An impossible choice: Doctors torn between patients and Florida's Medicaid system (Part 3)

On a Friday afternoon, two teenage parents walk into the waiting room at the Sarasota Children’s Clinic and sign in their baby, just 3 days old.

The new parents followed the instructions for getting Medicaid coverage for their newborn. They called the Florida Department of Children and Families in the hours after the baby was born and chose an insurance plan.

But at the clinic the baby’s insurance shows up as inactive. There are dozens of reasons why the baby may not be covered. But for Dr. Carola Fleener, none of that matters.

The baby is in her office. Her 30 years of experience tell her she can’t let the family walk out, even if it means she won’t be paid for the visit.

As soon as Fleener starts the exam, she sees the baby is not doing well and needs to be readmitted to the hospital.

While her focus stays on the baby, the wheels in her mind start turning: Who can monitor this baby? Where can I send the family?

Fleener calls the neonatologists at Sarasota Memorial Hospital, where the baby was born three days ago. They defer, suggesting that the parents seek help at All Children’s Hospital in St. Petersburg.

The pediatrician digs in her heels. She calls another colleague at Sarasota Memorial and makes her case. This time, they agree.

Fleecer creates a bill for the hour-long-visit, but she’s doubtful she’ll get paid retroactively when the insurance company officially activates the coverage for the newborn.

If the reimbursement does come back to her, it’ll be the most money she can earn for seeing such a Medicaid patient: $69.09.

She later learns the baby recovered and went home healthy. At least there’s that.

Appointments like this happen regularly at the Sarasota Children’s Clinic. Fleener’s practice, which she co-owns with her daughter, Dr. Barbara Fleener, conducts about 15,000 appointments per year, three-quarters of them paid for by Medicaid.

She’s one of the few Sarasota pediatricians accepting Medicaid patients and has one of the highest Medicaid patient concentrations in the region.

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Damarys Velazquez examines Ana Dely Medina’s son, Andres Lorenzo Cruz Medina, at Sarasota Children’s Clinic. STAFF PHOTO / RACHEL S. O’HARA

Her trials are not unique. In pediatric practices across the state, doctors are struggling to continue to serve needy patients in the face of paltry reimbursement rates and more intense demands of Medicaid insurance companies.

More than a dozen pediatricians and pediatric dentists recently testified in an ongoing federal case that they continue to spend more time on billing problems, eligibility changes and authorization requirements for their Medicaid patients than for their privately insured ones.

They described hiring more staff to handle the increased workload, limiting the number of new Medicaid patients they accept or dropping Medicaid altogether.

At 68, Fleener has been a practicing pediatrician in Sarasota for her whole career. She’s never had to worry about her practice as much as she does now.

“I’m looking at our financial statements every day. I have to worry every single day about paying our bills, keeping our lights on and making payroll. I’m taking money out of my retirement account. How is this happening at my age?”

“Sarasota Children’s Clinic, how may I assist you?”

§

Two years ago, the clinic’s financial future looked a lot brighter.

In an effort to encourage doctors to see newly insured patients after the passage of the Affordable Care Act, the federal government increased state Medicaid rates to federal Medicare rates — a 52 percent increase for Florida physicians.

The fee bump sent a wave of cash flowing through the Sarasota Children’s Clinic and other Florida pediatric practices. Most pediatricians used the opportunity to accept more Medicaid patients, because they were finally getting paid sustainable rates to care for them.

For Dr. Patricia Blanco, who owns and operates University Pediatrics in Sarasota and trained with Dr. Fleener in a residency program, the increased rates were a lifeline for her struggling practice.

Even before the parity money arrived in the early part of 2013, about 80 percent of Blanco’s patients were covered by Medicaid. The two years of higher rates allowed her to keep serving her patients, while also implementing an electronic medical record system in her office without being worried about seeing enough patients to pay her electricity and rent bills.

Fleener also took on more Medicaid patients. She no longer worried about making payroll and paid herself back the money that she’d sunk into the practice in previous years.

Fleener was sure that once the rates were raised, they’d never go back down.

She was wrong. At the end of 2014, Congress did not vote to keep the inflated Medicaid rates, and Florida lawmakers did not intervene to pay the difference. Overnight, her receipts were cut in half.

A few weeks after the rates dropped on Jan. 1, 2015, Blanco faced the possibility of shutting her doors.

She had to stop accepting most new Medicaid patients and instituted a rule that if patients, regardless of their insurance status, missed more than three appointments, they were discharged from the practice.

Blanco had to have other staff members tell the patients they couldn’t come to the office. She didn’t have the heart to do it.

She faced an impossible choice: stop accepting new Medicaid patients to keep the practice going, or close altogether.

“It’s really hard,” Blanco said. “We have to be there for the ones we can.”

