Medicaid Reform Pilot Transportation References

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Benefit Plans Requiring Co-Payments
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Type of Service Chiropractic I Hospital Inpatient: Behavioral Health I Hospital Inpatient: Physical Health Podiatrist I Hospital Outpatient Services (Non-Emergency) Hospital outpatient Surgery Mental Health I Home Health I Lab/X-Ray I Dental I Vision I Primary Care Phvsician Specialty Physician I ARNPlPhysician Assistant I Clinic (FOHC, RHC) I Transportation I Total I Total Number of Benefit Packages I Total Number of Benefit Packages Requiring No Copayments Percent of Benefit Packages Requiring No Copayrnents

Year 1 10 11
7

10
7

7 7 4 5 4 4 0 1 0 0

Year 2 0 1 1 0 1 1 3 1 1 4 0 0 1 0 0

Year 3 8 8 8 7 7 8 6 8 7 4 5

5 6 5
6 6 104 28 20 71%

5
82 28 12 43%

5
19 30

16
53%

10114/08: Molina Healthcare, Inc., ahnounced that its wholly owned subsidiary, Molina Healthcare of Florida, Inc., was awarded a Medicaid managed care contract by AHCA. The term of the contract would become effective December 1,2008, at which time Molina Healthcare of Florida would begin its initial enrollment of Florida NetPASS Medicaid members, with the full transition of Net PASS members expected to be completed in the firs1tquarter of2009. The contract award by AHCA follows its licensing of Molina Healtfcare of Florida to operate as a health maintenance organization in Dade County. 12/08: Reform Plan updates as o{December 2008 • United Health Care (HMO) ceased to operate in Broward effective Nov. 1, 2008 (continues to serve Medicaid Reform enrollees in Duval, Clay, Baker, and Nassau) I • Vista ofS. Florida (HMO) ceased to operate in Broward effective Dec. 1,2008 (continues to serve Medicaid Reform enrollees in Duval, Clay, Baker, and Nassau). Buena Vi~ta (HMO) ceased to operate in Broward effective December 1,2008 (continues to serve Medicaid Reform enrollees in Duval, Clay, Baker, and Nassau).

Evaluating Medicaid Reform in Florida: M D027 (UF Project #58750) Deliverable VIIl.B: Medicaid Reform in FlalMa: Key Events and Activities in 2008 January 2009

19

We would like 10 have quick response lith clear cut guidance that is consistent across plans. This is not happening .... different answers depending upon who you talk to .... we have had three to four contract managers since inception of Reform. Reform is constantly changing; we hat to continually change our processes. Risk adjustment and encounter data is changing ... everything keeps changing. [L5b

Administrative Burden Assoc1ated with Reform

Organizations participating in Reform cited increased administrative burden related to implementation as a negative aspect of Reform. In particular, plans operating with both Reform and non-Reform members cited mkgnified administrative costs related to participating in Medicaid. I The short timeline from Reform application to implementation was a major burden for participating organizations. The actual application was deemed onerous, and plans already participating in the Medicaid program found it to be redundant. Completing the application was expensive, and the short timeframe caused staff to be overworked. Many organizations used external resources such as consultants and actuaries to meet the deadline. One plan spokesperson stated that although they successfully Icompletedthe process, it took a lot of "pain" to get there. Systems issues and extra reporting also increased the administrative burden experienced by plans during Reform development and implementation. Both HMOs and PSNs cited increased reporting requirements under Refornit, and expressed concern about the related expenses. The reporting of encounter data is the largest change to reporting and oversight requirements. Getting the data has proven to be difficult anq a "big burden." A learning curve also exists with regard to sending and receiving encounter data'j Reform implementation resulted in additional training processes and system modifications for many HMOs and PSNs. Many organizations added new employees and new functions. Specifically, PSNs added third party ~dministrators and enrollee service departments. HMOs had to develop mechanisms for collectin~ encounter data, and for submitting claims to AHCA (for Kick payments which are the means through which AHCA reimburses health plans a one-time, fixed payment for specific services such as obstetrics and transplant services). In some cases, HMOs and PSNs did not understa9d the strict requirements in one area (e.g., transportation contracts) versus other, seemingly more important areas (e.g., disease management). One respondent suggested that AHCt has transferred administrative responsibility for all aspects of Medicaid to the HMOs and PSNs. AHCA expects them to do things perfectly, even though MediPass was perceived by some asl not entirely responsible for many of these activities in the past (e.g., verifying after hours coverage, gathering HEDIS measures from chart reviews, others).
Specific Quotes from Informants:

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There is no question Reform has quadrupled the number and type of reports than we were having to send. I

Evaluating Medicaid Reform in Florida: M~D027 (UF project # 58750) . Deliverable V.B: Medicaid Reform Organizational Analyses: July 2006 - March 2007 Juiy2007 I

47

Administrative costs with reform: at least 40 people spending 8 hours per week from JuneDecember-4 full time people.

