Miami-Dade Medicaid Forum

1. Miami-Dade Medicaid Forum United Way of Miami-Dade Miami, FL January 11, 2008

2. Florida Medicaid Reform Evaluation Paul DuncanPrincipal Investigator

3. Patient responsibility and empowerment Marketplace decisions Bridging public and private coverage Sustainable growth rate Florida Medicaid Reform Principles

4. More Choices for Beneficiaries HMOs and PSNs Customized benefit packages Opt-out to employer-sponsored plans Choice Counseling Enhanced Benefit Accounts Risk-adjusted Rates Low-income Pool What’s New?

5. UF Evaluation • UF contracted by AHCA to conduct five-year evaluation study • The UF evaluation studies will examine whether or not Reform achieves its stated objectives including: • the establishment of Health Plans and Networks, and related processes to manage and deliver health care to enrollees • development of a process for enrollees to choose the plan they prefer • improved health care processes • better health outcomes • improved enrollee satisfaction • predictability in costs/expenditures • Several additional projects and collaborations • also initiated

9. Medicaid Reform in Florida – Key Reform Elements & Results Reform Program Elements Reform Program Results • More Choices • PSNs • HMOs • Special Plans • ESI Opt-out Medicaid Expenditures $$ $$ $$ Enrollee Experiences Satisfaction In a Plan or Network Choice Counseling Process Disenrollment Customized Benefit Packages Healthy Behaviors Health Status; Racial Disparities; Clinical Outcomes Enhanced Benefit Accounts Utilization Opt-Out (ESI) Low Income Pool Access for Uninsured

10. Evaluating Medicaid Reform in Florida: MED027UF Evaluation Team Administration Paul Duncan (Principal Investigator) pduncan@phhp.ufl.edu Lilly Bell (Project Manager) lbell@phhp.ufl.edu Florida Advisory Committee Technical Advisory Committee Organizational Analyses Christy Lemak (Investigator) clemak@phhp.ufl.edu Amy Yarbrough (Investigator) ayarbro@phhp.ufl.edu Quality of Care, Outcomes, and Enrollee Experience Analyses Allyson Hall (Investigator) hallag@phhp.ufl.edu Rada Dagher (Investigator) rdagher@phhp.ufl.edu Fiscal Analyses Jeffrey Harman (Investigator) jharman@phhp.ufl.edu Low-Income Pool Analyses Niccie McKay (Investigator) nmckay@phhp.ufl.edu

11. Organizational Analyses Christy Lemak, PH.D.Amy Yarbrough, PH.D.

12. Organizational AnalysesUpdate • Health Plans and Networks • AHCA • Other Stakeholders • Legislature • Choice Counseling (ACS) • Others

13. Over 135 Interviews • Health Plans and Networks • 15 organizations; 58 interviews (3 rounds) • AHCA (Tallahassee and Area Offices) • 59 one-hour interviews (3 rounds) • Other Stakeholders • Survey Monkey (45 responses + 8 Follow-up Interviews) • Community Forums (Attended 8 Focus Groups + 7 additional interviews)

14. Key Finding 1 It is too soon to tell whether and how Reform is working—especially in terms of the big picture questions: access, costs, outcomes.

15. Key Finding 2 There are no simple solutions to complex problems.

16. Overarching Theme1:Implementation Went Well • Almost 200,000 enrollees in 5 counties with few bumps in the road • How? Why? • Leadership, Resources, Communication • A New Way of Working Together • Continuous Improvement Process

17. Overarching Theme 2:Some Elements of Reform Work Well or Show Potential to Do So • Choices for Enrollees (including PSNs) • Choice Counseling Process • Disease Management

18. Overarching Theme 3:Mixed Views on & Questions about Some Reform Elements • Choices • Enhanced Benefit Accounts • Risk Adjusted Rates • Opt-Out Program

19. Overarching Theme 4: Managed Care Can Be Difficult • Provider Perspectives • Specific Issues for Certain Populations • Mental Health • Disabled • Others

20. Overarching Theme 5: Continuous Learning and Knowledge Transfer • Contract language and processes • Flexible Benefits • Quality Measures • Outreach to providers • Choice Counseling • Special Needs Unit • Pharmacy • Enhanced Benefits Accounts • New Lists • New Tools

21. Looking Ahead • Ongoing Developments • Provider data • MEDS data • EBA studies • How to Best Capture Physician and Hospital Perspectives • Moving Beyond Implementation Phases

22. Allyson Hall, Ph.D.R. Paul Duncan, Ph.D. Quality of Care, Outcomes, and Enrollee Experience Analyses

23. Two Components • CAHPS-Style Surveys • Benchmark: Fall 2006 • Round 1: Fall 2007-Spring 2008 • Qualitative Interviews (Longitudinal Study) • Early Experiences and Health Beliefs • Broward and Duval: Focus groups, In-depth interviews • Clay, Baker, and Nassau: Focus groups • Longer-term experiences • Broward and Duval: In-depth interviews, Focus groups

