Evaluation of Florida s Managed Medical Assistance (MMA) Program Demonstration: Project 2 Final Interim Report

Transcription

1 Evaluation of Florida s Managed Medical Assistance (MMA) Demonstration: Project 2 Final Interim Report Contract Deliverable No. 12, Managed Medical Assistance Final Interim Report Project 2 DY1: Component 3 Presented to: Department of Health Outcomes and Biomedical Informatics College of Medicine University of Florida and Department of Behavioral Sciences and Social Medicine College of Medicine Florida State University April 26, 218

2 Table of Contents Executive Summary... 1 Data and Methods... 1 Key Findings... 1 Introduction... 3 Background... 3 Component 3 Evaluation Questions and Hypotheses... 4 Data and Methods... 5 Results... 5 Research Question 3A... 5 Research Question 3B... 7 Research Question 3C... 7 Research Question 3D... 9 Research Question 3E...11 Conclusion and Recommendations Appendix. DY1 MMA Evaluation Components and Research Questions... 13

3 List of Tables Table 1. Number of Healthy Behaviors s and Incentive Types... 6 Table 2. Enrollee Participation and Completion Rates in Healthy Behaviors s... 8 Table 3. Enrollee Participation and Completion Rates in Healthy Behaviors s by Gender... 9 Table 4. Enrollee Participation and Completion Rates in Healthy Behaviors s by Age... 11

4 List of Acronyms Agency CDPS CHCU CMS CY DY EBAP ER FS HB LIP LTC MMA OTC PMPM SFY SMMC STC UF Agency for Health Care Administration Chronic Illness and Disability Payment Child Health Checkup Centers for Medicare and Medicaid Services Calendar Year Demonstration Year Enhanced Benefits Account Emergency Room Florida Statutes Healthy Behaviors Low Income Pool Long-term Care Managed Medical Assistance Over-the-Counter Per Member Per Month State Fiscal Year Statewide Medicaid Managed Care Special Terms and Conditions University of Florida

5 Executive Summary This report presents the interim results of Project 2 of the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Evaluation for Demonstration Year 1 (DY1), State Fiscal Year (SFY ), the second year of the MMA program. Project 2 focuses on Component 3 of the evaluation, which examines the Healthy Behaviors programs, the voluntary rewards programs developed and implemented by participating MMA health plans. The MMA plans offer a variety of Healthy Behaviors initiatives in addition to the three Agencymandated programs. At a minimum, each managed care plan must establish a medically approved smoking cessation program, a medically directed weight loss program, and a medically approved alcohol or substance abuse recovery program. The managed care plans must identify enrollees who smoke, are morbidly obese, or are diagnosed with alcohol or substance abuse and establish written agreements to secure the enrollees' commitment to participation in the following mandated programs: (1) A medically approved smoking cessation program that is evidence-based and recognized by medical professionals as an effective treatment method in addressing tobacco/nicotine dependence. The program may include interventions such as counseling and/or the use of medications (nicotine replacement products) as a part of the overall therapeutic process. (2) A medically directed weight loss program that requires ongoing supervision by a physician and may include the use of prescription drugs/supplements depending upon the need and goals of the enrollee, along with other physician-approved interventions (diet, exercise, etc.). (3) A medically approved alcohol or substance abuse recovery program that is evidencedbased and recognized by medical professionals as an effective treatment method/approach. The program may include interventions such as medically assisted detoxification, medication and behavioral therapy, followed by treatment and relapse prevention as a part of the overall therapeutic process. Some of the optional programs include incentives for engaging in preventive care, cancer screening, and prenatal and postpartum care. Retail gift cards or points that can be converted into a monetary value are common incentives across the health plans. Data and Methods The results in this report were based on the review and analysis of quarterly and summary reports of the Healthy Behaviors programs for each plan. Aggregate descriptive statistics were calculated based on these reports. Key Findings Types of programs offered: A total of nine Healthy Behaviors programs are offered across Florida s 15 MMA plans in addition to the three required programs: Preventive well-child visits (9 plans) 1

