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Medicaid ‘Pilot’ scores up

By Carol Gentry
3/4/2010 © Health News Florida
Those who want to expand Medicaid's "Pilot" program from its current five counties to 24 have new ammunition: performance data.

Plans participating in the "Pilot" -- the new official name for what was once called "Reform" --  had a better-than-average performance on half of the quality-of-care categories the state measured last year, according to data recently presented to a medical advisory committee.

By contrast, health plans in non-pilot areas of the state scored better than the national average on just nine of the 28 categories measured, fewer than one-third, according to a chart from the Agency for Health Care Administration.

“It’s good to see them improving,” said Tallahassee consultant Brady Augustine, an authority on Medicaid. They still have a long way to go to meet the goal of 75 percent scores on all measures, however.

One might expect plans in the pilot counties -- where they must take all comers, both sick and well – to do worse than in non-pilot counties. Augustine has a theory.

“They know they’re being watched” in the pilot counties, he said. “When you’re being watched, you always do better.” 

But the advocacy group Florida CHAIN, which has fought the program from the get-go, suggested the chart presented in February to the Medicaid program's medical advisory committee is just a new wrapping for old, flawed data. 

"As part of its ongoing effort to portray the Medicaid Reform experiment as a success," wrote Policy Director Greg Mellowe last month, "AHCA has worked to present the rosiest picture of Reform possible."

As for the chart, Mellowe said, “I’m not sure it’s useful for anything.”  

The pilot-county plans had a lot of gaps in reporting, Mellowe said, and in any case the performance being measured was for plans that in many cases are no longer participating. Mellowe suggested the latest data release is part of a concerted campaign to expand the pilot.

In mid-February, as Health News Florida reported, AHCA Secretary Tom Arnold presented a Senate committee with a list of 19 counties that he would like to see get the Medicaid pilot expansion.  They range from Miami-Dade to rural Wakulla. 

Such an expansion could affect 375,000 people and save $58.7 million during the upcoming fiscal year. Managed-care supporters say expanding the pilot program would help reduce fraud and hold down spiraling Medicaid costs.

"We believe it does slow the growth of expenditures,'' Arnold said at the time. That's another contention that CHAIN disputes.

The pilot now is operating in Broward (Fort Lauderdale area), Duval (Jacksonville), and three rural counties around Duval.

The pilot program requires that virtually all Medicaid recipients be enrolled in an HMO or "provider service network," a coordinated-care arrangement headed by a hospital system or minority physicians' group. The pilot gives plans freedom to redesign benefits to more closely fit patients' needs, rather than having a set of services to which all are participants are entitled. 

The state pays the plans, and the plans pay those who care for patients. For that reason, proponents say, it cuts down on Medicaid fraud and abuse. However, there are possibilities for fraud by the plans themselves; in fact, last year the largest participating plan in the pilot program had to pay $80 million in fines to avoid federal prosecution. 

Consultants say that all else being equal, one would expect plans in the pilot counties -- where they must take all comers, both sick and well – to do worse than in non-pilot counties. But Augustine thinks psychology is at work.

“They know they’re being watched” in the pilot counties, he said. “When you’re being watched, you always do better.”

The Florida Association of Health Plans’ CEO Michael Garner was pleased to see that his members’ performance improved from 2008 to 2009 in many categories. “While there are still opportunities for improvement,” he said, “we believe these measures show a positive trend.”

A study released last month by Health Foundation of South Florida, “Medicaid Reform: Broward County Physicians’ Experiences,” reported that doctors’ major problem in the pilot counties is the same as outside. They have a hard time finding specialists who will accept referrals of Medicaid patients. 

Doctors in the pilot counties also grumbled about the administrative paperwork required in the pilot counties, which apparently stems from the greater reporting requirements for AHCA.

--Carol Gentry, Editor, can be reached at 727-410-3266 or by e-mail.