As a result of settling a class-action lawsuit, Florida must significantly change the government insurance program for low-income children.

State leaders, including members of the Legislature and the governor, have a choice: They can continue to grudgingly invest in Medicaid for children and provide minimal oversight, or they can significantly increase financial support for the program and insist — demand — that the managed-care companies in charge efficiently and effectively serve the patients and their parents.

The Florida Agency for Health Care Administration, part of the executive branch, has pledged to make improvements in Medicaid that will have “a positive impact on the overall health of children.” The agency has said it is “committed to improved quality outcomes and higher standards of care.”

A recent report by university-based researchers with a reputation for highly credible work and information — provided during a Herald-Tribune forum last week on children’s Medicaid — offers a framework for beginning reform.

For example, a survey of pediatricians in Florida, conducted by the Georgetown University Health Policy Institute’s Center for Children and Families, pointed to consensus concerns in several areas:

■ Low reimbursement rates.

Medicaid providers are woefully underpaid. Consider this: Medicaid pays a pediatric provider $69 for treating a critically ill young patient; Medicare pays $146 for the same type of visit.

During the Herald-Tribune forum, Dr. Carola Fleener, who treats a high volume of Medicaid patients in her Sarasota practice, said treating a child in that condition is as difficult — perhaps more challenging — than caring for a similarly sick senior.

The federal government, which runs budget deficits, sets Medicare rates. Florida, which must balance its budget yearly, sets its Medicaid rates. Nevertheless, other states face similar constraints. Yet Florida’s payment rates are sixth-lowest in the nation and the lowest of the Southern states, according to an Urban Institute study. That’s shameful.

If Medicaid rates were higher, more physicians would likely consider participating in the program, thus possibly increasing patient access to care.

Particularly challenging, pediatricians said, is finding specialists to whom children can be referred. “With extremely poor reimbursement rates, the number of services available for Medicaid patients is dismally small,” one respondent stated. “It is extremely difficult to find dental care, virtually impossible to get mental-health services other than for the most extreme cases.”

Since the 131 providers represented only a 6 percent response rate, the Georgetown analysts said the findings could not be “generalized.”

Nevertheless, they were consistent among the respondents, who reported heavy Medicaid caseloads. Both Dr. Fleener and forum panelist Anya Staton, whose children are on Medicaid, cited the same problem. Staton, a single working mother who is also attending college, explained in painful detail the difficulties she had obtaining care for one of her children when he was gravely ill. Extensive reporting by Maggie Clark of the Herald-Tribune and evidence in the federal lawsuit show that these anecdotes are representative of the entire program.

■ Inexplicable reassignment of children to different managed care plans.

Two-thirds of the survey respondents reported an increase in patients who had been reassigned to a new plan or doctor without their knowledge.

Reassignments interfere with the delivery of care and make it unacceptably difficult for parents to navigate the system. The state agreed to address this problem in the settlement: At the least, unrequested reassignments should be limited and only allowed for authorized reasons; if changes are made, parents should be given advance notice and an explanation. Florida should strictly monitor compliance.

There are many opportunities for improving Medicaid for children, but raising reimbursement rates and reducing unwarranted reassignments should be priorities.

Editorial: Report offers steps for Medicaid reform – Sarasota Herald
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