Medicaid Reform

My research has always revealed that health care follows the money. So I was not surprised that the Insurance Company industry is profiting from the Health Law Mandate. This is not a “bad profit” if coverage has high quality of care and high quality of life.

Bloomberg reports

The industry that was the loudest, most persistent critic of this law, the industry whose analysts and executives predicted it would suffer immensely because of the law, has thrived,” Gosselin said. “There is a shift to government work under way that is going to represent a fundamental change in their business model.

The Justice Department had filed its first brief on Friday in the US Supreme Court. The Court is being asked to define questions about Congress’s power. This will have huge impact in Florida if the Law is upheld and the state is forced to comply. A watchful eye on this issue is needed. For more information please follow the link below.

Panel Wrestles with Federal Rules for Health Funding
“The issue centers on a $1-billion-a-year program known as the Low Income Pool, which sends extra money to hospitals and other providers statewide that care for large numbers of poor and uninsured patients. The so-called “LIP” program was created as part of the pilot, which is controversial primarily because it requires most Medicaid beneficiaries in five counties to enroll in managed-care plans.

Federal officials agreed in December to extend the pilot through June 2014 but placed strings on how $50 million of the LIP money could be used. Those strings call for taking money that otherwise could go toward hospital services and requiring that it be spent on new or beefed-up programs to improve quality of care.”

http://www.sunshinestatenews.com/story/panel-wrestles-federal-rules-health-funding

From PR Newsletter:

JACKSONVILLE, Fla., Jan. 5, 2012 /PRNewswire via COMTEX/ — Blue Cross Blue Shield of Florida (BCBSF) and the AmeriHealth Mercy Family of Companies (AMFC) today announced an agreement to enter into a joint venture to bring best-in-class Medicaid managed care and services to Florida beginning in mid-2012.

The joint venture, called Florida True Health, Inc., will be an equal partnership between BCBSF and AMFC. Both companies will share in the startup costs, financial risk and risk-based capital, among other business practices. Florida True Health will be responsible for Medicaid member enrollment, claims processing, provider network development, utilization management, quality management, customer service, community outreach, marketing, finance, actuarial and public affairs.

“This joint venture with AmeriHealth Mercy enables us to enter the Florida market with competitive capabilities from day one,” said Steve Booma, executive vice president of strategy and diversified business. “AmeriHealth’s exceptional operations and strong history in serving Medicaid members, combined with BCBSF’s 67-year history serving the health care needs of all Floridians, creates a unique organization dedicated to serve the state’s Medicaid population.”

Michael A. Rashid, President and Chief Executive Officer of the AmeriHealth Mercy Family of Companies said, “It is a privilege to bring our proven care management expertise to Florida. Our medical management and outreach programs have improved the health of our members for nearly 30 years. We look forward to working with the providers, community partners, the state and our BCBSF partner to make a positive difference in the lives of Floridians in need.”

Florida True Health will be headquartered in Florida, although the specific location of its offices has yet to be determined. Florida True Health will enter Medicaid as soon as state approvals are obtained.

About Blue Cross and Blue Shield of Florida

Blue Cross and Blue Shield of Florida (BCBSF) is a leader in Florida’s health industry. Since 1944, the company has been dedicated to meeting the diverse needs of all those it serves by offering an array of choices. BCBSF is a not-for-profit, policyholder-owned, tax-paying mutual company. Headquartered in Jacksonville, FL, BCBSF is an independent licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. For more information concerning BCBSF, please see its website at www.bcbsfl.com .