24. MEDICAID REFORM ENROLLEE SATISFACTION: BASELINE CAHPS SURVEYIN BROWARD AND DUVAL COUNTIES Paul Duncan Allyson G. Hall Babette Brumback Jianyi Zhang Lorna P. Chorba

25. Pre-Reform Summary • The benchmark Medicaid Reform Evaluation Survey • Fieldwork conducted in Fall 2006 • Based on the Agency for Healthcare Research and Quality’s (AHRQ) “Consumer Assessment of Healthcare Providers and Systems” (CAHPS) model associated with the HMO Report Card • Goal: to measure health care experiences and satisfaction levels in Duval and Broward Counties prior to the implementation of Medicaid Reform

26. In a Context of Making Choices, Patient Satisfaction Matters • The survey instrument measured respondents’: • plan enrollment process and coverage • relationships with their providers • overall satisfaction and rating of providers and health plans • ability to access care and health care utilization • perception of the level of courtesy, respect, and helpfulness of office staff • ability to communicate with healthcare providers; • health literacy • health and wellness behavior • health status (SF-12)

27. Survey Results Overall, satisfaction levels were high. • On a scale of 0 to 10: • roughly 70% of survey respondents scored their health plan an 8, 9, or 10 in satisfaction level • 80% scored their overall health care an 8, 9, or 10 • There are, however, a few areas of concern that should be closely tracked during the evaluation period: • Many respondents indicated that they experienced difficulty: • getting help from Medicaid’s or a health plan’s customer service • accessing specialty care • and about 50% experienced delays while they waited for approval from Medicaid or their health plan • Enrollees prefer MediPass (less managed) to HMOs (more managed)

28. Enrollee Satisfaction – Example Responses

29. Health Plan Rating Results Shown by Plan

30. Qualitative Interviews: Longitudinal Study Allyson G. Hall Gail C. Young Lilliana L. Bell Keva S. Thompson Kimberly E. Elliott

31. Longitudinal Study: Demographics • Approximately 76 participants to date • About half of sample from six Focus Groups • Others from In-depth interviews • Gender: predominately female • Race / Ethnicity: (predominately Black) • Blacks, Whites, Hispanics, Other • Age: • Range 15- 61years • Eligibility: • > 75% SSI

32. Control of Health is Influenced by Individual Ability, Help from Others, Money, and Faith I am going to give an example of controlling my health. I used to smoke….I woke up in December of last year and told myself I am going to quit smoking and I quit smoking. Someone was helping me [to lose weight], encouraging me to eat the right stuff, yes someone to push me. If I try to do it on my own it’s not working. Even if they did lower the prices on the healthy stuff that don’t mean we are going to eat it…we are still gonna go against it, you have to be self-motivated. If I got a bunch of money I wouldn’t have to worry about this house, instead of taking all this medication, it might calm me down and make me feel better about myself. I think faith really does play a big role. A lot of times I be sitting at home and my pressure would be so high….and then I say Lord it is in your hands…and I sit for a few minutes…and then I know it [her blood pressure] will begin to drop.

33. Relationships with Physicians are Important The doctors be staying on me like you can’t do this, you have to do this and I appreciate this because they are keeping my health up. Actually my doctor really helped me, educated me about Medicaid. It makes you feel bad because you got a relationship with this doctor and then all of a sudden things change cause of the insurance and you feel discriminated, you feel deprived.

34. Before Reform Enrollees Experienced Barriers to Care It’s frustrating that Medicaid doesn’t pay all your medicine. They say they can’t help me with transportation because I have an HMO. I have major problems with transportation. I think the hardest part about Medicaid is just finding a doctor you can communicate with. And everybody you ask don’t take Medicaid...and there is only one dentist in Baker or Duval that takes Medicaid. I think I get treated differently being poor, you know and being on Medicaid. I think they don’t care as long as they get their money from the state.

35. Active Participation in Plan Selection But then I had questions, I had to call them and then I wrote down the different doctors that they didn’t accept and they did. Well I just had to keep looking through all of the plans, and look at my doctors, and see if they was on them plans keep calling back to the Medicaid. It was very simple. I called the Choice Counselor when I got the blue-green letter, and told them to leave me exactly where I was. One of the reasons I chose Humana because it works with Memorial Health System. I have talked to them [Choice Counselors] on special occasions. They were very helpful to me. They explained everything and you know just helpful to me.

36. Maintaining Continuity of Care is Important to Enrollees in Plan Selection I had to visit all my doctors to see what doctors were covered in whatever… I [wanted] to have all my specialist under this new program. So that was my main concern. At the doctor’s office, they gave us a booklet on different changes like First Coast and all of them little different small companies. And they was telling us which ones to switch to if you want to stay at that doctor’s office. The first plan I said was StayWell, the doctor I went to did not take that plan, so I had to change and I went to Preferred.

