Evaluation of Florida’s · Project 2 Final Interim Report Contract Deliverable No. 21, Managed Medical Assistance Final Interim Report – Project 2 SFY 2016-2017 (DY11): Component

Contract MED180

Evaluation of Florida’s

Managed Medical Assistance (MMA)

Program Demonstration:

Project 2 Final Interim Report

Contract Deliverable No. 21, Managed Medical Assistance

Final Interim Report – Project 2 SFY 2016-2017 (DY11): Component 3,

Healthy Behaviors

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

March 27, 2020

Table of Contents

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

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

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

Introduction ................................................................................................................... 4

Background ................................................................................................................... 4

Component 3 Evaluation Questions and Hypotheses ............................................... 6

Research Questions ................................................................................................................ 6

Data and Methods ......................................................................................................... 7

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

Research Question 3A ............................................................................................................ 7

Research Question 3B ............................................................................................................ 9

Research Question 3C ............................................................................................................ 9

Research Question 3D ...........................................................................................................12

Research Question 3E ...........................................................................................................16

Conclusion and Recommendations .......................................................................... 17

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

List of Tables

Table 1. Number of Healthy Behaviors Programs and Incentive Types ......................................................................... 7

Table 2. Enrollee Participation and Completion Rates in Healthy Behaviors Programs .............................................. 11

Table 3. Enrollee Participation and Completion Rates in Healthy Behavior Programs by Gender............................... 13

Table 4. Enrollee Participation and Completion Rates in Healthy Behaviors Programs by Age .................................. 15

List of Acronyms

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

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

Executive Summary

Overview

This report presents the interim results of Project 2 of the Statewide Medicaid Managed Care (SMMC) Managed Medical Assistance (MMA) Program Evaluation for Demonstration Year 11 (DY11), State Fiscal Year 2016-17 (SFY 2016-17), the third 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 Agency-mandated 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 participate in the following 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 evidence-based 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.

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 11 different types of Healthy Behaviors programs are offered across Florida’s 16 MMA plans in addition to the three required programs:

• Preventive well-child visits (8 plans)

• Pregnancy/maternity (11 plans)

• Baby Blocks (1 plan)

• Child/adolescent immunizations (1 plan)

• Dental (4 plans)

• Behavioral health follow-up (2 plans)

• Comprehensive diabetes care (4 plans)

• Preventive adult care (PCP visits) (4 plans)

• MMA backpack (1 plan)

• Breast cancer screening (3 plans)

• Cervical cancer screening (2 plans)

Types of incentives: The most common forms of incentives or rewards 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, Old Navy, Publix, Subway, Toys R Us/Babies R Us, Walmart), Visa gift cards, points or rewards associated with monetary values, backpacks, cookbooks, gym memberships, pedometers, water bottles, hats, T-shirts, tape and BMI measure, 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, board books, playpens and strollers).

Total enrollments/completions: The total number of enrollments in any Healthy Behaviors Program among all plans was 4,561,975. The total number of completions among all plans was 215,841.

Enrollment in mandatory programs: Of the mandatory programs required of all plans, the medically-directed weight loss program reported the highest number of current enrollees (31,273), as well as the highest number of enrollees who completed the program (658).

Enrollment in all programs: Of all programs offered (mandatory or optional), the program with the highest number of enrollees was the dental program (1,867,974), offered by Amerigroup, Prestige, Staywell, and Sunshine. The program with the second highest number of enrollees was the well-child visit program (1,325,921) offered by Better Health, Clear Health, Humana, Molina, Community Care, PHC, Prestige, Simply Healthcare, Staywell, and Sunshine.

Completion numbers: Out of all healthy behavior programs, the well-child visits program had the highest number of enrollees who completed the program (124,608), followed by the dental program (58,273).

Participation by gender: Among the mandatory programs, women were more likely than men to be currently enrolled in and to have completed the programs. For example, among all plans reported, about 65 percent of enrollees in the medically approved smoking cessation program


were women and about 35 percent were men.

Participation by age: Enrollee age distributions differed depending on the program type. For example, the smoking cessation program consisted largely of current enrollees and completed program enrollees ages 41-60 (50.1 percent and 40.4 percent, respectively) and ages 21-40 (34.5 percent and 43.0 percent, respectively), followed by those over age 60 (12.3 percent and 9.2 percent, respectively), and ages 0-20 (3.2 percent and 8.3 percent, respectively).


Introduction

This report presents the Demonstration Year 11 (DY11) evaluation results for the Healthy Behaviors program, Project 2 of the 2018 Revised Florida Medicaid 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 in the College of Medicine at Florida State University, and the Department of Health Services Administration at the University of Alabama-Birmingham.

