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Title: Florida's Medicaid program for children : MediPass and HMO
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Title: Florida's Medicaid program for children : MediPass and HMO
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Language: English
Creator: Institute for Child Health Policy, University of Florida
Publisher: Institute for Child Health Policy, University of Florida
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The Florida KidCare Evaluation Series:


Florida's Medicaid Program for
Children: MediPass and HMO, 2003







Prepared by
Institute for Child Health Policy
University of Florida

Under Contract to the
Agency for Health Care Administration


May, 2004


FIl rida KidCare


I'C~ \i














Authors


June Nogle, PhD
Associate Scholar
Institute for Child Health Policy


Elizabeth Shenkman, PhD
Director and Associate Professor
Institute for Child Health Policy
Interim Chairperson
Department of Health Policy and Epidemiology






















The authors acknowledge the following agencies for their support and provision of data
and information needed to conduct this evaluation:



The Agency for Health Care Administration
The Department of Health
The Department of Children and Families
The Florida Healthy Kids Corporation










Table of Contents

List of Tables, Figures, and A ppendices .................................................................. ....................... 2
I. Exec utive Sum m a ry ..................................................................... .............. ............................. 3
II. Intro d uc tio n ......................................................... ............................................................. 6
III. The Evaluation Approaches and Data Collection................................................................. 8
IV. Demographic Composition, Socioeconomic Status, and Household Characteristics............ 9
V. Presence of Special Health Care Needs Among Medicaid HMO Enrollees vs. MediPass
Enro lle e s ...................................................... . ...... ............................................. ........ 15
VI. Families' Satisfaction with the KidCare Program....................... ..... ............................ 17
VII. Dental Care .............................................................................................. 21
VII. Compliance with Preventive Care Guidelines................................... ............................. 22
VIII. Access to Employer-Provided Insurance Coverage .............................. ....................... 24
IX. Sum m a ry a nd C o nc lusio ns ............................................................................. ........................... 24


Florida KidCare Evaluation Series, Year 5 DRAFT 1
Medicaid: HMO and Medipass










List of Tables, Figures, and Appendices


Table 1. Federal Poverty Levels for a Fam ily of Four.............................................. ...................... 7
Table 2. Medicaid Enrollee Population and Sample Sizes ............................................................. 8
Figure 1. Racial-Ethnic Composition of MediPass and Medicaid HMO Populations...................... 10
Figure 2. Racial-Ethnic Composition of Medipass and Medicaid HMO Populations by Age ......... 11
Figure 3. Family Type of MediPass and Medicaid HMO Populations............................................. 13
Figure 4. Marital Status of Medicaid HMO Parents and MediPass Parents .................................... 13
Figure 5. CSHCN Screener Results for Medipass and Medicaid HMO Enrollees............................ 16
Figure 6. Percent of Enrollees by Program and Age Group that Met the CSHCN Screener........... 16
Table 3. Medicaid Enrollees' Satisfaction with Their Child's Doctor and Office Staff in Past Year. 19
Figure 7. Percent of Enrollees Taken to Exam Room within 15 Minutes of Appointment Time........ 19
Table 4. Medicaid Enrollees' Compliance with AAP Immunization Guidelines................................. 23
Table 5: Access to Employer-Provided Insurance for Parents of Medicaid Enrollees................... 24
Appendix A: Medicaid Managed Care Choices by County, October 2003.................................. 27


Florida KidCare Evaluation Series, Year 5 DRAFT 2
Medicaid: HMO and Medipass










I. Executive Summary


Introduction and
Purpose







Evaluation Data
Sources











Program
Structure














Key Findings

Demographic
Composition
and Family
Characteristics


The purpose of this report is to describe the quality of care children
receive in Medicaid's Primary Care Case Management (PCCM)
program and in Medicaid's Health Maintenance Organization (HMO)
option. This report is a component of the Year 5 Evaluation of the
entire Florida KidCare Program, of which Medicaid is a part. The
interested reader can review the overall program evaluation by
visiting http://www.ichp.edu/FloridaKidCare/flaKC.htm.