About AmeriHealth Mercy

The AmeriHealth Mercy Family of Companies is one of the nation’s leaders in health care solutions for the underserved. AmeriHealth operates in 11 states and serves more than 4 million Medicaid, Medicare and SCHIP members through its Medicaid managed care products, pharmaceutical benefit management services, behavioral health services, and other administrative services. Headquartered in Philadelphia, AmeriHealth Mercy is a mission-driven company with more than 25 years of experience serving low-income and chronically ill populations. AmeriHealth Mercy’s divisions include:

Keystone Mercy Health Plan, a Medicaid managed care health plan servicing over 321,000 members in five southeastern Pennsylvania counties;

AmeriHealth Mercy Health Plan, a Medicaid managed care health plan servicing 108,000 members in 15 Pennsylvania counties;

Select Health, a Medicaid managed care health plan serving 214,000 members throughout the State of South Carolina;

MDwise Hoosier Alliance, a Medicaid managed care health plan serving 133,000 members throughout the State of Indiana;

PerformCare/CBHNP Behavioral Health Services, servicing almost 1.1 million members in Pennsylvania, New Jersey, Indiana, and South Carolina;

Perform Rx, a pharmacy benefits manager servicing over 1.8 million members.

The AmeriHealth Mercy Family of Companies also provides other administrative services in New Jersey and Kentucky.

SOURCE Blue Cross Blue Shield of Florida

Copyright (C) 2012 PR Newswire. All rights reserved

Health Care Reform has been attempted by seven presidents. Obama’s administration with the Affordable Care Act, has put forth meaningful change. Even it’s detractors will state that it is legislation that is significant and can’t be ignored. There is strong argument that this is a mixed public policy debate on how to spend limited resources and survive in the political arena.

Whoever provides medical care or pays the costs of illness stands to gain the good will of the sick and their families. The prospect of these good-will returns to investment in health care creates a powerful motive for governments to intervene in the economics of medicine. Political leaders since Bismarck . . . have used insurance against the costs of sickness as a means of turning benevolence to power. Similarly, employers often furnish medical care to recruit new workers and instill loyalty to the firm. Unions have used the same means to strengthen solidarity. To be the intermediary in the costs of sickness is a strategic role that confers social and political as well as strictly economic gains. Paul Starr, The Social Transformation of Medicine

The quote above is a bit stale in today’s marketplace of medicine. Health Care services will always follow the streams of payment from whatever sources are available. With state governments unable to afford federal matching funds for entitlement programs the infrastructure of our community’s health care structure is truly at risk.

As the true cost of this health care infrastructure becomes more of a local government issue, limited funding may cause consolidation at the Hospital Level. Special Taxing Districts may increase to fund Hospitals. As the debate becomes more local a closer look a medical outcomes and cost of care will be fought at our doorsteps. We need to be watchful of this issue.

On March 23, 2011, Governor Rick Scott established a commission to review whether government-run hospitals are in the best interest of taxpayers. He was motivated by a Florida Tax Watch report. This report show the rapid growth in hospital special taxing districts to pay for indigent care.

The Commissions draft report does highlight how concerned hospitals are over the medicaid reform approach the state is taking. The report did not suggest that public hospitals are not in Florida’s best interest. Here is the pull quote from the report. It

The Legislature has also established timeframes for the Medicaid program to move to managed care for the vast majority of its recipients. This is to be completed for the individuals receiving Medicaid long term care services beginning July 1, 2012 and completed by October 1, 2013; and for Medical services by October 1, 2014—Implementation begins January 1, 2013.

In a managed care environment, health plans and hospitals will negotiate a rate. They are not tied to the Medicaid rate, but the Medicaid rate is normally used in the negotiations as a reference or starting point. Sometimes, it ends up being the negotiated rate. If the state moves to DRGs, questions will occur as to how this may affect the health plans/hospital negotiation and establishment of a rate, as well as how local contributions may be affected.

Health plans will be required to contract with “essential providers” that offer services that are not available from any other provider within a reasonable access standard. Statutory teaching hospitals, hospitals that are trauma centers, hospitals located at least 25 miles from any other hospital will be included in this group.
It will be essential that managed care companies selected by AHCA in the competitive procurement process for the new managed care programs receive a fair portion in the capitation payment for the cells that represent the hospital component for each individual. Providing a system where managed care companies and hospitals receive fair compensation is a major challenge that will need continued monitoring and development by the Agency and the Legislature. It has been a somewhat contentious battle between hospitals and managed care companies surrounding the rate issues. Hospital rate increases should not be implemented without coordination of the managed care rate for the new program to be a success.