The Healthy Behaviors programs are 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 DY11 MMA evaluation are listed in the Appendix to this report. The research questions for this component are stated below in the “Component 3 Evaluation Questions and Hypotheses” section.

Background

After implementation of the MMA waiver program in 2014, the State’s Enhanced Benefits Account Program (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 ($20), with the following exceptions:

(1) Programs 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 ($50).

(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 ($50) for each healthy behavior program.

For the first year of the MMA program (DY9), the key evaluation results for the Healthy


Behaviors program included:

• The total number of enrollments in any Healthy Behaviors program among all plans was 310,728.

• 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 (1,709).

• Of all programs offered (mandatory or optional), the program with the highest number of enrollments was the children’s nutrition incentive program (142,758) (offered by a single plan) followed by the well-child visit program (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.

For the second year of the MMA program (DY10), the key evaluation results for the Healthy Behaviors program included:

• The total number of enrollments in any Healthy Behaviors program among all plans was 304,903.

• The total number of completions among all plans was 14,554.

• Among the three mandatory programs, the medically directed weight loss program reported the highest number of enrollments (25,105), as well as the highest number of completions (2,170).

• Of all programs offered (mandatory or optional), the program with the highest number of enrollments was the well-child visit program (134,735) offered by five plans, followed by the children’s nutrition incentive program (134,162) offered by one plan.

• 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.


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 DY11 (SFY 2016-17). Component 3 consists of the following five evaluation questions along with their associated hypotheses.

Research Questions

The following questions are addressed in this DY11 evaluation of the Healthy Behaviors program. 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 (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?

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 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 programs.

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 2018-19) 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 (the 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. Additionally, several plans offer optional Healthy Behaviors programs. As shown in Table 1, the most common optional programs offered are preventive well-child visits (18) and pregnancy/maternity (16) programs. Other programs include diabetes care (6), well-adult visits (5), dental (4), child/adolescent immunizations (2), Baby Blocks (1), behavioral health follow-up (2), MMA backpack (1), and screening programs for breast cancer (3) and cervical cancer (2). Some plans offer more than one program in a single category. For example, Aetna offers two pregnancy/maternity programs: one for prenatal health and the other for postpartum health.

Table 1. Number of Healthy Behaviors Programs and Incentive Types

Healthy Behaviors Programa

Number of Plans

Offering

Programs

Types of Incentives Value of Incentives

Mandatory Programs

Medically Approved

Smoking Cessation

Program

16

Gift cards, discount/reward

cards, monetary, redeemable

points or credits

$1-$50

Medically Directed Weight

Loss Program 16



points or credits, weight

scale, cookbooks, gym

membership, and other

$1- $240


Healthy Behaviors Programa

Number of Plans

Offering

Programs

Types of Incentives Value of Incentives

health- or fitness-related

items

Medically Approved Alcohol

or Substance Abuse

Recovery Program

16



points or credits

$1 - $50

Optional Programs

Pregnancy/Maternity 16 Gift cards, points-monetary,

strollers, and playpens $1-$478

Baby Blocks 1 Gift cards, baby-related

merchandise <$10-$20

Well-Child Visits 18 Gift cards, points-monetary $1-$50

Child/Adolescent

Immunizations 2 Gift cards $20

Dental 4 Gift cards, Visa cards $10-$20

Behavioral Health Follow-Up

Program 2 Gift cards $30

Diabetes Care 6 Gift cards, Visa cards $10-$30

Breast Cancer Screening 3 Gift cards, Visa cards $10-$20

Cervical Cancer Screening 2 Gift cards $10

Health Risk

Assessment/Initial

PCP/Well-Adult

5 Gift cards, Visa cards $10-$25

MMA Backpack Project 1 Backpack $8.75

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.


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, Old Navy, Publix, Subway, Toys R Us/Babies R Us, Walmart), Visa gift cards, points or rewards associated with monetary values, backpacks, cookbooks, gym memberships, pedometers, water bottles, hats, T-shirts, tape and BMI measure, 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, board books, playpens and strollers).

Among the three required Healthy Behaviors programs, two plans did not report the type of incentive, if any, offered to enrollees who participated, and one plan offered incentives for the substance abuse 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 50 points or $50. The most common incentive offered for participating in optional programs were gift cards. Across all programs, reward or incentive values ranged from one dollar (monetary points) to $478 (triple stroller).

