FORT LAUDERDALE, Fla. - Federal health officials said Wednesday they expect to approve Florida's request to privatize Medicaid statewide as long as the state resolves several outstanding issues, including hiring an independent entity to monitor the process and having a robust plan to measure the quality of patient care in the controversial program.
The decision first reported by The Associated Press comes after nearly two years of negotiations between the state and the Centers for Medicare and Medicaid Services. Federal health officials heard from dozens of health advocates, doctors and patients about problems in a pilot program that has been running in Broward County, Duval County and three of its neighbors since 2006.
Federal health officials responded by insisting the state agree to tangible quality measurements using real-time data that evaluate whether the program is actually improving patient care along the way as promised, not just at yearly benchmarks. The state must also hold regular meeting with health advocates, patients and insurers and hire an ombudsmen to oversee the portion of the program that involves tens of thousands of elderly, long-term care patients, according to a letter sent by federal health officials to the state.
Federal health officials want the state to include "a comprehensive quality strategy that reflects the health needs of Florida beneficiaries, across the state's Medicaid program at large, that has specific data-driven achievable goals and strategies to achieve those goals that are aligned with the goals of improving care, improving health and lowering cost through these improvements," according to the letter.
Florida lawmakers passed sweeping bills in 2011, allowing them to expand a program that allows for-profit providers to determine the health care of 3 million of the state's poorest. The goal was to save the state money while improving services, though little solid data exists on whether the approach works.
"Improving the coordination of care in Medicaid means we will be able to better-manage chronic conditions and give more preventative treatments to help keep Florida families healthy," Gov. Rick Scott said.
He still has another big decision to make about Medicaid. Scott must consider whether he will expand Medicaid coverage to an estimate 900,000 more people under the federal health overhaul. Scott's spokespeople have said the governor was waiting on the privatization decision from the feds before making an announcement on Medicaid expansion.
Scott and other GOP lawmakers have repeatedly warned that Medicaid's roughly $21 billion annual costs were consuming Florida's budget and proposed the managed care plan to save money and improve care.
The privatization plan expands on a five-county pilot program that has been rife with problems. Critics worry for-profit providers are scrimping on patient care and denying medical services to increase profits. Some doctors have dropped out of the pilot program, complaining of red tape and that the insurers deny the tests and medicine they prescribe. Patients have complained they struggled to get doctor's appointments.
Several health plans also dropped out of the pilot program, saying they couldn't make enough money. Patients complained they were bounced from plan to plan with lapses in care. Nearly half of the 200,000 patients enrolled in the pilot have been dropped from at least one plan, federal health officials noted at one point during negotiations.
Lawmakers say they have fixed the pilot program's shortcomings, with provisions including increased oversight and more stringent penalties, including fining providers up to $500,000 if they drop out. The measures also increase doctors' reimbursement rates and limits malpractice lawsuits for Medicaid patients in hopes of increasing doctor participation in the program.
Advocates noted that the pending agreement with federal health officials is very different from the state's original proposal.
"The version of the experiment currently awaiting approval significantly limits the ability of managed care plans to vary benefits, evade accountability and consumer protections, and implement other dangerous elements of the original experiment...additionally, stronger accountability, oversight, and transparency requirements that will come with this waiver approval alleviate many of our worst fears," said Greg Mellowe, policy director of the health care advocacy group Florida CHAIN.
Earlier this month, the feds gave Florida the green light to move tens of thousands of older Medicaid recipients to get long-term care through managed care organizations, including home and community-based services to keep them out of nursing homes. But the feds are requiring an ombudsmen monitor that portion of the program.
Federal health officials have not given the state blanket approval of their initial request and nixed several proposals early in negotiations, including $10 monthly premiums on Medicaid beneficiaries and $100 co-pays for any non-emergency ER visits.
The state also had to agree to a provision that would require private health plans to spend 85 percent of funds on patient care. That issue had long been a sticking point, with state lawmakers instead pushing for a profit-sharing plan requiring providers to generate a 5 percent savings the first year.
Federal health officials said they have made significant progress in negotiations with the state and don't anticipate any roadblocks as they hammer out details for patient protection going forward.
"Florida can now get out of the check-writing business and into the contract compliance business, making sure that Medicaid recipients have access to primary care and to the medical specialists they need," said Republican Sen. Joe Negron, who shepherded the privatization plan through Florida's Legislature.
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