Evaluation of Florida’s · Evaluation of Florida’s Managed Medical Assistance (MMA) Program Demonstration: Project 3 Final Interim Report Contract Deliverable No. 22, Managed

Contract MED180

Evaluation of Florida’s

Managed Medical Assistance (MMA) Program

Demonstration:

Project 3 Final Interim Report

Contract Deliverable No. 22, Managed Medical Assistance

Final Interim Report – Project 3 SFY 2016-2017 (DY11): Component 4, Low Income Pool

(LIP) Evaluation

Presented to:

Prepared by:

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 17, 2019

Table of Contents

Executive Summary ...................................................................................................... 1

Overview .................................................................................................................................... 1

Key Findings .............................................................................................................................. 2

Introduction ................................................................................................................... 3

Background ................................................................................................................... 3

Component 4, Evaluation Questions and Hypotheses .............................................. 5

Research Questions .................................................................................................................. 5

Data and Methods ......................................................................................................... 6

Results ........................................................................................................................... 7

Component 4: The impact of LIP funding on hospital charity care programs .............................. 7

Research Question 4C ............................................................................................................ 7

Research Question 4D ...........................................................................................................11

Research Question 4E ...........................................................................................................12

Summary and Conclusions ........................................................................................ 16

References ................................................................................................................... 17

Appendix. DY11 MMA Evaluation Components and Research Questions ............. 18

List of Tables

Table 1. LIP Payments and Funding Tiers ................................................................................. 7

Table 2. Number of Unique Uncompensated Charity Care Individuals Served, Inpatient and

Outpatient Services .................................................................................................................... 9

Table 3. Number of Uncompensated Charity Care Individuals Served, Total Inpatient and

Outpatient Services ...................................................................................................................10

Table 4. Hospital Uncompensated Charity Care Expenditures by Tier ......................................10

Table 5. Number of Hospitals Providing Specific Services ........................................................12

Table 6. Number of Uncompensated Charity Care Encounters for Specific Services Reported by

Hospital Providers .....................................................................................................................13

List of Acronyms

Agency Agency for Health Care Administration CMS Centers for Medicare and Medicaid Services CY Calendar Year DY Demonstration Year FPL Federal Poverty Level FHURS Florida Hospital Uniform Reporting System LIP Low Income Pool MMA Managed Medical Assistance MUP Medically Underserved Populations SFY State Fiscal Year SMMC Statewide Medicaid Managed Care STC Special Terms and Conditions UCC Uncompensated Charity Care

Prepared by: 1 Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida Department of Behavioral Sciences & Social Medicine, College of Medicine, Florida State University

Contract MED180 Evaluation of Florida’s Managed Medical Assistance (MMA) Program Demonstration

Executive Summary

Overview

The purpose of the Low Income Pool (LIP) program is to ensure continuing support for the safety-net providers that furnish uncompensated care to Florida’s uninsured populations. More specifically, the LIP extends government support to safety-net providers for uncompensated care given to low-income individuals eligible for charity care or those without insurance (Florida Agency for Health Care Administration 2017, p.29). The Centers for Medicare & Medicaid Services (CMS) Special Terms and Conditions (STC) “set forth in detail the nature, character, and extent of federal involvement in state waivers and the state’s obligations to CMS during the life of the approved waiver” (Florida Agency for Health Care Administration, 2015, p.1). As stated in the STCs for the waiver amendment approved in October 2015:

“In Demonstration Year (DY) 11, the Low Income Pool (LIP) program provides government support for safety-net providers for the costs of uncompensated charity care (UCC) for low-income individuals that are uninsured. Uncompensated care includes charity care for the uninsured but does not include uncompensated care for insured individuals, “bad debt”, or Medicaid and CHIP shortfall.” (Florida Agency for Health Care Administration 2015, p.32).

This document reports on Project 3 of the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program waiver evaluation and focuses on the LIP program from July 2016 through June 2017 (DY11). In previous demonstration years, the evaluation reports were centered on the effects of LIP funding on access to care for Medicaid recipients and uninsured and underinsured patients. This report solely addresses the impact of LIP funding on access to care for uncompensated charity care recipients served in hospitals in DY11. As required under the CMS STCs for the waiver amendment approved in October 2015, the following document provides information relevant to the DY11 research questions associated with Component 4 of the evaluation of Florida’s MMA program:

• 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 funding?

• What types of services are being provided to uncompensated charity care recipients receiving care in LIP-funded hospitals?

• What is the difference in the type and number of services offered to uncompensated

charity care patients in hospitals receiving LIP funding?

