The state has spent about $2 million defending a class-action lawsuit that claims Florida is violating federal Medicaid requirements by providing inadequate medical and dental care to more than a million children.
The case, scheduled for trial next week, claims 390,000 children did not get a medical checkup in 2007 and more than 750,000 received no dental care.
The problem: Many doctors and dentists won't accept Medicaid as Florida's reimbursement rates are among the country's lowest. Medicaid pays $15 for a basic dental exam in Florida, compared to $25 in Tennessee, which is considered a model of success for Medicaid dental reform. It's about $40 for private insurance. A pilot program in Miami-Dade County pays dentists a monthly fee of $6.55 to treat each child.
"There are many counties where there are only one or two dentists willing to receive Medicaid patients and then they limit the number of Medicaid patients they do see," attorney Stuart Singer said. He filed the lawsuit in 2005 on behalf of Florida Pediatric Society, the Florida Academy of Pediatric Dentistry and all Floridians under age 21 who now or in the future would be eligible for Medicaid.
State officials mostly declined comment except to say they believe they will win at trial.
Florida reimbursement rates are so low that less than 9 percent of Florida dentists are significant Medicaid providers, leaving a backlog of children desperate for care and few doctors to see them, experts say. In 2003, one dentist served about 400 Medicaid children in Miami-Dade County. In 2007, one dentist served an average of 1,196 children, according to a study done by Columbia University.
The wait for specialists can be longer. In Tallahassee, a child on private insurance has a two- to four-week wait to see an ear, nose and throat doctor. The wait for a Medicaid child can be two to three months, said Dr. Louis St. Petery, a pediatric cardiologist and executive vice president of the Florida Pediatric Society. Children with fractures in South Florida are struggling to get appointments with orthopedic surgeons, he said.
A 10-year old boy on Medicaid complaining of leg pain came to a southwest Florida hospital in 2004. Doctors found a tumor, but further tests came up negative. Six months later he returned with severe neck pain and doctors ordered an MRI and CT scan, but couldn't get insurance authorization, despite repeated phone calls. Three months later they got permission and found a large tumor in his neck infringing on his spinal canal, said Dr. Chatchawin Assanasen, a pediatric oncologist at Nemours Children's clinic.
Getting the tests sooner would have provided "a much more benign outcome with treatment provided before the tumor progressed so significantly," he wrote in a letter to the insurance company. The boy was given emergency chemotherapy and survived, but today has little bone left to support his head and neck.
Doctors say that boy's story is a common tale in Florida's Medicaid system, where patients often have to drive long distances to find care. Hundreds of eligible people aren't even aware of their potential benefits, according to the lawsuit.
Administrative red tape in the program is so bad that children frequently have their coverage dropped or are switched to another provider without their parents' knowledge, experts say. It takes about 30 days to switch to another program. The state Agency for Health Care Administration _ which runs Medicaid _ has blamed the problems on glitches while switching over to a new computer system.
Kendra Garcia, a South Florida mother of three, says her children were twice switched from one plan to another without her knowledge.
"My kids have gone periods where they weren't getting any services because the doctors didn't take the insurance and it took 30 days for it to get worked out," she said.
During one switch, she brought her autistic son to his therapist of two years and was told her insurance had changed and they no longer accepted the new plan. At times she's had two children on one plan and one enrolled in another, without her authorization.
Critics say the state should have spent the $2 million used on legal fees to better care for children. The defendants include AHCA, the Department of Children and Family Services and the state Health Department.
St. Petery criticized the agencies' response to the lawsuit, saying "the first thing the state did is spend money defending this rather than turn around and recognize that kids aren't getting care."
DCF and the attorney general's office declined comment. An AHCA spokeswoman said agency attorneys are "busy preparing for the trial and believe we have a very strong case."
The agencies have argued that the children and health providers don't have legal standing to pursue the claims because the Medicaid program promises money but not necessarily the delivery of health services for particular individuals, as the lawsuit contends.
Courts nationwide have split on that issue. In an earlier hearing this year, a Miami federal judge said legal precedent in the federal 11th Circuit _ which includes Florida _ suggests that Medicaid is about delivery of health services, not just money.
If the plaintiffs succeed, it could cost Florida taxpayers tens of millions of dollars, but their attorneys argue it will save the state money in the long run by avoiding costs for children who didn't get adequate care early on. A mediation attempt earlier this year failed.
Raising reimbursement rates has had significant affect on children's access to health care nationally, according to testimony from the American Dental Association and the American Academy of Pediatric Dentistry before the House of Representatives in October.
Dentist participation in Virginia's Medicaid program increased by 80 percent after the state increased reimbursement fees and fixed administrative snafus in 2005. The number of children getting dental care increased by 55 percent after that. South Dakota, Alabama and Tennessee have had similar successes.