I.

Huge administrative burden associated with Enhanced Benefits- have to create system, enter the data (scan farms}, create reports, ~orrect the errors (much work associated with this). This is unlike anything we do. I I don't think there is anything unreasonable that is requested, anything ... most everything is useful for us. The only thing that I think just in general is kind of over the top is the transportation, the contract for transportation and the whole administration around transportation was like 30 pages. I It is humorous, I mean you look at it and you're like, I mean disease management is three pages long, and transportation is 20 somethrg pages .... where is our focus here?

IL5c

The Market is Crowded in Broward County

Many respondents were surprised b~ the number of plans and networks operating in Broward County, suggesting market confusion and a difficult, if not impossible, decision set for beneficiaries who would choose a plan there. Most respondents complained about the large benefit matrix and the hard time be1eficiaries would have in reading what was presented, let alone understanding differences among plans. Some plans suggested that the State Ishould have used a more rigorous selection process, or at least put in place some barriers to entry so that this confusion would not be allowed to go unchecked.
Specific Quotes from Informants: The biggest surprise is how these Plax1ers have competed so intensely for this population that no one wanted to touch last year. We did not expect 16plans to throw in their hat. No barriers to entry in the market.

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How is AHeA going to watch 16PlaT? With this many plans, all 16plans. this may lead to bias in choice counselors who don't want to go through

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Evaluating Medicaid Reform in Flortda: MFrD027 (UF project # 58750) Deliverable VB: Medicaid Reform Organizational Analyses: July 2006 - March 2007 July 2007 I

48

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Theme [V.2: Barriers to care In addition to disruptions in long-standing relationships, enrollees reported other challenges in receiving care such as the lack of transportation, wait time for services, gaps in coverage, limited prescription drug coverage, and thel Medicaid authorization process. There were significant barriers to care expressed by participants, including the prior authorization processes, lack of choice in providers and difficulty finding specialists, and perceptions of unfair treatment.

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Oh, when I had the surgery, it was, it was a wait. I had to wait. I had to get approved by Medicaid to make sure they coul& do the surgery on me and stuff like that. It was a wait. I mean I had to wait 'til the next day befate they could even do the surgery. I had to wait for three days. I had to make a couple phone calli' the hospital made a phone call and I made some more phone calls. The third day that I was inrthere they told me that they got approved for more money to do the surgery.

The negative that I know of, you or 60 percent 'off the Medicaid,

Ln

't get all your medicine off Medicaid.

You have to pay like 50 You got a prescription to

Jhen Medicaid don't cover everything.

go to the doctor and the doctor [giVe you a prescription

form, sometimes

Medicaid pays half of

your medicine and you got to pa1 the other half. And other medicine they don't cover at all.

Respondent:

I had to take my

S(r

to the dentist, because he had a toothache and they wouldn't

see my son and told me I had to bring him back on a Friday. Interviewer: Respondent: papers. Why did they tell you you had to bring him back on a Friday? Because they said !hiS Medicaid hadn't kicked in because I had just renewed the

How Medicaid does the people, Irey cut you off, they don 'I contact you and lei you know.

It's frustrating

that Medicaid doesn't cover all of your medicine.

Cause I got Medicaid prescriptions.

and I got to fight

I

trying to pay all this money for different

kinds of

Evaluating Medicaid Reform in Florida: MED02? (UF Project #58750) Deliverable V C: Medicaid Reform Preliminary Baseline Findings from Longitudinal Study July 20()7

24

1 have had bad experiences

J

not getting

my medication,

they would not prescribe

my

medications sometime. And 1 would have to call my doctor, and they would have to authorize it so that I can get my medication.

Interviewer:

Why is it so hardforlYou

to get transportation?

Respondent: I call them and the~ refuse me. They say they can't help because I have an HMO. I have major problems with transportation.

Almost all of the consumers physicians or specialists.

who ~ere

interviewed

expressed

concerns about finding new

I

It was hard (to find a gynecolog,list), because I only had a few to pick from. She was the closest and she told me no.

1 think the hardest part about Medicaid is just finding a doctor that you can communicate The good thing is that it (Medibaid) someone that understands exactl is there for me, although .

with.

it is like digging a ditch to get

what you mean.

