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Waiting list presents dilemma for Medicaid Reform

Editor's note: This article contains a correction.

Florida's unfolding plan to keep elderly and disabled Medicaid patients out of nursing homes through the use of HMOs faces a huge obstacle:

The state already has a long waiting list for the kinds of home- and community-based services those patients need. And  there is no state money on the table to address it.

An analysis of the project released today cited the waiting list as just one of several challenges facing Florida's plan to move all Medicaid patients into HMOs and other managed-care networks starting next year.

The research team from Georgetown University concluded that the state may not have allocated enough time or money to "assure smooth transitions for a very vulnerable population."

Also, the researchers said, the project may fail to accomplish one of its essential elements: saving money. It all depends on how the program, under the joint direction of the Agency for Health Care Administration and Department of Elder Affairs, is carried out.

Beth Kidder, assistant deputy secretary for Medicaid operations at AHCA, told a forum where the report was presented this morning that the planning is "going very well."

While patients may have to change doctors, they will have "good choices" and will get the services they need, she said. 

In passing the Medicaid Managed Care program last year, lawmakers ordered that virtually all of the nearly 3 million low-income people enrolled in Florida Medicaid be moved into HMOs and other tight managed-care networks that assume financial responsibility for their care.

While a majority of Medicaid patients are already enrolled in such plans, they tend to be the healthy populations -- children and pregnant women -- more often than the other groups, the mentally and physically disabled and frail elderly.

The "long-term-care" population, the elderly and disabled who require routine nursing care and frequent medical treatment, are slated to go first, in part because they are the most expensive at a time of budget troubles. The state is to begin negotiations with private companies in July, with enrollment to begin in October 2013 (Editor's note: The original version of this article listed an incorrect date). 

That timetable depends in part on receipt of permission from the federal Centers for Medicare and Medicaid Services, which is considering Florida's application for a waiver of the usual Medicaid rules.

According to the 10-page analysis, the group covered under the new Long-Term Care Managed Care program includes about 84,000 current Medicaid beneficiaries and another 27,000 eligible but on waiting lists. As a practical matter, patients on waiting lists can end up in nursing homes if there is a shortage of support services for those at home or in assisted living.

The cost to taxpayers of nursing-home care is far greater than the $18,000 a year it costs for the state's Nursing Home Diversion program.

Health plans participating in the Medicaid managed-care project will be given a set budget per patient -- a "capitation" -- within which they must provide necessary services. The payment is set to be 5 percent less than the average cost for such patients not enrolled in managed care.

At today's forum in Tallahassee, representatives of AARP and the nursing-home association thanked the sponsors of the report, saying that it raises troubling questions that need addressing before the experiment begins.

The idea of keeping Medicaid patients out of nursing homes and providing better care at home are "noble goals," worth a "hallelujah," said Jack McRay of AARP.

But success depends on what kinds of resources will be available when the transition begins, he said. He predicts enormous confusion for the elderly and disabled, and said making them go first is "absurd."

"The timeline is impossible," McRay said.

Tony Marshall of the Florida Health Care Association said the program has "significant design flaws" that ignore both the real costs of the conversion and the aging population bomb.

"How is this going to work?" he said. "Nobody can answer that question."

The report is part of a continuing series on Florida's Medicaid Reform experiment by Georgetown University's Health Policy Institute. Co-sponsors are the Jessie Ball duPont Fund in Jacksonville and the Winter Park Health Foundation (disclosure: both foundations are significant contributors to Health News Florida).

--Health News Florida is an independent, online publication dedicated to journalism in the public interest. Contact Editor Carol Gentry at 727-410-3266 or by e-mail.