WellCare HMO's care questioned
Parents, others give WellCare low marks on mental health services.
By KRIS HUNDLEY, Times Staff Writer
Published December 8, 2007
Kristy Curry's 9-year old son has cut his wrists twice, set her bathroom on fire and been institutionalized six times in the last four years for his own protection. "He's got a lot of problems," said the Largo woman.
But she said those problems have been exacerbated by the fact her son's Medicaid HMO, WellCare Health Plans, repeatedly delays or denies medications, therapy and specialist care recommended by his doctor. Another Largo mom, Melinda Norton, complained of almost identical problems getting treatment for her bipolar 10-year-old.
A WellCare spokeswoman, citing privacy laws, was unable to comment on the boys' cases.
But Curry, who just spent her kids' Christmas toy fund on a $310 prescription for her son, blamed the insurer for his unnecessary suffering. "He went two months recently without therapy or meds and ended up being Baker Acted hospitalized again," she said.
That's precisely the scenario many people feared three years ago when the state gave Medicaid HMOs the responsibility -- and dollars -- for members' mental health care. Previously, most Medicaid recipients received counseling and other mental health services from non-profit community groups that were paid directly by the state on a fee-for-service basis. The new arrangement inserts HMOs in the equation, screening both the cost and need for services.
WellCare, Florida's largest Medicaid provider, lobbied aggressively to win mental health dollars in 2004. That move may come back to haunt the company. WellCare's behavioral care program appears to be a focus in the ongoing federal and state investigation into the Tampa managed care company.
During a raid of WellCare's headquarters on Oct. 24, agents were instructed to seize, among other items, documents related to mental health services for Florida Medicaid members. Also targeted were any records reflecting "monetary overpayments" to WellCare from government health programs.
No charges have been filed, and WellCare, which has more than 350,000 Florida Medicaid members, said it is cooperating fully with the investigation.
Whether WellCare ends up regretting its move into the behavioral health business -- worth $64.2-million in reimbursements from Florida over the last two years -- remains to be seen. But advocates for the mentally ill who fought the change remain solidly opposed.
"Every one of my fears has come true," said Bob Sharpe, the former head of Florida's Medicaid program who now runs an association of the state's nonprofit community mental health agencies. "Consumers are hurt; providers are hurt; it's reaching crisis proportion. We can't continue on this road."
In 2004, advocates like Sharpe worried managed care companies would skimp on services despite a requirement that 80 percent of the state's behavioral health allotment be spent on patient care.
They weren't reassured when several HMOs, including WellCare, failed to meet that benchmark and had to make refunds to the state. WellCare's refunds totaled $2.55-million over the past two years.
Advocates became even more wary when the managed care industry slipped an item in the state's budget this year that would have eliminated the 80 percent requirement. That triggered a May veto by Gov. Charlie Crist, who condemned the effort to reduce services "to Florida's most vulnerable."
Bob Wychulis, head of Florida's managed care trade association, said his group thinks it is unnecessary for the state to mandate specific spending levels for mental health care. There is no such requirement on the larger, medical portion of the Medicaid allotment.
Wychulis, president of Florida Association of Health Plans in Tallahassee, also believes Medicaid beneficiaries have been well-served by having HMOs handle their mental health needs.
"Reports show there have been better outcomes or the same as in the past," he said. "And it's meant a predictable number of dollars to the state."
Annual evaluations of Medicaid mental health managed care by the Louis de la Parte Florida Mental Health Institute at University of South Florida have been mixed. The latest report said there have been cost savings because fewer mental health services are being provided. Meanwhile there continue to be delays in payments as well as authorizations from HMOs.
Though the report said there was "no clear and consistent evidence" patients have suffered under HMOs, it also concluded the quality of care had not improved.
Such double-talk frustrates Sharpe, who said the public needs to look no further than the November report by Florida's Supreme Court on the high cost of the mentally ill to the criminal justice system.
"Do we have fewer admissions to state hospitals? Do we have higher graduation rates for emotionally unstable students? Do we have more people in stable housing? Those are the important benchmarks," Sharpe said, adding that Florida ranks 48th nationally on per capita spending for mental health services. "I can't imagine we've got it right and 47 other states have it wrong."
Regardless of the outcome of the WellCare investigation, Sharpe said it should trigger a look at the broader issue of how much profit HMOs are allowed to make on the state taxpayer's dollar, even raising the benchmark for mental health services to 85 percent.
"Fifteen percent should be good enough for profit and administrative costs," he said.
Meanwhile, the Largo mom who's dealing with a severely disturbed 9-year-old has an easier solution. In January she's moving her son to another HMO that won't make her jump through so many hoops.
Kris Hundley can be reached at hundley@sptimes.com.
FAST FACTS: For mental health
What's the story: WellCare Health Plans of Tampa fought aggressively in 2004 for the right to provide mental health services to members of its Medicaid HMO.
What's the hitch: Federal and state officials are investigating how WellCare has spent that money.
How much money is at stake: In 2006, WellCare received $37.5-million from Florida out of a total Medicaid HMO budget for behavioral care of about $70-million.