Data for this evaluation were collected in telephone surveys
conducted with families whose children are enrolled in Florida's
Medicaid program. These families may have entered KidCare
through use of the one-page KidCare application, or by other means.
A total of 904 surveys were conducted in the fall, 2003, representing a
population of 199,222 KidCare enrollees who had been enrolled for at
least twelve months. The sample was then divided according to
whether the respondents were enrolled in a Medicaid HMO or in the
PCCM program, called MediPass. Of the 904 surveys conducted, 302
were families enrolled in a Medicaid HMO and 602 were from
MediPass-enrolled families.

In thirty-four of Florida sixty-seven counties, families of new Medicaid
enrollees have the choice of enrolling their child in either a Medicaid
HMO or in MediPass, which is a Primary Care Case Management
program. Choice counseling is provided through a third party to assist
families in making this choice. Families who fail to indicate their
choice are randomly assigned to a managed care plan. Of the 602
Medipass respondents, 300 respondents resided in counties where
Medipass was the only Medicaid program option, but 302 Medipass
respondents resided in counties where both Medipass and HMO
health plan selections were offered. In this report, the phrase
"MediPass choice enrollees" refers to those enrollees residing in
counties where there is a choice between MediPass and a HMO. The
phrase "MediPass only enrollees" refers to those enrollees living in
counties with a MediPass option only.

The key findings are summarized below:

Demographic composition of the three Medicaid programs varies
considerably. On average, HMO enrollees were 8.0 years, while
MediPass only enrollees were 8.7 years old and Medipass choice
enrollees were 8.5 years old. The most noticeable difference between
the three populations is in their racial and ethnic compositions.
Among HMO enrollees, 33% reported they were Hispanic, 32%
reported they were black non-Hispanic, 32% reported they were


Florida KidCare Evaluation Series, Year 5 DRAFT 3
Medicaid: HMO and Medipass









white non-Hispanic, and the remaining 3% reported they were of
another racial-ethnic background, or of mixed race. Among the
MediPass only group, 16% reported they were Hispanic, 23% reported
they were black non-Hispanic, 59% reported they were white non-
Hispanic, and the remaining 2% reported they were of another racial-
ethnic background, or of mixed race. Among the MediPass choice
group, 12% reported they were Hispanic, 24% reported they were
black non-Hispanic, 60% reported they were white non-Hispanic, and
the remaining 4% reported they were of another racial-ethnic
background, or of mixed race.

There were significant differences in primary language among the
programs. Only seventy percent of HMO parents spoke English as their
primary language at home; a quarter of HMO parents spoke Spanish
as their primary language. Larger shares of Medipass only parents
(87%) and Medipass choice parents (93%) spoke English as their
primary language at home.

The HMO group had the lowest household incomes, with 35%
reporting household incomes of less than ten thousand dollars. The
two Medipass groups had similar income distributions, each with 30%
reporting household incomes of less than ten thousand dollars.

The majority of HMO enrollees surveyed (55%) reported that they
resided in two-parent families, while 45% reported they resided in
single-parent families. Among MediPass only enrollees, the pattern
was similar, with 57% in two-parent families and 43% in single-parent
families. Families of Medipass choice enrollees were almost equally
split between single-parent families (48%) and two-parent families
(52%).


CSHCN Screener The Children with Special Health Care Needs Screener (CSHCN) was
used to identify children with special needs. A significantly larger
share of the Medipass group (30% of Medipass only and 33% of
Medipass choice) met the CSHCN screener compared to the HMO
group (21%). Over a third of Medipass enrollees aged 5-19 met the
screener, more than the other age and program groups.

Satisfaction with Enrollees in the HMO and Medipass programs were very satisfied with
the Medicaid the care they receive through Medicaid.
Program
Eighty-five percent of families reported that it was "not a problem" to
get care for their child in Medicaid, while 8% reported it was "a small
problem" and 6% indicated it was "a big problem." Sixty percent of
enrollees reported that they did not experience delays in getting
health care due to awaiting approval from Medicaid. Another 28%
reported they had a small problem with delays and 12% reported

Florida KidCare Evaluation Series, Year 5 DRAFT 4
Medicaid: HMO and Medipass









having a "big problem" with delays.


