The first Florida Medicaid patients required to join managed-care plans under the just-approved overhaul won't be the strong and healthy. The first wave will be made up of frail elders and the disabled.
Until now, Florida's plans to transfer Medicaid patients into managed care have focused on children and families, not the sick and frail elderly who need constant care. The assumption was that health maintenance organizations' complicated rules would trip up weak, confused elders.
But that thinking has changed. In the Medicaid overhaul that the Legislature passed and Gov. Rick Scott is expected to sign, the elderly and disabled would be the first group required to enroll in managed care.
If federal health officials approve the plan, in July 2012 the state will officially begin lining up HMOs and provider-service networks to take on the population beginning in October 2013.
Other Medicaid patients — mostly healthy children and pregnant women — won't have to enter a managed care organization until 2014, although they can enroll sooner if they want.
Older adults are where the money goes in Medicaid. In Florida, where 30 percent of Medicaid patients are elderly or disabled, they accounted for almost 70 percent of spending in 2007, according to the web site State Health Facts.
A spokeswoman for House Speaker Dean Cannon, Katherine Betta said one reason for giving the elderly the priority is the potential for improved care in that population is great, by helping them stay independent and out of nursing homes as long as possible.
A state team will determine each patient's level of need. Level 1 Medicaid long-term-care patients must be in a nursing home. Level 2's have significant physical or mental impairment but can still live in the community. Level 3's will be mildly impaired, physically or mentally.
The monthly premiums that the plans receive for the Level 2's would be greater than for the Level 3's. For the Level 1s — the nursing home patients — the state will require plans to pass on the full payment without taking part of it off the top.
For the first year only, all nursing home patients will be protected from discharge, whether or not their level of need changes. However, plans will receive financial incentives from the Agency for Health Care Administration to shift at least 2 percent of nursing home patients to community care by the second year. After that, the incentive is tied to a shift of 3 percent of patients or more.
The incentives will continue until no more than 35 percent of plan recipients are in institutional settings.
Health care consultant Paul Gionfriddo says there are a couple of dangers with this arrangement. Nursing home patients who really need to stay could be discharged to home care against their will or their family's.
Also, Gionfriddo says, a decision on when Alzheimer's patients need institutionalization will no longer be up to the family and the patient's doctor. It "will be up to a managed care company with a motive," he said.
Lawmakers who supported the addition of long-term care to the Medicaid managed care system noted that there are built-in protections, including quality measures and independent audits.
A study for the Florida House by the Pacific Health Policy Group reported last year that a managed long-term care program in Texas was saving $94 per member per month by its second year. Savings for the two years, the report said, were $123 million.