration with a major challenge, since the new federal health care law relies heavily on Medicaid to cover many people who now lack health insurance.
“Having a Medicaid card in no way assures access to care,” said Dr. James B. Aiken, an emergency physician in New Orleans.
Nicole R. Dardeau, 46, a nurse in Opelousas, La., in the heart of Cajun country, can attest to that. She said she could not work because of unbearable pain in her right arm. Doctors have found three herniated discs in her neck and recommended surgery, but cannot find a surgeon to take her as a Medicaid patient.
From her pocketbook, she pulls an insurance card issued by the Louisiana Department of Health and Hospitals.
“My Medicaid card is useless for me right now,” Ms. Dardeau said over lunch. “It’s a useless piece of plastic. I can’t find an orthopedic surgeon or a pain management doctor who will accept Medicaid.”
Medicaid, which is paid for jointly by the federal and state governments, is the subject of an intense debate in Washington over how to make it more efficient as Congress addresses the budget deficit and the growing federal debt.
But for now the administration is counting on Medicaid to play a vital role in expanding access to care under the law President Obama signed last year. The program is already a major presence here, paying for 70 percent of births in Louisiana. State health officials estimate that the Medicaid program will grow by more than 40 percent as a result of the federal health law, with the addition of 467,000 new recipients to 1.1 million now on the rolls.
“How can an already overtaxed Medicaid system handle such a huge influx of people?” asked Dr. Michael A. Felton, a family doctor in Church Point, La., near Lafayette.
It is a question being asked in many states. With the expansion of Medicaid to cover nearly all people under 65 with incomes up to 133 percent of the official poverty level (up to $29,330 a year for a family of four), Medicaid will soon be the nation’s largest insurer. It accounts for almost half of the increase in coverage expected under Mr. Obama’s health law, but has received less attention than other parts of the law regulating private insurance.
The Congressional Budget Office predicts that average monthly Medicaid enrollment, now 56 million, will rise to 71 million by 2016, with another five million people added to the rolls in the five years after that.
Like many states, Louisiana has been struggling with a fiscal crisis. To hold down costs, it has cut Medicaid payments to doctors, dentists, hospitals and other health care providers several times in the last two years. Many providers report that the cuts, taken together, total 15 percent to 20 percent.
Louisiana officials said the cuts were necessary for two reasons: to avoid a budget deficit in the Medicaid program and to comply with a state law that limits Medicaid spending to amounts appropriated by the State Legislature.
For patients like Draven Smith, whose mother said his behavior problems stemmed from attention-deficit hyperactivity disorder, the result is lack of access to doctors, especially specialists. For Draven’s pediatrician, Dr. Rachel Z. Chatters in Lake Charles, La., caring for poor children is a mission. About 80 percent of her patients are on Medicaid. It is, she said, frustrating to beg and plead with other doctors to see Medicaid recipients.
“I devote one afternoon a week, every Wednesday afternoon, to trying to find specialists for my patients — a pulmonologist for children with chronic persistent asthma, a neurologist for children with seizures or developmental delays, a psychiatrist for children with serious mental health problems, a hematologist for patients with sickle cell disease,” Dr. Chatters said.
Draven’s mother, Ana M. Smith, said: “I have tried for more than a year to find a child psychiatrist or psychologist to get Draven evaluated, but the mental health professionals in this area have told me they absolutely do not take Medicaid. If Draven could get the help he needs, I believe it would be unbelievably beneficial to him.”
Some uninsured people will surely receive better care when they gain Medicaid coverage, doctors say. The new health law calls for a temporary two-year increase in Medicaid payments for some primary care services, but this does not affect specialists.
With the expansion of Medicaid in 2014, Louisiana officials expect to enroll three groups: 260,000 newly eligible parents and childless adults, 20,000 parents now eligible but not enrolled and 187,000 adults and children who drop private coverage and sign up for Medicaid.