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 program participation data for each quarter (rather than individual-level data), the information reported was obtained from a cumulative total of all four quarterly reports for DY11. An important limitation of this approach is that there will be duplication in counts as enrollees are captured multiple times if they participate across quarters. For most plans, all summary reports were used with the exception of Children’s Medical Services (CMS), where Quarter 4 reports were missing (see Conclusion and Recommendations).

The total number of enrollments in any Healthy Behaviors Program among all plans was 4,561,975. The total number of completions among all plans was 215,8411.

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 (31,273), as well as the highest number of enrollees who completed the program (658).

Of all programs offered (mandatory or optional), the program with the highest number of enrollees was the dental program (1,867,974) offered by Amerigroup, Prestige, Staywell, and Sunshine. The program with the second highest number of enrollees was the well-child visit program (1,325,921) offered by Better Health, Clear Health, Humana, Molina, Community Care, PHC, Prestige, Simply Healthcare, Staywell, and Sunshine. The well-child visits program has the highest number of enrollees who completed the program (124,608), followed by the dental

1 Total enrollments and total completions are the sums of the first and second rows in Table 2, respectively.


program (58,273). A greater percentage of Medicaid enrollees participated in Healthy Behaviors programs in DY11 compared to DY10. 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 those diagnosed with a specific health condition, so not every enrollee is eligible to participate in certain Healthy Behaviors programs.

Completion rates are not included because MMA plans often did not report completion rates for a subset of the Healthy Behavior programs they offered, making it impossible to report aggregated completion rates across plans. More accurate percentages of enrollees who have completed Healthy Behaviors programs will be provided when individual-level information becomes available in DY13. As of December 1, 2018, the Agency has developed and implemented a revised template for plans to submit Healthy Behaviors data.

This template will require plans to report the Medicaid ID of each participant, which will allow the evaluation team to connect it with the claims, encounter, and eligibility data as needed to track outcomes. With this caveat in mind, the completion rates for each program are shown in Table 2.


Table 2. Enrollee Participation and Completion Rates in Healthy Behaviors Programs

Mandatory Programsa

Optional Programs

Medically Approved Smoking Cessation Program

Medi-cally

Direct-ed

Weight Loss

Program

Medically Approved Alcohol or Substance

Abuse Recovery Program

Preg-nancy /Mater-

nity

Baby Blocks

Well-Child Visits

Child/ Adoles-

cent Immuniza

-tions

Dental

Behavioral Health Follow-

Up Program

Diabetes Screening

Breast Cancer

Screening

Cervical Cancer

Screening

Health Risk Assessment /Initial PCP Well Adult

MMA Backpack

Project

Number Currently Enrolled, DY 11 b

2,283 31,273 327 58,306 6,915 1,325,921 42,692 1,867,974 10 139,274 107,699 3 632,057

347,241

Enrollees who Completed Program

228 658 47 5,384 1,098 124,608 0 58,273 577 824 1,554 10,677 11,913 0

Plans Offering Program

ALL ALL ALL

Ameri-group, Better Health, Clear

Health, Aetna,

Humana, Magellan,

Molina, Comm-

unity Care,

Prestige, Simply Health-care,

Staywell, Sunshine

United

Better Health, Clear

Health, Humana, Molina,

Commu-nity Care,

PHC, Prestige, Simply Health-care,

Staywell, Sunshine

Ameri-group

Ameri-group,

Prestige, Staywell, Sunshine

Prestige, Sunshine

Community Care,



Prestige, Sunshine

Molina, Community

Care, Staywell, Sunshine

Staywell

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 1-4 summary reports for each plan (Quarters 1-3 for CMS).


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, about 65 percent of enrollees in the medically approved smoking cessation program were females and about 35 percent were males. Almost seventy percent of all enrollees who completed the smoking cessation program as of the end of DY11 were female.

Among optional programs, the pregnancy/maternity, Baby Blocks, breast cancer screening, and cervical cancer screening programs consisted of almost 100 percent females, not surprisingly. United Healthcare runs the Baby Blocks program, which provides rewards to pregnant mothers and babies for going to the doctor. For the other programs, current and completed enrollment rates between males and females were relatively equally distributed, with some exceptions (i.e., diabetes screening program had slightly higher rates of females).