6 Pregnancy/maternity (7 plans) Cancer screenings (2 plans) Children s nutritional incentive (1 plan) Baby blocks (1 plan) Behavioral health follow-up (1 plan) Comprehensive diabetes care (1 plan) Preventive adult care (PCP visits) (1 plan) Child health checkup (CHCU) (1 plan) Types of incentives: The most common forms of incentive or reward offered by the plans for participating in the smoking cessation, weight loss, or substance abuse recovery programs were gift cards or points, which were converted to monetary values. In addition to gift cards and points, the MMA plans offer a variety of incentives to enrollees participating in Healthy Behaviors programs. Incentives include retail gift cards (CVS, Walgreens, Subway, Publix, Toys R Us/Babies R Us, For Your Entertainment, itunes, Old Navy), points or rewards associated with monetary values, cash, over-the-counter (OTC) credits at pharmacies, pedometers, cookbooks, gym memberships, movie tickets, grocery store food coupons, discount cards, water bottles, hats, salad shakers, T-shirts, tape and BMI measure, points or credits redeemable for goods or services, and items for infants and toddlers (for example diaper bags, teething rattle, nursing cover, first aid kits, digital or bath thermometer, feeding sets, dental care sets, childproofing kits, shower/bath accessories, toys, and board books). Enrollment in mandatory programs: Of the mandatory programs required by all plans, the medically-directed weight loss program reported the highest number of current enrollees (25,15), as well as the highest number of enrollees who completed the program (2,17). Enrollment in all programs: Of all programs offered (mandatory or optional), the program with the highest number of enrollees was the well-child visits program (134,735), offered by five plans. The program with the second highest number of enrollees was the children s nutrition incentive program (134,162) offered by Humana. Completion rates: The well-child visits program has the highest number of enrollees who completed the program (6,434) followed by the children s nutrition incentive program (4,25) and the medically-directed weight loss program (2,17). Participation by gender: Among the mandatory programs, females were more likely than males to be currently enrolled in and to have completed the programs. For example, among all plans reported, 63.6 percent of enrollees in the medically-approved smoking cessation program were females and 36.4 percent were males. Almost sixty percent of all enrollees who completed the smoking cessation program as of Quarter 4 were female. Participation by age: Age distributions differed depending on the program type. For example, among the mandatory programs, the smoking cessation program consisted largely of current enrollees and completed program enrollees ages 41-6 (57 percent and 59 percent, respectively), followed by ages 21-4 (3.6 percent and 29.2 percent, respectively), over age 6 (1.8 percent and 1.3 percent, respectively), and ages -2 (1.6 percent and 1.6 percent, respectively). By contrast, the weight loss program consisted of current enrollees ages -2 (37 percent), followed by ages 21-4 (31.5 percent), ages 41-6 (26 percent) and over age 6 (5.5 percent). 2

7 Introduction This report presents the Demonstration Year 1 (DY1) results of Project 2, one of the four projects of the 217 Revised Florida Medicaid Managed Medical Assistance (MMA) Evaluation conducted by the Department of Health Outcomes and Biomedical Informatics in the College of Medicine at the University of Florida, the Department of Behavioral Sciences and Social Medicine in the College of Medicine at Florida State University, and the Department of Health Services Administration at the University of Alabama-Birmingham. Project 2 focuses on evaluating the Healthy Behaviors programs, the voluntary rewards programs developed and implemented by participating MMA health plans. Project 2 consists of Component 3, Participation in the Healthy Behaviors programs and its effect on participant behavior or health status. The five research questions in this component address the types and number of Healthy Behaviors programs offered by MMA plans, the incentives offered, enrollee participation, and service utilization. All the components and research questions for the DY1 MMA evaluation are listed in the appendix to this report. Background After implementation of the MMA waiver program in 214, the state s Enhanced Benefits Account (EBAP), in which Medicaid enrollees who engaged in an approved list of health behaviors would receive credits that could be redeemed at a Medicaid-participating pharmacy, was replaced by the Healthy Behaviors program, a voluntary rewards program offered by MMA plans. The state requires MMA plans to offer three mandatory Healthy Behaviors incentive programs to enrollees: (1) a medically approved smoking cessation program, (2) a medically directed weight loss program, and (3) a medically approved alcohol or substance abuse treatment program. In addition to the three mandated programs, the MMA plans offer a variety of healthy behavior initiatives. Some of these additional programs include incentives for engaging in preventive care, cancer screening, and prenatal and postpartum care. Retail gift cards or points that can be converted into a monetary value are a common incentive across the health plans. Incentives and rewards are limited to a value of twenty dollars ($2), with the following exceptions: (1) s that require the enrollee to complete a series of activities, such as a series of health education classes. In these instances, the incentive or reward is limited to a value of fifty dollars ($5). (2) Incentives such as infant car seats, strollers, and cloth baby carriers/slings that are offered to encourage participation in a healthy behavior program or as a reward for completion of an action or a series of activities may be given a special exception to the dollar value, with Agency approval. (3) Participation in multiple healthy behavior programs (e.g.; smoking cessation and substance abuse recovery program). In these instances, the incentive or reward is limited to a value of fifty dollars ($5) for each healthy behavior program. For the first year of the MMA program (DY9), the key evaluation results for the Healthy 3