Bruce D. Greenstein, secretary of the Louisiana Department of Health and Hospitals, said, “We have a hard time finding specialists for Medicaid enrollees.”
Mr. Greenstein said the state expected to improve care and save money by enrolling most Medicaid recipients in managed care, an approach adopted by many states in recent years. In return for fixed monthly fees paid by the state, private health plans would coordinate the care of Medicaid patients, using networks of providers.
In passing the new health law, Congress wanted to make sure current Medicaid recipients would not lose coverage. Under the law, states generally cannot roll back Medicaid eligibility, but they can cut Medicaid in other ways — by reducing provider payment rates or by eliminating optional benefits.
About 20 states cut Medicaid payment rates for doctors last year, according to a survey by the Kaiser Family Foundation. At least 16 governors have proposed rate reductions this year for health care providers.
Gov. John Kitzhaber of Oregon, a Democrat, proposed cutting Medicaid payment rates for doctors, dentists, hospitals and nursing homes by 19 percent. Christine Miles, a spokeswoman for Mr. Kitzhaber, said his priority was to preserve eligibility.
In Illinois, Gov. Pat Quinn, a Democrat, has proposed reducing Medicaid reimbursement rates by 6 percent for hospitals and nursing homes.
Gov. Brian Sandoval of Nevada, a Republican, has proposed cutting Medicaid rates by 5 percent for hospitals, 15 percent for nonprimary care doctors and 25 percent for dentists.
In South Dakota, Gov. Dennis Daugaard, a Republican, just signed a budget bill cutting Medicaid rates for doctors, dentists, hospitals and nursing homes — even primary care physicians and pediatricians.
States have broad discretion in setting Medicaid payment rates. Federal law sets standards, but they are rather vague. Rates are supposed to be “consistent with efficiency, economy and quality of care,” and sufficient to ensure that services are available to Medicaid recipients at least to the same extent as to the general population in the area.
In a few states, Medicaid recipients and providers have blocked cuts or secured higher reimbursement through litigation. But in many states, the promise of equal access remains unfulfilled.
Dr. Kim A. Hardey, an obstetrician-gynecologist in Lafayette, said he received about $1,000 from the Louisiana Medicaid program for providing prenatal care and delivery for a full-term pregnancy, compared with $2,400 from private insurance.
With the expansion of Medicaid eligibility, he said, more of his patients will be on Medicaid, and fewer will have private insurance, which helps offset the financial losses doctors sustain on their Medicaid business.
Already, Dr. Hardey said, many of his patients have jobs with private insurance but switch to Medicaid when they become pregnant, avoiding premiums, deductibles and co-payments.
“Having a Medicaid card in no way assures access to care,” said Dr. James B. Aiken, an emergency physician in New Orleans.
Nicole R. Dardeau, 46, a nurse in Opelousas, La., in the heart of Cajun country, can attest to that. She said she could not work because of unbearable pain in her right arm. Doctors have found three herniated discs in her neck and recommended surgery, but cannot find a surgeon to take her as a Medicaid patient.
From her pocketbook, she pulls an insurance card issued by the Louisiana Department of Health and Hospitals.
“My Medicaid card is useless for me right now,” Ms. Dardeau said over lunch. “It’s a useless piece of plastic. I can’t find an orthopedic surgeon or a pain management doctor who will accept Medicaid.”
Medicaid, which is paid for jointly by the federal and state governments, is the subject of an intense debate in Washington over how to make it more efficient as Congress addresses the budget deficit and the growing federal debt.
But for now the administration is counting on Medicaid to play a vital role in expanding access to care under the law President Obama signed last year. The program is already a major presence here, paying for 70 percent of births in Louisiana. State health officials estimate that the Medicaid program will grow by more than 40 percent as a result of the federal health law, with the addition of 467,000 new recipients to 1.1 million now on the rolls.