Florida’s Agency for Health Care Administration (the Agency) provided data on the facilities, payments, and reporting documents used to analyze the impact of LIP funding on access to care and the provision of healthcare services to uncompensated charity care patients served in hospitals in DY11. The analysis included the number of individuals served, the types of services provided, and the number of encounters for all hospital providers receiving LIP supplemental payments that had submitted milestone data as of December 2017. In DY11 (SFY



2016-17), 157 hospital providers received LIP funding and 155 hospitals received LIP funds and submitted milestone data. In addition, the evaluation team performed an independent review and analysis of documentation related to the LIP Annual Milestone Statistics and Findings Report and the calendar year (CY) 2017 Florida Hospital Uniform Reporting System (FHURS) data.

Key Findings

• Total LIP funding for hospitals in DY11 was approximately $576.8 million.

• A total of 157 hospitals divided into four tiers received LIP funding.

• The distribution of hospitals and LIP payments in each tier was:

o Tier 1: 25 hospitals, $466.9 million



o Tier 4:106 hospitals, $1.4 million

• 155 hospitals received LIP supplemental payments and reported milestone data for individuals eligible for uncompensated charity care. Those hospitals reported providing approximately:

o 370,000 uncompensated charity care individuals who received inpatient services

o 2.1 million uncompensated charity care individuals who received outpatient

services

• Charity care deductions from revenue for hospital providers in each tier were

approximately:

o $1.8 billion in Tier 1

o $674.3 million in Tier 2



• Over 90 percent of the hospitals in each tier provided diagnostic X-ray and laboratory

services and speech, physical, and occupational therapy services.

• Overall, fewer than 10 percent of hospitals provided durable medical equipment,

prosthetic and orthotic devices, or nursing home care.

• There were 7.5 million encounters across six service categories (discharges, inpatient

days, emergency room visits, outpatient visits, affiliated encounters, and filled

prescriptions) for uncompensated charity care patients.

• In DY11, the three services with the greatest number of encounters for uncompensated

charity care patients across all tiers were:

o Emergency room visits, 2.1 million total encounters

o Inpatient days, 1.9 million total encounters

o Outpatient visits, 1.5 million total encounters



Introduction

Project 3 is part of the Florida Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program 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 at Florida State University, and the Department of Health Services Administration at the University of Alabama-Birmingham.

This report presents the findings from Component 4, “The Impact of LIP Funding on Hospital Charity Care Programs.” For DY11, the research team evaluated three research questions focused on access to care for recipients of uncompensated charity care who received care in LIP-funded hospitals. Component 4 has one additional research question, RQ 4F, that will be addressed starting with the evaluation of DY12 (SFY 2017-2018). All the research questions for Project 3 and all the components and research questions for the DY11 MMA evaluation are presented in the Appendix.

Background

Florida’s Low Income Pool (LIP) program was implemented on July 1, 2006 as part of a broad Medicaid Reform demonstration project. The LIP program consists of a capped annual allotment (the “pool”) funded primarily by intergovernmental transfers from local governments matched by federal funds.

In October 2015, CMS authorized amendments related to the LIP program for the period of July 1, 2016 through June 30, 2017. During this period, the state authorized supplemental funding for hospitals to provide stability and offset uncompensated medical care costs as charity care for uninsured low-income individuals with a maximum amount of $607,825,452 in DY11 (Florida Agency for Health Care Administration, 2015).

Hospital providers were divided into four tiers or subgroups based on the ratio of uncompensated charity care costs or charges to privately insured patient care costs or charges. The LIP payment to each provider was proportional to the amount of uncompensated charity care costs or charges as a percentage of the hospital’s privately insured patient care costs or charges. Therefore, hospitals that provided varying proportions of UCC were grouped into tiers based on their percentages of uncompensated care payments. Moreover, hospital providers that received a LIP payment were paid the same percentage of their reported charity care cost within each tier (Florida Agency for Health Care Administration, 2015).

Key terms used throughout this report are defined as follows:

Individuals served: The most comprehensive measure of services is the number of individuals served. Hospitals must provide an unduplicated count of individuals served in the following categories: Medicaid (inpatient and outpatient) and uninsured/underinsured (inpatient and outpatient). Given these categories, this report used the number of “uninsured/underinsured” individuals as the number of uncompensated charity care patients.

Medicaid: Enacted in 1965 through amendments to the Social Security Act, this health care and long-term care coverage program is jointly financed by states and the federal government. Each state establishes and administers its own Medicaid program and determines the type, amount, duration, and scope of services covered within broad federal guidelines. States must



cover certain mandatory benefits and may choose to provide other optional benefits.

Federal law also requires states to cover certain mandatory eligibility groups, including qualified parents, children, and pregnant women with low income, as well as older adults and people with disabilities with low income. States have the flexibility to cover other optional eligibility groups and set eligibility criteria within the federal standards. The Affordable Care Act of 2010 creates a new voluntary national Medicaid minimum eligibility level that covers most Americans with household income up to 133 percent of the Federal Poverty Level (FPL). This new eligibility requirement was effective January 1, 2014, however, states chose whether or not to expand coverage prior to that date [or at all] (Centers for Medicare & Medicaid Services, 2013).

