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Senate paging Dr. Welby

By Jim Saunders
2/19/2010 © Health News Florida 

As Florida lawmakers struggle to overhaul the Medicaid system, state Rep. Ed Homan describes the choice in stark terms: Plan A or Plan B.
The Tampa Republican, an orthopedic surgeon, doesn't want Plan A --- expanding a five-county pilot program that requires Medicaid recipients to enroll in managed-care plans. 

Instead, Homan is pushing Plan B --- "medical homes.'' The idea is to give primary-care physicians a larger role in directing and coordinating the care of Medicaid patients to improve treatment and reduce expensive trips to the hospital. 

"The medical-home model is Marcus Welby medicine,'' Homan told members of the Senate Health Regulation Committee on Thursday. Welby was a lovable television character in the 1970s, who was beloved for his great bedside manner.

Lawmakers are studying medical homes as they grapple with exploding costs in the Medicaid system. Medicaid is projected to cost $19.18 billion during the upcoming fiscal year, adding to longstanding calls to make major changes in the system. 

But while some lawmakers praise the idea of medical homes, it was clear during a hearing in the Senate Health Regulation Committee that they also have questions about how such a system would be structured and financed. 

Committee Chairman Don Gaetz, R-Niceville, said after the hearing that he wants to see a "business model.''  He and Sen. Dennis Jones, R-Seminole, questioned how the medical-home system would attract physicians to participate. 

Many doctors do not want to treat Medicaid patients now because of low payment rates. It is so hard to find some specialists who will take Medicaid that families are suing the state in federal court to gain better access. 

A task force on medical homes created by the Legislature last year also raised that question.
"To be successful in Florida, the task force finds that a medical-home pilot project must address core funding issues for those who agree to provide health-care services through this program,'' the task force said in its report. 

The medical-home concept centers, at least in part, on each Medicaid patient having a primary-care physician. That doctor would treat the patient and coordinate care through a broader system in the community. 

Other states, such as North Carolina and Oklahoma, have moved forward with medical-home programs in recent years. In North Carolina, for instance, the program includes 14 community networks, more than 3,500 physicians and serves more than 950,000 Medicaid enrollees, according to the Florida task-force report. 

The North Carolina community networks offer support to the doctors through services such as medical directors, case managers and pharmacists, the report said. The doctors' practices receive fees each month for offering round-the-clock availability to patients and for coordinating specialty care. Also, they receive fees for joining the community networks. 

Doctors in North Carolina get paid higher Medicaid rates than their Florida counterparts, whether the doctors take part in medical-home programs or not. Homan and Pensacola physician Coy Irvin, who served on the task force, said Florida would need to assure that doctors receive some of the savings that would result from a medical-home system.

Another question senators raised was how medical homes would differ from already-existing managed-care plans or from MediPass, a fee-for-service part of the Medicaid program that is designed to have primary-care doctors coordinating patients' care. 

Supporters of medical homes describe them as a community-based approach to caring for Medicaid patients. For instance, Irvin said, "umbrella'' organizations could be set up to provide social workers and case managers. 

Irvin said that neither MediPass nor managed care has been able to stem the flow of Medicaid patients seeking care at hospitals.

"What we're doing right now is not keeping people out of the emergency rooms,'' Irvin said.

The task force recommended creating at least two pilot sites, with one in a rural area of Florida and another in an urban area that has a medical school. 

If lawmakers decide to move forward during the legislative session that starts March 2, it is not clear how the local medical-home programs would be administered. 

Gaetz said medical-home systems could be organized in various ways, by managed-care companies, physician groups or federally qualified health centers. Also, county health departments and hospital systems could be involved. 

-- Capital Bureau Chief Jim Saunders can be reached at 850-228-0963 or by e-mail at