Making Strides on Orlando Medical News

Making Strides

By: LYNNE JETER

Posted: Wednesday, August 11, 2010 8:14 am

Making Strides | Ed Homan, Madelyn Butler, Patient Centered Medical Home, PCMH, Florida Legislature, managed care companies, WellCare

Healthcare Leaders, FMA Working toward PCMH Legislation Passage in 2011

Earlier this year during the regular Florida legislative session, House Health & Family Services Policy Council Chair Ed Homan, MD, worked diligently to bring legislation to a vote for approval of adopting the Patient Centered Medical Home (PCMH) model for the state, arguably the best of four options presented to the Florida House of Representatives in a Medicaid Managed Care Evaluation by The Pacific Health Policy Group in March.

Crafting a System

Proposed medical home legislation in Florida calls for a system of providing healthcare, where the primary care provider is the patient's first and continuing contact throughout the delivery of a comprehensive range of healthcare services. Medical homes have been characterized by use of health information technology, patient education, preventive services, behavioral healthcare, and disease management, the coordination of specialty and inpatient care, and the diagnosis and treatment of acute illness.

Primary care providers would form medical homes either through provider-sponsored networks (PSNs) or by joining other primary care providers and health professionals and facilities that agree to collaborate to coordinate care. Medicaid recipients could be assigned to a medical home provider, but must choose to participate.

Homan, an orthopedic surgeon from Tampa who also sits on the House Health Care Appropriations Committee, had introduced a House bill combining the best of successful PCMH programs in North Carolina and Oklahoma that have saved both states significant sums while dramatically improving access to care for its Medicaid residents.

The bill, which passed out of committee but then died as a result of political pressure from managed care companies, would have offered, as AARP & Medical Home Task Force member Jack McRay described it, "care management" for better health, not "managed care" for better profits.

Snapshot

Florida operates its Medicaid managed care program for the state's 2.6 million Medicaid beneficiaries through the Agency for Health Care Administration (AHCA), authorized in 2005 to reform Medicaid with the intent of improving health outcomes of Medicaid beneficiaries and achieving budget predictability. Like most states, Florida turned to managed care to achieve that goal. As of January, 1.9 million—70 percent—of the state's 2.7 million Floridians eligible for Medicaid were enrolled in some form of managed care. Of 23 managed care organizations, 16 are HMOs; seven are PSNs. Estimated spending in fiscal year 2009-10: $17.9 billion.

The Role of FQHCs

According to the National Association of Community Health Centers and the Robert Graham Center/AAFP Center for Policy Studies, Florida has 286 health center sites. In 2008, those centers served 778,450 patients. Roughly 10 percent of the centers do not receive federal funding, leaving an estimated 258 identified as federally qualified health centers (FQHCs) in Florida to facilitate the medical home system.

"We let insurance companies become managers of healthcare. Huge mistake!" said Homan. "Managed care companies have made money by denying care. Reimbursement, which is slow, has gotten so low—57 cents on the dollar treating Medicaid patients versus Medicare patients—that many doctors no longer accept new Medicaid patients. They can't afford to!"

For example, Homan pointed out, only six orthopedic offices in Florida accept state Medicaid (Medipass) patient appointments for an elective procedure.

"If you have a torn cartilage in your knee and you're a state Medicaid patient, you either go to a medical school or one of six offices for treatment," he explained. "Otherwise, the only way to get care is in an emergency room, and the Medicaid crisis has had ripple effects in that arena, too. Not many doctors want to take call anymore. In fact, about three-fourths of hospitals around the state pay doctors to take call. So what happens, because of the lack of money being applied to direct care for patients, is that the state Medicaid patients often show up at medical schools. For example, I recently saw a patient from Jacksonville at USF who broke her arm a month ago, couldn't find a doctor, called AHCA, and was told to drive to Tampa. Then, the wait time for treatment is unreasonable," Homan said.

"If they don't have a fracture, I've seen Medicaid patients wait up to a year to get an appointment. And if they need surgery, we're booking surgery for Medicaid patients seven months out," he said. "So if you need an appointment, you're looking at waiting until this time next year, and then if you need surgery, you're waiting seven to nine months beyond that."

The Medical Home Option

Of the four Florida Medicaid Managed Care options evaluated by The Pacific Health Policy Group in a House-commissioned study—incremental expansion, medical home, statewide capitated managed care, and managed long-term care—the medical home would require a short-term investment, with the potential to reduce program growth over time. It would have no impact on local funding or the safety net delivery system. It would promote access to primary care and the development of community-based delivery systems, and enhance opportunities to identify fraud via electronic health records. Federal authority would rely on current MediPass authority. The implementation effort would be moderate to high; the system would create additional oversight responsibilities; and independent evaluators and state staff would monitor the quality of care.