Services provided: Information about the type and amount of specific services provided is also important in understanding the link between LIP payments and the provision of health services to uncompensated charity care patients. For hospitals, measures of services provided include hospital discharges, hospital inpatient days, emergency care encounters, outpatient encounters, affiliated encounters, primary care or preventive care clinic visits, specialist visits, surgical care furnished in a physician’s office, home health services, durable medical equipment, prosthetic or orthotic devices not associated with outpatient therapy visits, nursing home care, and the number of prescriptions filled. The number of uncompensated charity care individuals is provided for each type of service as well as a total for all services.

Uncompensated charity care expenditures: Uncompensated care in this report refers to services provided to uninsured low-income patients. Uncompensated charity care expenditures in this report were measured as the sum of charity care deductions from revenue reported in the Florida Hospital Uniform Reporting System (FHURS) data. As outlined in the CMS STCs, uncompensated charity care costs do not include bad debt and must be “incurred pursuant to a charity care program that adheres to the principles of the Healthcare Financial Management Association” (Florida Agency for Health Care Administration, 2015, p. 34).

Uncompensated charity care individuals: LIP-funded hospitals reported the total number of uninsured/underinsured individuals served as well as the number and types of services provided to uninsured/underinsured individuals in the LIP Annual Milestone Statistics and Findings Report. Given that hospitals do not specifically report the number of patients served who are eligible for charity care or the number of uninsured individuals separately from the underinsured, the number of uninsured/underinsured individuals was used as a proxy for the number of uncompensated charity care individuals in this document.

Underinsured: These are persons without third-party coverage for a particular service rendered on the date(s) of service captured within a defined cost reporting period. This means a patient had third-party coverage, but the particular service provided was not covered as part of the individual’s benefit package. For example, a patient had insurance coverage for inpatient hospital services but his or her covered benefit package did not include outpatient hospital services. In this example, the individual would be considered insured for any inpatient hospital services received. This person would be considered underinsured for any outpatient hospital services received so costs associated with a particular outpatient hospital service would not be included as a cost when calculating uncompensated care costs for the LIP. Similarly, a patient with coverage in which a lifetime or annual benefit cap is applied would be considered underinsured for services furnished beyond that cap. The cost of uncompensated care specifically excludes charges/cost associated with any unpaid service costs, including unpaid deductible and coinsurance amounts for services covered by a patient’s insurance plan. While these amounts may be written off as bad debts or charity care, they are not eligible costs that



may be claimed through the LIP. In reporting a patient’s liability, the provider must distinguish between amounts due for copays and deductibles and amounts due for services not covered by a third-party payer. The cost of uncompensated care eligible for the LIP may not include any cost shortfalls for services covered by other liable third parties (Florida Agency for Health Care Administration, 2012, pp. 6-7).

Uninsured: Persons with no source of third-party coverage on the date of service captured within a defined cost reporting period (Florida Agency for Health Care Administration, 2012, p. 6).

Component 4, Evaluation Questions and Hypotheses This report addresses Project 3 (Component 4) and the associated research questions

concerning LIP funding and access to care for uncompensated charity care recipients as part of

Florida’s MMA evaluation for DY11.

Research Questions

Two research questions, 4A and 4B, addressing the effects of LIP funding on Medicaid recipients and uninsured and underinsured patients served in hospitals were sunset after the DY10 evaluation and therefore are not included in this report. Research questions 4C through 4E which relate to uncompensated care, are addressed in this report because starting in DY11, LIP funds were distributed based on the burden placed on providers by services for low-income, uninsured individuals for whom no other coverage options are, or could be, made available. Efforts will be made in future reports to identify trends, to the extent possible based on factors including but not limited to data availability, data accuracy, and applicability.

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 funding?

Hypothesis 4C. Research question 4C is descriptive and provided for context. It is not possible to conduct statistical tests given how the data is provided, therefore there is no hypothesis to test for this question.

4D. What types of services are being provided to uncompensated charity care recipients receiving care in LIP-funded hospitals?

Research question 4D is included to provide context (description of types of services being provided through LIP) for this component. Therefore, there is no hypothesis to test for this research question.

4E. What is the difference in the type and number of services offered to uncompensated charity care patients in hospitals receiving LIP funding?



Hypothesis 4E. There will be no change in the types of services or the number of services offered to uncompensated charity care patients in hospitals receiving LIP funding.i

Data and Methods

The unit of analysis for this evaluation report is the hospital. The Agency provided data on the DY11 LIP payments, the facilities that received LIP funding, charity care expenditures, and milestone data. These data were used to report on 1) LIP funding and access to care, and 2) the provision of health care services to uncompensated charity care patients in hospitals in DY11. The evaluation team conducted an independent review and analysis of data from the DY11 LIP Annual Milestone Statistics and Findings Report and FHURS.