And everybody you ask, don't take Medicaid. And then you call Medicaid and ask them and they send their booklet. And there is only one dentist listed in Baker or Duval County that takes Medicaid.

I

.

If I could find me a better doctor, I would love to.

Several respondents who had experilnce far more restrictive.

with fee-for-service

Medicaid thought Medil'ass was

MediPass is worse than straightlediCaid.

MediPass is a limited branch

+::

It kind of limits where you can go. Doctors sometimes

do not want to take it, we don't take MediP ass, we take Medicaid ... and treat you as good as somebody with Medicaid.

if they take you they don't

They don't have too many doctO!, that "ally I Medicaid is the gold card. MedTass

take MediP ass.

isjust like a white paper, a pass, 25

Evaluating Medicaid Reform in Florida: MED027 (UP Project #58750)
Deliverable VC: Medicaid Reform Preliminary Baseline Findings from Longitudinal Study July 2007

I

9) Describe some ofthe ways in which you get information about Medicaid?

(Probe: Choice counselor, adverlitements, Fiend?)
10) Please tell me about a good and bad experience you had using Medicaid?

(Probe: For example with gaininglaccess, quality of physicians, or counselors) SECTION 4 - Many of you may al~eady be aware that the state is changing how Medicaid services are being offered. If you dp not know about these changes, that is fine, what you can do is tell me how, if at all, your health plan has been changed.
11) What have you heard about the c~anges in Medicaid/Medicaid Reform?

(Probe: Did any of you receive the "Check it out Package "/ the green and blue envelope? What do YOIl know about this package or about the changes to Medicaidr)
12) Talk about some of your concernsl about Medicaid or Medicaid Reform?

(Probe: What are some of the barriers to care [long waiting room stay, unhelpful staff]? What are some fi-ustrationslgpod experiences that you have had with Medicaid? What questions do you think we s1.0uld ask when we want to learn about Medicaid users' issues with Medicaid andlor Medicaid Reform? What would be some good to ask about how Medicaid helps/hinders your health care?) I

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13) Is there anything else that you would like to share?

THIS IS THE END OF THE SE~U-STRUCTURED QUESTIONS. THE FOLLOWING QUESTIONS ARE LOGISTIC QiESTIONS. SECTION 5. We are interested inJgiving people the best opportunity to be a part of our study so that they can tell us about their Medicaid health care experiences. We would want them to participate every 6 months/over the next four years.
14) Do you think it would be better to ask people these questions in a group discussion like our session today, or via an interview with each individual over the telephone?

(Probe: Why or why not?)

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15) What would be a good way of asking people to describe their experiences picking health plans, or staying enrolled in Medicaid?

(Probe: Is this an easy process, do you feel aware of the benefits, are you confused about what to do next?) I
16) What would be some good wayJ to get others like you to participate in our study? That is, participating in interviews every 6 months over the next four years?

(Probe: Please tell me what you ~hinkit would take to get people to come to a discussion like this about the changes in Medicaid in this county [e.g., transportation stipend?])

Evaluating Medicaid Reform in Florida. MED027 (UF Project #58750) Deliverable V C: Medicaid Reform Preliminary Baseline Findings from Longitudinal July 2007

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37
Study

Transportation ~ Is transportation an issue? Why or why not? ~ Based on your recent experiences would you go back to that place for care? Would you return for the same kind of care?

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Other services );> Did you have any other kind of care recently-hospitalizations, );> Describe this experience to me. I );> Was it a good or bad experience? lab work, prescription drugs, ER?

Section 5. Wrap up

I
system

In wrapping up we would now like yo~ to describe your opinions about how the healthcare meets your needs and in what ways. I

10) Do you believe that the healthcare ~ystem-doctors, hospitals, ERs, nurses-is designed to help you get the best care possible? If so in WI hat way and if no why not? (conceptual) PROBES );> Describe a specific positive or negative experience? For example with gaining access, quality of physicians, or counselors. I );> What's your perception of how well they healthcare system meets the needs of people on Medicaid, who are low-income o~ are uninsured? );> Are there enough doctors and hospitals? );> Do the system doctors, nurses, etc., treat you as you should be treated? );> Is the way the health care syste1 set up affecting fulfilling your healthcare needs and in helping you make health choices? 11) Is there anything else that you would like to share? I Comments: Thank you for agreeing tolparticipate in this study. We appreciate your input. The information you have provided will be very relevant and useful.