8 Behaviors program included: 1 The total number of enrollments in any Healthy Behaviors among all plans was 31,728. The total number of completions among all plans was 31,834. Among the three mandatory programs, the medically directed weight loss program reported the highest number of enrollments (22,295), as well as the highest number of completions (1,79). Of all programs offered (mandatory or optional), the program with the highest number of enrollments was the Children s Nutrition Incentive (142,758) (offered by a single plan) followed by Well-Child Visit (136,636) (offered by four plans). Among the mandatory programs, females were slightly more likely than males to have been currently enrolled in and to have completed the programs. Enrollee age distributions differed depending on the program. Across all service utilization categories (inpatient, outpatient, ED, professional, physician and specialist), mean service utilization in the MMA period was lower among those individuals who had been enrolled in EBAP in the pre-mma period compared to those who were not enrolled in EBAP in the pre-mma period. Component 3 Evaluation Questions and Hypotheses This report addresses Project 2 (Component 3) of the MMA evaluation concerning the Healthy Behaviors programs as part of Florida s MMA Evaluation for DY1 (SFY ). Component 3 consists of the following five evaluation questions along with their associated hypotheses. Research Questions The following questions will be addressed in the evaluation of DY1 (SFY ). Research Questions 3A-3D are included to provide context (i.e., description and number of Healthy Behaviors programs provided by plans, as well as associated incentives and rewards) for the Healthy Behaviors program statewide. Therefore, there are no hypotheses to be tested for these research questions. 3A. What Healthy Behaviors programs do MMA plans offer? What types of programs and how many are offered in addition to the three required programs (medically approved smoking cessation program, the medically directed weight loss program, and the medically approved alcohol or substance abuse treatment program)? 3B. What incentives and rewards do MMA plans offer to their enrollees for participating in Healthy Behaviors programs? 3C. How many enrollees participate in each Healthy Behaviors program? How many enrollees complete Healthy Behaviors programs? Which types of Healthy Behaviors programs attract 1 Data reported in Quarter 3, the last quarter reported for this analysis, are cumulative and therefore represent enrollments for the entire period, July 214 through March

9 higher numbers of participants? 3D. How does participation in Healthy Behaviors programs vary by gender, age, race/ethnicity and health status of enrollees? 3E. What differences in service utilization occur over the course of the demonstration for enrollees participating in Healthy Behaviors programs versus enrollees not participating? (DY13 and beyond upon receipt of individual-level Healthy Behaviors data) Hypothesis 3Ei. There will be no difference in utilization of 1) preventive services and 2) outpatient services between enrollees participating in Healthy Behaviors programs and enrollees not participating in Healthy Behaviors programs. Hypothesis 3Eii. There will be no change in the utilization of ER, inpatient and outpatient hospital and physician specialty services for treatment of conditions that these programs are designed to prevent or manage for enrollees after enrolling in the Healthy Behaviors program. Question 3E and the race/ethnicity and health status components of Question 3D will be answered when individual-level Healthy Behaviors data for DY13 (SFY ) and subsequent years become available. Data and Methods The results in this report were based on the review and analysis of quarterly and summary reports of the Healthy Behaviors programs for each plan. Aggregate descriptive statistics were calculated based on these reports. Specific details about the data and analytical approaches used to produce these results are provided along with the results for the individual research questions in the next section. Results The research questions in this component address the types and number of Healthy Behaviors incentive programs offered by the plans and the service utilization. Research Question 3A What Healthy Behaviors programs do MMA plans offer? What types of programs and how many are offered in addition to the three required programs (medically approved smoking cessation program, the medically directed weight loss program, and the medically approved alcohol or substance abuse treatment program)? MMA plans are required to offer three Healthy Behaviors programs: a medically approved smoking cessation program, a medically directed weight loss program and a medically approved alcohol or substance abuse treatment program. Several plans offer additional Healthy Behaviors programs, most of which fall into one of two categories: preventive well-child visits or pregnancy/maternity. Other programs include child nutrition, maternal/child health, diabetes care, and behavioral health. Some plans offer more than one program in a single category. As shown in Table 1, MMA plans offer nine preventive well-child visit programs, seven 5