The LIP Annual Milestone Statistics and Findings Report includes data on the volume of individuals, the types of individuals, and the volume of services provided in LIP-funded hospitals. Thus, analyses included data on the number of individuals served, the types of services provided, and the number of encounters for all hospital providers receiving LIP supplemental payments that had submitted milestone data.

The FHURS dataset includes financial and cost data submitted annually to the Agency by every hospital in Florida. Because individual hospitals may have fiscal years that do not align with the state fiscal year (July 1 – June 30), the FHURS dataset includes data for hospitals with a fiscal year-end that occurred in the latter half of CY 2017. Therefore, LIP payment data for DY11 (SFY 2016-17) will not exactly match the revenue charity care deductions used as a substitute for hospital expenditures for uncompensated charity care patient analyses. Analyses were performed using charity care deductions from revenue data submitted to the FHURS for all hospital providers that received LIP funding in DY11.

This report is based on the independent review and analysis of data for 155 hospital providers that received LIP funding in DY11 (SFY 2016-17) and reported milestone data as of December 2017, as well as the 154 hospital providers that received LIP funding in DY11 (SFY 2016-17) and reported FHURS data as of the hospital fiscal year-end occurring in 2017.

It is important to note that based on the data received, it was not possible to attribute specific amounts of the LIP funds used explicitly for individuals that received care through uncompensated charity care programs.

In addition, because hospitals do not report uncompensated charity care patient counts separately, the data for uninsured and underinsured individuals reported in the LIP Annual Milestone Statistics and Findings Report was used as the proxy for recipients of uncompensated charity care in research questions 4C through 4E.

i This research question was introduced in DY11; therefore, no data is available for comparisons. However,

descriptive data is provided for DY11, and future evaluations will include year-to-year comparisons.



Results

Component 4: The impact of LIP funding on hospital charity care

programs

Results focus on the numbers of uncompensated charity care individuals served and the type of services provided (e.g., discharges and outpatient visits for hospital services), along with the number of reporting providers by tier who received LIP funds.

In DY11, LIP payments made to hospital providers were distributed as shown in Table 1.

Table 1. LIP Payments and Funding Tiers

LIP Payment Tier

Number of

Hospitals

Total LIP

Payments

Minimum

Payment

Average

Payment

Maximum

Payment

Tier 1 25 $466,962,614 $546,196 $18,678,505 $107,395,764

Tier 2 4 $72,872,837 $3,527,147 $18,218,209 $52,622,670

Tier 3 22 $35,519,883 $12,795 $1,614,540 $17,001,075

Tier 4 106 $1,400,550 $240 $13,213 $177,728

Total All Funding

Tiers 157 $576,755,884 $240 $3,673,604 $107,395,764

Research Question 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 funding?

Hypothesis 4C. Research question 4C is descriptive and provided for context. It is not possible to conduct statistical tests given how the data is provided, therefore there is no hypothesis to test for this question.

Hypothesis 4C. Remarks. Data to address this question were provided to the evaluators in aggregate form, therefore it was not possible to conduct statistical tests.

Number of Individuals Served

As shown in Table 2 and Table 3, the 155 reporting hospitals that received LIP supplemental payments in DY11 reported providing inpatient and outpatient services to individuals eligible for uncompensated charity care services as follows:

Total Uncompensated Charity Care All Funding Tiers

Inpatient services were provided to approximately 369,600 individuals. The minimum number of inpatient services provided by a hospital was two, the average number of inpatient services was



about 2,400, and the maximum number was nearly 37,000.

Outpatient services were provided to approximately 2.1 million individuals. The minimum number of outpatient services provided by a hospital was zero, the average number of outpatient services was almost 13,800, and the maximum number was approximately 171,200. Among all hospitals in all funding tiers, inpatient and outpatient services were provided to a total of approximately 2.3 million individuals. An average of 15,100 individuals per hospital received inpatient and outpatient services. The minimum number served was 96 and the maximum was approximately 194,800.

Tier 1 Uncompensated Charity Care (25)

Inpatient services were provided to approximately 67,200 individuals. Outpatient services were provided to approximately 475,600 individuals. Overall combined inpatient and outpatient services were provided to approximately 511,600 individuals. Inpatient and outpatient services were provided to an average of about 20,500 individuals per Tier 1 hospital. The minimum number of individuals served in a Tier 1 hospital was 230 and the maximum was almost 95,000.


Inpatient services were provided to approximately 6,900 individuals. Outpatient services were provided to approximately 41,500 individuals. Overall combined inpatient and outpatient services were provided to approximately 44,800 individuals. Inpatient and outpatient services were provided to an average of 11,200 individuals per Tier 2 hospital. The minimum number of individuals served in a Tier 2 hospital was about 6,000 and the maximum was approximately 19,700.