Evaluating Medicaid Reform in Florida: MEJD027 (UF Project #58750) Deliverable VC: Medicaid Reform Preliminary Baseline Findings from Longitudinal July 2007

45
Study

I

MEDICAID

ROUND

2

EXECUTIVE

SUMMARY

The "Longitudinal Study" component 10fthe Medicaid Reform Evaluation is designed to elicit consumers' views about their health, their health care, and experience obtaining care as the changes occur to Florida's Medicaid Ptogram. The study is termed "longitudinal" because it is designed to track a subset of enrolleeslthroughout the life ofthe evaluation. Early experiences were reported on in July 2007. This report provides preliminary findings from interviews and focus groups conducted between July 2007 rd December 2007. A total of 45 enrollees participated in 14 in-depth telephone interviews and four focus groups conducted between July 2007 and December 2007. To date, nine of these interviews have been transcribed and coded. The following themes have emerged from this initial analysis:
CD



o

The process of plan and primary care provider selection is problematic for some but not all enrollees. Compared to baselirie findings consumers are more aware of the health plan selection process and Choice Counseling. Health plan selection appears to be based on maintaining relationships with existing providers. Consumers spoke of several problems, notably finding a primary care prq~ider and misinformation or incorrect information provided by the Choice Counselors. I There is some discontentment with aspects of care once enrolled. Discontentment was linked with perceived greater rest+ctions associated with referral processes, maintaining continuity of care with primary care providers, gaining access to specialty services, limitations on prescription drugs, and transportation barriers. The Enhanced Benefits Account (EBA) program continues to be a relatively untested concept among enrollees. AlthoJgh most enrollees had heard about the EBA program, there were mixed opinions about whether or not they would participate in the program.
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During 2008, the Longitudinal Study [l'eam will continue to talk with Medicaid enrollees about their health care experiences. Key issues that will be explored include: • • • • • • the ability ofthe Choice Counseling program to provide accurate and up-to-date information on primary care provider availability to enrollees; the availability of an appropriate and adequate distribution of primary care and specialty care providers; I the impact of drug formulary restrictions on the health of enrollees; the availability oftransportttion providers; enrollee participation in thel EBA program; and the extent to which there are differences across health plans in enrollee experience with care.

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I Evaluating Medicaid Reform in Fiorlda: MFJP027 (UP Project #58750) Deliverable VI C: Medicaid Reform. J nteriml Findings from Round 2 of the Longitudinal Study January 2008

3

representations of their own experiences. They express both positive and negative views and inferences should not be drawn about how frequently one might expect to find those positive and negative views among other enrollees'

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FINDINGS
This interim report is based on data from nine of the 14 in-depth interviews conducted within this study period. The subsequent report will include data from the remaining five in-depth interviews, four focus groups, and additional in-depth interviews and focus groups. Each direct quote has been italicized and clarifiers denoted by bdckets have been included to facilitate easier comprehension by the reader. Overall, this round ofin-depth interviews revealed that enrollees were aware of Medicaid Reform and had both positive and negative experiences with the various Reform elements. While many of the comments about Reform were negative, they were not overwhelmingly so. Key concerns raised by enrollees center around facilitating I adequate choice and selection of primary care and specialty care providers, greater restrictions associated with specialty care referrals and use of prescription drugs, and transportation barriers to care.

I. Some enrollees are having no prbblems
This new round of focus groups and iili-depth interviews revealed that some enrollees had positive experiences with Reform. I So far we haven't had any

=:

It's been real good ...I guess I have been pretty lucky.

Well, I liked the doctor I was assigned to. Any time I called I didn't have any problems or anything. I was able to get an appointment soon, even like the next day, or whatever depending on the situation. I II. The process of plan and primary care provider selection was difficult for some, but not all participants I Active Participation in Health Plan Choice-Compared to baseline findings, enrollees are more aware of the Choice Counseling and liealth plan selection process. Some enrollees spoke of their active participation in the selection process, Yeah, but then I had questions. I had to call them and then, like, sometimes I wrote down the different doctors that they didn 't accept and they did, and then if I misplaced my paper I called them back and they helped me again .... Well I just had to keep looking through all of the plans, and look at my doctors, and see if they was on [the 1plans and keep calling back to the Medicaid what thd insurance program to make sure that all of my doctors was on there and scratch off the ones that they didn't accept that I was going to. So I had to wait and do a check and baZare.
I

Evaluating Medicaid Reform in Florida: MEJ,D027 (UF Project #58750) Deliverable VJ.C: Medicaid Reform: Interim Findings from Round 2 of the Longitudinal Study
January 2008

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9

Before Reform,

everything was beautiful.