“How can an already overtaxed Medicaid system handle such a huge influx of people?” asked Dr. Michael A. Felton, a family doctor in Church Point, La., near Lafayette.
It is a question being asked in many states. With the expansion of Medicaid to cover nearly all people under 65 with incomes up to 133 percent of the official poverty level (up to $29,330 a year for a family of four), Medicaid will soon be the nation’s largest insurer. It accounts for almost half of the increase in coverage expected under Mr. Obama’s health law, but has received less attention than other parts of the law regulating private insurance.
The Congressional Budget Office predicts that average monthly Medicaid enrollment, now 56 million, will rise to 71 million by 2016, with another five million people added to the rolls in the five years after that.
Like many states, Louisiana has been struggling with a fiscal crisis. To hold down costs, it has cut Medicaid payments to doctors, dentists, hospitals and other health care providers several times in the last two years. Many providers report that the cuts, taken together, total 15 percent to 20 percent.
Louisiana officials said the cuts were necessary for two reasons: to avoid a budget deficit in the Medicaid program and to comply with a state law that limits Medicaid spending to amounts appropriated by the State Legislature.
For patients like Draven Smith, whose mother said his behavior problems stemmed from attention-deficit hyperactivity disorder, the result is lack of access to doctors, especially specialists. For Draven’s pediatrician, Dr. Rachel Z. Chatters in Lake Charles, La., caring for poor children is a mission. About 80 percent of her patients are on Medicaid. It is, she said, frustrating to beg and plead with other doctors to see Medicaid recipients.
“I devote one afternoon a week, every Wednesday afternoon, to trying to find specialists for my patients — a pulmonologist for children with chronic persistent asthma, a neurologist for children with seizures or developmental delays, a psychiatrist for children with serious mental health problems, a hematologist for patients with sickle cell disease,” Dr. Chatters said.
Draven’s mother, Ana M. Smith, said: “I have tried for more than a year to find a child psychiatrist or psychologist to get Draven evaluated, but the mental health professionals in this area have told me they absolutely do not take Medicaid. If Draven could get the help he needs, I believe it would be unbelievably beneficial to him.”
Some uninsured people will surely receive better care when they gain Medicaid coverage, doctors say. The new health law calls for a temporary two-year increase in Medicaid payments for some primary care services, but this does not affect specialists.
With the expansion of Medicaid in 2014, Louisiana officials expect to enroll three groups: 260,000 newly eligible parents and childless adults, 20,000 parents now eligible but not enrolled and 187,000 adults and children who drop private coverage and sign up for Medicaid.
Bruce D. Greenstein, secretary of the Louisiana Department of Health and Hospitals, said, “We have a hard time finding specialists for Medicaid enrollees.”
Mr. Greenstein said the state expected to improve care and save money by enrolling most Medicaid recipients in managed care, an approach adopted by many states in recent years. In return for fixed monthly fees paid by the state, private health plans would coordinate the care of Medicaid patients, using networks of providers.
In passing the new health law, Congress wanted to make sure current Medicaid recipients would not lose coverage. Under the law, states generally cannot roll back Medicaid eligibility, but they can cut Medicaid in other ways — by reducing provider payment rates or by eliminating optional benefits.
About 20 states cut Medicaid payment rates for doctors last year, according to a survey by the Kaiser Family Foundation. At least 16 governors have proposed rate reductions this year for health care providers.
Gov. John Kitzhaber of Oregon, a Democrat, proposed cutting Medicaid payment rates for doctors, dentists, hospitals and nursing homes by 19 percent. Christine Miles, a spokeswoman for Mr. Kitzhaber, said his priority was to preserve eligibility.
In Illinois, Gov. Pat Quinn, a Democrat, has proposed reducing Medicaid reimbursement rates by 6 percent for hospitals and nursing homes.
Gov. Brian Sandoval of Nevada, a Republican, has proposed cutting Medicaid rates by 5 percent for hospitals, 15 percent for nonprimary care doctors and 25 percent for dentists.
