Florida Nurse Practitioners Allege Exclusion From Medicaid Reform

The following article was published in The Sunshine State News on November 21, 2011:

Florida Nurse Practitioners Allege Exclusion from Medicad Reform

By Kenric Ward

A study forecasting multibillion-dollar savings by Florida’s Medicaid reform program should be taken with a large grain of salt, say skeptical health-care providers.

The five-year-old pilot project is saving taxpayers up to $161 million annually, and could cut costs by $1.9 billion if it is extended statewide, according to the Foundation for Government Accountability.

Currently operating in five counties, the program will expand to the remaining 62 counties if the state receives approval from the Obama administration.

Commissioned by the conservative Heritage Foundation think tank in Washington, D.C., the Naples-based FGA asserted that the program has:

• Maintained health outcomes at or above the national average for the majority of indicators and improved outcomes for recipients through financial incentives.
• Achieved patient satisfaction levels above the national averages of other state Medicaid programs and even commercial health maintenance organizations.
• Restrained costs, flattening the cost curve for per-person spending.

Describing a “tectonic shift from central state management,” Tarren Bragdon, the study’s author, said the pilot program gives patients “a meaningful choice of multiple private plans, which offer varying sets of benefits and various provider networks.”

Additionally, Bragdon found “an innovative monetary rewards system that encourages and incentivizes patients toward healthy, responsible behavior in managing and improving their own health.”

“In the old system, the state simply paid claims, leaving taxpayers to pay hundreds of millions of dollars per year in fraud and abuse,” Bragdon wrote.

Under the reform pilot program, the private marketplace absorbs the risk as the state shifts to paying premiums rather than using the fee-for-service system.

Currently operating in Broward, Duval, Baker, Nassau and Clay counties, the pilot serves a mixture of urban and rural Medicaid patients.

Participation is mandatory for low-income families and children and for those eligible for Medicaid who were receiving Supplemental Security Income (the elderly and those with disabilities).

The 290,000 covered Medicaid recipients total more individuals than the Medicaid programs in 17 states.

“If Florida’s Medicaid reform pilot experience were replicated nationwide, Medicaid patient satisfaction would soar, health outcomes would improve, and Medicaid programs could save up to $91 billion annually,” Bragdon estimated.

Not so fast, say the Florida Hospital Association and a state association of nurse practitioners.

“Medicaid isn’t designed for health plans to make a profit,” said Bruce Rueben, CEO of the Florida Hospital Association.

“There’s no lesson in Florida that other states should look to. They should design their own delivery systems based on unique and special circumstances.”

Rueben recalled that “a lot of HMOs abandoned the Florida market” in the initial years of the Medicaid pilot program. He said that situation has stabilized somewhat as provider service networks picked up the slack.

“It’s better than it was, but it’s been hit and miss,” he said.

Rueben said that from an acute-care perspective, the FHA continues to work as a partner with the state.

“As long as there’s full accountability and transparency that every organization plays, it can be effective,” he said.

“You have to know where the money goes, all along the way. And you have to make sure people truly have access to care. That’s what the taxpayers are paying for.”

The state currently spends more than $22 billion a year on Medicaid, the second largest budget item after education.

Though the Medicaid reform pilot was approved by large bipartisan majorities at the Legislature, critics objected to provisions that allow private managed-care companies to add or limit benefits, expand provider networks, revise drug formularies and incentivize healthy behaviors.

A Georgetown University study released in April declared that “much critical information is still lacking about the impact of Florida’s Medicaid pilots, including whether or not the pilots have saved money — and if they have, whether the savings came at the expense of needed care.”

Nurse practitioners alleged the program’s restrictive regulations limit patient access while passing up larger savings.

By requiring Medicaid recipients to register with a primary care physician, the revised program disenfranchises nurse practitioners, who say they can provide primary-care services at a fraction of the cost.

“This exclusion is contrary to straight Medicaid or Medipass, where NPs are recognized under federal law as primary-care providers and a patient can choose an NP if they want,” said Susan Lynch, vice chair for public relations of the Florida Council of Advanced Practice Nurses PAC.

Currently, less then 5 percent of physicians accept Medicaid patients, and in several rural counties the only health-care provider is an NP, Lynch said.

If the program goes statewide — as outlined in House Bill 7107 — “all of these patients will have to drive long distances to obtain care from a physician,” she said.

In a health-care study released earlier this year, Florida TaxWatch estimated that the state’s taxpayers would save $339 million annually if the Legislature enabled nurse practitioners to function at their “full scope” of practice. That study covered all medical practice, not just Medicaid.

The Florida Medical Association, which opposes full-scope practice by NPs, said it was in the process of reviewing the FGA-Heritage report.

“But even after a quick glance, it’s obvious the nurses are trying to shoehorn their desire to practice medicine without having to go to medical school into a report that has nothing to do with this issue,” said Rebecca O’Hara, FMA’s vice president of governmental affairs.

“Their assertion that designation of a primary care physician will prevent them from serving patients is utterly baseless, as there is nothing in the report or in
HB 7107 that even implicitly suggests that. If the nurses’ extrapolations had any basis in reality, one would expect the Heritage Foundation report to at least make a note of it, because the pilot program covers several rural counties.

“To the contrary, the report concludes there are significant cost savings and mentions no problems regarding access to care in the rural pilot counties,” O’Hara concluded.

But Lynch said NPs are already being told they cannot be impaneled in Medicaid HMOs and that their supervising physicians must sign up on these insurance companies’ panels.

“This is causing problems because some of the HMOs will not impanel some supervising physicians. So the patients cannot be seen by their regular primary care NP. This will cause real problems in communities where the only provider is an NP,” Lynch said.

The FGA study says the pilot reform program shows how market competition can contain costs while improving outcomes in Medicaid, whose expenses have grown rapidly to consume a third of the state’s $69 billion budget.

In a survey of participating patients, 83 percent of measurements were at or above the national Medicaid benchmark, and at or above the national commercial plan benchmarks.

One innovative dimension of the plan is the Benefit Reward$ program, which issues cash credits to health-focused patients.

In a typical month, up to 37,000 individuals receive credits, with awards of $31 million dispensed so far. Individuals can earn up to $125 in credits per year for activities, including blood pressure management, asthma management, diabetes management and various preventive services.

The $31 million in payouts — representing about 1.1 percent of the $2.73 billion spent on reform pilot individuals — can be used to purchase over-the-counter items at pharmacies.

Reward$ costs are built into the capitated rates and are not additional costs to the program.

Following up on his study, FGA’s Bragdon on Thursday said he sent a letter to the Centers for Medicare and Medicaid Services urging the federal agency to approve the state’s pending waiver requests to authorize expansion of the pilot program.

FGA last month issued a report projecting that Florida’s drug testing of welfare recipients would save taxpayers $9.1 million in the current fiscal year. The drug screens have since been halted by a federal judge, who will rule on the constitutionality of the program.

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