37. For Some, Finding a Primary Care Provider is Problematic I love my primary care doctor, but when the switch was made, he doesn’t take Humana. I had to get a new primary care doctor…man [the doctor] doesn’t know me from Adam. I called her [Choice Counselor] and said well the doctor is not taking no new patients, what do I do? She goes, well, we are trying to look for you in your area and so far there is no other doctor right now taking Medicaid. When you get a brochure, you call to make an appointment, the doctor is no longer on that plan, or the doctor was never on that plan.

38. Some Enrollees Expressed Discontent with Choice Counselors You cannot depend upon these Counselors; you’ve got to go to the place yourself and check it. You can’t make phone calls. You’ve got to go to the site and check it out or have someone go with you, because if you depend over the phone with these Counselors or whatever, you’re going to be messed up. They don’t have enough education. No, I was not satisfied, not satisfied, [with Choice Counselors] I called maybe like 20 people, transfer to this person, this department, that department, the lady got aggravated, I got aggravated, I end up going to sleep with stress.

39. Enrollees Noted Greater Restrictions Associated with Access to Specialty Services Before I didn’t have to, my doctor would send me to any specialist without any problem. My PCP would make an appointment, and I would just go to the appointment. Now the difference is that I will have to go to my primary care provider, tell them I have to go to whatever specialist, then they do the paperwork, and give me a referral. …the new injection they give patients with macular degeneration goes directly to the eye. Referrals that are given from doctors just covers the regular check-up, it doesn’t cover the injection. So they have to call the primary doctor and sometimes they don’t answer the phone. I need someone I can go to for arthritis…the girl in the office that takes care of the referrals hasn’t found anybody to go to.

40. Enrollees Noted Barriers to Getting Prescription Drugs I was getting this medication for foot fungus. Unfortunately, when I went over to Humana, I wasn’t able to get it. I am going back to my podiatrist and see if one of the anti-fungus ointment that he has may work for me, because the one that works for me, it’s not on the Humana medical, pharmaceutical list. The Medicaid Reforms is a system that was designed that is not working. Now we can’t get certain medications.

41. The Enhanced Benefits Program is a Relatively Untested Concept for Enrollees Interviewer: Remember, they have a list of behaviors that if you participate in them, you can earn money. Would that encourage you to change your health, your behaviors? Respondent: Nope. I ain’t changing nothing different, no way. I am going to be going to do the same thing I have been doing. Interviewer: Oh, so you wouldn’t do it even if they are giving you free money to help you? Respondent: Nope. Interviewer: They have an enhanced benefit account… Respondent: Oh yeah, they sent me a pamphlet the other day. I just got it in the mail last week. You earn points. I would probably participate in that because it is getting what you don’t have.

42. Fiscal AnalysisEnrollee Per Member Per Month Expenditures: Early Results Jeff Harman, Ph.D.

43. Comparing Pre and Post Reform PMPM Expenditures • Compared PMPM expenditures pre-Reform to PMPM expenditures post-Reform • Pre-Reform expenditures were calculated for enrollees who would be eligible for Reform for services covered by Reform during FY0506 • Reform expenditures were calculated for beneficiaries enrolled in a Reform plan or PSN from 9/1/2006 through 12/31/2006

44. Pre-Reform PMPM Expenditures • Pre-Reform Expenditures • Had to live at least one month in a Reform county • Had to be eligible through TANF or SSI • Excludes Dually Eligible, Medically Needy, ICF/DD, MediKids, Women with Cervical or Breast Cancer • Only months in Reform county and Reform-eligible • Only Reform-eligible services used in the calculations • Excluded most waiver services (AIDS, DD, etc.), school-based services, Home Safe Net, Supportive Living, and BHOS Services • N = 2,733,140 person-months

45. Reform PMPM Expenditures • Reform expenditures • Only beneficiaries enrolled in Reform plan or PSN included in calculations • Expenditures were payments made to PSNs or Plans • PSN payments based on FFS claims of enrollees • Plan payments based on risk-adjusted monthly capitated premiums • Encounter data not available at this time • N = 201,751 person-months

46. Expenditure Comparison • Compared pre-Reform PMPM expenditures to Reform PMPM expenditures • All Reform-eligible or Reform enrollees • Broken down by SSI vs. TANF • Broken down by Broward vs. Duval • Broken down by SSI vs. TANF for Broward and Duval separately

47. Total PMPM Expenditures In The Year Prior To Reform And First Four Months of Reform

48. Total PMPM Expenditures In The Year Prior To Reform And First Four Months of Reform By County

49. Conclusions • Total PMPM expenditures dropped by an average of $8 • Most of the reduction in SSI population • Mostly in Broward County • No encounter data (yet) • Reform expenditures are not necessarily for direct care • Do not know what types of services affected • Could be more efficient provision of care • Could be reduced access to care

50. General Observations