Several women had stories to tell about their children. Laquesha Brown, 21, said she didnt take her 2-year-old son to see a pediatrician frequently because she thought his HMO required her to pay half of his charges. She waited until he had a real bad asthma attack before taking him to the Hollywood Memorial ER. She still hasnt gotten the bill.
No Medicaid plan requires 50 percent payments, but Elkin, Browns obstetrician, called it extraordinarily frightening that somehow she had gotten that idea, because it would clearly hinder her seeking care for her child.
But its not all negative. Arlene Wilson of South Broward said she was hit with an ER bill of $740 to pay even though shes on Medicaid, but her 2-year-old son with asthma has no trouble getting a quick appointment with his pediatrician.
Maura Mendoza, 24 and pregnant, said she struggled for months to get qualified for Medicaid for this second pregnancy. But she praised the care of her daughter, Leah, 7 months, who has Better Health, the for-profit PSN. Its easy to get an appointment, she said. That insurance helped a lot.
Last December, UF released its 76-page study of the first five years of the pilot project. Florida Medicaid, which paid for the report, forwarded it to Washington listing its positives: improved access for consumers, higher scores in quality measures, taxpayer savings.
Lead-author Duncan summarized the report, saying the pilot appears to have cut costs, without a huge outcry from unhappy patients.
A UF colleague in health services research, professor Jeffrey Harman, estimates that reform expenses were roughly $100 million lower annually than would have been expected if the patients were in traditional Medicaid.
But the key question is it greater efficiency or reduced care that is lowering costs? remains unanswered. Duncan says new data may shed light on that but that he hasnt yet found the money to continue the study.
Were hopeful that we can close some of these remaining questions before the state takes this statewide, he says.
Some bottom-line findings of the study: Customer satisfaction in the reform plans differed little from those outside reform. In measuring costs, most PSNs showed greater savings than HMOs. Speciality care continued to be a challenge, as it was for Medicaid recipients not in reform plans. And in mental health, two key measures frequency of patients committed under the Baker Act and arrest rates showed no change.
Though the plans showed some improvement in quality measures such as breast cancer screening and lead screening in children, most reform plans still ranked well below the performance of Medicaid HMOs elsewhere in the nation. The bonuses offered in return for healthy behaviors showed some benefit, with 70 percent of participants earning rewards to spend on nonprescription healthcare items. Most popular: diapers, sunscreen and toothpaste.
Responses to the report have been across the board. Benz, the Memorial executive, called it spot on, while Elkin, the Hollywood ob-gyn, said he was stunned the report was so different from what he hears from patients and colleagues. Its truly hard for me to imagine how they are getting their data.
The Florida Center for Fiscal and Economic Policy concluded the data showed overall access to primary care in the pilot counties was significantly and consistently worse than prior to the launch of reform. And a study financed by the Jessie Ball DuPont Fund found that the enhanced benefits program appeared to be popular with beneficiaries, but there was little evidence that it was changing behaviors.
A report on the website of the conservative Heritage Foundation cited the Duncan study when it called the pilot a decided success, predicting that if it is copied nationwide, patient satisfaction would rise and Medicaid programs could save up to $91 billion annually.
ABOUT THE FUTURE
Earlier this year, the Obama administration approved a three-year extension of the five-county pilot but insisted that HMOs and PSNs operating in the pilot spend at least 85 percent of the money they receive for healthcare on recipients, meaning no more than 15 percent can go for marketing, administration and profit.
The 85 percent requirement has been strongly opposed by Florida Gov. Rick Scotts administration as interfering with private enterprise, but Cabrera, the HMO executive, says most reform plans already operate within those margins.
Meanwhile, there are inklings of improvement in Floridas pilot. Rosenstock, the mother of the brain-damaged son who has badgered politicians and bureaucrats to get care for her son, said that for the past year, Jason has been in the Better Health PSN with a personal case manager dealing with his problems.
Though she continues to hit occasional obstacles, shes satisfied overall: Theyre really good.
The much larger issue is whether the federal government will accept the plan to take the pilot statewide, scheduled to start in 2014 for most recipients.
Senior, Floridas Medicaid director, says the statewide plan will include fixes to some issues that troubled the pilot. For the five-county pilot, most health plans were allowed in. For the state rollout, the number of health plans would be limited and they would have to bid to get the state contract. If a plan dropped out of one area because it wasnt doing well, it would be required to drop out of the whole state to prevent cherry-picking.
State Democratic leaders and others have written to the Obama administration asking that it reject or greatly modify Floridas statewide plans. The Florida Medical Association, which represents the states doctors, also sent a letter opposing the plan.
The Obama administration has yet to rule on the statewide plan, but it has rejected two of its provisions requiring the poor to have a $10 co-pay for doctors visits and a $100 co-pay for non-emergency visits to ERs, regardless of age or ability to pay.
Obamas team has yet to decide on the 85 percent requirement. Sen. Nan Rich, D-Sunrise, who has opposed much of the pilot, believes thats absolutely key: You have to protect the consumers. These are extremely vulnerable people.
Yet after all these years of intense debate, the two sides agree that change is necessary. Both the Obama administration and the Florida pilot aim to eliminate fee-for-service plans.
Medicaid managed care is here to stay, Rich said. Everybody wants to move away from fee-for-service. Its the most costly way of doing business. Negron, her Republican counterpart, agrees.
The larger question remains: Whats the best way to manage care?
The Obama administration is looking closely at Oregon, where the governor, a former emergency room doctor, is establishing a coordinated care organization in each major city in which the main providers hospitals, doctors and others join together to manage care for the poor. While the Florida model depends on for-profits competing for business, Oregon wants to see if cooperation would be better.