By STEPHEN NOHLGREN and ALISA ULFERTS
Published April 28, 2004
TALLAHASSEE - Elderly Medicaid clients in Pinellas and Hillsborough counties would be required to join HMOs under a proposal resurrected Tuesday in the Legislature.
All Medicaid services for seniors - including nursing homes, assisted living homes, adult day care and home-delivered meals - would be coordinated by managed care organizations in a five-county experiment.
Everyone older than 60 who needed Medicaid would have to sign up. The state would pay the HMO a fixed rate for each of them, and the HMO would decide what care to provide.
It would be a dramatic experiment in how Florida provides long-term care to the elderly, turning over decisions made by government and local nonprofit agencies to private insurance companies.
"It will be a win across the board for everyone," predicted Bob Wychulis, president of the Florida Association of Health Plans. Small pilot programs have shown managed care "keeps elderly people out of nursing homes and at home and independent, and it cuts health care costs. It's very successful."
But some nursing home representatives, smarting over a 5 percent cut in Medicaid payments, worry HMOs might squeeze them more.
"It's not going to be a very pretty picture," said Erwin Bodo, spokesman for the Florida Association of Homes for the Aging. "Basically, we got shafted. Probably 92 to 93 percent of nursing homes are not getting a rate sufficient to provide care to their Medicaid residents. Now those same providers are going to have to contract with managed care. How many of those contracts are going to be at a rate that is lower than they are already getting?"
When the idea of mandatory Medicaid HMOs surfaced two weeks ago, Senate President Jim King, R-Jacksonville, swore it would not pass this year because it had not been given a sufficient hearing. That proposal called for a statewide program, triggering an outcry from legislators who were caught by surprise.
King eased lawmakers' fears by assuring them the issue would have to wait a year.
But the issue surfaced again over the weekend, though lawmakers recessed Tuesday night before getting to it. The new version would create a pilot project in Pinellas, Hillsborough, Polk, Orange and Seminole counties. Medicaid clients living outside those counties would get services directly from nursing homes and other Medicaid programs.
King said he agreed to allow a hearing on the pilot project after talking to several lawmakers interested in the issue.
"They wanted to make sure that before we went statewide we'd better know what we are doing," he said.
But the experiment might be losing support, and the Legislature is scheduled to adjourn Friday. Two Tampa Bay area lawmakers are maneuvering to keep the HMO pilot project out of their back yard. Sen. Les Miller, D-Tampa, filed an amendment exempting Hillsborough County from the proposal even though Rep. Sandra Murman, R-Tampa, supports the concept and says seniors deserve to have their care better managed. Senate Majority Leader Dennis Jones, R-Treasure Island, filed an amendment exempting Pinellas.
"The I-4 corridor ends in Hillsborough. If it's good we can expand it, but for the time being Pinellas prefers to be on the sidelines," Jones said.
Medicaid, which consumes one-fourth of the state budget, provides health care for poor people, children of working-class parents and people so frail they need permanent long-term care, including middle-class nursing home residents who have exhausted their savings.
The federal government pays for 59 percent of Medicaid, with the state picking up the rest. But the price tag for Florida is increasing 8 to 10 percent a year. Gov. Jeb Bush and the Legislature are casting around for money saving reforms, including the possibility of capping Medicaid spending and turning people away when that money runs out.
Nursing home care offers a tempting target. Two-thirds of Florida's 70,000 nursing home residents are covered by Medicaid, which can cost $60,000 a year per person. Given the right services, some of these clients might be kept at home. That's where managed care comes in.
Under proposals pending in the House and Senate, the state would pay HMOs a fixed rate - something around $2,000 a month - for everyone who could qualify for Medicaid living in the targeted counties. The HMOs would pay for drug management, home health therapies, transportation and other services to keep those people in their homes or in assisted living homes.
HMOs that did a good job presumably would make a profit. Those that skimped on care would risk losing money if their clients got sick and landed in nursing homes, because the HMO would have to pay those bills.
Nursing home representatives and advocates for the elderly worried earlier permutations of the HMO proposal might have put some of Florida's best nursing homes out of business because the HMOs might contract only with homes with lots of empty beds.
The Senate bill addresses that by requiring the HMOs to contract with "all qualified nursing homes." If a rate could not be agreed upon, the HMO would have to pay the existing Medicaid rate. The bill also says current nursing home residents would not have to move.
Ed Towey, spokesman for the Florida Health Care Association, Florida's largest nursing home trade group, said HMOs would "still have all the leverage in a deal like this."
"The reality is that if we don't reach agreements under their terms, we are not going to get those patients," he said, and no Florida nursing home can survive without Medicaid patients.
Randy Smith, a director for Evercare, Florida's largest longterm care HMO, would not commit to working with all nursing homes, saying the Legislature has yet to work out the details.
But "we are supportive of high-quality nursing homes," Smith said. "We see them as a solution in any program."
Mary Ellen Early, another nursing home lobbyist, wondered how decisions would be made when couples are involved. What if an HMO determined a Medicaid patient could be cared for at home, but he or she had a healthy spouse who didn't feel up to it? Would the healthy spouses lose their rights to put loved ones in nursing homes?
"Who will have the ultimate say?" Early said. "Suppose she has Alzheimer's and has sundown syndrome and she's up all night long, and you've got to go to work at 7 a.m.?"
Mandatory HMOs also might cost the state more money, not less, said Bodo, the nursing home representative. That's because all sorts of new Medicaid clients could show up for service.
Florida has long waiting lists for home-based care. Costs are controlled because federal law allows the state to cap spending on these programs. But Medicaid service in a nursing home is a federal entitlement. The state must pay for anyone who qualifies.
Elder law attorneys specialize in rearranging people's finances so even wealthy couples can qualify for Medicaid in a nursing home. If this population suddenly qualifies for at-home services, Bodo said, the number of clients will grow rapidly.
"If people are really going to get home and community-based services, they are going to start divesting themselves (rearranging finances)," Bodo said. "The caseload is going to increase. We may pay less per client, but in terms of dollars, I don't see that it will cost much less."
MANAGED CARE
Under proposals pending in the House and Senate, the state would pay HMOs a fixed rate - something around $2,000 a month - for everyone who could qualify for Medicaid between Pinellas and Orlando. The HMOs would pay for drug management, home health therapies, transportation and other services to keep those people in their homes or in assisted living homes.
