Florida Medicaid: Survey of Patients, HMO Wellcare Abuse

The Florida Medicaid reform has created many problems, including increased instances of fraud, denial of care and treatment, increased insurance costs and a decrease in the quality of care. There have been many companies that have been fined for fraudulent behavior.

Read Part 1: Florida Medicaid: Expanding Privatization

Read Part 2: Florida Medicaid: Private Insurance Companies

There have been a number of researchers who have contended that the problems with the test program have been blown out of proportion. A study at the University of Florida was paid for by the state and found that the reforms were actually saving money, though it was hard to say exactly how much. Paul Duncan, the lead University of Florida researcher, said that relying on information from doctor surveys can be misleading. He stated, "Doctors weren't happy with the old Florida Medicaid system. It's hard to imagine how they were going to suddenly get more happy."

Duncan's satisfaction surveys of patients reported that 68 percent of the test counties rated satisfaction levels between 9 and 10 on a 10 point scale. He also states, "Generally speaking, they were happy before the demonstration and they stayed pretty happy after the demonstration on average, and you have to emphasize on average. There is no doubt individual patients are mad as hell."

In the second year of the Florida Medicaid reform, that same patient satisfaction rate dropped drastically. The state Office of Program Policy Analysis and Government Accountability (OPPAGA) made not much of the contradictions in University of Florida's patients data regarding satisfaction. The Office concluded that there was not enough data to reflect what the cost savings have been, so there is no way to justify the expansion of Florida Medicaid reform without concrete data.

Even if there are proven cost savings, advocates for patients claim that the patients could be having severe health implications for Florida Medicaid recipients who were possibly denied vital treatments.

Based on information from documents in a recent federal criminal complaint against the largest HMO in the state, abuse of the Florida Medicaid program was astounding. The HMO was Wellcare Health Plans, Inc. based in Tampa. In 2007, Wellcare was raided by the FBI and the company eventually admitted to being involved in a series of schemes.

There were documents that showed Wellcare worked to end coverage for sick people and as a result, the company saved $20,000 for every one of the 425 prematurely delivered babies that were dropped from their plan. They also received $11,500 for each patient that has a terminal illness. Employees were removing certain patients from coverage because they cost too much money. When the goal was reached, Wellcare hosted a celebratory dinner. The company also tried to get more than the 20 percent it was entitled to from the amount the state was paying for each patient. Wellcare did not inform the state that there was $23.6 million in overpayments and they tried to keep the difference.

Wellcare finally paid the state an amount of $80 million in order to settle the criminal complaint. An additional $137.5 million settlement is pending with the federal government. Aside from Wellcare, there have been other companies that have been fined by the Agency for Health Care Administration. These fines were due to denying care to those receiving Florida Medicaid. There was an instance of more than 1,000 children being denied speech therapy.

Michael Garner, a representative for multiple HMOs in Florida declined to talk about any individual companies. He did defend the track record of the HMOs and compared it to records of health care providers overall. Garner argued that the HMOs only constitute a small portion of Medicaid fraud in Florida and stated, "You have to step back and give equal coverage to how many violations are there by hospitals, by physicians, by dentists, by pharmaceutical companies and medical device companies."

Garner also stated that managed care can save money and despite the learning curves and growing pains of the test program, Florida Medicaid reform is a positive thing. He said, "We see dramatic cost differences and it's consistent; we see it each time."

The argument from residents of Florida is that these savings will come at a human cost. Rosenstock made a final statement, asking, "Do any of these legislators have handicapped or sick or needy people in their lives? Do they even care?"
by Dave Henderson (Medicaid Consultant: Sarasota, FL)

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