Inpatient services were provided to approximately 69,800 individuals. Outpatient services were provided to approximately 389,500 individuals. Overall combined inpatient and outpatient services were provided to approximately 436,200 individuals. Inpatient and outpatient services were provided to an average of almost 19,800 individuals per Tier 3 hospital. The minimum number of individuals served in a Tier 3 hospital was about 1,700 and the maximum was approximately 194,800.


Inpatient services were provided to approximately 225,600 individuals. Outpatient services were provided to approximately 1.2 million individuals. Overall combined inpatient and outpatient services were provided to approximately 1.4 million individuals. Inpatient and outpatient services were provided to an average of about 13,000 individuals per Tier 4 hospital. The minimum number of individuals served in a Tier 4 hospital was 96 and the maximum was approximately 141,400.



Table 2. Number of Unique Uncompensated Charity Care Individuals Served, Inpatient and Outpatient Services

Service Type and Tier

Number of

Hospitals

Reporting

Number of Individuals

Served Minimum Average Maximum

INPATIENT

Tier 1 25 67,234 2 2,689 14,491

Tier 2 4 6,911 954 1,728 3,271

Tier 3 22 69,815 5 3,173 36,902

Tier 4 104 225,604 10 2,169 36,960

Uncompensated

Charity Care Inpatient

Services Across All

Tiers

155 369,564 2** 2,384 36,960**

OUTPATIENT

Tier 1 25 475,595 229 19,024 86,004

Tier 2 4 41,470 4,914 10,368 18,769

Tier 3 22 389,539 1,688 17,706 171,225

Tier 4* 104 1,227,336 0 11,801 143,035

Uncompensated

Charity Care Outpatient

Services Across All

Tiers

155 2,133,940 0** 13,767 171,225**

Note: Calculations based only on hospitals receiving LIP payments and reporting milestone data.

*Two hospitals that received LIP payments did not report milestone data for DY11.

** Minimums and maximums across all tiers refer to the minimum and maximum values, respectively, shown for any tier for the

given service.



Table 3. Number of Uncompensated Charity Care Individuals Served, Total Inpatient and Outpatient Services

Inpatient and Outpatient Services

Number of Hospitals Reporting

Number of Uncompensated

Charity Care Individuals

Served

Minimum Average Maximum

% of Total Uncompensated

Charity Care individuals

served

Tier 1 25 511,573 230 20,463 94,993 21.8%

Tier 2 4 44,782 5,964 11,196 19,674 1.9%

Tier 3 22 436,242 1,730 19,829 194,847 18.6%

Tier 4* 104 1,353,223 96 13,012 141,357 57.7%

Uncompensated Charity Care Inpatient and Outpatient Services Across All Tiers

155 2,345,820 96** 15,134 194,847** 100.0%

Note: Calculations based only on hospitals receiving LIP payments and reporting milestone data. The number of individuals served

in Table 3 is higher than than in Table 2 because some indivdiuals in Table 2 received both inpatient and outpatient services and

hence are counted twice in Table 3.


** Minimums and maximums across all tiers refer to the minimum and maximum values, respectively, shown for any tier for the

given service

Uncompensated Charity Care Expenditures

Table 4 displays the charity care deductions from gross revenue based on the FHURS data for hospitals that received a LIP payment during DY11 and had a fiscal year-end in CY2017. As shown, uncompensated charity care expenditures across all tiers totaled approximately $8.4 billion.

Table 4. Hospital Uncompensated Charity Care Expenditures by Tier

LIP

Funding

Tier

Number of

Reporting

Hospitals

Total LIP

Payments

Revenue: Charity

Care Deductions

Minimum

Expenditure

Average

Expenditure

Maximum

Expenditure

Tier 1 25 $466,962,614 $1,767,049,521 $662,371 $70,681,981 $425,747,000

Tier 2 4 $72,872,837 $674,258,985 $50,310,654 $168,564,746 $420,870,818

Tier 3 22 $35,519,883 $1,917,892,768 $506,347 $87,176,944 $802,295,904

Tier 4* 103 $1,362,069 $4,049,970,994 $0 $39,320,107 $545,905,366

All Hospitals

154 $576,717,403 $8,409,172,268 $0 $54,605,015 $802,295,904

Notes: Calculations based only on hospitals receiving LIP payments and reporting charity care deductions from revenue. Fiscal

year-end dates vary among hospitals.

* One of the 104 hospitals reporting milestone data failed to report uncompensated charity care expenditures.



Research Question 4D

What types of services are being provided to uncompensated charity care recipients receiving care in LIP-funded hospitals?

Research question 4D is included to provide context (description of types of services being provided through LIP) for this component. Therefore, there is no hypothesis to test for this research question.