Table 3. Enrollee Participation and Completion Rates in Healthy Behavior Programs by Gender

Mandatory Programsa Optional Programs


Medically Directed Weight Loss

Program



Pregnancy/Maternity

Baby Blocks

Well-Child Visits

Child/ Adolescent

Immuni-zations

Dental

Behavioral Health

Follow-Up Program

Diabetes Screening

Breast Cancer

Screening

Cervical Cancer Screen-

ing

Health Risk

Assess-ment/ Initial

PCP/Well-Adult

MMA Back-pack

Project

Number Enrolled, DY11 b

2,283 31,273 327 58,306 6,915 1,325,921 42,692 1,867,974 10 139,274 107,699 3 632,057 347,241

Males (%)

799 (35.0%)

11,653 (37.3%)

147 (45.0%)

0

0

670,030 (50.5%)

21,684 (50.8%)

946,261 (50.7%)

7 (70.0%)

46,077 (33.1%)

0 0 266,798 (42.2%)

174,406 (50.2%)

Females (%)

1,483 (65.0%)

19,620 (62.7%)

180 (55.0%)

58,306 (100%)

6,915 (100%)

655,891 (49.5%)

21,008 (49.2%)

921,713 (49.3%)

3 (30.0%)

93,197 (66.9%)

107,699 (100%)

3 (100%)

360,925 (57.1%)

172,835 (49.8%)

Enrollees who Completed Program b

228 658 47 5,384 1,098 124,608 0 58,273 577 824 1,554 10,677 11,913 0

Males (%)

72 (31.6%)

155 (23.6%)

17 (36.2%)

165 (3.1%)

0

60,591 (48.6%)

0 28,505 (48.9%)

283 (49.0%)

248 (30.1%)

2 (0.1%)

0 2,535

(21.3%) 0

Females (%)

156 (68.4%)

503 (76.4%)

30 (63.8%)

5,219 (96.9%)

1,098 (100%)

59,710 (47.9%)

0 29,768 (51.1%)

294 (51.0%)

576 (69.9%)

1,552 (99.9%)

10,677 (100%)

9,378 (78.7%)

0



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 41-60 (50.1 percent and 40.4 percent, respectively) and ages 21-40 (34.5 percent and 43.0 percent, respectively), followed by those over age 60 (12.3 percent and 9.2 percent, respectively), and ages 0-20 (3.2 percent and 8.3 percent, respectively).

The weight loss program consisted of current enrollees ages 0-20 (36.6 percent), followed by ages 21-40 (32.6 percent), ages 41-60 (23.8 percent) and over age 60 (7.0 percent). Among enrollees who completed the weight loss program, 38.8 percent were ages 21-40, followed by those ages 41-60 (30.4 percent), ages 0-20 (24.3 percent), and over age 60 (6.5 percent).

The alcohol or substance abuse recovery program consisted of current enrollees largely between the ages of 41-60 (41.6 percent) and ages 21-40 (36.7 percent), followed by those ages 0-20 (13.1 percent) and those over age 60 (7.6 percent). Among those who completed the recovery program, 51.1 percent were ages 21-40, 38.3 percent were ages 41-60, 8.5 percent were ages 0-20, and 2.1 percent were over age 60.

Among optional programs, the pregnancy/maternity and Baby Blocks programs primarily consisted of those ages 21-40 (77.2 percent and 90.8 percent currently enrolled, respectively; 83.4 percent and 92.8 percent completed, respectively). The following programs consisted mostly of those ages 0-20: well-child visits (99.1 percent currently enrolled and 99.7 percent completed), child/adolescent immunizations (100 percent currently enrolled, no completions), dental (99.4 percent currently enrolled, 99.9 percent completed), behavioral health follow-up (60.0 percent currently enrolled, 75.4 percent completed), health risk assessment (65.4 percent currently enrolled), and MMA backpack (100 percent currently enrolled and no completions). The following programs consisted mostly of those ages 41-60: diabetes (54.4 percent currently enrolled and 57.2 percent completed), breast cancer screening (80.1 percent currently enrolled and 64.5 percent completed), and cervical cancer screening (100 percent currently enrolled and 80.1 percent completed ages 21-40).

Of note, the completion rates (number of enrollees who completed programs as a percentage of the number currently enrolled in DY11) are not presented 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 in DY13 (SFY 2018-19).


Table 4. Enrollee Participation and Completion Rates in Healthy Behaviors Programs by Age

Mandatory Programsa Optional Programs


Medically Directed Weight Loss

Program



Pregnancy/Maternity

Baby Blocks

Well-Child Visits

Child/ Adolescent

Immuni-zations

Dental

Behavioral Health

Follow-Up Program

Diabetes Screening

Breast Cancer

Screening

Cervical Cancer Screen-

ing

Health Risk

Assess-ment/ Initial

PCP/Well-Adult

MMA Back-pack

Project

Number Enrolled, DY11 b

2,283 31,273 327 58,306 6,915 1,325,921 42,692 1,867,974 10 139,274 107,699 3 632,057 347,241

Ages 0-20 (%)