Taking both reports together, it would seem likely that property taxes may increase to fund local indigent care in the public hospitals. Keep an eye on this issue.

It is a hard time to be a Florida lawmaker. The State of Florida is over budget over one billion dollars. It makes me wonder why the state turned down the federal funds that would help pay providers for services citizens of Florida need. Keep your eyes on the Health Care Lobby fighting for funding to pay for care.

Fla. legislators likely to cut budget again – BusinessWeek.

“At the state level, Gov. Rick Scott is trying to persuade the Obama administration to give Florida a waiver from federal requirements in return for Medicaid funds. The main issue is how to control the unmanageable costs — Medicaid now takes the lion’s share of the state budget — without shortchanging patients. The irony is that Republicans in Tallahassee condemn the federal healthcare overhaul for “rationing care” but they’ve devised a system that perforce rations care for Medicaid patients by putting them into managed-care systems.”

Keep your eyes on the spin factor as the fallout of CMS approval of Florida’s Medicaid Waiver expands. The Heritage Foundation post on Medicaid Reform shows how the politics of reform can be hyped.

Florida’s Medicaid Reform Pilot is pro-patient and pro-taxpayer, and the Obama Administration agrees. ….The Florida reforms work by giving patients a choice of the private health plan that works best for them. Enrollees can choose from plans with varied benefits and provider networks, and a monetary rewards system creates incentives for healthy, responsible behavior. By shifting away from failed policies of central planning toward a consumer-driven program, the program has been successful on a number of levels.

Compare and contrast to Floirda CHAIN. Florida CHAIN is a statewide consumer health advocacy organization.

“The message sent today by the Administration is clear: insurance companies will be held accountable and there’s no way around it. The decision by HHS sends a strong message that the important consumer protections in the ACA can’t be stripped away, regardless of maneuvers by insurers to boost profits or by state leaders to push a political agenda. “Individuals and families in Florida are expected to gain up to an additional $70 million in health insurance rebates, which is anticipated to be paid out by August 2012. We are thrilled to be able to report this huge victory for the hard-working people of Florida, who stand to gain money saved in their health care premiums and peace of mind that they’re health care dollars are being spent to keep them healthy.” click here for full report

Insight can be gained on the Obama Administration response itself. As Forbes reports:

The Department of Health and Human Services has denied the State of Florida’s request that they be permitted a waiver to the medical loss ratio requirements of the Affordable Care Act.

Rather than live with the 80 to 85 percent requirements established by the health care reform law, Florida had asked for an adjustment that would allow insurers to meet the signficantly lower thresholds of 68 percent in 2011, 72 percent in 2012 and 76 percent in 2013. Click Here for full report

So as the groundwork of private insurance for medicaid patients is established in the state of Floirda, all parties are fighting for how much profit can be in the system to administer the program and adjust to the risk of utilization of services. If private insurance can in fact step up and provide mandated services in a more efficient manner, they will be fighting a steady retraction of funding per patient as the Baby Booms start into the long term care system. With limited financial reward for improvement, then it stops being true insurance and becomes “dollar trading”. Dollar Trading will result in significant limits in profitability and shareholder value. The public policy debate will continue to twist the politics of Medicaid Reform.

For those clients seeking Medicaid at this time, the value of good advice can be very helpful. Understanding the changing landscape of care and how families will be asked to contribute more financially is a radical shift from the Medicaid of the past. With proper planning clients can have more choices and a better understanding how the system works. Once the impact to famlies is understood a more nuanced discussion can take place. Until then, more shouting from both sides is needed to create well thought out solution to Long Term Care.