Hospital Services

Types of Services

Each facility that received LIP funding for the corresponding year is required to report to the Agency certain outpatient and affiliated services provided. Outpatient care includes diagnostic X-ray and laboratory services; surgical care in an outpatient facility; outpatient facility care; and speech, physical, and occupational therapies. The affiliated services hospitals report consist of primary care or preventive care visits, specialist visits, surgical care services in a provider’s office, home health care, durable medical equipment, prosthetic and orthotic devices, and nursing home care. In addition, hospitals are required to supply a list of any other services provided using LIP funds.

Proportion of Facilities that Provide Each Type of Service

In DY11, 155 hospitals provided certain outpatient and affiliated services.



Table 5 displays the proportion of reporting facilities that provided specific types of services. Among hospital outpatient care services, approximately 97 percent of the reporting facilities in DY11 provided diagnostic laboratory and radiology services. For outpatient speech, physical, and occupational therapy services, 95 percent of facilities provided these services in DY11. Approximately 75 percent of reporting hospitals receiving LIP payments in DY11 indicated providing outpatient surgeries and 83 percent of reporting hospitals receiving LIP payments in DY11 indicated providing outpatient facility care.

For affiliated services, 28 percent of the reporting hospitals in DY11 provided primary care or preventive care clinic visits, approximately 25 percent of the reporting facilities provided specialist visits, and 18 percent of hospital facilities indicated providing surgical care services in physicians’ offices in DY11. In DY11, 15 percent of hospitals provided home health services and six percent of reporting hospitals provided durable medical equipment. Seven percent of the reporting facilities provided prosthetic or orthotic devices (not associated with outpatient therapy visits) in DY11, and seven percent of the reporting facilities provided nursing home care (skilled or intermediate) services.

Examples of other services provided by the reporting hospitals include the following; rural health services furnished in a facility-operated rural health clinic, discharge clinics for patients with congestive heart failure (CHF) and pulmonary diagnoses, ER diversion clinics, community education and support, emergency outpatient dialysis, and patient transportation services.



Table 5. Number of Hospitals Providing Specific Services

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Th

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s

Tier 1 (n=25) 12 11 5 6 2 2 2 24 17 20 23

Percent of Reporting

Hospitals 48% 44% 20% 24% 8% 8% 8% 96% 68% 80% 92%

Tier 2 (n=4) 2 1 1 1 1 1 0 4 4 4 4


Hospitals 50% 25% 25% 25% 25% 25% NA 100% 100%

100

% 100%

Tier 3 (n=22) 8 5 3 3 1 1 1 22 16 15 21


Hospitals 36% 23% 14% 14% 5% 5% 5% 100% 73% 68% 95%

Tier 4 (n=104)* 21 22 19 14 6 7 8 100 79 89 99


Hospitals 20% 21% 18% 13% 6% 7% 8% 96% 76% 86% 95%

Total Number of

Hospitals Providing

Services, DY11 (N=155)

43 39 28 24 10 11 11 150 116 128 147


Hospitals 28% 25% 18% 15% 6% 7% 7% 97% 75% 83% 95%

Note: Calculations based only on hospitals that received a LIP payment and reported milestone data in DY11 (n = 155) and reported

nonzero services provided for a given category.

* Out of the 106 hospitals receiving LIP funds in Tier 4, two hospitals that received LIP payments did not report milestone data for

DY11.

Research Question 4E

What is the difference in the type and number of services offered to uncompensated charity care patients in hospitals receiving LIP funding?

Hypothesis 4E. There will be no change in the types of services or the number of services offered to uncompensated charity care patients in hospitals receiving LIP funding.ii

Hypothesis 4E Remarks. This research question was introduced in DY11, therefore, support for the hypothesis cannot be determined at this time.

This section describes the volume and types of services provided to individuals eligible for uncompensated charity care by reporting hospital providers that received LIP supplemental funding. Specific services include discharges, inpatient days, emergency care services, hospital-based outpatient services, affiliated services (primary care or preventive care clinic visits, specialist visits, surgical care furnished in a physician’s office, home health services,

ii This research question was introduced in DY11; therefore, no data is available for comparisons. However, descriptive data is provided for DY11, and future evaluations will include year-to-year comparisons.



durable medical equipment, prosthetic or orthotic devices not associated with outpatient therapy visits, and nursing home care), and prescriptions filled.

UCC Hospital Encounters

The analysis of hospital service encounters does not include all services provided to individuals who received uncompensated charity care in Florida. Only those services for which the provider received a LIP supplemental payment in DY11 and submitted milestone data as of December 2017 are included in the analysis. Table 6 presents the number of encounters for specific services reported by hospital providers in DY11.

For all categories of encounters in DY11, 155 reporting hospitals receiving LIP payments provided approximately 7.5 million encounters for specific services to uncompensated charity care patients.

