Medicaid reform is arriving with a splash in Jacksonville and Ft. Lauderdale, Fla. It's being plugged in radio commercials, touted on billboards and talked up with church groups. All of the hype aims to prep recipients so that, from the moment they receive a bright lime-green and blue envelope in the mail, they feel they're joining the cause.
The first of about 210,000 people in Duval and Broward counties have begun to take part in Florida's newest Medicaid experiment. The goal is to give patients incentives to make smart choices about their own health care, making them the driving force in keeping costs down for taxpayers.
Florida's two-county pilot program is at the forefront of efforts around the country to give Medicaid beneficiaries more control over their health care. But Idaho, Kentucky and West Virginia all rolled out programs this summer that vary in specifics but adopt the same approach to saving taxpayers' money. South Carolina hopes to follow suit as soon as federal regulators sign off on its plans.
Federal approval is needed because the state and federal governments jointly run - and pay for - Medicaid, an insurance program that covers 59 million poor Americans, including families, the elderly and disabled.
In the two Florida counties, enrollees will choose from one of several health insurance plans. Like their private counterparts, those plans will offer different menus of doctors, covered prescriptions and co-payments.
As in the private marketplace, the plans will compete against each other for customers. The state is offering insurers a set amount of money to cover each patient, and the plans are offering packages based on that price.
"There's more competition in Duval and Broward counties among plans, therefore, what that equates to is a better deal for Medicaid recipients," said Florida Medicaid Director Tom Arnold.
He noted that several of the plans offer full adult dental coverage, including cleanings and fillings, a benefit Florida's Medicaid program never before has covered.
Meanwhile, Medicaid recipients can earn up to $125 a year to use for medical supplies, such as over-the-counter medicines. They can accrue those benefits by engaging in healthy behaviors, such as showing up for doctor's appointments, undergoing routine screenings, losing weight or quitting smoking.
Rewards for healthy behaviors are a common thread among the states championing consumer-directed health care.
Healthier beneficiaries are cheaper than sicklier ones. A patient who actively manages his diabetes, for example, is less likely to need expensive emergency care.
So West Virginia is now requiring Medicaid recipients in three counties to sign a member agreement that lays out both the member's rights and responsibilities.
Members are automatically signed up for a basic plan that has fewer benefits than the state's normal Medicaid package. But if they sign the agreement and follow its tenets, they can receive extra benefits, such as mental health services and greater prescription drug benefits.
Kentucky plans to offer expanded benefits for patients who faithfully follow disease management programs. So, for example, someone who keeps up with treatment for his asthma or obesity could earn credits toward dental and vision care.
Idaho offers a medical savings account for users. Healthy behavior can earn them money to pay premiums (for the few who have to pay them) or to cover smoking cessation or dieting services.
"Part of our idea here is to try to create a system that is more health-driven instead of sick-driven," said Ross Mason, a spokesman for the Idaho Department of Health and Welfare.
There's also another component that links the state efforts. Each is beginning to treat different types of beneficiaries differently.
Until February, states generally had to offer the same Medicaid benefits to all recipients, including poor children and their parents, low-income seniors, the blind and disabled.
But the Deficit Reduction Act, which President Bush signed in February, allows states to tailor their benefits to different populations.
Florida, which designed its plan before the new federal law took effect, is moving toward a system in which the state will pay private plans more money per patient for the costly populations, such as the elderly and disabled, than for healthier patients.
It is the only state so far to use competition among private insurers as the centerpiece of its Medicaid reform.
Kentucky is splitting its Medicaid program into four pieces. In addition to its current two main programs geared toward children and the general Medicaid population, Kentucky is offering a program with benefits geared for elderly patients who also are covered by Medicare, the federal insurance program for seniors. A proposed benefits package for the mentally retarded and disabled still needs federal approval.
Idaho is rolling out a similar strategy creating three different categories for coverage instead of four.
Both states hope they can save money by offering different populations the services they're most likely to need, without having to offer them to everyone receiving Medicaid.
There are limits to how much those strategies might save, pointed out Barbara Edwards, a former Ohio Medicaid director and principal in the consulting firm Health Management Associates.
The most expensive Medicaid patients are also its most vulnerable: seniors in nursing homes, and disabled children and adults. For the most part, though, the Deficit Reduction Act protects those patients from benefit cuts, higher co-payments and other money-saving techniques, she said.
"Don't think you're going to see a lot of budgets balanced as a result of being able to slightly modify the benefit package for healthy people, or in the case of Kentucky … saying healthy adults can't get (mental retardation) benefits, when they weren't getting (mental retardation) benefits in the first place," Edwards told reporters at a Capitolbeat conference in August.
Plus, there is still an ongoing debate over how adept Medicaid recipients will be in taking greater control of their health care choices.
Anne Swerlick, deputy director of Florida Legal Services, said she's concerned that many Medicaid recipients in Duval and Broward counties don't know about the impending changes, despite the state's media campaign.
She also said the process can be confusing for recipients who do try to navigate the coverage choices. The comparison charts provided by the state (available here ) can be confusing and leave out key details, such as which services require preauthorization, she said.
Counselors who are trained to help the beneficiaries often don't have up-to-date information from the plans, she added.
Joe Rogers, a top official for the North Broward Hospital District, a public hospital system that includes 30 health care facilities in the Ft. Lauderdale area, said Medicaid recipients were having a tough time, at least initially, becoming active consumers.
Many show up for treatment not knowing which plan they're covered by, he said. And one patient who left North Broward's coverage to get free diapers under another plan came back when she realized her doctor wasn't covered by the competing plan, Rogers said.
Still, Kentucky Gov. Ernie Fletcher (R), a former physician, told a gathering of health policy experts in Washington last week that Medicaid recipients can make better decisions.
"Having worked with them, some folks felt that maybe they're not capable of managing their own health care, but believe me, I think that is a myth that needs to be dispelled. An individual with the proper incentives and the proper education can take a very active role in managing (his) health care," Fletcher said.