Miami Herald: Federal trial will decide changes in Florida’s child Medicaid program

The Miami Herald published this story on December 6, 2009

BY CAROL MARBIN MILLER
cmarbin@miamiherald.com

A federal trial that begins in Miami on Monday could effect the medical care of 1.4 million Florida children.

In a class-action lawsuit filed four years ago, disabled or impoverished children whose healthcare bill is paid for by Medicaid claim they must endure long waits — or long drives — to find doctors or dentists who accept the insurance plan. They argue their medical care is at times so poor that it violates federal law.

Under the federal Social Security Act, states that accept Medicaid dollars must provide eligible children with access to reasonably prompt medical care equal to what is available to children with private insurance in the same area.

The children represented by the lawsuit contend, however, that they are forced to endure “unreasonably long” waits for care, long-distance travel to find participating doctors and often must pay out of pocket for treatment they can’t otherwise get.

“Unfortunately, in Florida, the Medicaid program has not come close to meeting these federal requirements,” said attorney Stuart Singer with Boies, Schiller & Flexner, who is representing the children. “The Florida Legislature has for years rejected proposals from state agencies to increase reimbursement rates for healthy-kid checkups, for specialists, and for dentists, so the situation is deteriorating further.”

Administrators at the state Agency for Health Care Administration, which regulates Medicaid in Florida, declined to comment on the lawsuit at length.

“The agency will present its case in court,” agency spokeswoman Tiffany Vause said Friday. “We believe we have a very strong case.”

In court pleadings, the agency argued that several other states had already been sued for their handling of the healthcare program — and won.

Under federal law, the state Attorney General’s office wrote, Florida is obligated only to pay for medical care for the needy — not to ensure it is actually provided.

In court pleadings, the state argues that no Florida children ever were hurt due to the state’s management of the Medicaid program. “Plaintiffs have not been able in this case to identify any child in Florida who did not receive any necessary medical care, including a check up,” the Attorney General’s office wrote. “It is clear that the problems experienced by plaintiffs are isolated and anecdotal in nature, and not reflective of systemic issues warranting class-wide or even individual relief.”

Children represented by the lawsuit vary in age from infancy to late adolescence.

Among the medical care children involved in the lawsuit have had trouble accessing: pediatricians, orthopedists, dentists, immune system specialists, psychiatrists, spinal cord specialists, psychologists, radiologists, ear-nose-and throat doctors and gynecologists .

DELAY IN CARE

One child, identified in court pleadings only as J.S., has had to travel from Jupiter, in Palm Beach County, to Miami — a 160-mile round trip — to treat her immune deficiency condition.

In 2007, J.S. broke her wrist and was told by an emergency-room doctor to see a specialist quickly. “J.S. did not receive timely treatment, however, because the orthopedic surgeon she was referred to did not accept Medicaid,” U.S. Magistrate Chris McAliley wrote in an order in the case.

“J.S.’s mother then called 10 or 15 doctors who were listed in the phonebook, and about six doctors whose names were provided to her by [the state], none of whom accepted Medicaid,” McAliley added. The girl had to wait three days to have her wrist treated. She also had to wait days to treat a broken ankle, because she couldn’t find an orthopedist then, either.

Another child, T.G., a medically needy youngster who was adopted from foster care, had to wait a year for needed back surgery in 2004 because his doctor dropped out of Children’s Medical Services, a Medicaid affiliate, records show. During the delay, his severe scoliosis worsened.

Lawyers for the children claim that delaying medical care — even for weeks or months — can have tragic consequences.

In September 2005, a Pensacola doctor wrote to several state leaders about a 10-year-old boy who had to wait a month for a needed CT scan after doctors discovered a lump on his neck that they believed signaled the return of fast-growing lesions originally discovered on the boy’s leg.

Without telling the boy’s parents or his primary care doctor, the boy’s Medicaid managed care network changed his pediatrician. When the boy finally was able to see his new doctor, and obtain the CT scan, “the result was noted to be gravely concerning,” Dr. Chatchawin Assanasen, a pediatric hematologist/oncologist, wrote.

Now, the boy — identified only as J.W. — had a “significant tumor” that had invaded his spinal canal “and very little bone [was] left to support his head and neck.” wrote Assanasen, who practices at Nemours Children’s Clinic in Pensacola. After months in a specialized neck brace and chemotherapy, J.W. improved.

“I believe that this serves as a prime example of how `managed’ Medicaid has failed the most vulnerable population it was established to protect,” Assanasen wrote in a letter entered into the court file.

Throughout the state, 1.4 million children are enrolled in the Medicaid program. In addition to children from poverty-stricken families, Medicaid pays for the healthcare of elders, disabled children and adults, pregnant women and impoverished adults.

ACCESS PROBLEMS

Florida’s is the fifth-largest Medicaid program in the country by spending, and the fourth-largest by population, state records show.

 An AHCA report for budget year 2008 acknowledged “critical access to care problems” for children who need dermatologists, neurosurgeons, neurologists and orthopedists.

In April 2007, for example, a Medicaid nursing director in Panama City wrote in an e-mail that not a single orthopedist in the area would accept Medicaid.

Perhaps the most difficult Medicaid service to access is dental care, records show.

An AHCA legislative report for the 2009 budget year shows that only 17 percent of all licensed dentists in Florida serve Medicaid recipients.

Another report said less than nine percent of licensed dentists are considered “significant providers” — meaning they provide care to at least 100 Medicaid beneficiaries.

“Access to dental services in many areas of the state is critically low, and in many rural counties, access is virtually nonexistent,” a 2008 report said.

Almost one in three Florida counties have fewer than two dentists who treat children insured by Medicaid, court records show.

Records also show that Florida’s reimbursement rate is only about 40 percent of “dentists’ usual and customary fees.” Within the past five years, the number of dentists who accept Medicaid declined by 15 percent.

And Florida consistently has ranked near the bottom of all states for use of dental care among Medicaid recipients.

For budget year 2007, records show, Florida posted a 21 percent utilization rate for dental care. No other state’s rate was lower, though Delaware tied Florida at 21 percent.