Evaluating Medicaid Reform in Florida: Early Findings

1. Evaluating Medicaid Reform in Florida: Early Findings Presented by: Allyson Hall, PhD On behalf of the UF MRE Team AcademyHealth: State Health Policy Interest Group Meeting June 7, 2008

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

3. Evaluation • The UF evaluation examines 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; and • predictability in costs/expenditures

4. Evaluating Medicaid Reform in Florida: UF 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

5. Organizational AnalysesChristy Lemak and Amy Yarbrough Key Informant Interviews • Health plans and networks • 15 organizations; 58 interviews (3 rounds) • AHCA (Tallahassee and Area offices) • 59 one-hour interviews (3 rounds) • Legislators • Other stakeholders • Interested parties survey (45 responses + 8 follow-up interviews) • Community forums (attended 8 focus groups + 7 additional interviews)

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

7. Some Elements Appear to Work Well or Show Strong Potential • More Choices for Enrollees (including PSNs) • The Choice Counseling Process • Disease Management Programs • Encounter Data

8. Mixed Views About Some Reform Elements • Choices • Enhanced Benefit Accounts Program • Risk-Adjusted Rates • Opt-out Program

9. Difficulties Associated with Managed Care • Provider Perspectives • Specific Issues for Some Populations • Mental Health • Disabled • Others

10. Patient Experiences Allyson Hall and R. Paul Duncan • CAHPS-Style Surveys • Benchmark: Fall 2006 • Round 1: Fall 2007 - Spring 2008 • Qualitative Interviews • Early experiences and health beliefs • Broward and Duval: focus groups, in-depth interviews • Baker, Clay, and Nassau: focus groups • Longer-term experiences • Broward and Duval: in-depth interviews, focus groups

11. Consumer Assessment of Healthcare Providers and Systems Survey Ratings (0-10) • Overall plan satisfaction • Overall satisfaction with care • Personal doctor rating • Specialist rating

12. Consumer Assessment of Healthcare Providers and Systems Survey Preliminary analysis • Crosstabs (various permutations) • 2006 vs.2007-2008 • SSI vs. non-SSI • Broward vs. Duval • Duval • 2006 vs. 2007-2008 differences tend to be not significant • Broward • 2006 vs. 2007-2008 some statistically significant differences

13. DemographicCharacteristics Broward and Duval counties only * Statistically significant difference

14. CAHPS: Summary of Findings SSI - Broward and Duval * Statistically significant differences

15. CAHPS: Summary of FindingsSSI - Broward County * Statistically significant differences

16. CAHPS: Summary of Findingsnon SSI - Broward County * Statistically significant differences

17. Qualitative Interviews with BeneficiariesDemographics • 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 – 61 years • Eligibility: • > 75% SSI

18. Major Themes • Control of health is influenced by individual ability, help from others, money, and faith • Relationships with physicians are important • Before Reform enrollees experienced barriers to care • Active participation in plan selection • Maintaining continuity of care is important to enrollees • For some, finding a primary care provider is problematic • Some enrollees expressed discontent with Choice Counselors • For some greater restrictions associated with access to specialty services and prescription drugs • The Enhanced Benefits Account program is a relatively untested concept for enrollees

19. Fiscal AnalysisJeff Harman 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

20. 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 = 945,635 person-months

21. Total PMPM Expenditures In The Year Prior To Reform And First 10 Months of Reform

22. Total PMPM Expenditures In The Year Prior To Reform And First 10 Months of Reform By County

23. Fiscal Analysis: Conclusions • Total PMPM expenditures increased by an average of $3 • Overall increase due to greater percentage of enrollees in SSI in Reform than pre-Reform • Average expenditures decreased when comparing by eligibility category • $8 drop for TANF (6.3%) • $70 drop for SSI (7.7%) • Looking at longer-term trends

24. No “Bottom Line” Yet, But… • ‘Process’ of reform smooth • Varied patient experiences • Positive and negative • Relative to the previous year – some savings • Possible market changes

25. Team Effort Babette Brumback, PhD Lorna Chorba Jianyi Zhang, PhD Lilly Bell, MHA Contact: Paul Duncan pduncan@phhp.ufl.edu 352 273 6065 Allyson Hall hallag@phhp.ufl.edu 352 273 5129