10 pregnancy/maternity programs, and one program for each of the other programs noted above. Four programs, while available as options, did not have any enrollees for DY1. Those programs were preventive care for adults, cancer screenings (mammogram and cervical cancer) and child health checkup (CHCU). Table 1. Number of Healthy Behaviors s and Incentive Types Healthy Behaviors s a Number of s Types of Incentives Value of Incentives Mandatory s Approved Smoking Cessation 18 Gift cards, points, monetary, discount cards, pharmacy credit, clothing or fitness items $1-$5 Directed Weight Loss 18 Gift cards, points, monetary, discount cards, pharmacy credit, health or fitness related items, cookbooks, gym membership $.87- $24 Approved Alcohol or Substance Abuse Recovery 18 Gift cards, points, monetary, discount cards, or redeemable points or credits <$1 - $5 Optional s Children's Nutrition Incentive 1 Gift cards $2 Preventive Well-Child Visits 8 Gift cards, points-monetary, pharmacy credit $1-$5 Pregnancy/Maternity 7 Gift cards, points-monetary $1-$5 Baby Blocks 1 Gift cards, baby-related merchandise <$1-$2 Behavioral Health Follow-Up 1 Gift card $5 Comprehensive Diabetes Care 1 Gift card $2-$3 6

11 Healthy Behaviors s a Number of s Types of Incentives Value of Incentives Preventive Adult Care (PCP visits) b 1 Pharmacy credit $5 Cancer Screenings b 2 Not reported Not reported Child Health Checkup b 1 Gift cards, grocery coupons, movie tickets Not reported a All plans are required to offer the three mandatory Healthy Behaviors programs listed here. Select plans also offer optional Healthy Behaviors programs as indicated. b s did not have any enrollees for DY1. Research Question 3B What incentives and rewards do MMA plans offer to their enrollees for participating in Healthy Behaviors programs? The MMA plans offer a variety of incentives to enrollees participating in Healthy Behaviors programs. Incentives include retail gift cards (CVS, Walgreens, Subway, Publix, Toys R Us/Babies R Us, For Your Entertainment, itunes, Old Navy), points or rewards associated with monetary values, cash, over-the-counter (OTC) credits at pharmacies, pedometers, cookbooks, gym memberships, movie tickets, grocery store food coupons, discount cards, water bottles, hats, salad shakers, T-shirts, tape and BMI measure, points or credits redeemable for goods or services, and items for infants and toddlers (for example diaper bags, teething rattle, nursing cover, first aid kits, digital or bath thermometer, feeding sets, dental care sets, childproofing kits, shower/bath accessories, toys, and board books). Among the three required Healthy Behaviors programs, four plans did not report the type of incentive, if any, offered to enrollees who participated, and one plan offered incentives for the weight loss program but did not report incentives for the other two programs. The most common forms of incentive or reward offered by the plans for participating in the smoking cessation, weight loss, or substance abuse recovery programs were gift cards or points, which were converted to monetary values. For instance, many of the Healthy Behaviors programs indicated that 1 point = $1, with an earning maximum of 5 points or $5. Across all programs, reward or incentive values ranged from less than one dollar to $24 (see Table 1). Research Question 3C How many enrollees participate in each Healthy Behaviors program? How many enrollees complete Healthy Behaviors programs? Which types of Healthy Behaviors programs attract higher numbers of participants? Evaluators used Healthy Behaviors summary reports for each plan to capture enrollee participation and completion rates. Because the summary reports for each plan reported cumulative, aggregate data for each quarter (rather than individual-level data), the information reported was obtained from the last reported quarter for each plan in SFY For most plans, Quarter 4 summary reports were used with the exception of Integral Quality Care, South 7

