Transcript Document

Miami-Dade
Medicaid Forum
United Way of Miami-Dade
Miami, FL
January 11, 2008
Florida Medicaid Reform
Evaluation
Paul Duncan
Principal Investigator
Florida Medicaid Reform Principles
• Patient responsibility and empowerment
• Marketplace decisions
• Bridging public and private coverage
• Sustainable growth rate
What’s New?
• 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
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
Medicaid Reform in Florida – Key Reform Elements & Results
Reform Program Elements
Choice
Counseling
Process
More
Choices
Reform Program Results
Customized
Benefit
Packages
• PSNs
• HMOs
• Special Plans
• ESI Opt-out
Enrollee
Experiences
Satisfaction
In a Plan or
Network
Enhanced
Benefit
Accounts
Healthy
Behaviors
Disenrollment
Health Status;
Racial Disparities;
Clinical Outcomes
Medicaid
Expenditures
$$
$$
Utilization
Opt-Out
(ESI)
$$
Low
Income
Pool
Access for
Uninsured
Evaluating Medicaid Reform in Florida: MED027
UF Evaluation Team
Administration
Paul Duncan (Principal Investigator)
[email protected]
Lilly Bell (Project Manager)
[email protected]
Florida Advisory
Committee
Organizational Analyses
Christy Lemak
(Investigator)
[email protected]
Amy Yarbrough
(Investigator)
[email protected]
Technical Advisory
Committee
Quality of Care,
Outcomes, and
Enrollee Experience
Analyses
Allyson Hall
(Investigator)
[email protected]
Rada Dagher
(Investigator)
[email protected]
Fiscal Analyses
Jeffrey Harman
(Investigator)
[email protected]
Low-Income Pool
Analyses
Niccie McKay
(Investigator)
[email protected]
Organizational Analyses
Christy Lemak, PH.D.
Amy Yarbrough, PH.D.
Organizational Analyses
Update
• Health Plans and Networks
• AHCA
• Other Stakeholders
– Legislature
– Choice Counseling (ACS)
– Others
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)
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.
Key Finding 2
There are no simple
solutions to complex
problems.
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
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
Overarching Theme 3:
Mixed Views on & Questions
about Some Reform Elements
•
•
•
•
Choices
Enhanced Benefit Accounts
Risk Adjusted Rates
Opt-Out Program
Overarching Theme 4:
Managed Care Can Be Difficult
• Provider Perspectives
• Specific Issues for Certain Populations
– Mental Health
– Disabled
– Others
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
Looking Ahead
• Ongoing Developments
– Provider data
– MEDS data
– EBA studies
• How to Best Capture Physician and
Hospital Perspectives
• Moving Beyond Implementation Phases
Quality of Care, Outcomes, and
Enrollee Experience Analyses
Allyson Hall, Ph.D.
R. Paul Duncan, Ph.D.
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
MEDICAID REFORM
ENROLLEE SATISFACTION:
BASELINE CAHPS SURVEY
IN BROWARD AND DUVAL COUNTIES
Paul Duncan
Allyson G. Hall
Babette Brumback
Jianyi Zhang
Lorna P. Chorba
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
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)
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)
Enrollee Satisfaction – Example Responses
Using any number from 0-10, where 0 is the worst health plan possible and 10 is the best plan
possible, what number would you rate your health plan?
ENROLLEE SATISFACTION
BROWARD COUNTY
DUVAL COUNTY
Weighted
Weighted
N
0 Worst Health Care Possible
%
N
%
1358
1.64
963
1.7
1
425
0.51
800
1.41
2
699
0.84
429
0.76
3
691
0.83
872
1.54
4
1287
1.55
647
1.14
5
3898
4.7
4008
7.07
6
3709
4.48
2427
4.28
7
6379
7.7
5470
9.65
8
14421
17.41
8293
14.63
9
11401
13.76
6883
12.14
10 Best Health Care Possible
35086
42.35
24404
43.04
Missing
3493
4.22
1501
2.65
TOTAL
82848
100
56696
100
Health Plan Rating Results Shown by Plan
Using any number from 0-10, where 0 is the worst health plan possible and 10 is the best plan possible, what
number would you rate your health plan?
(Reflects percentage of respondents who rated satisfaction level at 8, 9, or 10)
HEALTH PLANS
Unweighted Data (%)
2006 (PRE-REFORM)
BROWARD
DUVAL
Medicaid FFS
58.7%
60.8%
MediPass
72.2%
73.0%
PSN
68.9%
CMS
77.7%
MPNs
HMOs
ONE YEAR LATER
BROWARD
*
DUVAL
*
*
81.1%
*
AFTER 2 YEARS
BROWARD
*
DUVAL
*
*
*
*
*
AFTER 3 YEARS
BROWARD
*
*
*
*
PhyTrust
71.8%
Pediatric
Associates
78.4%
*
*
*
Amerigroup
69.9%
*
*
*
Buena Vista
76.3%
*
*
*
HealthEase
71.9%
Humana
76.7%
*
*
*
Preferred
56.1%
*
*
*
StayWell
75.2%
*
*
*
United
Health Care
67.3%
*
*
*
66.9%
*
*
*
*
*
*
*
75.4%
*
*
*
NetPass
70.5%
DUVAL
*
*
*
*
*
*
Qualitative Interviews:
Longitudinal Study
Allyson G. Hall
Gail C. Young
Lilliana L. Bell
Keva S. Thompson
Kimberly E. Elliott
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Fiscal Analysis
Enrollee Per Member Per Month
Expenditures: Early Results
Jeff Harman, Ph.D.
Comparing Pre and Post
Reform PMPM Expenditures
• Compared PMPM expenditures preReform to PMPM expenditures postReform
• 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
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
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
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
Total PMPM Expenditures In The Year Prior
To Reform And First Four Months of Reform
$905
$801
$238
$230
$128
All Enrollees
$115
TANF
Pre-Reform
SSI
Reform
Total PMPM Expenditures In The Year Prior
To Reform And First Four Months of Reform
By County
$1,055
$919
$695
$253 $241
Broward
$651
$214 $213
Duval
$129 $113
$127 $118
Broward
TANF
Duval
TANF
Pre-Reform
Reform
Broward
SSI
Duval SSI
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
General Observations
No “Bottom Line”
Yet, But…
•
•
•
•
Talking to physicians and other providers
The pharmacy problems
Choosing is not always fun
People prefer that their healthcare not be
managed
• But given Managed Care, the Reform version
is not observably worse that other versions
• Some savings appear to be emerging
For Further Information
Paul Duncan, Ph.D.
Principal Investigator
Department of Health Services Research, Management & Policy
College of Public Health & Health Professions
University of Florida
PO Box 100195
Gainesville, FL 32610-0195
Telephone: (352) 273-6073
Website: http://mre.phhp.ufl.edu/
Email: [email protected]
AHCA Florida Medicaid Reform Website:
http://ahca.myflorida.com/Medicaid/medicaid_reform/in
dex.shtml