As an active Florida RN [Registered Nurse] with over 34 years experience in three states, I would like to add a comment or two regarding your May 17, 2011, article “Florida to restructure Medicaid to benefit insurance industry.”
I am currently working as a complex case manager for a Florida HMO [Health Maintenance Organization] Medicaid company. I feel it is important to add that the majority of the HMO Medicaid providers offer their patients substandard care. They are rapidly closing their panels to new Medicaid patients.
Is it because of the low reimbursement they receive, their lacking of medical expertise, or their just not really caring about the welfare of people, especially the poor?
The fee-for-service program is antiquated and has been replaced by the state’s standardized, and paltry, Medicaid reimbursement fee schedule. When necessary, providers are reimbursed at as high as 150 percent through Medicare when they are out of the HMO’s network.
Are these reasons for providers to rampantly provide terrible and appalling care, forcing the patient to over-utilize the ER [emergency room]?
Contributing in part to this problem is the lack of continuity of care in the indigent population.
I offer as a very simple example, the patient with obstructive bronchitis who is given an inhaler by his or her primary care physician, but never the teaching and/or referral to a pulmonary specialist who is better qualified for an aggressive assessment and treatment plan.
These are basic and expected standards of care. Pearls of Practice. Best Practices. Common medical sense. They quite rarely are utilized.
In part this is why this population has a higher than “normal” utilization of the ER. They are also stigmatized for its use. It’s far easier to get the quick fix in the ER for the poorly diagnosed and treated. It simply is. There is no other treatment offered for our “sample patient” when the condition exacerbates. No respiratory action plan, no nebulizer, no rescue inhaler, no education ever provided in simple terminology, nothing.
To charge them for this will be a fascist disaster, further denigrating a general populace which has no voice.
So [Florida Governor] Rick Scott’s pipe dream is: If we give them to the HMOs they’ll all have a case manager.
But they won’t get licensed professionals to manage their care, keep cost reduction low, improve their quality of life. That would cost way too much money to have Registered Nurses and Clincial Social Workers managing all these sick folks.
Instead, the HMOs put the high-cost Medicaid patients in the staff's hands—squeeze that staff into making the metrics look brilliant and laugh all the way to the bank! Increase their patient load to 100. Who cares—we’re out of here by 5 pm!
Another salient point regarding ER use: So very few of our indigent have been taught about their illness(es), their options, and taught to understand they can take control of their health, increase their longevity and sustain a desirable quality of life.
This is where my colleagues and I step in. Sometimes with big guns, and other times gently, depending on each individual’s needs (and how lousy their provider may be). Without going into my job description, please be informed our health team has been known to actually harass doctors so they will order the appropriate tests; we obtain the tests results and follow up with the doctor to prescribe the correct formulary (covered) medication(s).
Rick Scott, a.k.a The Medicaid/Medicare bandit, is well despised, for many things. His scheme to further exploit the poor sickens the majority of us, the front-line workers.
Remember, the Medicaid HMO is reimbursed by the state per capita enrolled in their plan. So once again the impoverished are exploited, for there exists an ornament made of dollars hanging over their collective heads, that ornament only to be hung on the CEO’s Christmas tree.
Thank you for your attention,
Nurse with a Conscience, CCRN, CCM