Dental Care


Preventive Care
and
Immunizations



Access to
Employer-
Provided
Coverage


Respondents were asked to rate their usual care provider on a scale
from 0 to 10, with 0 being the worst doctor or nurse possible, and 10
being the best doctor or nurse possible. The mean ratings ranged
from 9.0 for Medipass only parents to 9.1 for HMO parents and 9.2 for
Medipass choice respondents.

Overall, 27% of respondents reported that their child needed to see a
specialist. HMO respondents and Medipass choice respondents were
more likely than Medipass only respondents to report that their child
needed to see a specialist, with rates of 28%, 28%, and 26%,
respectively. The mean rating of specialists was 8.6 for HMO enrollees,
8.7 for Medipass only, and 9.1 for Medipass choice.

About half (49%) of respondents indicated that their child had one or
more dental visits in the year prior to the interview. There was no
variation by program, with 49% of HMO and Medipass choice
enrollees and 50% of Medipass only enrollees having one or more
dental visits in the year prior to the interview.

When asked to rate their dental care on a scale of zero (worst) to ten
(best care possible), enrollees in all three program components rated
dental care equally high. The means were almost identical for the
three program components, 8.8 for HMO enrollees, 8.7 for Medipass
only enrollees, and 8.6 for Medipass choice enrollees.

The vast majority of Medicaid enrollees surveyed were compliant with
AAP recommendations for well-child visits to primary care proves.
Compliance with AAP guidelines for immunizations was also high,
except for HIB and the newly-recommended Pneumococcus
vaccine.

A small proportion of all parents have access to family coverage at
their place of work. About 12% of Medipass only parents, 13%
Medipass choice parents, and 13% of HMO parents are eligible to
enroll their children in an employer-provided family insurance plan.
About six percent of parents in each of the three program
components have access to individual coverage through their
employer, but not family coverage. More than seventy percent of all
parents did not have access to employer-provided coverage for their
children because they are not employed, their employer does not
offer any coverage, or they are ineligible for whatever coverage is
offered.


Florida KidCare Evaluation Series, Year 5 DRAFT 5
Medicaid: HMO and Medipass










II. Introduction


Introduction This report is a component of the Year 5 Evaluation of the entire Florida
and Purpose KidCare Program, of which Medicaid is a part. The interested reader
of the Report can review the overall program evaluation by visiting
http://www.ichp.edu/FloridaKidCare/fla KC.htm.

The purpose of this report is to describe the quality of care children
receive in Medicaid's Primary Care Case Management (PCCM)
program known as Medipass and in Medicaid's Health Maintenance
Organization (HMO) option. This report describes differences between
the two programs in terms of demographic characteristics of enrollees,
satisfaction with the program, enrollee health status, provision of
preventive care, and parent's access to employer-provided health
insurance coverage.

Program Florida KidCare is an umbrella program, comprised of the following
Structure components:

1. MediKids, a Medicaid "look-alike" program for children ages 1
through 4 years, who are between 134 percent and 200 percent
of the Federal Poverty Level (FPL) (see Table 1);
2. Healthy Kids, a program for children 5 through 18 years of age,
which provides a benefits-rich package comparable to that of
Medicaid, for a low monthly premium. Children aged 5 years old
can be covered under Healthy Kids if their family income is
between 134 percent and 200 percent FPL; children ages 6
through 18 can be covered if their family income is between 101
percent and 200 percent FPL;
3. CMS or Children's Medical Services, serves children 0 through 18
years old who have a special health care need and reside in
families at or below 200 percent FPL;
4. Medicaid serves children 0 through 18 years of age who reside in
families at or below 100 percent FPL, as well as those under 1
year old between 101 percent and 200 percent FPL, and those
aged 1 through 5 years who are between 101 percent and 133
percent FPL.

The Medicaid program is by far the largest component of KidCare,
comprising four-fifths of the program enrollment, or over 1.2 million
children as of October 30, 2002. The majority of Medicaid enrollees are
covered using Title XIX funds; only those aged 17 through 18 and those
aged 0 to 1 year who are between 185 percent and 200 percent FPL
are covered using Title XXI funds.