In South Dakota, Gov. Dennis Daugaard, a Republican, just signed a budget bill cutting Medicaid rates for doctors, dentists, hospitals and nursing homes — even primary care physicians and pediatricians.
States have broad discretion in setting Medicaid payment rates. Federal law sets standards, but they are rather vague. Rates are supposed to be “consistent with efficiency, economy and quality of care,” and sufficient to ensure that services are available to Medicaid recipients at least to the same extent as to the general population in the area.
In a few states, Medicaid recipients and providers have blocked cuts or secured higher reimbursement through litigation. But in many states, the promise of equal access remains unfulfilled.
Dr. Kim A. Hardey, an obstetrician-gynecologist in Lafayette, said he received about $1,000 from the Louisiana Medicaid program for providing prenatal care and delivery for a full-term pregnancy, compared with $2,400 from private insurance.
With the expansion of Medicaid eligibility, he said, more of his patients will be on Medicaid, and fewer will have private insurance, which helps offset the financial losses doctors sustain on their Medicaid business.
Already, Dr. Hardey said, many of his patients have jobs with private insurance but switch to Medicaid when they become pregnant, avoiding premiums, deductibles and co-payments.
Join our listserv, and visit us on Facebook (adaexpertise). Send us a message, at mdubin@pobox.com. Twitter? @ADAexpertise
Problems with Medicaid Reform in Florida Exposed - FL Moves Forward Anyway
http://www.palmbeachpost.com/health/grading-hmos-medicaid-test-the-state-prepares-to-1360961.html?viewAsSinglePage=true
TALLAHASSEE — Amy Silverman said she feels like a refugee - lucky to have escaped from a frightening place, but at a very high cost.
Silverman, 55, of suburban Delray Beach, fled Broward County last year to break free of Florida's 5-year-old experiment, which placed most Medicaid patients there in managed care.
One county north, helped by aging parents who emptied retirement accounts to ease her move, Silverman said her health has improved.
In Palm Beach County, she's back in conventional Medicaid coverage, which provides her access to the same doctor on a regular basis and to medication the doctor prescribes.
But she worries: The experiment is poised to go statewide.
"I am horrified that the legislature is even considering spreading Medicaid reform to the rest of Florida," said Silverman, who is covered by the program for a psychiatric disability. "This will be horrible and I don't want anyone to go through what I did."
In a bid to squeeze $1 billion out of a recession-wracked state budget, Florida lawmakers are set to push most of the state's 2.9 million Medicaid patients into HMO-style health coverage plans, similar to those launched in Broward, Baker, Clay, Nassau and Duval counties, beginning in 2006.
Republican Gov. Rick Scott and the GOP-led legislature say the statewide effort will inject private-sector efficiency into a government-run system plagued by skyrocketing costs, fraud and poor management.
Others say it will only magnify problems that marred the five-county pilot program.
"We've seen plenty of red flags raised in the pilot counties, like Broward," said Joan Alker, a professor at Georgetown University Health Policy Institute, who has been studying Florida's overhaul. "This is a very vulnerable population. And the more barriers you put up to them receiving care, the more likely that they will not get care or just wind up in emergency rooms."
Silverman said that was her experience.
Enrolled in Broward HMOs for four years, Silverman said she rarely saw the same doctor twice, was placed on different medication by her plan to save money and saw her condition worsen - in part, because of the emotional toll the program took on her.
"It was hell," Silverman said.
"This program doesn't save money," she said. "This was all about making money. The managed care companies just pocketed what they could. Decent doctors dropped out, and the patients were left holding the bag."
Costs rising quickly
The state, though, has learned from these missteps, supporters said.
"We've gone out and heard from people," said Sen. Joe Negron, R-Stuart, the Senate's Health and Human Services budget chief. "We've heard the stories about people bouncing from plan to plan. We've heard about people not being able to see specialists. But we've also heard that the current system is irretrievably broken, and we're starting a new program."