74 (3.2%)

11,436 (36.6%)

43 (13.1%)

12,433 (21.3%)

478 (6.9%)

1,314,065 (99.1%)

42,692 (100%)

1,856,111 (99.4%)

6 (60.0%)

2,807 (2.0%)

0 0 413,371 (65.4%)

347,241 (100%)

Ages 21-40 (%)

787 (34.5%)

10,188 (32.6%)

120 (36.7%)

45,026 (77.2%)

6,280 (90.8%)

11,743 (0.9%)

0 11,743 (0.6%)

0 29,766 (21.4%)

6,992 (6.5%)

0 137,670 (21.8%)

0

Ages 41-60 (%)

1,144 (50.1%)

7,445 (23.8%)

136 (41.6%)

834 (1.4%)

157 (2.3%)

0 0 0 3

(30.0%) 75,713 (54.4%)

86,302 (80.1%)

3 (100%)

52,722 (8.3%)

0

Over 60 (%)

280 (12.3%)

2,184 (7.0%)

25 (7.6%)

13 (0%)

0 0 0 0 1

(10.0%) 30,988 (22.2%)

14,405 (13.4%)

0 28,294 (4.5%)

0

Enrollees who Completed Program b

228 658 47 5,384 1,098 124,608 0 58,273 577 824 1,554 10,677 11,913 0

Ages 0-20 (%)

19 (8.3%)

160 (24.3%)

4 (8.5%)

793 (14.7%)

48 (4.4%)

124,252 (99.7%)

0 58,219 (99.9%)

435 (75.4%)

24 (2.9%)

4 (0%)

0 472

(4.0%) 0

Ages 21-40 (%)

98 (43.0%)

255 (38.8%)

24 (51.1%)

4,489 (83.4%)

1,019 (92.8%)

502 (0.4%)

0 40

(0%) 68

(11.8%) 101

(12.3%) 19

(1.2%) 8,553

(80.1%) 6,809

(57.2%) 0

Ages 41-60 (%)

92 (40.4%)

200 (30.4%)

18 (38.3%)

102 (1.9%)

31 (2.8%)

24 (0%)

0 14

(0%) 63

(10.9%) 471

(57.2%) 1,003

(64.5%) 1,975

(18.5%) 3,652

(30.7%) 0

Over 60 (%)

21 (9.2%)

43 (6.5%)

1 (2.1%)

0 0 2

(0%) 0 0

11 (1.9%)

229 (27.8%)

528 (34.0%)

149 (1.4%)

980 (8.2%)

0



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 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 (SFY 2018-19) and beyond. Data on the Healthy Behaviors program are aggregated by plan and currently are 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 While there is a universal reporting template that plans follow, there are inconsistencies in reporting Healthy Behaviors program participation and completion rates across health plans. For example, there is no way to determine whether plan reports represented cumulative or point-in-time rates, and therefore it was not possible to produce reliable estimates of participation or completion rates. This has been an ongoing issue from previous years, but may be more pronounced in this report as there is much more program participation than in previous years. Therefore, no comparisons with participation and completion rates from previous years are discussed. In addition to inconsistent reporting across plans, several errors were found within plan reports where subgroup counts, such as those reported by gender and/or age when aggregated did not equal the total counts included in the same report. It is also unclear how certain programs that appear to offer one-time incentives (i.e., well-child visits, dental) are reporting ‘currently enrolled’ versus ‘completed’ versus both. Ultimately, the reports submitted by plans make it unclear how many total enrollees versus how many completed enrollees are in each program. Issues with data consistency and quality may be addressed after individual-level Healthy Behaviors program data are provided, which would allow evaluators to aggregate and report data in a uniform manner. Specifically, having data available on participants’ race, health status, and service utilization will be critical for a full examination of research questions 3D and 3E. Ensuring that the Medicaid Identification number for each recipient is indicated in this data would be a top priority so that it can be linked to the claims and encounter data. 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, emergency department, etc.) than non-participants with COPD? Of note, the Agency has taken steps to improve the Healthy Behaviors reports submitted by plans by adding more specific individual-level information (e.g., race/ethnicity) in order to assist with Agency monitoring efforts and evaluation. Importantly, this revised template will include the Medicaid ID number of each participant. The ultimate goal is for this data to be available for evaluation by DY13 (SFY 2018-19) given that the revised template was implemented effective December 1, 2018.


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

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 care2

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?

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


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?

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 · Project 2 Final Interim Report Contract Deliverable No. 21, Managed Medical Assistance Final Interim Report – Project 2 SFY 2016-2017 (DY11): Component