Nov. 17--The first crucial date is a mere six weeks away for Florida to obey a requirement to start paying Medicaid providers higher rates, but even with the recent softening tones of the state's Republican leadership, it's unclear whether the state will approve the payments.
Under the Affordable Care Act, Medicaid payments to primary care doctors increase starting Jan. 1 to the much higher rates paid by Medicare, with the feds picking up the total cost of the increase for two years.
"In the state of Florida, where payment rates are very low, this is huge," said Julia Paradise, a Medicaid specialist with the Kaiser Family Foundation, a Washington nonprofit studying healthcare issues.
The Kaiser website shows that primary care Medicaid rates in 2008 were 55 percent of Medicare rates. That means a doctor who had been getting $50 to see a Medicaid patient would likely get about $90 under the new plan.
Medical associations complain that Medicaid rates in Florida are so low many doctors don't accept the state-federal insurance that covers the poor. Federal policymakers want the increased payments to provide better primary care to keep people out of expensive visits to emergency rooms, and to increase the number of doctors taking Medicaid to prepare for a large expansion of the program slated for 2014.
"It is a federal law," Paradise said. "There isn't a provision for the statute not to be followed."
Federal officials are telling journalists in Washington that the funds will flow automatically and don't require any state action, but a Tallahassee spokeswoman says the state needs to take actions that are far from automatic.
"The Florida Legislature must provide authority for the Medicaid program to draw down federal funds to cover the fee increase," said Shelisha Coleman, spokeswoman for the Florida Agency for Health Care Administration.
That process can happen during the two-month legislative session -- which starts in March, two months past the federal deadline -- or could be considered earlier by the Legislative Budget Commission, Coleman said.
Several former legislators told The Herald that the commission generally considers only items presented to it by the governor.
Gov. Rick Scott's press office did not respond directly to an inquiry about whether he planned to present the Medicaid pay increase to the commission. Press secretary Jackie Schutz said Friday that the commission needed to act. "We are waiting to see if the LBC will meet in December."
Scott on Friday also sent a letter to Health and Human Services Secretary Kathleen Sebelius saying the state would not meet the Friday deadline for another provision of the reform act, one requiring the states to announce whether they will establish healthcare insurance exchanges for people seeking insurance without fear of being turned down for pre-existing conditions. Under the law, the federal government will set up exchanges for any state that doesn't set them up on its own.
Scott asked for a meeting with Sebelius "at your earliest opportunity" to discuss ways to deal with "the ever-increasing cost of healthcare and the need for better access by all Florida families to quality healthcare."
Scott said that with the way the Affordable Care Act structured the exchanges, "current information available to us does not offer any indication that ... [an] exchange lowers healthcare costs for Floridians."
HHS did not immediately respond to inquiries about Scott's request for a meeting or what HHS would do if Florida did not start paying Medicaid doctors at the new rates, but HHS spokeswoman Erin Shields Britt issued a brief general statement: "Under the law, the federal government is increasing the rate primary care physicians are paid in Medicaid to improve care ... and boost quality for beneficiaries," noting that the feds are paying all costs for the increase.
About the exchanges, Britt said HHS "will work with any state to set up an exchange at any time. Consumers in all 50 states will have access to an exchange come January of 2014."
Neither HHS nor AHCA responded to questions about how much money might come to Florida doctors under the proposal.
Timothy J. Stapleton, executive vice president of the Florida Medical Association, said the pay increase was long overdue. "We believe that increasing Medicaid physician payment rates will improve access, lead to healthier Floridians and save money in the long-term by ensuring that fewer patients seek treatment in costly settings like hospital emergency rooms."
Matt Salo, executive director of the National Association of Medicaid Directors, said the U.S. Supreme Court ruling last spring on the healthcare act allowed states to opt out of the provision for expanding Medicaid to more patients but determined that all other provisions of the law -- including increased doctors pay -- were lawful.
Salo noted that the federal law only requires Washington to pay for the Medicaid payment increases for two years. "That is going to create a difficult situation for states," he said . States will need to lobby Washington to get the pay extended. If the efforts fail, the states would have to pick up the increased cost or doctors' rates would have to be slashed -- choices that states would hate to deal with, Salo said.
Shortly after the election, Sen. Don Gaetz, R-Destin, the incoming Senate president, said he supports paying Medicaid primary care doctors more and fought for such legislation at the last session, but lost. Gaetz said he feared approving increased federal funding for Florida programs that might end, leaving legislators with unpleasant choices.
Paradise, of the Kaiser Foundation, said the reform act has a two-year limit because Congress wanted to see what effects the pay increases had. The law requires states to collect data to see if the added pay brought more doctors into Medicaid and whether that increased patients' access to care.
The governor's offer for discussions with HHS mentioned an additional point of tension between the state and federal governments: Florida's request for a federal waiver to allow the state to carry out a huge reform of Medicaid that would include putting recipients throughout the state in managed care plans.
"We appreciate all the work your staff has done on the current Medicaid waiver request," Scott wrote to Sebelius at HHS, "and look forward to your approval."
Paradise noted that the Affordable Care Act includes a clause that requires even Medicaid managed care plans, which often set their own fee schedules, to pay primary care doctors at Medicare rates.
(c)2012 The Miami Herald
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