Medicaid patients with chronic health problems, be prepared: Frequent doctor visits are no longer allowed.
Hospitals also are taking new hits from the state Medicaid program for the poor and disabled. Payments for "frequent flier" patients to emergency room stops with the seventh visit in one year.
The Florida Legislature approved the caps this past spring. The state Agency for Healthcare Administration recently notified hospitals and doctors of the changes that kicked in Aug. 1.
The catch is a consumer watchdog group, Florida CHAIN, says it has asked the state for proof it has sought approval from the federal government to make the changes.
So far the proof hasn't been forthcoming, said Laura Goodhue, executive director of Florida CHAIN, which advocates for citizens' access to quality and affordable medical care.
"We have been stonewalled," she said, adding that the state has a history of moving ahead with privatizing services, capping benefits or outright taking benefits away without having federal approval.
Medicaid program officials were unavailable for comment on the consumer group's claim.
About one-third of the state's $24 billion state budget is spent on Medicaid and finding ways to curtail growth in program spending is an ongoing challenge for state lawmakers.
The new limits only apply to adults and do not apply to pregnant women.
Also exempt are clinics designated by the federal government as serving a proportionately higher number of poor patients. That applies to clinics operated by the Healthcare Network of Southwest Florida in Collier County and the Family Health Centers in Lee County.
Hospital officials point out that long-standing laws require emergency rooms to treat and stabilize all patients regardless of ability to pay. That means hospitals will get stuck with no Medicaid reimbursement after the seventh "frequent flier" visit. That compounds how hospitals must absorb huge unpaid bills from uninsured patients.
Dr. Allen Weiss, president and chief executive officer of the NCH Healthcare System in Collier County, said the goal of the Medicaid program needs to be getting the right health care at the right time to patients.
"I don't know if legislative rules that seem arbitrary will give better access and value, and value is defined as quality divided by cost," Weiss said.
He said 5 percent of Americans consume 50 percent of medical care due largely to chronic medical conditions. Changing that dynamic, a huge undertaking, is what needs to be addressed, he said.
"The solution is to manage their care," Weiss said, adding that NCH is striving to do that with its physicians and hospital services. "I think we will try to manage these patients so they won't need to end up in the emergency room. It's better for them and it's better for Medicaid."
The publicly operated Lee Memorial Health System in Lee County had more than 2,100 Medicaid patients who went to the emergency room six or more times in 2011, according to Mary Briggs, spokeswoman for the system. That was about 6 percent of the total 36,000 Medicaid patients who went to the emergency room that year.
Lee Memorial, in conjunction with the United Way, opened medical clinics in Dunbar and North Fort Myers in 2011. The intent is providing essential primary care to the needy in those communities and to lower emergency room visits.
Dr. Carrie Gittings, one of the physicians at the clinics, said in trying to get a new patient's chronic medical condition under control, a patient may be seen more than twice a month. After that, they should require fewer visits.
She has mixed feelings about the state's plan to limit physician visits.
"I think the impact of the limits is not going to hit a lot of patients but the ones who will be hit are the sickest," she said.
Expecting that state lawmakers would move forward with the changes, Florida CHAIN asked the federal Centers for Medicare and Medicaid to reject the state's plans. The group was joined by the Florida Center for Fiscal and Economic Policy, the Florida Public Interest Research Group, two unions and the state NAACP, among others.
"The proposed reductions in the amount of services that recipients can receive are dangerous, unjustifiable, and undermine the purpose of the Medicaid program," the consumers' groups wrote to CMS.
In addition, the group pointed out that state officials have no clear determination of how many Medicaid patients would be affected.
Legislative staff put the number at 38,000 while another figure was 90,000 patients would be affected by the two-visit limit to doctors.
About 677,400 patient visits to emergency rooms would be absorbed by hospitals under the six-visit limit per-year reimbursement rule.
Another concern is that no exceptions to the limits are offered based on a patient's medical condition.