12 Florida Community Care Network and Preferred Medical Plan, Inc., wherein Quarter 3 reports were used due to missing/incomplete Quarter 4 summary reports. As depicted in Table 2, of the mandatory programs required by all plans, the medically directed weight loss program reported the highest number of current enrollees (25,15), as well as the highest number of enrollees who completed the program (2,17). Of all programs offered (mandatory or optional), the program with the highest number of enrollees was the well-child visit programs (134,735), offered by Better Health, Inc., Humana, Molina Healthcare of Florida, Prestige Health Choice, and Simply Healthcare, Inc. The second highest enrollee program was the children s nutrition incentive program (134,162) offered by Humana. With nearly 4 million individuals enrolled in Florida Medicaid s MMA plans, a relatively small percentage of Medicaid enrollees participate in Healthy Behaviors s. It is important to note that enrollment in Healthy Behavior programs is voluntary, and some programs are exclusively targeted to those of a particular age or health condition, so not every enrollee is eligible to participate in certain Healthy Behaviors programs. Of note, Table 1 refers to the number of Healthy Behaviors programs offered across all health plans while Table 2 refers to the plans that offer optional programs in addition to the three mandatory programs. Plans that offered a program but had no past/current (DY1) enrollees were not listed in Table 2 (e.g., Clear Health Alliance and Preferred Medical, Inc. for pregnancy/maternity and Clear Health Alliance for well-child visits). The well-child visits program has the highest number of enrollees who completed the program (6,434), followed by the children s nutrition incentive program (4,25) and the medically directed weight loss program (2,17). Table 2. Enrollee Participation and Completion Rates in Healthy Behaviors s Approved Smoking Cessation Mandatory s a Directed Weight Loss Approved Alcohol or Substance Abuse Recovery Children's Nutrition Incentive Pregnancy/ Maternity Optional s Well- Child Visits Baby Blocks Behavioral Health Follow-Up Comprehen -sive Diabetes Care Number Enrolled, 1,7 25, ,162 7,93 134,735 2, DY 1 b Enrollees who Completed 575 2,17 8 4, , Plans Offering ALL ALL ALL Humana Better Health, Humana, Molina, Prestige, Simply Healthcare Better Health, Humana, Molina, Prestige, Simply Healthcare United Prestige Prestige a All plans are required to offer the three mandatory Healthy Behaviors programs listed here. Select plans also offer optional Healthy Behaviors programs as indicated. b Data in table obtained from Quarter 4 summary reports for each plan (Quarter 3 for Integral Quality Care, South Florida Community Care Network, and Preferred Medical Plan, Inc.). 8

13 Research Question 3D How does participation in Healthy Behaviors programs vary by gender, age, race/ethnicity and health status of enrollees? The evaluation team used Healthy Behaviors summary reports for each plan to capture program participation and completion rates by gender and age. The summary reports did not include race/ethnicity or health status of enrollees, and thus this information is not presented. However, these analyses will be conducted when individual-level Healthy Behaviors data becomes available, which is anticipated to be in DY13 and beyond. Participation by gender: As depicted in Table 3, among the mandatory programs, females were more likely than males to be currently enrolled in and to have completed the programs. For example, among all plans reported, 63.6 percent of enrollees in the medically approved smoking cessation program were females and 36.4 percent were males. Almost sixty percent of all enrollees who completed the smoking cessation program as of Quarter 4 were female. Among optional programs, the pregnancy/maternity and Baby Blocks programs consisted of 1 percent females. United Healthcare runs the Baby Blocks program which provides rewards to pregnant mothers and babies for going to the doctor. For the nutrition and well-child visit programs, current and completed enrollment rates between males and females were relatively equally distributed. Of note, the number of enrollees who completed programs is not presented as a percentage of the number enrolled in DY1 because the number of program enrollments and the number of unique enrollees may differ (e.g., when an individual enrolls in more than one program at a time). Percentages of enrollees who complete Healthy Behaviors programs will be provided when individual-level information becomes available. Table 3. Enrollee Participation and Completion Rates in Healthy Behaviors s by Gender Approved Smoking Cessation Mandatory s a Directed Weight Loss Approved Alcohol or Substance Abuse Recovery Children's Nutrition Incentive Optional s Pregnancy/ Maternity Well- Child Visits Baby Blocks Behavioral Health Follow-Up Comprehensive Diabetes Care Number Enrolled, 1,7 25, ,162 7,93 134,735 2, DY1 b Males (%) 39 (36.4) 9,586 (38.2) 28 (38.4) 67,528 (5.3) 67,397 (5.) 1 (5) 62 (26.4) Females (%) 68 (63.6) 15,519 (61.8) 45 (61.6) 66,634 (49.7) 7,93 (1) 67,338 (5.) 2,428 (1) 1 (5) 173 (73.6) 9

