Crist vetoes HMO increase bill and landlords bill

http://miamiherald.typepad.com/nakedpolitics/2007/05/crist_vetoes_hm.html

Gov. Charlie Crist late tonight announced that he has vetoed four bills, including a controversial measure that gave a rate increase to Medicaid HMOs and repealed a state law that mandated how much Medicaid plans must spend on providing mental health services to Medicaid patients.

Crist also vetoed a bill dealing with cosmetology, a bill that changes how much landlords can charge tenants who break leases, and a measure that would have raised boat vessel registration fees $2 in order to pay for derelict vessel removal.

The bill dealing with Medicaid HMOs, SB 1116, was one of the so-called conforming bills that accompanied the $71.5 billion budget that Crist signed into law today. But this bill was changed behind closed doors in the waning hours of the session to give Medicaid HMOs a $5 million rate increase starting in January. Crist also faulted the bill for ending a current requirement that Medicaid health plans provide at least 80 percent of money they receive for mental health care on direct services to patients.

"Even more disturbing is that many of these provider driven provisions were not discussed in an open forum,'' Crist wrote in his veto message.

Crist, who still rents an apartment in St. Petersburg, said he vetoed the bill dealing with landlords because the "impact" on those who can least afford it would be too great. The bill, HB 1277, would have allowed landlords to charge additional fees to tenants who want to break their leases early.

To read the veto message on the Medicaid bill: Download VETOSB1116.pdf

Posted by Gary Fineout at 09:43 PM on May 24, 2007 in Charlie Crist | Permalink

Dear Drs. Palamara and Ronik

On behalf of the Medicaid Reform Advocates Coalition, I extend the following "Thank You" to each of you as follows:

Dr. Palamara,

Thank you for finding time in your busy schedule to share your thoughts and expertise with those of us who read the Florida Medicaid Reform blog. We must remain diligent and proactive in our collective effort to protect Florida’s most vulnerable Patients.

Sincerely,

Dr. Marion D. Thorpe, Jr.

Dr. Ronik,

Thank you for your eloquent description of the problems facing our Mental Health Patients and our Medicaid Patients. Hopefully, the exposure gained via your Sun-Sentinel article will lead to improved quality of care and treatment accessibility for south Florida’s Patient population.

Sincerely,

Dr. Marion D. Thorpe, Jr.

The Medicaid Reform Disaster

By Arthur E. Palamara, MD
May 18, 2007

In 2005, Florida embarked upon a grand new experiment: placing all Medicaid recipients into HMOs or a similar contrivance called Provider Service Networks. The results may save the state treasury considerable money, but the impact on patients has been less well received, at times catastrophic. The impact on doctors has been equally disastrous. Already reimbursed far below customary rates, many doctors may no longer participate. Bureaucratic hurdles placed by HMOs make it increasingly difficult for physicians to provide care. A survey suggests that it will not be long before docs just opt out.

Before reform, about 95% of Florida doctors - roughly 33,000 - participated in Medicaid. But only 13,000 of these provided any substantial amount of care. Now a survey conducted by Georgetown University indicates that more doctors are dropping out of Medicaid and those that remain are seeing fewer patients. Most doctors stay in the system only out of loyalty to their patients with whom they’ve enjoyed an established relationship. Feeling overwhelmed by the harrowing challenges of just complying with arcane regulations and realizing that reimbursements are inadequate, many doctors are simply quitting. This is especially true among specialists where fully 2/3 plan to resign unless things improve. And there is little likelihood that things will get better since payment to doctors is down while paperwork is up. Not a reassuring combination.

In the pediatric community, pediatricians are finding it increasingly difficult to provide care, especially for 600 children with special needs. Previously, physicians had to deal with the requirements of only one system. Now each HMO has its own indigenous, time-consuming authorization procedure that forces doctors to comply. Often, these “authorizations” are complex and repetitive. The task is particularly burdensome to small offices that lack the staff to fulfill dogmatic regulations. This challenge is even worse for doctors who treat children with HIV since many medications are not part of the HMO’s formulary.

Pregnant women fare no better. Those tough obstetricians who have accepted the challenge of working within the new system do so only because they acknowledge a “social responsibility”. As such, many established Medicaid providers are flooded with new, expectant mothers seeking care. Because of financial constraints, they are finding it necessary to turn away new Medicaid patients.

Even if an obstetrician accepts lower compensation, the additional headache of dealing with 14 separate entities – each with its own bizarre rules – makes doctors disinclined to participate. Where once it was easy to write a prescription for a uterine ultrasound and send a patient to the nearest hospital, now the physicians’ staff must cast about seeking a specific facility that services that HMO. Gone are the days when a doctor just provided care. The doctor has become an uncompensated agent for the HMO.

More frustrating still, some expectant mothers arrived at the doctor’s office unaware of the change because more than a few patients were randomly assigned to HMOs without the patient’s knowledge. As a result of bureaucratic snafus, some expectant mothers were forced to switch plans a mere 2 weeks before delivery!

These Medicaid changes have diminished the number of specialists available to treat complex problems. Hypertensive specialists who treat pregnancy induced high blood pressure – a very demanding problem replete with legal overtones – are few and far between. Unassisted, Ob-gyn doctors are left to deal with the problem as best they can.

