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Medicaid settlement: Florida will work harder to ensure health care for children

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Medicaid settlement: Florida will work harder to ensure health care for children

Picture of Maggie Clark
The Herald-Tribune
Wednesday, April 6, 2016

In a sweeping agreement, pediatricians, pediatric dentists and parents reached a settlement with Florida’s Medicaid agencies, ending a 10-year legal battle over adequate care for children enrolled in the joint federal and state health program.

The agreement, which must be approved by a federal court, requires that Florida's Agency for Healthcare Administration, Department of Health and Department of Children and Families do more to ensure that children enrolled in the Medicaid program receive the services to which they are entitled.

The settlement also requires the state agencies to pay $12 million for legal fees and expenses to the health providers and parents of the Medicaid enrolled children who brought the lawsuit in November 2005.

“This settlement is a significant step forward in improving access to medical care for the 2 million Florida children on Medicaid,” said Dr. Tommy Schechtman, president of the Florida chapter of the American Academy of Pediatrics. “We look forward to this new collaborative relationship with Florida’s state agencies to ensure all Florida children obtain the quality health care they need and deserve.”

The settlement marks a new day in relations between the state agencies, pediatricians and dentists, who have been adversaries in the long-running legal battle.

“I am happy that we were able to find a very positive resolution for this case and am grateful for all of the hard work that the Agency has put forth in reaching this agreement,” said Agency for Healthcare Administration Secretary Elizabeth Dudek in a statement.

The settlement ends a case that revealed significant problems in Florida’s health care program for needy children. A 2014 finding by Judge Adalberto Jordan concluded that Florida was violating federal law by denying care to children. But the state rejected those findings, arguing that the Medicaid program had changed significantly over the last several years and its new statewide managed care program offered more access to care for families and accountability for providers and health plans.

The problems in Florida's Medicaid program were the subject of a Herald-Tribune investigation "2 Million Kids. $24 Billion Battle" published in January, outlining the reasons that hundreds of thousands of Florida children miss out on care every year. The findings included the fact that Florida ranks 50th out of 51 states and Washington, D.C., in per-child spending on Medicaid, and spends only about one-third of the amount that top-spending state allocate.

While the settlement aims to correct those and other problems, it does not require either side to accept liability for the previous Medicaid program. Instead it looks toward what the agencies will do to improve the system.

That was deliberate, said Stuart Singer, lead attorney for the families and physicians.

"We have a 153-page finding from a federal judge that says the state violated federal law, but it wouldn’t be productive for us to rub their noses in that in a settlement," Singer said. "We’re looking forward and this is a way of working together on improving the system and we’ve acknowledged they’ve made improvement since the time of the 2012 trial on which those conclusions were based."

Spelled out in the 29-page settlement are requirements that the AHCA, which is responsible for ensuring that Medicaid-enrolled children have access to the services they are due, gives incentives to the state’s Medicaid managed care plans to improve access to care for children.

The health plans, which took over most of the care for children in the fall of 2014 when the managed care system was rolled out statewide, will be measured by specific metrics starting in fall 2016. If the plans fail to meet the higher standards, the agency is required to fine them.

AHCA must also work with the health plans to increase reimbursement rates for physicians, which can be as little as $14 for a visit with a pediatrician.

Over the next few months, the agency will work with health plans to set performance objectives for physicians, so that they can earn Medicare rates, which are currently about twice as high as Florida Medicaid rates for similar visits.

The reimbursement increases through 2019 will be funded from savings achieved by the health plans, Singer explained, by keeping children healthy and keeping them out of the high-cost emergency room. If the plans don't achieve adequate savings, the agency must ask for more money from the Legislature. If lawmakers refuse, the court will get involved, Singer said.

The agency must also enforce standards for reaching an available doctor within a reasonable time and distance standard from a Medicaid member’s home. While the rules are already in place, the settlement calls for them to be more aggressively enforced. That would solve the problem for parents forced to drive hours to find a doctor who will accept their child’s Medicaid insurance.

Additionally, beginning in 30 days, AHCA will conduct a study of the number and the locations of pediatric dental providers, and how the agency can ensure providers are paid on time and have less administrative overhead.

The emphasis on dental care is focused on increasing the number of children who get dental care, which was just 32 percent of Florida children in 2014.

When it comes to the number of children who actually received treatment for a diagnosed dental problem, the rates dropped to just 12 percent, the second-lowest in the nation behind Wisconsin, according to data submitted by Florida to the federal government.

All three agencies agreed to do more to make sure that children weren’t switched to different insurance plans without their parents’ knowledge and that newborns are enrolled in their Medicaid coverage quickly, so that they can start getting care right away.

Newborns going without coverage is a significant problem -- the Sarasota Children’s Clinic, a private practice with a large percentage of Medicaid patients, typically sees several newborns each week that have not had their coverage activated. Pediatricians often don’t get paid for caring for these children.

If any of the provisions in the settlement aren’t followed, the pediatricians, dentists and parents can go back to court until 2018 for violations by the Department of Children and Families, and until 2022 for violations by AHCA.

While the settlement requires much action from the state agencies, nothing in the settlement is an admission of liability on the part of the state. It doesn’t require any action by the agencies to correct previous problems.

"You can’t look backwards," Schechtman said. "This settlement is a great opportunity for us to move forward and make changes together, and make Florida a model for the country in the way that it takes care of its children enrolled in Medicaid."

For the child advocates, the settlement was bittersweet.

"If I have any regret, it’s that we haven’t been able to accomplish this sooner," Singer said. "There have been millions of kids who did not get the benefits that future kids will get. But there are no losers in this settlement, and the biggest winners are the children."

[This story was originally published by The Sarasota Herald-Tribune.]

[Photo by Kevin Slavin via Flickr.]