Florida's Medicaid spending is on track to reach $22 billion next year - almost one-third of the state's depleted budget, although the federal government will pay about $12 billion .
Medicaid costs are stoked by the state's prolonged economic slump, with patient rolls climbing, as Floridians losing jobs find themselves without health coverage.
But with state lawmakers struggling to close an almost $3.8 billion budget shortfall, Medicaid has been targeted as a fat, wasteful program in need of a fix.
The House and Senate are advancing different Medicaid overhauls, but both are anchored on managed care.
The House dealt with two dozen proposed amendments to its plan (CS/HB 7107, CS/HB 7109) Tuesday, before giving it preliminary approval, with a final vote expected Thursday. The Senate holds the first hearing on its bill (SB 1972) today, in the Health Regulation Committee.
Scott, who built his $218 million net worth in the health care industry, backs the change.
"The biggest driver in our budget right now is the cost of Medicaid," Scott said. "We need to have a viable safety net for the poor. We've got to come up with a better way to make sure the dollars are spent better."
Supporters point to the success of other states, where more modest overhauls of Medicaid have cut rising costs. Arizona, Georgia and Texas have all reported saving hundreds of millions of dollars through managed care, compared with traditional fee-for-service Medicaid programs.
The underlying premise of the Medicaid revamp is to improve health care services by giving managed care plans authority to design programs that meet the specific needs of patients, improve preventive health services and promote cost-saving competition between plans.
Instead of sick or injured patients showing up in doctor's offices or emergency rooms seeking treatment, with bills paid directly by Medicaid, health management organizations would guide patients into health plans and manage the dollars.
Patients would have to use doctors within a plan's network, and prescriptions would be limited to those on formulary lists approved by the managed care plan.
Most analysts agree for-profit HMOs will dominate the new system, but neither the House nor Senate would require health care providers to be HMOs. Provider service networks operated by hospitals or doctors' groups also are envisioned, along with other forms of managed care.
How much profit?
The House and Senate disagree, for now, on how to divide the state into managed care regions. They also differ on how to hold HMOs and other types of plans accountable for serving patients.
The Senate would force plans to spend 90 percent of the money they receive on care - known in the insurance industry as a "medical loss ratio." The House proposes a profit-sharing formula that would require plans to reimburse the state if they make more than 5 percent in profits.
Michael Garner, president of the Florida Association of Health Plans, said HMOs prefer the House proposal, fearing the Senate approach would add heavy administrative costs.
HMOs work on a modest profit margin, anywhere from 1 percent to 3 percent, he said. But the legislative proposals are built in a way that competition will yield lower cost and better quality, Garner said.
"I think we've all learned from the pilot program," he said.
The five-county experiment prompted a revolving door of managed care plans, patients and doctors said.
Patients, who are predominantly low income, complained of being shuffled from one to another, with HMOs or provider service networks cutting costs by denying or delaying care, and restricting access to medications.
"It was like our names were just tossed into a lottery," said Kendra Garcia, of Miramar, whose three young children receive treatment for emotional and developmental issues. "I've been put into so many different plans, I probably have five different cards right now in my purse."
Obstacles and complexity
Health care providers also struggled. Dr. Lydia Reid, a Broward speech and language pathologist, said patients she treated had to find another doctor when HMOs declined to include her in their networks.
"I was told by the plans, they had enough, they didn't need anyone else in my specialty," Reid said. "But I've also had patients tell me the doctors they're assigned are far away. And they can't get there by bus."
But Rep. Ronald Renuart, R-Ponte Vedra Beach, a doctor, said a reworked Medicaid system holds promise in Florida - if done right.
"The costs go up when the doctor isn't preventing illness, trying to get the patient out of the hospital, isn't managing the patient," Renuart said. "That's uncoordinated care. And that's what we have now in Florida."