The Difference

If the same scenario occurred with the PCMH model, a Medicaid patient's primary physician would contact Homan.

"That doctor would say, 'my patient has a torn cartilage,' they would pay the Medicare rate, and the patient would be taken care of immediately," he explained. "If you provide timely care, and keep Medicaid patients out of the ER and off food stamps and unemployment, then the money saved can provide adequate reimbursement that physicians will see all patients equally. When North Carolina and Oklahoma moved to the PCMH model, that's exactly what happened. The weak spot for managed care companies, which typically infuse political campaigns with hundreds of thousands of taxpayer dollars, was the rural community.

"The medical home model started in rural communities, where managed care companies don't go because there's not enough population density to make enough profit," said Homan. "When North Carolina and Oklahoma saw how well it was working and realized they could do better, they decided to run the program throughout the entire state and the managed care companies found they couldn't compete and they left both states."

In both states, patients sign contracts with the doctor assigned as their medical home. Doctors sign contracts with the state to be available around the clock to their patients.

The WellCare Malady

When deception and fraud was discovered at the heart of Florida's largest Medicaid HMO contractor, Tampa-based Wellcare Health Plans Inc., state officials took a closer look at managed care operations and began mulling other options. The scrutiny continues.

Last month, WellCare agreed to pay $137.5 million to settle civil claims by the U.S. Justice Department and the state Attorney General's office. Last year, the company agreed to pony up $80 million to avoid prosecution for fraud, and to be monitored for 18 months.

The three executives charged with orchestrating the fraud who resigned in January 2008—Todd Farha, president, chairman and CEO; Paul Behrens, CFO; and Thaddeus Bereday, general counsel—may face high-level individual indictments. A federal judge's ruling in early July—two weeks after WellCare reached the preliminary agreement to pay $137.5 million—allows the company to pursue claims against the three former employees embroiled in the financial scandal. The controversial ruling by U.S. District Judge Virginia Hernandez Covington also protects current and former members of WellCare's board of directors, including former Florida Gov. and U.S. Sen. Bob Graham, from potential liability in a lawsuit filed by shareholders in 2007.

The fraud involved Harmony Behavioral Health, a phantom subsidiary of WellCare created to cloak unspent money from the company's Medicaid HMOs—HealthEase and StayWell—instead of returning it under the terms of their contracts with Medicaid and Florida Healthy Kids Corp.

Whistleblower Sean Hellein said, among other things, that WellCare tried to move high-cost patients, such as sick babies and terminally ill people, out of its health plans. An insider who worked for WellCare at the time of the raid has speculated the company "still is a haven for white collar crime" and that more information will be revealed "when the company is taken to court."

On the day before the 2007 raid, WellCare's stock traded at $115.47 a share. A day later, the stock price had plummeted to $42.67. At press time, the stock was trading in the mid-twenties.

"Doctors get to know the patients, and hold them accountable for primary care and all other health initiatives," explained Homan, who toured both states to see the PCMH model in action before initiating legislation for Florida. "If they're overweight, they're instructed to lose to a healthier weight and are given the tools within reason to achieve that goal. They must take prescribed meds. The doctor will send a case manager to the patient's house to make sure they have them. The primary care provider is the quarterback for the patient's entire medical team."

For Florida to move to the PCMH model, the obstacle of managed care companies' political clout needs to be eliminated, said Homan.

"After an article on WellCare theft ran, I sent an email to House and Senate leaders and asked, 'why are we doing business with these people?' The whole legislature is very much anti-fraud in healthcare and we're doing business with the biggest crooks in the state," he said. "And the other managed care companies just haven't been caught yet!'"

Homan pointed to a recent development in Mississippi, where the University of Mississippi Medical Center, an academic medical institution, and the Jackson-Hinds Comprehensive Health Center (JHCHC), a federally qualified health center (FQHC), embarked on an innovative collaboration on July 1 to provide better access to primary care medical services to medically underserved Mississippians.

"That's the medical home concept in a nutshell," he said. "Federally qualified health centers are big players, and Florida has nearly 300 across the state."

The Next Step

Homan, who could not seek re-election because of term limits wraps his final term in November. He still hopes to see the PCMH model move forward. "When I was elected, I was the only doctor in the House," he said. "Since then, two doctors have been elected and will hopefully take the reins."

Madelyn Butler, MD, an obstetrician-gynecologist from Tampa who is taking over as president of the Florida Medical Association this month, has pledged her support of the PCMH model as a viable solution to the state's Medicaid crisis.

"The Medicaid HMO concept has not served patients or physicians well," said Butler, who does not accept new Medicaid or Medicare patients in her private practice. "The medical home model represents a more intensive level of coordination. Before, money for the healthcare coordinator was going to the managed care companies in the form of profits. Now we're hoping this money can be put back into patient care."