Pull full article from the Floirda CHAIN website:

Greg Mellowe, has an expansive post explaining the extension of Florida’s Medicaid Reform Experiment. Although the posting is broader than just senior issues, to is one of the clearest statements of the current Medicaid Reform. A few of the points raised in the agreement between CMS and the State of Florida are below.

* Obtain federal approval for any type of expansion of Medicaid managed care beyond the five Pilot counties. Florida has such a request pending at this time.

* Spend at least 85% of taxpayer-funded Medicaid payments on direct patient care or direct care quality improvement activities.

* Set a well-defined minimum standard for plans to provide Medicaid benefits that meet the needs of at least 98.5% of enrollees. Plans may not reduce benefit levels below this minimum standard.

* Prevent disruptions in patient care, particularly those caused by plans in the past. Florida must take steps to prevent plans from pulling out of any geographic area. The State must also use a detailed procedure to ensure continuity of care for patients when they’re forced to change plans.

* Hold managed care plans more accountable to ensure access to and quality of care.

Florida:
- must set, justify, and enforce standards for plans, including standards for provider network adequacy and access to care.
- must ensure that the patient-level “encounter data” that has been promised for more than five years is collected, analyzed, and used to monitor health care access and quality.
- must receive federal approval of any process used to select and negotiate with managed care plans as well as plan contract documents.

* Allow most recipients who do not have a choice of at least two managed care plans to enroll in the MediPass program (or regular fee-for-service Medicaid).

* Improve its choice counseling efforts, not reduce them. Florida must not only continue its choice counseling activities to help patients make informed choices, the State must also perform activities that were supposed to have been doing since 2006, including increasing health literacy and reducing minority health disparities through outreach. Choice counseling must also use a plan rating system.

* Apply the same rules for determining eligibility and requiring co-payments in any Medicaid managed care experiment that apply elsewhere in Medicaid. The State cannot use the flexibility of the Medicaid waiver to jack up co-pays, demand payment of premiums, or restrict who can qualify for Medicaid. In other words, the State cannot use the waiver to evade the basic protections of Medicaid.

12/08/11 © Health News Florida

Gov. Rick Scott’s proposed budget would inflict particular pain on hospitals that treat large numbers of Medicaid patients, but the amount of the pain varies.

A preliminary analysis from the Safety Net Hospital Alliance of Florida, updated Thursday afternoon, indicates the hardest-hit would be Jackson Memorial, at $133.5 million.

Next-highest is Shands Hospital at the University of Florida in Gainesville, with estimated losses of more than $60 million.

Here is the updated list:

–Miami Children’s: $34.4 million

–All Children’s, St. Petersburg: $38.9 million

–Shands-Gainesville: $51.8 million

–Jackson Memorial, Miami: $133.5 million

–Mount Sinai, Miami Beach: $237,749

–Shands-Jacksonville: $13.6 million

–Tampa General: $32.5 million

–Orlando Health: $937,187

–Broward Health, Fort Lauderdale: $42.2 million

–Memorial Healthcare, Fort Lauderdale: $58.4 million

–Lee Memorial, Fort Myers: $20.9 million

–Sacred Heart, Pensacola: $3.7 million

–Bay Medical, Panama City: $2.6 million

–Sarasota Memorial: $9 million

–Halifax Medical Center, Daytona Beach: $2.8 million

Medicaid rates vary within a community because hospitals that offer specialized levels of care, such as trauma centers and neonatal units, have higher average costs.

April 28, 2011

TALLAHASSEE, Fla. – Basic health security for seniors, the poor and people with disabilities would be privatized under a Republican plan pending in the Florida Legislature.

Laura Goodhue, executive director of the Florida Community Health Action Information Network, takes issue with the plan, outlined in Senate Bill 1972.

“The main goal is to move all Floridians that are on Medicaid into privatized care, into privatized plan networks.

Goodhue underscores Florida’s dependence on Medicaid and says a pilot program to move people into a private health maintenance organization has not received rave reviews.