Renuart said he hopes that provider service networks run by doctor groups or hospitals emerge as potent competitors to HMOs in the new Florida system. He thinks they can better coordinate a patient's complete care.
Still, he acknowledged a lingering fear: that state Medicaid costs will decline only because the poor, elderly or disabled aren't seeking care in a system that proves too complex to navigate, or denies easy access to treatment.
"I would hope it doesn't come to that," Renuart said.
Join our listserv, and visit us on Facebook (adaexpertise). Send us a message, at mdubin@pobox.com.
Twitter? @ADAexpertise.
TALLAHASSEE — Amy Silverman said she feels like a refugee - lucky to have escaped from a frightening place, but at a very high cost.
Silverman, 55, of suburban Delray Beach, fled Broward County last year to break free of Florida's 5-year-old experiment, which placed most Medicaid patients there in managed care.
One county north, helped by aging parents who emptied retirement accounts to ease her move, Silverman said her health has improved.
In Palm Beach County, she's back in conventional Medicaid coverage, which provides her access to the same doctor on a regular basis and to medication the doctor prescribes.
But she worries: The experiment is poised to go statewide.
"I am horrified that the legislature is even considering spreading Medicaid reform to the rest of Florida," said Silverman, who is covered by the program for a psychiatric disability. "This will be horrible and I don't want anyone to go through what I did."
In a bid to squeeze $1 billion out of a recession-wracked state budget, Florida lawmakers are set to push most of the state's 2.9 million Medicaid patients into HMO-style health coverage plans, similar to those launched in Broward, Baker, Clay, Nassau and Duval counties, beginning in 2006.
Republican Gov. Rick Scott and the GOP-led legislature say the statewide effort will inject private-sector efficiency into a government-run system plagued by skyrocketing costs, fraud and poor management.
Others say it will only magnify problems that marred the five-county pilot program.
"We've seen plenty of red flags raised in the pilot counties, like Broward," said Joan Alker, a professor at Georgetown University Health Policy Institute, who has been studying Florida's overhaul. "This is a very vulnerable population. And the more barriers you put up to them receiving care, the more likely that they will not get care or just wind up in emergency rooms."
Silverman said that was her experience.
Enrolled in Broward HMOs for four years, Silverman said she rarely saw the same doctor twice, was placed on different medication by her plan to save money and saw her condition worsen - in part, because of the emotional toll the program took on her.
"It was hell," Silverman said.
"This program doesn't save money," she said. "This was all about making money. The managed care companies just pocketed what they could. Decent doctors dropped out, and the patients were left holding the bag."
Costs rising quickly
The state, though, has learned from these missteps, supporters said.
"We've gone out and heard from people," said Sen. Joe Negron, R-Stuart, the Senate's Health and Human Services budget chief. "We've heard the stories about people bouncing from plan to plan. We've heard about people not being able to see specialists. But we've also heard that the current system is irretrievably broken, and we're starting a new program."
Florida's Medicaid spending is on track to reach $22 billion next year - almost one-third of the state's depleted budget, although the federal government will pay about $12 billion .
Medicaid costs are stoked by the state's prolonged economic slump, with patient rolls climbing, as Floridians losing jobs find themselves without health coverage.
But with state lawmakers struggling to close an almost $3.8 billion budget shortfall, Medicaid has been targeted as a fat, wasteful program in need of a fix.
The House and Senate are advancing different Medicaid overhauls, but both are anchored on managed care.
The House dealt with two dozen proposed amendments to its plan (CS/HB 7107, CS/HB 7109) Tuesday, before giving it preliminary approval, with a final vote expected Thursday. The Senate holds the first hearing on its bill (SB 1972) today, in the Health Regulation Committee.
Scott, who built his $218 million net worth in the health care industry, backs the change.
"The biggest driver in our budget right now is the cost of Medicaid," Scott said. "We need to have a viable safety net for the poor. We've got to come up with a better way to make sure the dollars are spent better."