I

Discontentment was associated with perceived greater restrictions associated with the referral processes, maintaining continuity of dre with their primary care providers, gaining access to specialty services, limitations on prescription drugs, and transportation barriers. Greater restrictions associated with referral processes and use of specialty services-Some of the discontentment expressed by enrollees was associated with the increased restrictions imposed by health plans in obtaining specialty Icare referrals. Before, 1 didn't have to; my doctor would send me to any specialist without any problem, and they in turn would call the specialist, make an appointment, and ljust would go to the appointment. Now the difference is that 1 will have to go to my PI, my primary healthcare doctor, ... tell them that 1 need to go to whatever specialist 1 need to go to, then they have to drop the paperwork and give me the referral in order for me to go to [the specialist] and make the appointment and have my whatever procedure 1 need to be done on that. But now with Reform, even though you pick an insurance, an HMO, you are restricted to where you are going because this doctor is not working with that doctor, that doctor is not working with this doctor, and this doctor is not taking that insurance. Then you have a problem . ... the new injection [they give] patients of macular degeneration that goes directly into the eye. Referrals that are givenfrom the doctors,just covers the regular, the check up that they want to do ... it doesn't c4ver this injection. So they have to call ... the primary doctor and sometimes they don't answer the phone and they leave the phone on the voice mail, and they still don't call back ..... [My doctor] is just a little fru)trated because of my blood work situation. They can no longer draw blood at the [previous sites}. 1 have to go outside to have my blood drawn ... You are going to an outside laboratory ... So 1 have to travel on a bus to get there ...I have to take two buses to get there ... Interviewer: Oh, OK, well, can you describe that to me a little bit, like the transition and what, and how it has affected you? Respondent: Well, number one llost a couple of my doctors. Number two, when 1 was hospitalized, 1 had major surgery done and the procedure is completely different than from when 1 had major surgery done before and was on the Medicaid. All my doctors would come and see me, you know, all the doctors except the ones that were involved in my operation would see me this time. 1 had, that person, 1 had no idea who they were, kinds of feeling. 1 had to be dischargeq by some other doctor. Every time 1 go to the doctor, I have to get a referral note. If 1 don't have a referral note, 1 can't see the doctor. Sometimes my primary healthcare doctor will sometimes, one time 1 had problems in getting uh, a referral and the reason because 1 have multitude problems because of the sickle cell anemia.

Evaluating Medicaid Reform in Florida.' M"JU{}d! (UF Project #58750) Deliverable VI C: Medicaid Reform: Interim Findings/rom Round 2 of the Longitudinal Study January 2008

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You walk in and you can't get change.

1
I

medicine. You know you couldn't get it with this Reform

The Medicaid Reforms is a system that was designed that is not working. Now we can't get certain medications. I

Transportation Barriers-As health plans contract with new transportation providers, some enrollees are reporting logistical issues associated with those companies. While these concerns reflect perceptions of Longitudinal Study enrollees, it should be noted that during the early phase of Medicaid Reform several non-Medicaid Reform events occurred in Broward County such as the sudden change to a new non-emergency transportation vendor. These issues may have been incorrectly attributed to Medicaid Reform.
Transportation had been given to me for the last 11 years .... It was working wonderfully. Then all of a sudden, this Medicaid Reform came in and I received a letter that I was being transferred to a company in B~evard County. I called the company as the letter said. They knew nothing about what was going on and they told me to call back after the Christmas holidays. 1 called back and they said they didn't know yet, but they would let me know. I called back and they said they Iwere not accepting patients from the South Florida Community Network. January, 1 had to cancel my doctor's appointment. At the time, they told me I would be receiving a bus pass every month. So I mailed them the form the first month-the fax number at the bottom of the form was not the right fax number. The next month when I sent off the form, I got [a} fax transmission, that it was received by them. Well, 1 am at the end of the month and I don't receive a bus pass and again 1 had to cancel my appolintment. Yeah, I take the transportation and it is not always that good because sometimes they might schedule two different people at the same time in two different directions, miles apart. One individual indicated that transportation under Reform was working well. 1 get there via the transportation under Staywell. And that's the one thing 1 gotta say-they are excellent on that. The people are very nice to deal with when you call to set up an appointment. They use Celebrity Wheelchair Service. They are superb, I have to say.

