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Pediatricians: More obstacles to care under private Medicaid plans

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Polysystic ovary syndrome -- Many women with this hormonal disorder have irregular periods, weight gain and difficulty getting pregnant. It can also involve enlarged ovaries, but not always. The keys are infrequent or prolonged (iStock/ senkaya)

TALLAHASSEE, Fla. – Florida pediatricians say children covered by Medicaid face more obstacles to getting needed care than they did before the state switched them over to private health-care plans, a recent survey found.

The survey, released last month by Georgetown University's Health Policy Institute, showed that two-thirds of responding physicians saw an increase in the number of Florida children being reassigned to other doctors or health-care plans without their parents' knowledge or consent.

"Some of our patients keep getting switched to plans where they have to go all the way across the state for primary care," one physician reported.

Respondents also said newborns were assigned to different plans than their mothers, while medical staff spent considerable time helping families return to their previous plans so that children could stay with their regular doctors.

"We spend much time and money appealing denials, even for treatments that patients have received for many years," a respondent said.

The state's Medicaid program has undergone a ten-year transition to managed care, with 95 percent of children covered by Medicaid moved to private managed-care plans by July 2015.

Under the new system, the managed-care plans get a monthly fee rather than payment for individual services --- and the Georgetown survey was, in part, designed to evaluate the change.

It found that 84 percent of pediatricians said their patients in Medicaid managed care had difficulty obtaining prescriptions or over-the-counter medications, while 55 percent had cases in which a health plan kept them from providing needed treatment due to limits on benefits or requirements for prior authorization from the plans. Fifty-nine percent said families struggled to find specialists who would accept Medicaid, with referrals to behavioral or mental-health professionals the most difficult to fill.

Sarasota pediatrician Carola Fleener said Thursday she often advised patients to pay out of pocket for crutches or prescriptions they needed immediately, because getting the plans to approve would take too long.

Fleener also said the reimbursement rate for seeing Medicaid patients is so low that many doctors can't afford it --- and that private plans often challenge or deny their requests for payment.

Additionally, the survey found that just 27 percent of Florida children covered by Medicaid and the Children's Health Insurance Program receive preventive dental care, compared to 48 percent of the programs' recipients nationwide.

The survey was distributed to members of the Florida Chapter of the American Academy of Pediatrics from late February to early May. The sample size of 131 respondents was small --- just under 6 percent of those contacted --- although the study noted that 61 percent of those responding drew a majority of their patients from Medicaid enrollees.

However, the Florida Agency for Health Care Administration, which oversees the state's Medicaid program, said the respondents represent less than 1 percent of all of the 37,593 physicians "who can provide services to our recipients."

"We would not say that this survey is a true reflection of the program," AHCA spokeswoman Mallory McManus wrote in an email.

Additionally, McManus said, surveys by the private plans show that those enrolled in Medicaid managed care "are satisfied with the access and care they are receiving."

"We have on average fewer than two complaints from patients in any given month about having their plans switched, and we process those complaints promptly," she wrote. "All Medicaid-eligible children are receiving medically necessary services. If anyone is aware of a child who is not receiving medically necessary care, they need to contact AHCA immediately."

Others, however, say the state fails to provide proper oversight of its Medicaid managed-care plans.

"Florida has some decent protections in the managed-care contracts, but they're clearly not being enforced," said Joan Alker, executive director of Georgetown's Center for Children and Families, in a recent interview.

"I don't see where (the state is) overseeing anything," Fleener said.

But Heather Urquides, spokeswoman for WellCare Health Plans, wrote in an email that the state is diligent in overseeing her company's Staywell program for Medicaid beneficiaries.

"As part of the selection process, Staywell committed to meeting stringent benchmarks and quality metrics to ensure our members get the care they need," Urquides wrote. "The state aggressively manages our performance to ensure we deliver on those commitments."

Alker, however, said the complaint process for Medicaid managed care is "deeply buried" in AHCA's website.

"It's clear that families are not well-informed about what to do if they have a problem," she added.

McManus said AHCA "takes very seriously the level of care all Florida Medicaid recipients receive."

"We have strengthened our contracts and our oversight to the highest levels ever in the program," she said. "The contracts give the agency the authority to ensure that our plans are providing the highest quality of care."