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Who decides, Medicaid or doctor?

3/29/2009 © Florida Health News

Can a state Medicaid program cut treatments to a child if a doctor says they are medically necessary? Three states, including Florida,  say yes, and made that argument this week before a federal appeals court in Atlanta.

The child in question is Callie Moore, who lives in North Georgia. Her mother sued Georgia Medicaid when it cut home-health nursing hours from 94 to 84 a week. A U.S. district judge said the state could not cut the hours since Callie's doctor deemed them necessary. (Read coverage of the case by Fulton County Daily Report.)

The appeal was filed by Dr. Rhonda Medows, commissioner of Georgia's Department of Community Health. She served as secretary of the Agency for Health Care Administration in Florida under Gov. Jeb Bush.  

In an amicus brief filed jointly by Florida and Alabama, AHCA Acting General Counsel Justin M. Senior wrote that the lower-court ruling, if upheld, "would essentially invalidate a Florida statute and prompt a drastic shift in Medicaid funds ... into unproven, unnecessary, ineffective, cosmetic, and dangerous treatments for persons under 21."

"Treating physicians...cannot be trusted with this sort of discretion," Senior writes. "When left to their own devices, they advocate for their patients and deem all manner of unproven, dangerous, ineffective, cosmetic, unnecessary, bizarre, and controversial treatments as 'medically necessary.'"

He continued: "Case law provides examples of treating doctors claiming medical necessity and attempting to bill Medicaid for: cosmetic procedures; sex-change operations; (unapproved) drugs; abortion on demand; 'treatments' that have never been proven to work; and round-the-clock nursing and personal assistance for patients who obviously do not need it..."

Holland & Knight partner Robert S. Highsmith Jr. argued on behalf of WellCare of Georgia, which sides with the state as a major Medicaid contractor. The company is a subsidiary of Tampa-based WellCare Health Plans Inc.

Arguing for the Moores was Atlanta Legal Aid Society General Counsel David A. Webster. He said no one knows Callie better than her doctor and that the state was cutting back the nursing hours because of economics, not medicine.

--Questions? Contact Carol Gentry, Editor, by e-mail or at 727-410-3266.