Psychiatric patients comprise another very vulnerable population. Emotionally unprepared for the changes wrought by Medicaid Reform, this population already lacked insight needed to make difficult life-decisions. While the law provided choice counselors to help patients select their best option, most choice counselors were under-trained and lacked critical knowledge especially in the area of psychotropic medications. Often taking years to strike an effective balance, stabilizing medications are vitally important to psychiatric patients. Choice Counselors had wrong or insufficient information when answering detailed medication questions. Many patients are now suffering the consequences. The impact on the physician is even more troubling. When the doctor writes a prescription, the doctor does not know if it is going to be filled correctly. This frustration has caused many doctors to opt out of the system.

While doctors are being paid less, the 14 HMOs and Networks are being paid more. Prior to reform, HMO profit was a staggering 18.6%. Despite this, the Florida legislature is planning an 11.7% increase in payments to HMOs. The securities firm CIBC World Markets and Goldman-Sachs reported that WellCare – a major Florida Medicaid HMO – has been shifting money to the Cayman Islands in the form of reinsurance premiums. Goldman-Sachs spokesman Carl McDonald stated that "Florida appears to be overpaying its Medicaid plans, and it would seem to be only a matter of time before the state figures this out." They're making tons of money," said Oliver Marti, a partner and portfolio manager at CCI, a Stamford, Conn., investment firm. "How does the government allow that?" (April 11, 2007, Tampa Tribune.) How indeed!

Florida’s stated objective was to improve both access and care while saving money. Medicaid Reform seems to be accomplishing little except enriching privately held HMOs. There is little evidence to suggest that this reform should be expanded beyond Broward and Duval Counties.

Patients want a trusted provider and physicians want to provide care free from corporate hassle. Medicaid reform seems to have alienated both those who serve and those who are served. With projected shortages of doctors estimated to be 50% within the next 10 years, it remains to be seen where Medicaid patients will receive their care. Probably from emergency rooms - which will place an even greater burden on local property taxes.





Dr. Arthur Palamara is a vascular surgeon in private practice in Broward County. In 2000 and 2001 he served as the Florida Medical Association representative on the Florida Commission on Excellence, which spearheaded many of the improvements in medical care quality that are just now emerging. He served on the Florida Patient Safety Corporation's Near Miss Task Force, and currently serves on the Corporation's Patient Advocacy Committee. Dr. Palamara is former FMA Vice President, serves on the Association's Council on Legislation.

We are interested in hearing from Medicaid Recipients in Broward County and Duval County. Please contact us by email at medicaidreform@pobox.com.

www.floridamedicaidreform.org

Treatment worth time, money and action

By Dr. Steven Ronik
Posted on the South Florida Sun-Sentinel, May 21 2007

America is still reeling from the tragedy at Virginia Tech. As we move forward, the natural reaction has been to find fault. We search for the "answer" -- the evidence of what went wrong. While there are undoubtedly many factors that might have changed the outcome of April 16, there is an underlying issue that can't be ignored. While we know that people with mental illnesses are no more violent than the general population, some stark realities are before us to consider.

Mental illness affects almost 60 million Americans. That's an estimated one in every four adults and one in five children. Mental illness is more common than cancer, diabetes or heart disease, making it the leading cause of disability in the United States.

As Americans, we have become so frightened by mental illness, or the stigma associated with it, that we do a fairly good job at ignoring it. Unfortunately, so has our government.

Despite advances in medicine and therapy that make it possible to treat and prevent lifelong disability from mental illness with increasingly greater success, the health systems that do so are dramatically underfunded at all levels. Even Medicare discriminates against mental health treatment, as do private health insurance companies. Almost 90 percent of private health plans place limits on mental health care that they don't place on medical/surgical care.

In Florida, unfortunately, the problem of underfunding is exponentially worse. We rank 48 out of 50 states in per capita public mental health funding -- and whether you are rich or poor, serious mental illness can strike, and comprehensive services are only offered through the publicly-funded system.

To add fuel to the fire, Broward has been chosen as one of two counties to participate in Medicaid reform, which for all intents and purposes is simply a shift to Medicaid managed care. It means that, overwhelmingly, care is authorized by for-profit HMOs.

In fact, in this recent legislative session, the one protection consumers had in this area (which provided that HMOs spend at least 80 percent of their capitation rate on direct service) has been removed. Medicaid reform is intended to be "revenue neutral" but it would be wise to "follow the money."

Clearly less money is going to providers of service, meaning less service is available to our citizens in an already dramatically underfunded county and state.

The cost of all of this is horrific. Senseless tragedies. Wasted lives. Broken families. Increased crime. Lost productivity. Not to mention, losing our most basic and fundamental obligation -- to help those most vulnerable.

Mental illness didn't "cause" the tragedy in Blacksburg. But, it is an example of how our nation's funding priorities did not allow for a comprehensive system of early intervention, assessment, monitoring, and treatment. Many states, and especially Florida, have become a "fail first" system.

In other words, due to incredibly minimal resources, funding priorities are directed to those who have been most impaired and disabled -- creating a system that is too focused on inpatient care and emergencies.

There are solutions. Treatment works. There's no mystery anymore in helping people recover from even the most severe mental illnesses. Early intervention goes a long way in preventing further complications from what can be easily treated more minor mental illnesses. But the problem is of such magnitude that it will take a dramatic shift in our thinking and government action, recognizing the prevalence of mental illness and recognizing that treatment is indeed worth our time -- and our money

The author is chief executive officer at Henderson Mental Health Center.



We are interested in hearing from Medicaid Recipients in Broward County and Duval County. Please contact us by email at medicaidreform@pobox.com.

www.floridamedicaidreform.org