“Our organization has looked at various aspects of the pilot, and our conclusion is it hasn’t worked and people have really suffered.”

Republican lawmakers say the measure is needed to keep the state from sinking even further into debt.”

Florida state records show almost 3 million Floridians rely on Medicaid. Goodhue believes Medicaid privatization backed by Gov. Rick Scott is a bad idea, and the federal General Accounting Office says the efforts by Florida lawmakers to shut down expansion of Medicaid set for 2014 would deny coverage to millions of needy Floridians.

Les Coleman, Public News Service – FL

Florida among states cutting costs by limiting Medicaid hospital coverage
By Ashley Lopez | 10.24.11 | 1:58 pm
The Florida Independant

Kaiser Health News and USA Today report that Florida is among a slew of states that have been cutting costs by limiting hospital coverage in their Medicaid plans. Last week, an official for Florida’s Agency for Health Care Administration suggested that the state further cut coverage to a maximum of 12 emergency room visits a year for each Medicaid beneficiary.

Arizona and Hawaii are currently waiting for federal approval of their plans to cut hospital coverage in their plans, much like Florida already has.

“Advocates for the poor and hospital executives say the moves will restrict patients’ access to care, force hospitals to absorb more costs and lead to higher charges for privately insured patients,” Kaiser/USA Today reports. “States defend the actions as a way to balance budgets hammered by the economic downturn and the end of billions of dollars in federal stimulus funding this summer – funds that had helped prop up Medicaid, the state-federal health insurance program for the poor.”

Florida is already among the list of states that have limited hospital coverage for Medicaid recipients in an effort to cut costs. The state’s Mediciad program currently only covers 45 days in a hospital for its beneficiaries.

Last week, acting Medicaid director Justin Senior told a Florida House health care committee that the state “could reduce home health visits for Medicaid beneficiaries and slash the amount of inpatient hospital care the program covers,” The News Service of Florida reported.

Senior said the state could limit emergency room visits to a maximum of 12 a year for each Medicaid recipient, which he said could save the state $12.2 million.

State Rep. Janet Cruz, D-Tampa, raised concerns for terminally ill patients who typically need more hospital visits. However, other members of the panel were “receptive” to the idea, the News Service reported:

Chairman Matt Hudson, R-Naples, said such a move could drive people to get treatment from primary-care doctors instead of emergency rooms, which could improve their health care.

Rep. John Wood, R-Winter Haven, appeared miffed that some Medicaid beneficiaries might go to the emergency room more than once a month, calling it “unacceptable.”

“If we’re allowing that type of behavior, shame on us,” Wood said.

Health advocates for low-income people are among those opposed to plans by states to limit hospital coverage for Medicaid patients.

Kaiser and USA Today report:

In Alabama, which has had a 16-day limit for more than decade, hospitals have billed patients for days not covered by Medicaid, said Larry Gardella, director of advocacy at Legal Services Alabama. Because poor patients often are unable to pay, the hospitals typically must pick up the cost, he said.

Another problem: Patients may also delay seeking elective services if they’ve already reached the coverage limit, Gardella said.

The state Legislature made significant cuts to the Florida program in the past year. Hospital coverage has been just one of the services that has been limited for Medicaid beneficiaries as the state aims to cut costs.

Friday, June 10, 2005
Governor Bush Signs Changes To Medicaid
Welcome to Law4elders.blogspot.com!

On Friday June 3, 2005 Governor Jeb Bush Signed legislation that will allow him to roll out his new plans for Medicaid as a test project in both Duval and Broward County where nearly 300,000 Medicaid recipients reside. The Governor has proposed an aggressive schedule that includes having his program active statewide by 2006.

No matter your political position; contact your local legislator and let them know how you feel about these issues. The future of Medicaid is changing. It is up to every one of us to ensure our voice has been heard before law makers enact these changes.

Have a great weekend!