Florida pediatricians have one last hope — a clause in the legislation creating the statewide Medicaid managed care program that requires insurance companies to raise reimbursement rates up to Medicare levels within two years of operating in Florida.

The Florida Agency for Health Care Administration, which is responsible for enforcing the fee increase with the insurance companies, said that it is working with the companies to get the rate hikes in place by the summer of 2016. Exactly how the raise would roll out is not yet clear.

The rate increase would not come from more tax dollars, but from savings achieved in other areas by the Medicaid managed care plans, said Shelisha Coleman, spokeswoman for the agency.

The Florida Medical Association, which advocates for doctors, is also working to ensure the clause is enforced.

“We’ve had conversations with the agency on whether they’ll enforce it, and we’ll hold their feet to the fire,” FMA General Counsel Jeff Scott said.

Still, Fleener doesn’t want to get her hopes up again.

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Dressed for work, a young father balances his toddler on his hip while he signs in on the daily roster, and takes a seat in the crowded waiting room at the Sarasota Children’s Clinic.

On the other side of the counter, Jenny, the 17-year veteran receptionist, grabs the boy’s chart from the stack. She types in the boy’s name to the Florida Medicaid information system to check his insurance status.

Jenny looks at the computer, sighs and braces herself. She has to tell Dad that his son isn’t covered and can’t be seen today.

When she tells him the news, Dad’s brow furrows. He calls his wife, who is frustrated and not sure what happened.

The toddler tucks his head into Dad’s shoulder.

They’ll try to come back on Monday, if one of the parents can get time off work.

Recently, many newborns have been coming in the office with inactive Medicaid coverage. The parents generally follow the rules: they call the Department of Children and Families to report that their baby is born, and they choose a Medicaid plan and a pediatrician.

But because the managed care companies tend to have a few days’ lag between when the baby is born and when the coverage is activated, babies could be technically uninsured for the first few days of life, and the doctor has to submit reimbursement retroactively and hope to be paid later.

Parents and pediatricians are doing their best, but the confusion is overwhelming. Fleener has printed instruction cards to hand to new parents while they’re still in the hospital, in the hopes that they’ll be able to get their newborn’s coverage activated as soon as possible.

A familiar scene played out at the Sarasota Children’s Clinic on a Friday afternoon. A new mom brings her newborn and toddler into the office for the baby’s first visit.

Mom says the customer service representative at the Department of Children and Families told her that her own Medicaid insurance would cover the baby for 30 days and that the pediatrician can just bill under the mother’s Medicaid number.

That’s wrong. Billing the mother’s insurance company for the baby’s care is Medicaid fraud.

But Mom doesn’t know that, and perhaps she misunderstood the customer service representative. But now she’s standing in the office and her baby looks jaundiced.

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Staff at Sarasota Children’s Clinic work in the office looking for files, calling patients and prepping immunizations. STAFF PHOTO / RACHEL S. O’HARA

Fleener agrees to a “triage visit,” a free visit she’s recently invented to deal with the stream of uninsured newborns that have been coming through her practice in the last few months. It’s the same visit she had with the newborn that had to be readmitted to the hospital.

Thankfully, this baby is healthy aside from the jaundice, and they schedule a visit for the following week, in the hopes that the insurance coverage will be active by then.

The mother left grateful, with a card with directions on how to activate her newborn’s Medicaid coverage.

Fleener wants to care for these babies, but feels like the state is taking advantage of her through these free visits. She will submit a retroactive claim for this visit, but says that most of those claims are never paid or are paid months later.

Fleener says her office usually deals with several newborns a week with inactive Medicaid coverage. On a recent Monday morning, Fleener knew she had three newborns coming into the office that needed free visits. Their Medicaid insurance was not yet active. She’ll try to get paid for those visits, but isn’t confident the payment will come.

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For all the recent business struggles, the clinic is a happy place to visit.

It’s a healing place, chock full of memories. Nurses who have lost 100 pounds, beat addictions, reconciled with estranged family members. Longtime staff members who’ve raised their families, brought their own children in for care, cared for a community.

At nurse practitioner Lisa A. Bernard’s desk, she pins up doodles of hearts and smiley faces that her young patients draw on small pads of paper. Bernard keeps them in patient files so she can share the mementos with the kids as they grow up. She says the mothers almost always cry when they see their little ones’ artwork.

They know their patients by name. There are grandparents who were brought up in the office, who now bring their newborn grandchildren in for checkups. Other health professionals bring their own children through the clinic.

At the check-out desk, kids excitedly pick a sticker to take with them for a job well done. One from the movie “Frozen” seems to make their shots sting a little less.

But occasionally, patients get angry when Fleener tells them things they don’t want to hear. The practice has several negative online reviews.