14 Enrollees who Completed Males (%) Approved Smoking Cessation Mandatory s a Directed Weight Loss Approved Alcohol or Substance Abuse Recovery Children's Nutrition Incentive Optional s Pregnancy/ Maternity Well- Child Visits Baby Blocks Behavioral Health Follow-Up Comprehensive Diabetes Care 575 2,17 8 4, , (4.5) 664 (3.6) 3 (37.5) 2,191 (51.6) 3,222 (5.1) 34 (24.8) Females (%) 342 (59.5) 1,56 (69.4) 5 (62.5) 2,59 (48.4) 428 (1) 3,212 (49.9) 551 (1) 1 (1) 13 (75.2) a All plans are required to offer the three mandatory Healthy Behaviors s listed here. Select plans also offer optional Healthy Behaviors programs as indicated. b Data in table obtained from Quarter 4 summary reports for each plan (Quarter 3 for Integral Quality Care, South Florida Community Care Network, and Preferred Medical Plan, Inc.). Note: Quarter 4 data represents 12 months of cumulative data for the Healthy Behaviors program. Participation by age: As shown in Table 4, enrollee age distributions differed depending on the program type. Among the mandatory programs, the smoking cessation program consisted largely of current enrollees and completed program enrollees ages 41-6 (57 percent and 59 percent, respectively), followed by ages 21-4 (3.6 percent and 29.2 percent, respectively), over age 6 (1.8 percent and 1.3 percent, respectively), and ages -2 (1.6 percent and 1.6 percent, respectively). The weight loss program consisted of current enrollees ages -2 (37 percent), followed by ages 21-4 (31.5 percent), ages 41-6 (26 percent) and over age 6 (5.5 percent). Among enrollees who completed the weight loss program, 34.7 percent were ages 41-6, followed by those ages 21-4 (3.6 percent), ages -2 (25.8 percent), and over age 6 (9 percent). The alcohol or substance abuse recovery program consisted of current enrollees largely between the ages of 41-6 (49.3 percent) and ages 21-4 (31.5 percent), followed equally by those over age 6 (9.6 percent) and ages -2 (9.6 percent). Among the eight enrollees who completed the recovery program, two (25 percent) were ages 21-4, 4 (5 percent) were ages 41-6, and two (25 percent) were over age 6. Among optional programs, the pregnancy/maternity and Baby Blocks programs primarily consisted of those ages 21-4 (approximately 9 percent of those currently enrolled and completed). For the nutrition program, well-child visit program, and behavioral health follow-up program, 1 percent of current enrollees and those who completed were ages -2. For the comprehensive diabetes care program, current enrollees and enrollees who completed the program were largely ages 41-6 (57 percent and 58.4 percent, respectively) and over age 6 (36.6 percent and 35.8 percent, respectively), followed by ages 21-4 (6 percent and 5.8 percent, respectively), and ages -2 (.4 percent and percent, respectively). Of note, the number of enrollees who completed programs is not presented as a percentage of the number currently enrolled in DY1 because the number of program enrollments and the number of unique enrollees may differ (e.g., when an individual enrolls in more than one program at a time). Percentages of enrollees who complete Healthy Behaviors programs will be provided 1

15 when individual-level information becomes available. Table 4. Enrollee Participation and Completion Rates in Healthy Behaviors s by Age Approved Smoking Cessation Mandatory s a Directed Weight Loss Approved Alcohol or Substance Abuse Recovery Children's Nutrition Incentive Pregnancy/ Maternity Optional s Well- Child Visits Baby Blocks Behavioral Health Follow-Up Comprehensive Diabetes Care Number Enrolled, 1,7 25, ,162 7,93 134,735 2, DY1 b Ages -2 (%) 17 (1.6) 9,286 (37.) 7 (9.6) 134,162 (1) 557 (7.9) 134,735 (1) 186 (7.7) 2 (1) 1 (.4) Ages 21-4 (%) 327 (3.6) 7,95 (31.5) 23 (31.5) 6,273 (88.4) 2,173 (89.5) 14 (6.) Ages 41-6 (%) 61 (57.) 6,537 (26.) 36 (49.3) 262 (3.7) 69 (2.8) 134 (57.) Over 6 (%) Enrollees who Completed Ages -2 (%) 116 (1.8) 1,377 (5.5) 7 (9.6) 86 (36.6) 575 2,17 8 4, , (1.6) 559 (25.8) 4,25 (1) 43 (1.) 6,434 (1) 55 (1.) 1 (1) Ages 21-4 (%) 168 (29.2) 663 (3.6) 2 (25) 371 (86.7) 476 (86.4) 8 (5.8) Ages 41-6 (%) 339 (59.) 753 (34.7) 4 (5) 13 (3.1) 2 (3.6) 8 (58.4) Over 6 (%) 59 (1.3) 195 (9.) 2 (25) 49 (35.8) a All plans are required to offer the three mandatory Healthy Behavior s listed here. Select plans also offer optional Healthy Behavior programs as indicated. b Data in table obtained from Quarter 4 summary reports for each plan (Quarter 3 for Integral Quality Care, South Florida Community Care Network, and Preferred Medical Plan, Inc.). Research Question 3E What differences in service utilization occur over the course of the demonstration for enrollees participating in Healthy Behaviors programs versus enrollees not participating? Hypothesis 3Ei. There will be no difference in utilization of 1) preventive services and 2) outpatient services between enrollees participating in Healthy Behaviors programs and 11

