A buried clause in a bill creates the "biggest mass conversion" of beneficiaries to managed care, which officials find troubling.
By ALISA ULFERTS
Published June 7, 2004
TALLAHASSEE - They were just two sentences in a 92-page bill, but they added up to $140-million to HMOs angling for state contracts.
The clause, one of the most controversial measures state lawmakers passed this year, shifted hundreds of thousands of Medicaid psychiatric and substance abuse patients into health maintenance organizations.
What made it controversial wasn't just how it was passed - it was buried in a budget bill without public debate in any committee - but that it unraveled a bill lawmakers passed unanimously last year after months of debate.
That bill set up an advisory board, Florida Substance Abuse and Mental Health Corp., to oversee the gradual shift of Medicaid psychiatric and substance abuse patients into managed care.
Under that plan, HMOs could apply to offer the prepaid plans, as could nonprofit community health centers.
But the clause lawmakers approved this year, many without initially realizing it, gave HMOs the right to the business immediately. The change was pushed by WellCare, a Tampa HMO that has supported House Speaker Johnnie Byrd's Republican U.S. Senate bid.
"It will be the biggest mass conversion of Medicaid beneficiaries to managed care in the history of Medicaid," said Bob Sharpe, who was the state Medicaid director until last month and now president of the Florida Council on Behavioral Healthcare, an association of community mental health providers.
"That can be very confusing and disruptive to care," Sharp told the advisory board during two days of testimony on the issue last week.
Allowing HMOs to serve psychiatric patients has been tried as a pilot project in a handful of counties, Hillsborough included, for the past decade, with mixed results.
Sharpe warned the advisory board that the pilot project has been far from trouble free.
"Nine years into this demonstration, there are major deficiencies across the board," Sharpe said.
"The implementations were done too quickly and were poorly planned," Sharpe said.
The deficiencies Sharpe outlined included poorer patient access to care, less accountability, inadequate state oversight and failure to spend at least 80 percent of the state contract money on direct care as required. Administrative costs also went up, Sharpe noted.
Too often, Sharpe and other advocates for the mentally ill said, the state assumed all was well with the pilot program because patients were not calling the state to complain. But psychiatric and substance abuse patients generally do not have the wherewithal to act as consumers of health care who complain about the service. They simply fall through the cracks.
Many end up in jail, said Tom Riggs, president and chief executive of Directions for Mental Health in Clearwater.
But Bob Wychulis, president of an HMO trade group, the Florida Association of Health Plans, said the most recent state evaluation of the pilot project shows that with a few minor exceptions, mental health patients are doing as well or better in HMOs as those served in community mental health networks.
HMOs say they are the experts in managing care and they will contract with the counselors who have served those Medicaid patients for years.
But the Florida Substance Abuse and Mental Health Corp. isn't so sure. The advisory board has asked the state to hold off on the patient transfer at least until it can study the issue.
The advisory board will release a report in December, said executive director Ellen Piekalkiewicz.
But the Agency for Health Care Administration has no choice but to move forward with the transfer, an agency spokeswoman said, and expects to request bids by November.
The psychiatric and substance abuse care of Medicaid patients will be turned over to the HMOs that provide their medical care. Advocates for the mentally ill say community mental health centers provide the best care to patients because many cannot navigate through the bureaucracy of HMOs. About 60 percent of Medicaid patients get their regular health care through HMOs.
Taking it statewide is part of an effort to rein in Florida's runaway Medicaid costs. Medicaid, the state-federal health care program for the poor, gobbles a fourth of the state budget. The state is expected to spend more than $14-billion on the program this year alone. Prescription drugs are a culprit, and mental health drug costs are increasing three times faster than other drugs.
But advocates for the mentally ill say the patients are most in peril, partly because they depend so heavily on their specific combination of services to lead everyday lives. Some may be suicidal, and regular HMO doctors who can prescribe psychiatric drugs are not specifically trained to diagnose suicide risk.
Profit-driven HMOs also spend less on care, Riggs said.
"The consequences can range from, at worst, homicide or suicide to cost-shifting to hospitals," Riggs said. His outpatient facility served nearly 7,000 clients last year.
But the fragility of mental health and substance abuse patients is exactly why they deserve to have their care coordinated by their regular health plan instead of having it splintered across several providers, Wychulis said .
"We provide an integrated, full-service system for the recipient who has chosen to stay in their HMO," Wychulis told advisory board members.
"The truth of the matter is we are delivering services in a comprehensive way," Wychulis said. He also disagrees that the language lawmakers passed this year undoes last year's bill. Rather, Wychulis said, it clarifies it.
Wychulis said the patients are being served well in the pilot project and the state is saving money, even as Sharpe reminded the advisory board that Florida ranks near the bottom in mental health spending.
The Florida Substance Abuse and Mental Health Corp. also is looking as part of its study at the effectiveness of the pilot project.