IV. Some access problems existed prior to Reform
Issues of specialty care access and limits on prescriptions existed previously under MediPass. Respondents in rural areas in particular noted the lack of access to specialty providers existed many years prior to Reform and that they did not expect that healthcare Reform would solve this problem. I There came a point, under Reform, that he [enrollee's Primary Care Physician} didn't have an endocrinologist, a diabetic specialist, for me. So 1 called them for the list that time. 1 went through the entire list, and only found one doctor. The majority of the times, the
Evaluating Medicaid Reform in Florida: MED027 (UF Project #58750) Deliverable VI.C: Medicaid Reform: Interim Findings from Round 2 of the Longitudinal Study
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14

January

2008

CONCLUSlbN

AND ISSUES TO WATCH

During the past year, as would be expected, awareness and knowledge of the changes to the Medicaid programs have increased sighificantly among enrollees. Many enrollees have played an active role in selecting health plans and primary care providers. However, it does appear that maintaining continuity of care with primary and specialty care providers is problematic. In addition, some plan formularies have placed restrictions on access to prescription drugs and certain kinds oftherapy. For some Medicaid enrollees, this restriction in access may have a detrimental impact on their health. For others, changes to the Medicaid program may have no impact at all. This first year of the demonstration represents a period of time in which enrollees were learning to adjust to the changes, and AHCA was making programmatic modifications in response to enrollee needs and concerns. Thus, it is still too early to make conclusions about Medicaid Reform and its impact on enrollee access to care. Nevertheless, AHCA and the University of Florida must continue to monitor key issues over the long term. These issues include: • • • • • • the ability of the Choice Counseling program to provide accurate and up-to-date information on primary care provider availability to enrollees; the availability of an appropriate and adequate distribution of primary care and specialty care providers; the impact of drug formulary restrictions on the health of enrollees; the availability of transportation providers; enrollee participation in the enhanced benefit program; and the extent to which there are differences across health plans in enrollee experience with care.

NEXT STEPS
As Florida Medicaid Reform continues to evolve, so too will the experiences of Medicaid enrollees. The Longitudinal Study Team will continue to have conversations with enrollees about their interactions with the healthcare system. Immediate next steps will include coding and analysis ofthe remaining interviews conducted so far, new focus groups with consumers in the five Reform counties, and in-depth tthephone interviews with existing and new Medicaid enrollees. The longitudinal study was designed to track experiences of enrollees as they system at varying points in time. Therefore, enrollees who were interviewed in half of2007 (either in focus groups or in-depth interviews) will be interviewed addition, focus groups of consumers in Broward and in the three rural counties throughout the first half of2008. move through the 2006 and the first again in 2008. In will be convened

Evaluating Medicaid Reform in Florida: MBD027 (UF Project #58750) Deliverable VI. C: Medicaid Reform: interim Findings from Round 2 of the Longitudinal January 2008

16
Study




How did you decide where to you have always gone? What are some of the barriers

gb for care? Is [insert location

mentioned] the place where

r

care [long waiting room stay, unhelpful staff]?

When to go (or care • Aside from when you (or YOUrlkidS) are sick, what other factors determine when you seek care? .

Getting an appointment



The last time you went to this place did you make an appointment? How hard was it to get that appointment? Did you have to wait in the waiting room for a long time?



What about the attitude of the

r:':

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Were the office and nursing staff polite? Helpful?

Your doctor



What do you like about your current doctor? Why is that important to stay with that doctor?

• •

• Any issue with referrals or going to specialists? Finding a doctor that takes Medicaid?
Are you treated differently bec~use you are on Medicaid, because of your ethnicity, age? How do you know this? I

• Have you had any issues with the care you received? If so what were they?
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Did you understand what they said? Were they respectful? Did they answer your questions?

Transportation




Is transportation an issue - wry or why not?
Based on your recent experiences - would you go back to that place for care? Would you returnfor the same kind of carle?

Other services • Describe your experience getting prescription drugs. Has it changed for the better/worse? In what ways? I Describe your experience getting the service that you needfor your [include health concern(s) here, e.g., mentaltealth needs, prescription drugs, etc.]



Evaluating MQdtcaid Reform in Florida. MEJD02? (UF Project #58750) Deliverable VIC: Medicaid Re!orm.lnterimIFindingsjrom Round 2 of the Longitudinal Study January 2008

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21

(Yes) Y questions

(No) N questions Does the incentive need to be higher? Choice counselors Picking a health plan is a personal decision. Florida Medicaid Reform enrollees can now talk with a Choice Counselor for free. The Choice Counselor will provide information that can help you pick a plan that is best for you. • Would using the services of Choice Counselors encourage you to engage in the healthy behaviors we talked about earlier? • Why or why not? • Do you think the Choice Counselors would help you make a choice? If not what other factors would lead you to make the decisions? • What other kinds of information would you like to have to help you with your choices? • Would you participate in any of the new programs that I explained earlier such as the Opt-Out program? • The Enhanced Benefits? • Or contact a Choice Counselor for help? • Why or why not? • Are you looking forward to experiencing these new changes with Medicaid?