Supporters point to the success of other states, where more modest overhauls of Medicaid have cut rising costs. Arizona, Georgia and Texas have all reported saving hundreds of millions of dollars through managed care, compared with traditional fee-for-service Medicaid programs.
The underlying premise of the Medicaid revamp is to improve health care services by giving managed care plans authority to design programs that meet the specific needs of patients, improve preventive health services and promote cost-saving competition between plans.
Instead of sick or injured patients showing up in doctor's offices or emergency rooms seeking treatment, with bills paid directly by Medicaid, health management organizations would guide patients into health plans and manage the dollars.
Patients would have to use doctors within a plan's network, and prescriptions would be limited to those on formulary lists approved by the managed care plan.
Most analysts agree for-profit HMOs will dominate the new system, but neither the House nor Senate would require health care providers to be HMOs. Provider service networks operated by hospitals or doctors' groups also are envisioned, along with other forms of managed care.
How much profit?
The House and Senate disagree, for now, on how to divide the state into managed care regions. They also differ on how to hold HMOs and other types of plans accountable for serving patients.
The Senate would force plans to spend 90 percent of the money they receive on care - known in the insurance industry as a "medical loss ratio." The House proposes a profit-sharing formula that would require plans to reimburse the state if they make more than 5 percent in profits.
Michael Garner, president of the Florida Association of Health Plans, said HMOs prefer the House proposal, fearing the Senate approach would add heavy administrative costs.
HMOs work on a modest profit margin, anywhere from 1 percent to 3 percent, he said. But the legislative proposals are built in a way that competition will yield lower cost and better quality, Garner said.
"I think we've all learned from the pilot program," he said.
The five-county experiment prompted a revolving door of managed care plans, patients and doctors said.
Patients, who are predominantly low income, complained of being shuffled from one to another, with HMOs or provider service networks cutting costs by denying or delaying care, and restricting access to medications.
"It was like our names were just tossed into a lottery," said Kendra Garcia, of Miramar, whose three young children receive treatment for emotional and developmental issues. "I've been put into so many different plans, I probably have five different cards right now in my purse."
Obstacles and complexity
Health care providers also struggled. Dr. Lydia Reid, a Broward speech and language pathologist, said patients she treated had to find another doctor when HMOs declined to include her in their networks.
"I was told by the plans, they had enough, they didn't need anyone else in my specialty," Reid said. "But I've also had patients tell me the doctors they're assigned are far away. And they can't get there by bus."
But Rep. Ronald Renuart, R-Ponte Vedra Beach, a doctor, said a reworked Medicaid system holds promise in Florida - if done right.
"The costs go up when the doctor isn't preventing illness, trying to get the patient out of the hospital, isn't managing the patient," Renuart said. "That's uncoordinated care. And that's what we have now in Florida."
Renuart said he hopes that provider service networks run by doctor groups or hospitals emerge as potent competitors to HMOs in the new Florida system. He thinks they can better coordinate a patient's complete care.
Still, he acknowledged a lingering fear: that state Medicaid costs will decline only because the poor, elderly or disabled aren't seeking care in a system that proves too complex to navigate, or denies easy access to treatment.
"I would hope it doesn't come to that," Renuart said.
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Twitter? @ADAexpertise.
Friday, April 1, 2011
FL Legislature Proposes to require people with developmental disabilities to have managed care
April 1, 2011:
In a dramatic change from the current Medicaid Reform program currently in effect in several counties, the Florida legislature proposes to expand Medicaid Reform (managed care) statewide, and to include people with developmental disabilities in the mandated care. Presently, individuals with developmental disabilities are excluded from the Medicaid reform experiment.
From 2005: "Children with chronic medical conditions, Medicaid-eligible children in foster care, and persons with developmental disabilities (are excluded)." Source: http://www.ncsl.org/default.aspx?tabid=14043
Join our listserv, and visit us on Facebook (adaexpertise). Send us a message, at mdubin@pobox.com.