Hospitals reported 433,300 encounters for discharges and approximately 1.9 million inpatient days for uncompensated charity care patients in DY11. There were approximately 2.1 million emergency room encounters and nearly 1.5 million encounters for outpatient services reported for individuals eligible for uncompensated charity care. In DY11, hospital providers reported roughly 681,300 encounters for affiliated services, including primary care/preventive care clinic visits, specialist visits, surgical care furnished in a physician’s office, home health services, durable medical equipment, prosthetic/orthotic devices (not associated with outpatient therapy visits), and nursing home care (skilled or intermediate). Finally, almost 882,000 filled prescriptions were furnished to uncompensated charity care patients in DY11. Among the 155 hospitals in all four tiers that reported providing encounters, the minimum number of encounters for all services provided was zero, the average number provided was just over 8,000 and the maximum number of encounters was about 325,700.

Table 6. Number of Uncompensated Charity Care Encounters for Specific Services Reported by Hospital Providers


Number of

Hospitals

Reporting

Total

Encounters Minimum Average Maximum

DISCHARGES

Tier 1 25 88,614 2 3,545 17,416

Tier 2 4 8,382 1,120 2,096 4,086

Tier 3 22 86,859 6 3,948 45,223

Tier 4* 104 249,446 11 2,399 42,994

Total Uncompensated Charity Care

Discharges 155 433,301 2 2,795 45,223

INPATIENT DAYS

Tier 1 25 394,352 3 15,774 94,920

Tier 2 4 36,312 3,615 9,078 19,250

Tier 3 22 369,975 33 16,817 201,217




Number of

Hospitals

Reporting

Total


Tier 4* 104 1,084,147 39 10,424 147,783


Inpatient Days 155 1,884,786 3 12,160 201,217

EMERGENCY ROOM ENCOUNTERS

Tier 1 25 486,691 0 19,468 96,723

Tier 2 4 46,034 6,235 11,509 17,096

Tier 3 22 434,095 6 3,948 45,223

Tier 4* 104 1,161,735 0 11,171 79,747

Total Uncompensated Charity Care ER

Encounters 155 2,128,555 0 13,733 204,673

OUTPATIENT ENCOUNTERS

Tier 1 25 641,257 128 25,650 278,305

Tier 2 4 32,217 400 8,054 29,734

Tier 3 22 174,198 172 7,918 54,630

Tier 4* 104 626,875 0 6,028 209,151


Outpatient Encounters 155 1,474,547 0 9,513 278,305

AFFILIATED ENCOUNTERS

Tier 1 25 217,484 0 8,699 99,606

Tier 2 4 12,853 0 3,213 9,572

Tier 3 22 58,609 0 2,664 30,854

Tier 4* 104 392,383 0 3,773 199,669


Affiliated Encounters 155 681,329 0 4,396 199,669

NUMBER OF PRESCRIPTIONS FILLED

Tier 1 25 798,223 0 31,929 325,727

Tier 2 4 26,551 0 6,638 26,551

Tier 3 22 28,390 0 1,290 28,390

Tier 4* 104 28,804 0 277 15,457




Number of

Hospitals

Reporting

Total



Prescriptions Filled 155 881,968 0 5,690 325,727

TOTAL ENCOUNTERS FOR ALL

SERVICES

Tier 1 25 2,626,621 0 17,511 325,727

Tier 2 4 162,349 0 6,765 29,734

Tier 3 22 1,152,126 0 6,098 201,217

Tier 4* 104 3,543,390 0 5,679 209,151


Encounters for All Services 155 7,484,486 0 8,048 325,727

Note: Calculations based only on hospitals receiving LIP payments and reporting milestone data.




Summary and Conclusions • In DY11, 157 hospitals received a total of approximately $577 million in LIP

supplemental payments for providing services to uncompensated charity care

individuals.

• Funding Tier 2 had the fewest hospital providers (4) and Tier 4 had the greatest number

of hospitals (106).

• Across all funding tiers, 2.3 million uncompensated charity care patients received

inpatient and outpatient services in hospitals that received LIP funding and reported

milestone data in DY11.

• For inpatient and outpatient services, hospitals in Tier 2 served the fewest number of

uncompensated charity care individuals ( approximately 44,800), and hospitals in Tier 4

served the most UCC individuals (approximately 1.4 million).

o Hypothesis 4C. There will be no difference in 1) the number of uncompensated charity care patients served or 2) their expenditures based on i) hospital access to LIP funding and ii) different tiers of LIP funding.

Hypothesis 4C. Remarks. Analyses of Hypothesis 4C were inconclusive, indicating that it is not possible to say with the required statistical confidence that the differences observed across the tiers are real and not due to random chance.

• In DY11, the majority of hospitals in each tier provided diagnostic radiology and

laboratory services as well as speech, physical, and occupational therapy services.