• •








How did you hear about them? Did you see billboard ads? Where they helpful? What about the written material? How did you end up making a choice? What factors lead you to make the I decisions? What additional kind of information would you like to have had?

/

Have you participated in any of the new programs or used any ofthe new services? Opt-Out Program? I Enhanced Benefits Program? Choiice Counseling Program? Why or why not? Describe your experiences with the new Medicaid system, such as length oftime on it, problems you have had, good experiences you've had.
[BE SURE TO PROBE ON THE IMPACT REFORM " "
to

OF MEDICAID

ON PHYSICIAN ACCESS DRUGSl

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TRANSPORTATION PRESCRIPTION
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Evaluating Medicaid Reform in Florida: MED027 (UF Project #58750) Deliverable VI.C: Medicaid Reform: Interim Findings from Round 2 of the Longitudinal Study January 2008

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Ms. Young's poster presentation suggests that Medicaid enrollees' beliefs may have some impact on their ability and willingness to control, manage, and participate in their healthcare decision making and behaviors.
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A copy of this presentation is included in Appendix E.

HEALTHCARE

EXPERIENCES OF MEDICAID FLORIDA

ENROLLEES

IN

Dr. Rada Dagher was invited to present a poster at the AcademylIealth Meeting, on June 29,2009, in Chicago, IL.

Annual Research

Dr. Dagher's poster discussed enrollee experiences with Medicaid. Study participants reported problems they experienced, such as.difficulty with <access and referrals to specialists, changing primary care providers, inadequate prescription drug coverage, lack of dental care, transportation barriers, long wait times for services, and perceptions of discrimination. ' A copy of this presentation is included in Appendix

r.:
MEDICAID

ENROLLEE

SATISFACTION

IN

A CHANGING

PROGRAM'
Dr. Paul Duncan was invited to present a poster at theAcademyHealth Meeting, on June 29,2009, in Chicago, IL.
. . -j .•. "'.
,

Annual Research

.

Dr. Duncan's poster presentation discusseddifferences in enrollee satisfaction pre- and post-Reform. The differences demonstrated are modest in magnitude, located in the subsets of enrollees, and refer to speeiyc 'aspects of care. A copy of this presentation is included in Appendix G.

FINANCIAL INCENTIVES FOR HEALTHY BEHAVIORS: EARLY DATA FROM FLORIDA'S MEDICAID ENHANCED BENEFITS REWARD$PROGRAM
Kim Elliot was invited to present a poster at the AcademyHealth Meeting, on June 29,2009, in Chicago, IL. Annual Research

Ms. Elliot's poster presentation discussed the circumstances and potential impact of incentive programs in Medicaid Reform. The poster suggested that credit earnings were significantly higher than debits spent, which is likely related to the newness of the Enhanced Benefits Reward$ program.

Evaluating Medicaid Reform in Florida: Ml!.LJ027 Deliverable IXC: Research Presentations Phase 7: January-June July 2009

3
2009

Evaluating Medicaid Reform in Florida

Healthcare Experiences of Medicaid Enrollees in Florida
Rada Dagher, PhD, MPH;l Allyson Hall, PhD, MBA, MHSI
I, Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida

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l

,
In recent and West Medicaid consumer research July health

INTRODUCTION
years, benefit choice. Iirerature. a number packages There of patients' consumer following of states (Florida, and/or adopting Idaho, elements Kentucky, their of in the targeted Study participants These included inadequate services. experiences their doctors. reported difficulty a number with access drug coverage, of discrimination Virginia)

RESULTS
of problems and referral they experienced
10

IMPLICATIONS FOR POLICY, PRACTICE, OR DELIVERY
as participants to switch barriers, in the demonstration. primary lengthy
Cafe

have experimented
is surprisingly experiences choice model

with modifying little qualitative with Medicaid project

specialists.

having

providers, for with Pervasive maintaining inadequate problems with Medicaid continue

prescription and perceptions

lack of dental

care, transportation However,

wait times positive

under Medicaid.

they also reported

access to care remain such as difficulty
continuity prescription of care through drug coverage.

to exist. Key issues of accessing specialists, problems
care providers, findings suggest and
3

documentation to a competitive 1,2006,

such as being thankful

for Medicaid

and the services

it provides

them and being satisfied

primary Study

In FIOJida,

a demonstration

need for

carne into effect on

CMS approval Waiver. of Medicaid in Broward

of a Section
enrollees and Duval

1115 the

policymakers to address the underlying issues that prevent Medicaid patients from having access to timely and quality health care.