16 enrollees not participating in Healthy Behaviors programs. Hypothesis 3Eii. There will be no change in the utilization of ER, inpatient and outpatient hospital and physician specialty services for treatment of conditions that these programs are designed to prevent or manage for enrollees after enrolling in the Healthy Behaviors program. This question will be answered when individual-level Healthy Behaviors data becomes available, which is anticipated to be in DY13 and beyond. Data on the Healthy Behaviors program are aggregated by plan and currently not available at the level of the individual beneficiary. Therefore, estimates of participation in the Healthy Behaviors program by specific enrollee cannot be determined. In addition, program participants currently cannot be linked to enrollment, encounter and claims data to determine their service utilization. Conclusion and Recommendations Both participation and completion rates for the Healthy Behaviors s remain low, limiting the potential impact of the program to improve enrollees health and subsequent reductions in acute care utilization. Overall, less than 8 percent of MMA enrollees participated in any Healthy Behaviors program, and less than 1 percent completed the program and earned rewards. Although not assessed in this evaluation, it is possible that the incentives provided by health plans were insufficient to convince enrollees to participate in these programs. MMA plans may want to consider engaging with their patient populations to understand why enrollees chose not to participate in Healthy Behaviors programs, and why those who participated often did not complete the program. This feedback could allow health plans to tailor their programs to improve participation and completion rates, and in turn, improve health and lower costs among their populations. By obtaining individual-level data, it will be possible to assess if and to what extent participation in certain Healthy Behaviors programs may impact potentially preventable adverse events. For example, do participants with chronic obstructive pulmonary disease (COPD) in the smoking cessation program have lower service utilization (inpatient, outpatient, ED, etc.) than nonparticipants with COPD? This will be reported through question 3E when the data becomes available. 12

17 Appendix. DY1 MMA Evaluation Components and Research Questions Component 1. The effect of managed care on access to care, quality and efficiency of care, and the cost of care Research Questions 1A. What barriers do enrollees encounter when accessing primary care and preventive services? 1B. What changes in the accessibility of services occur with MMA implementation, comparing the accessibility in pre-mma implementation plans (Reform plans and 1915(b) waiver plans) to MMA plans? 1C. What changes in the utilization of services for enrollees are evident post-mma implementation, comparing: 1) utilization of services in the pre-mma period (FFS, Reform plans and pre-mma 1915(b) waiver plans) to utilization of services in post-mma implementation; 2) utilization of services in specialty MMA plans versus standard MMA plans for enrollees eligible for enrollment in a specialty plan (e.g., enrollees with HIV or SMI) who are enrolled in standard MMA plans versus enrollees in the specialty plans? 1D. What changes in quality of care for enrollees are evident post MMA implementation, comparing: 1) quality of care in pre-mma implementation plans (Reform plans and 1915(b) waiver plans) to quality of care in MMA plans in the MMA period; 2) quality of care in specialty MMA plans versus standard MMA plans for enrollees eligible for enrollment in a specialty plan (e.g. enrollees with HIV or SMI) who are enrolled in standard plans versus enrollees in the specialty plans (to the extent possible)? 1E. What strategies are standard MMA and specialty MMA plans using to improve quality of care? Which of these strategies are most effective in improving quality and why? 1F. What changes in timeliness of services occur with MMA implementation, comparing timeliness of services in pre-mma implementation plans (Reform plans and 1915(b) waiver plans) to post-mma implementation plans? 1G. What is the difference in per-enrollee cost by eligibility group pre-mma implementation (FFS, Reform plans and pre-mma 1915(b) waiver plans) 13

18 compared to per-enrollee costs in the MMA period (MMA plans as a whole, standard MMA plans and specialty MMA plans)? 2. The effect of customized benefit plans on beneficiaries choice of plans, access to care, or quality of care Note: Since the MMA plans do not offer customized benefit plans, the state will evaluate the effect of expanded benefits on enrollees utilization of services, access to care, and quality of care. 3. Participation in the Healthy Behaviors programs and its effect on participant behavior or health status 2A. What is the difference in the types of expanded benefits offered by standard MMA and specialty MMA plans? How do plans tailor the types of expanded benefits to particular populations? 2B. How many enrollees utilize expanded benefits and which ones are most commonly used? 2C. How does Emergency Department (ED) and inpatient hospital utilization differ for those enrollees who use expanded benefits (e.g. additional vaccines, physician home visits, extra outpatient services, extra primary care and prenatal/perinatal visits, and overthe-counter drugs/supplies) vs. those enrollees who do not? 2D. How do enrollees rate their experiences and satisfaction with the expanded benefits that are offered by their health plan? 3A. What Healthy Behaviors programs do MMA plans offer? What types of programs and how many are offered in addition to the three required programs (the medically approved smoking cessation program, the medically directed weight loss program, and the medically approved alcohol or substance abuse treatment program)? 3B. What incentives and rewards do MMA plans offer to their enrollees for participating in Healthy Behaviors programs? 3C. How many enrollees participate in each Healthy Behaviors program? How many enrollees complete Healthy Behaviors programs? Which types of Healthy Behaviors programs attract higher numbers of participants? 3D. How does participation in Healthy Behaviors programs vary by gender, age, race/ethnicity and health status of enrollees (DY13 and beyond)? 3E. What differences in service utilization occur over the course of the demonstration for enrollees participating in Healthy Behaviors programs versus enrollees not participating (DY13 and beyond)? 14

