Waddling into the doctor’s office at eight months pregnant, two kids in tow, Danielle Johnson fully expected to see her obstetrician.
She handed the receptionist her Medicaid card, then sipped a glucose drink to prepare for a diabetes test.
Suddenly the receptionist called her name. “I’m sorry, but your insurance has been switched," she said. "Now you’re on First Coast, and we don’t take (that)."
What happened to Johnson is worth a listen, because she lives in Duval County, one of the five test sites for a Medicaid experiment that moves enrollees into HMOs or similar managed-care networks.
That pilot is about to go statewide under bills already passed in the House and pending in the Senate.
As lawmakers hammer out the details, patient advocates have raised concerns about groups that may be tripped up by the complexity of managed-care rules: the developmentally disabled, the mentally ill and frail elders in nursing homes.
Not much has been said about pregnant women, even though more than half of them in Florida depend on Medicaid to pay the bills, according to Agency for Health Care Administration data.
In Broward, Duval and three rural counties where the Medicaid managed-care pilot has been tested for five years, some pregnant women who ran into difficulties were able to bail out and go back to their doctor, with Medicaid paying the bill, as Johnson did.
But that option won't be available under the statewide expansion bills now pending. That lack of an escape hatch, said Rep. Elaine Schwartz, D-Hollywood, places women at risk.
Delays on top of delays
Obstetricians in the pilot counties have told Health News Florida they are concerned about a statewide expansion, based on their experiences. Dr. Aaron Elkin in Broward said he has had to turn away patients, work without pay, and spend hours sorting out insurance issues for mothers-to-be.
"Every day in my office I hear the same thing over and over,” he said. “All these little fires are happening. But in the end, it only means one thing: a denial of care.”
Nassau County OB William McGrath said HMOs routinely deny tests for high-risk patients. Often, he said, they simply don’t have needed specialists in their network.
But these accounts aren't backed up by data showing statistically significant differences in birth outcomes between pilot counties and the state overall.
Michael Garner, president of the Florida Association of Health Plans, says HMOs have no incentive to deny tests or referrals, because that could lead to expensive complications with the child and mother -- bills the HMO would have to pay.
“We want these women to get care, not just because it’s the right thing to do, but also because once the baby is born it’s our responsibility,” he said.
Also, he said, HMOs face fines from the state if they do not have appropriate specialists in their network.
Garner said it's inherently difficult to get Medicaid patients into prenatal care, regardless of whether they're in an HMO or on traditional fee-for-service Medicaid. The Department of Children and Families, which handles enrollment, is "overwhelmed," he said, and can be slow to help patients get enrolled.
Robin Grunfelder of Healthy Start in Broward says delays can stem from all parties involved. And that can include patients, who often have troubled home lives or low education levels. They don't always reach out for care as early as they should, she said.
"Who's to blame? I really can't say," she said. “But certainly it would be nice to see a smoother, more rapid process than there already is.”
The clock ticks
If women do not receive timely prenatal care, consequences can be dire.
Prenatal vitamins, sonograms, and tests that determine infections and potential delivery complications must be within specific time frames. As time drags on, the delivery becomes more risky, said Dr. Robert Klein of Pembroke Pines.
“The earlier the contact with a physician, the better the outcome,” Klein said. “We are operating in a system that encourages bad outcomes.”
One way the state tries to get pregnant women into prenatal care quickly is by offering likely Medicaid candidates "presumptive eligibility," which covers them while their application is processed.
Yet, doctors can be reluctant to take on these patients because if Medicaid eligibility is ultimately denied, they become charity cases for the rest of their pregnancies, Grunfelder said.
Dr. McGrath in Nassau County said even if he wants to take a patient on presumptive Medicaid, his hands are tied because others in the system refuse. “Nowadays, everything has to be sent out for tests," he said, "and nobody is going to do those tests if the patient hasn’t been accepted to Medicaid.”
When Health News Florida called two obstetricians in non-pilot counties, the doctors said that their Medicaid patients have no problems enrolling, using their presumptive eligibility or getting approved for referrals and tests. All seven obstetricians called in pilot counties listed problems in each area.
In the past, the health department has provided a safety valve for women who needed prenatal care and couldn't wait for the enrollment process, but now some patients report a six-week wait. The line may grow longer if Gov. Scott is successful in cutting primary care in Department of Health units.
It took a month
When Danielle Johnson found out she’d been switched, the Jacksonville mother called the Medicaid office then and there. But it took a month to get out of First Coast Advantage and back to her doctor.
That’s standard operating procedure: Plan switching takes place only once a month.
One day while Johnson was in insurance limbo, back pains sent her to the emergency room. Doctors there told her she was in early labor with contractions three minutes apart. They gave her an intravenous solution that stopped her contractions and told her to go back to her own obstetrician.
Her contractions returned the next day, but her obstetrician’s office again turned her away because it accepts only fee-for-service Medicaid and her paperwork hadn’t gone through. She finally got in for an appointment three weeks later. Her intermittent contractions have continued, and she’s set to deliver any day.
What happened to Johnson should never occur because patients are notified by mail before their insurance is switched, said Shelisha Coleman, spokeswoman for AHCA.
But Johnson said she received no notice.
“Nobody warned me or asked if I wanted to switch plans,” she said. “If I was five months pregnant, I might have just switched doctors (to one in First Coast). But I wasn’t, I was eight months pregnant and I didn’t know where to go.”
--Reporter Brittany Davis, who is based in South Florida, can be reached at 954-495-6766 or Brittany.Davis@HealthNewsFlorida.org.