In a dramatic change from the current Medicaid Reform program currently in effect in several counties, the Florida legislature proposes to expand Medicaid Reform (managed care) statewide, and to include people with developmental disabilities in the mandated care. Presently, individuals with developmental disabilities are excluded from the Medicaid reform experiment.
From 2005: "Children with chronic medical conditions, Medicaid-eligible children in foster care, and persons with developmental disabilities (are excluded)." Source: http://www.ncsl.org/default.aspx?tabid=14043
Join our listserv, and visit us on Facebook (adaexpertise). Send us a message, at mdubin@pobox.com.
Analysis of Medicaid Reform Bill
From
George Andrew Summary of the Medicaid Reform bill 234 pages long as of 2-17-11.
This is as it relates to APD not including the medical part DD folks would still be subject to.
Executive Summary:
Adds Downs Diagnosis to our program.
Requires monthly payments by Medicaid recipients.
Prevents using a Medicaid service if employer has health care sponsored plan
Requires parental income based fee for DD kids in HCBS waivers.
Require AHCA to apply to modify Federal Waiver & run limited managed care if denied
Requires all Medicaid recipients to be enrolled in Medicaid managed care (Emphasis added)
Prevents Medicaid recipient from enrolling in managed care if has employer sponsored HC.
Plans require Primary care providers to get same Medicare rate
APD required to develop / implement a comprehensive redesign the program
AHCA can impose and collect fees from recipients if approved by Medicare s. 409.906(13)(d)
(Continued on site, at http://specialgathering.wordpress.com/2011/02/24/summary-of-florida-medicaid-reform-bill-as-it-relates-to-apd/)
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Specialgathering's Weblog
We are grateful for the work that George Andrew did in summerizing the Medicaid Reform Bill as it relates to APD. Andrew has more than a decade working with people with disabilities. He worked first for APD and later because a support coordinator, where he is currently serving.George Andrew Summary of the Medicaid Reform bill 234 pages long as of 2-17-11.
This is as it relates to APD not including the medical part DD folks would still be subject to.
Executive Summary:
Adds Downs Diagnosis to our program.
Requires monthly payments by Medicaid recipients.
Prevents using a Medicaid service if employer has health care sponsored plan
Requires parental income based fee for DD kids in HCBS waivers.
Require AHCA to apply to modify Federal Waiver & run limited managed care if denied
Requires all Medicaid recipients to be enrolled in Medicaid managed care (Emphasis added)
Prevents Medicaid recipient from enrolling in managed care if has employer sponsored HC.
Plans require Primary care providers to get same Medicare rate
APD required to develop / implement a comprehensive redesign the program
AHCA can impose and collect fees from recipients if approved by Medicare s. 409.906(13)(d)
(Continued on site, at http://specialgathering.wordpress.com/2011/02/24/summary-of-florida-medicaid-reform-bill-as-it-relates-to-apd/)
Join our listserv, and visit us on Facebook (adaexpertise). Send us a message, at mdubin@pobox.com.
Proposed Medicaid Changes Put Children With Disabilities at Risk
http://www.miamiherald.com/2011/03/29/2140322/dead-wounded-kids-at-center-of.html
“This bill is affecting the most vulnerable and needy people in the state of Florida – those are disabled children,” Maria Tejedor, an Orlando trial attorney, told lawmakers last week. “It creates two doors to the courthouse: One for the haves. And one for the have-nots.”
Read more: Article on Budget Cuts and Danger to Children
“This bill is affecting the most vulnerable and needy people in the state of Florida – those are disabled children,” Maria Tejedor, an Orlando trial attorney, told lawmakers last week. “It creates two doors to the courthouse: One for the haves. And one for the have-nots.”
Read more: Article on Budget Cuts and Danger to Children
Join our listserv, and visit us on Facebook (adaexpertise). Send us a message, at mdubin@pobox.com.
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