• Hospitals that received LIP funding and reported milestone data in DY11 reported providing approximately 7.5 million total service encounters for uncompensated charity care patients across six service categories.

• Hospitals in Tier 2 had the fewest number of total encounters for all services (approximately 162,300), and hospitals in Tier 4 had the largest number of total encounters for all services (approximately 3.5 million).

o Hypothesis 4E. There will be no change in the types of services or the number of services offered to uncompensated charity care patients in hospitals receiving LIP funding. Since this is the first year evaluating this research question, support for the hypothesis cannot be determined at this time.



References 1. Florida Agency for Health Care Administration. (2015). Centers for Medicare & Medicaid

Services special terms and conditions. CMS amended October 15, 2015. Tallahassee, FL.

Retrieved from

http://www.fdhc.state.fl.us/medicaid/Finance/finance/LIP-

DSH/LIP/pdfs/FL_MMA_STCs_CMS_Approved_10-15-15.pdf

2. Centers for Medicare & Medicaid Services. (2013). Medicaid. Retrieved from

http://medicaid.gov/

3. Florida Agency for Health Care Administration. (2014) Centers for Medicare & Medicaid

Services special terms and conditions. Approved July 31, 2014. Tallahassee, FL. Retrieved

from

http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_w

aivers/docs/mma/SpecialTermsandConditionsCMSApprovedJuly312014.pdf

4. Florida Agency for Health Care Administration. (2015). Centers for Medicare & Medicaid

Services special terms and conditions. CMS amended October 15, 2015. Tallahassee, FL.

Retrieved from

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_w

aivers/docs/mma/FL_MMA_STCs_CMS_Approved_2015-10-15.pdf

5. Florida Agency for Health Care Administration. (2017). Centers for Medicare & Medicaid

Services special terms and conditions. CMS amended December 21, 2017. Tallahassee,

FL. Retrieved from

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_w

aivers/docs/mma/FL_MMA_STCs_CMS_APPROVED_2017-12-21.pdf

6. Florida Agency for Health Care Administration. (2018). State of Florida Hospital Uniform

Reporting System. Version 2018-1 June 2018. Tallahassee, FL.

http://www.fdhc.state.fl.us/medicaid/Finance/finance/LIP-DSH/LIP/pdfs/FL_MMA_STCs_CMS_Approved_10-15-15.pdf

http://www.fdhc.state.fl.us/medicaid/Finance/finance/LIP-DSH/LIP/pdfs/FL_MMA_STCs_CMS_Approved_10-15-15.pdf

http://medicaid.gov/

http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/SpecialTermsandConditionsCMSApprovedJuly312014.pdf

http://www.fdhc.state.fl.us/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/SpecialTermsandConditionsCMSApprovedJuly312014.pdf

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/FL_MMA_STCs_CMS_Approved_2015-10-15.pdf

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/FL_MMA_STCs_CMS_Approved_2015-10-15.pdf

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/FL_MMA_STCs_CMS_APPROVED_2017-12-21.pdf

http://ahca.myflorida.com/medicaid/Policy_and_Quality/Policy/federal_authorities/federal_waivers/docs/mma/FL_MMA_STCs_CMS_APPROVED_2017-12-21.pdf



Appendix. DY11 MMA Evaluation Components and

Research Questions Component Research Questions

1. The effect of managed care on access to care, quality and efficiency of care, and the cost of care

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) 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.

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 over-the-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?

3. Participation in the Healthy Behaviors programs and its effect on participant behavior or health status

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)?

4. The impact of LIP funding on hospital charity care programs

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 careiii

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?

6. The impact of efforts to align with Medicare and improving beneficiary experiences and outcomes for dual-eligible individuals

6A. How many MMA enrollees are also Medicare recipients (dual-eligibles) and to what extent do dual-eligible enrollees utilize behavioral health and non-emergency transportation services? 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 dual-eligible enrollees? 6C. How do dual-eligible enrollees rate their experience and satisfaction with delivery of care they received related to behavioral health and non-emergency transportation services?

iii Component 5 will sunset following the evaluation of DY12 (SFY 2017-18).



7. The effectiveness of enrolling individuals into a managed care plan upon eligibility determination in connecting beneficiaries with care in a timely manner

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?

8. The effect the Statewide Medicaid Prepaid Dental Health Program has on accessibility, quality, utilization, and cost of dental health care services

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 Program?

8C. What changes in quality of dental health services occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program?

8D. What changes in the accessibility of dental services occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program?

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 health services occur with the implementation of the Statewide Medicaid Prepaid Dental Health Program?

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?

Documents

Evaluation of Florida’s · Evaluation of Florida’s Managed Medical Assistance (MMA) Program Demonstration: Project 3 Final Interim Report Contract Deliverable No. 22, Managed