Research and Demonstration
care experiences demonstration Medicaid

This study examined Counties.

under the Florida

Enrollee Experiences with Care Under the Medicaid Demonstration Pilot

METHODS
This study employed two waves 10 in-depth October purposive telephone sampling interviews of Medicaid The eruollees throughout included enrollees between of data collection.

l
first wave
all conducted -Difficulty Accessing Specialists Americans (60%) Focus with the speeallst endcerinoloqist, It's I-bard to find endocrinologistfor Medicaid." hard to find,Onlyone specialist for the whole Jacksonville and how many people in Jacksonville. Do you know how many? Irs millions."
-It's "Very difficult, very difficult to find. They send us HealthEase, they send us a booklet with

1
Problems Accessing Drugs Prescription

Lengthy

1 ::!::Wait Times

LIMITATIONS
These findings primarily highlight the results of qualitative in-depth interviews throughout

with Medicaid

r
"I

of Medicaid

and focus groups
the duration

with small samples of enrollees of tile study. Thus, these findings are not
popularion. over time; thus, --with and

and three focus groups 2006

(27 enrollees)

and May 2007. mainly of African African

~w~ a problem have

II
-

representative
"My medication is a problem as well. When I go101ill a prescription, they---automatically, after Ihave been taking itfora couple of years, change it to generic and generic." "Before you aa decide to reform things, I didn't have to worry about medlcalions.l don't have to worry about none
of that, You reformed know what rm Now I got to do without some of my medications. Medications that I'vo been on for almost two or threedecadcs."

of the larger Medicaid
of enrollees

Interviewees and Caucasians group wave

constituted (20%)

and were primarily female

female Americans

(70%).

participants included

were mostly

(63%) and with Medicaid

Hispanics enrollees between mainly slightly mostly

(261'0) and predominantly
23 in-depth telephone groups and four focus of African more Caucasians primarily

(97%). The second
conducted constituted

"Sometimes I know it is not easytogetthroughtothe Medicaid office. You have.to call and call and then when you do get through you get put on hold and then you get those representatives,[who say] "I don't know", "I don't know."" "I romember going to Ihis doctor. I got there about 9 or 10 o'clock. I didn't get waited on until about, Ididn't even get waited on. It was about 12 o'clock and Istill hadn't gotten seen by a doctor. Ijust walked out and left,'' "If you are not in Medicaid, you are soon quick."

love the Medicaid. With Medicaid you can go anywhere, ycudon'thave any problems, any city or state, cause sometimes I travel." "Wollto me Itis scary if I don't havo any Medicaid. That is what makes this very scary. I mean, t had a good job all my life until I got in that car accident," "Notenough doctors. Not enough doctors. There are low Income people, not enough doctors who on Medicaid,not
enough:'

Different ------clianges
!

samples

were interviewed

in enrollee expenen--c-es over time could nocbe examined=
the study participants For example, individuals had varied levels of experience
111

I

In addition, Medicaid.

who had participated

Medicaid

interviews Interviewees

for a longer time period

were more expressive

(30 enrollees)

perceptions

than enrollees with shorter participation
and negative experiences, in general

of their experiences periods.

July 2007 and June 2008. Americans (53%) males (52%). Focus

(48%) and Caucasians
group (80%). participants Americans

(38%) and
were (40%) and

everything, you

For both positive
distinguish initiative indicate sample

enrollees

and African

specialist. When it's time to caD 1I1edoctor, they say, ·We don't accept""

saying?

the Medicaid being undertaken

program

did not always from the demonstration findings design factors and large that may

in Florida. employing, to capture ill Florida's

These preliminary longitudinal program. the longstanding Medicaid

constituted

offemales

that future research, sizes, is necessary to changes

The smdy team reviewed transcripls and developed a coding algorithm to identify and verify overarching themes/findings.
In-depth focus Eight interviews findings themes interview and General were coded were coded were identified instruments Experience using Atlas.ti 5.0 software 2.0 software. Medicaid and group global using NVivo based including

"Cause l havc a lot (If anxiety and depression andwhen you are messing with that medicine, you knowwhatl'm saying?"

be attributed

on the focus group

and in-depth Experience

with Care.

UFIFLORIDA

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Cw••lu.Q1;lnIJ Mttclllc.ld

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Thisresearch (UF Project # 58750) was funded by the Florida Agcncy for Health Care Administration(AReA) through contract f MED027,

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