An angry father recently bullied the staff into a free visit after his child’s Medicaid coverage showed up in the system as inactive.

The first time the family came to the office with their newborn, their Medicaid insurance coverage wasn’t active, and Fleener had to tell them that they couldn’t have a full visit that day. Dad didn’t respond well.

“What’d we come here for,” he barked to Mom. “I never want to see that doctor again.”

When the family showed up the second time, Fleener was encouraged. But then she looked at the chart. No insurance. No ability to pay.

She braced herself and told Dad they’d have to call Medicaid again. He balked, and demanded to see Dr. Barbara Fleener. She agreed to give him a free visit, but they had to come back in an hour when she was available. When the family came back, they told her they would never see that old doctor again.

“It really hurts because I know what I do for my patients,” Carola Fleener said. “But do they go to Publix and walk out with free food? I have to think about my business. We’d provided them between $400 and $500 in free care at that point. We’ll never see that back. How can I look my daughter in the eye and tell her to go see these babies in the hospital, when we won’t be getting reimbursed for it?”

No one else will talk to the parents so frankly about insurance.

“I do it to help them,” Fleener said. “I bring them into a room and sit there while they call Medicaid because I want them to have their coverage sorted out so that their kids can get treated.”

“But they don’t understand. They think we don’t want to help their kids. It hurts.”

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Fleener and her team are fierce advocates for the children, who often come into the world facing tough odds. They come from low-income families in which the parents often have limited education. Many of her youngest patients have teenage parents who are struggling to adjust to parenthood.

Fleener tries not to let finance or social barriers get in the way of providing care, and spends hours on the phone securing referrals and follow-up care with specialists for those children who need extra help.

She employs a referrals coordinator, Lucy Moulton, who sets up visits with specialists who accept Medicaid. Moulton’s concierge-like role is an expensive necessity for Fleener to ensure that parents take their children to get the specialist care they need.

Moulton’s job recently got a lot tougher — the insurance company Molina recently took over the local Medicaid patients who’d been served by another insurance company, Integral.

Since the switch on Nov. 1, Moulton can’t find a neurologist or ophthalmologist who will take Molina insurance and is within a reasonable distance from Sarasota. She’s also getting calls from confused parents about the new insurance cards and letters they’re getting in the mail.

“Transition hits this population the hardest,” Fleener said. “They’re not equipped for change.”

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Lucy Moulton is the referrals coordinator for Sarasota Children’s Clinic. STAFF PHOTO / RACHEL S. O’HARA

Moulton is part of the practice’s medical-home model, which requires that Fleener be on call at night for her thousands of patients. She recently handed off two nights to a nurse, but is still available if a call gets complicated.

The around-the-clock availability is a requirement of running this type of practice, Fleener said.

The patients often don’t make it easier. They call back if she doesn’t respond to a call within five minutes. They want service now.

“These families need the most help,” Fleener said. “And we get the least amount to take care of them.”

The way forward for the Sarasota Children’s Clinic is not clear. She is keenly aware of the harm that closing the practice would cause her staff. They all have families and most have been with the practice for decades. She’s fiercely loyal to them.

Fleener could also stop accepting new Medicaid patients, but there is no guarantee that privately insured patients would take their place.

Closing her doors to Medicaid would dramatically shrink the practice that she intends to leave her daughter, Barbara, who works full time in the practice with her mom.

“If it wasn’t for Barbara, I’d take my shingle down and go home,” Fleener said.

These days, they divide the work — Barbara takes on all the newborn patients and visits them in the hospital, while Carola takes all the overnight calls and manages the business.

While Barbara knows about the financial position of the practice, it’s her mom who pores over the receipts each morning and the budget spreadsheets each night.

Barbara, who’s been at the practice since 2012, already knows the patients and she loves the one-on-one interaction with the families and children. But she’s also worried about the future of the business.

“I really do love the focus on medicine,” Barbara said. “For me, dealing with the business, it takes away from the patient. It takes away from the medicine for me.”

At 68, Fleener wants to retire, or at least cut back her hours.

But instead of putting more money into her retirement account, Fleener is taking it out. She’s transferred more than $100,000 into the practice so far, and doesn’t see it changing.

Every now and then, Fleener walks down the hallway, past the patient rooms to the billing office, to thumb through her three-ring binder of printed spreadsheets detailing the practice’s financial situation.

There’s a photo of her granddaughter on the cover, flapping her toddler arms with the gulls at the beach. Fleener calls the binder her “I can fly” book.

“She believes she can fly,” Fleener said, looking at the picture of her granddaughter. “I try to believe I can fly with this little money. I know I can’t, but I try. We’re going to have to do something soon.”

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

Photographs by Rachel S. O'Hara/Sarasota Herald-Tribune.