19 4. The impact of LIP funding on hospital charity care programs 4A. What is the impact of LIP funding on access to care for Medicaid, uninsured, and underinsured recipients served in hospitals? That is, how many Medicaid, uninsured, and underinsured recipients receive services in LIP-funded hospitals? 4B. What types of services are being provided to Medicaid, uninsured, and underinsured recipients receiving care in LIP-funded hospitals? 4C. What is the impact of LIP funding on access to care for uncompensated charity care recipients served in hospitals? That is, how many uncompensated charity care recipients receive services in LIP-funded hospitals? How does this compare among hospitals in different tiers of LIP finding? 4D. What types of services are being provided to uncompensated charity care recipients receiving care in LIP-funded hospitals? 4E. What is the difference in the type and number of services offered to uncompensated charity care patients in hospitals receiving LIP funding? 4F. What is the impact of LIP funding on the number of uncompensated charity care patients served and the types of services provided in FQHCs, RHCs, and medical school physician practices? 5. The effect of having separate managed care programs for acute care and LTC services on access to care, care coordination, quality, efficiency of care, and the cost of care 2 6. The impact of efforts to align with Medicare and improving beneficiary experiences and outcomes for dual-eligible individuals 5A. How many enrollees are enrolled in separate Medicaid managed care programs for acute (medical) care and LTC services? 5B. How many enrollees are enrolled in comprehensive plans for both acute (medical) care and LTC services? 5C. Are there differences in service utilization, as well as in the appropriateness of service utilization (to the extent this can be measured), between enrollees who are in a comprehensive plan for both MMA and LTC services versus those who are enrolled in separate MMA and LTC plans? 6A. How many MMA enrollees are also Medicare recipients (dual-eligibles) and to what extent do dualeligible enrollees utilize behavioral health and nonemergency transportation services? 2 Component 5 will sunset following the evaluation of DY12 (SFY ). 15

20 6B. What specific care coordination strategies and practices are most effective for ensuring access to and quality of care for behavioral health services and non-emergency transportation services for dualeligible enrollees? 6C. How do dual-eligible enrollees rate their experience and satisfaction with delivery of care they received related to behavioral health and nonemergency transportation services? 7. The effectiveness of enrolling individuals into a managed care plan upon eligibility determination in connecting beneficiaries with care in a timely manner 8. The effect the Statewide Medicaid Prepaid Dental Health has on accessibility, quality, utilization, and cost of dental health care services 7A. How quickly do new enrollees access services, including expanded benefits in excess of State Plan covered benefits, after becoming Medicaid eligible and enrolling in a health plan? 7B. Among new enrollees, what is the time to access services for enrollees who are enrolled under Express Enrollment compared to enrollees who were enrolled prior to the implementation of Express Enrollment? 8A. How does enrollee utilization of dental health services vary by age, gender, race/ethnicity, and geographic area? 8B. What changes in dental health service utilization occur with the implementation of the Statewide Medicaid Prepaid Dental Health? 8C. What changes in quality of dental health services occur with the implementation of the Statewide Medicaid Prepaid Dental Health? 8D. What changes in the accessibility of dental services occur with the implementation of the Statewide Medicaid Prepaid Dental Health? 8E. What barriers do enrollees encounter when accessing dental health services? 8F. How many enrollees utilize expanded benefits provided by the dental health plans and which ones are most commonly used? 8G. How does enrollee utilization of dental health services impact dental-related hospital events (e.g., Emergency Department, Inpatient hospitalization)? How does utilization of expanded benefits offered by the dental health plans impact dental-related hospital events? 8H. What changes in per-enrollee cost for dental 16

21 health services occur with the implementation of the Statewide Medicaid Prepaid Dental Health? 8I. How do enrollees rate their experiences and satisfaction with dental health services, including timeliness of dental health services, provided by their dental health plans? 8J. How do enrollees rate their experiences and satisfaction with the expanded benefits offered by their dental health plans? 17