Jack Rosenkranz, JD

posted by Jack Rosenkranz @ 8:30 AM 0 comments

Friday, June 03, 2005
Highlights From The First Rosenkranz Report
Welcome to law4elders.blogspot.com! I hope you have all had a wonderful memorial day weekend.

When the Jeb Bush released his plans to alter Medicaid in the up and coming year, I took action. I consumed a tremendous amount of time researching the governor’s plans, alternatives, the key players involved, and all articles that had been released on the subject in the year before the governors first official release. We have seen a tremendous amount of political activity in Tallahassee since that first release in January. I have followed these events with cautious optimism. I have released a series of reports over the last six months entitled, “The Rosenkranz Report.” I am posting some highlights from the first Rosenkranz Report, and will publish them in their entirety on this web site in the months to come. Thanks!

HIGHLIGHTS FROM THE FIRST ROSENKRANZ REPORT:

In his continued effort to support the elderly of the great state of Florida, Jack Rosenkranz of Rosenkranz Law firm has come across information that is of unparalleled importance to you. In early January of 2005, Governor Jeb Bush (R-Florida) released a proposal for overhauling Medicaid. He is calling for many changes to the system that will greatly affect everyone who has a stake in the future of Medicaid.

The wheels are already turning. A joint committee on Medicaid reform composed of some thirty Senators and Medicaid experts toured Florida taking public suggestions for changing the system. It has become evident that something needs to change: at the current rate of growth, Medicaid spending will consume more than 60% of all spending by the State of Florida. Lawmakers are not going to allow this to happen. There are other important programs that also require money: education, safety, highways and roads, just to name a few. Medicaid currently costs more per year than any of these programs.

So what is going to change? Governor Jeb Bush has proposed dramatic alteration to the system. To summarize: if the governors original plan passed today, people on Medicaid would be assigned a counselor to help them pick the type of health care they want. Recipients would then be given money to help them purchase private insurance. Some sort of co-pay structure would likely be involved. This proposal assumes that the majority of Medicaid recipients will participate and have the ability to make good choices about their medical care. Jack Rosenkranz believes, after years of experience working with the elderly, that many people will be intimidated by the system and not use it at all. He is also concerned about elderly people with dementia and other cognitive impairments. How would these people be protected to ensure that they are not overlooked by the system?

Rules of eligibility to obtain Medicaid benefits are being challenged and reworked to drastically altering the look back times to obtain benefits. Some proposed changes would remove two of the three tests for determining eligibility and rely totally on household income. The new system would also factor in a portion of assets for determining eligibility. Basically, the higher a persons combined income/asset level is, the less likely they will be to qualify. Removing the Medicaid annuity is also being proposed, which will reduce benefits for some people.

Yet another proposal suggests creating a Medicaid HMO; a model that many of you are familiar with from experiences with Medicare HMO’s. This would undoubtedly bring about the same cumbersome aspects of accessing medical care and obtaining prescription coverage Medicare recipients experience. Recipients will have to travel from doctor to doctor to get specific types of care and deal with the limits associated with insurers making medical decisions. This is just one option that has been looked at.

The most disturbing aspect of the governors proposal involves giving recipients the chance to obtain coverage rather than entitlement to coverage. Basically, having entitlement gives a person a legal right to the money allotted by Medicaid. If you have the opportunity to obtain coverage and the funding is not there, you would be out of luck. You could not sue to get the money because you would not be entitled to it. Entitlement also ensures that medical facilities get paid. Without entitlement, businesses would have no legal recourse and many would become insolvent in a short time.

Jack Rosenkranz is following these proposals with cautious optimism. None of these things has happened yet. Legislators are still in the planning process. So what does this mean to you? Medicaid is going to be overhauled in the next year to eighteen months. Florida lawmakers are going to take action to change Medicaid. What will change and to what degree remains to be seen.

posted by Jack Rosenkranz @ 6:48 AM