Florida KidCare Evaluation Series, Year 5 DRAFT 6
Medicaid: HMO and Medipass









Most families enrolling in Medicaid may select the type of managed
care program they want for their children. Depending on the county of
residence, the children can receive their care through an HMO or
through MediPass. In
Miami-Dade and Broward Counties, a Provider Service Network (PSN) is
also available. Those children whose families choose an HMO option
receive care through one of the Medicaid HMOs participating in their
county. In the MediPass PCCM program, providers receive a monthly
capitation fee for the children in their panels to provide care
coordination services. All other health care services are reimbursed
according to the Medicaid fee schedule. Providers participating in the
HMO program receive capitated reimbursement for services. See
Appendix A for a list of counties with and without Medicaid HMOs.

Families of Medicaid beneficiaries receive information from an
enrollment broker to assist them in making the decision between
managed care programs. Florida has contracted with ACS to provide
enrollment and disenrollment services. All new Medicaid enrollees are
sent materials outlining the choices of managed care plans for their
county. Since Medicaid HMOs do not operate in thirty-three of Florida's
sixty-seven counties, enrollees in those counties are automatically
assigned to the Medipass plan. Enrollees in the other thirty-four counties
call ACS to indicate their choice of Medipass or an HMO. Enrollees who
fail to do so within 60 days are assigned to a plan; if more than one
HMO plan is available, enrollees are assigned to a plan by ACS.


Table 1. Federal Poverty Levels for a Family of Four

Income as a Percent of
1998 1999 2000 2001 2002 2003
Federal Poverty Level
100% $16,450 $16,700 $17,050 $17,650 $18,100 $18,400
133% $21,789 $22,211 $22,677 $23,475 $24,073 $24,472
185% $30,433 $30,895 $31,543 $32,653 $33,485 $34,040
200% $32,900 $33,400 $34,100 $35,300 $36,200 $36,800















Florida KidCare Evaluation Series, Year 5 DRAFT 7
Medicaid: HMO and Medipass











III. The Evaluation Approaches and Data Collection


Populations
Included in
the
Telephone
Surveys


Data for this evaluation come from telephone surveys conducted with
families whose children are enrolled in Florida's Medicaid program.
These families may have entered KidCare through use of the one-page
KidCare application, or by other means. A total of 904 surveys were
conducted in fall, 2003. The sample was then divided according to
whether the respondents were enrolled in a Medicaid HMO or in
MediPass. Of the 904 surveys conducted, 302 were from Medicaid HMO
enrollees and 602 were from MediPass-enrolled families (see Table 2).
Medipass enrollees in counties without HMO health plan options
(hereafter referred to as Medipass only) completed 300 questionnaires,
while Medipass enrollees in counties with HMO plan options (hereafter
referred to as Medipass choice) completed 302 questionnaires.

The survey instrument was designed to gather information from families
whose children had been enrolled in Medicaid for at least twelve
consecutive months. The questionnaire contains a number of items
pertaining to the family's satisfaction with their child's KidCare
coverage, and the quality of care they received in the program, as
well as questions about their demographics, their child's health status,
and unmet medical needs.

Information is not available for this report about the sociodemographic
or health characteristics of those who could not be located. It is not
known how generalizable the findings in this report are to the overall
pool of children in MediPass and Medicaid HMOs. Additional
information on survey methodology and cooperation rates is available
in the KidCare Year 5 Evaluation report, available at
http://www.ichp.edu/FloridaKidCare/fla KC.htm.


Table 2. Medicaid Enrollee Population and Sample Sizes
Confidence
Population Size Sample Size Confidenc
Program Interval (%).
Progm (weighted N) unweightedd n) I .
P<=.05*
All Medicaid Enrollees, September 30, 2003 1,112,248
Medicaid Enrollees in Program for 12 199,222 904
months or more (the universe of
established enrollees for this report)
Medicaid HMO established enrollees 129,572 302 +/- 5.63
Medipass only established enrollees (in 38,423 300 +/- 5.64
counties without HMOs)
Medipass choice established enrollees (in 31,227 302 +/-5.61
counties with HMOs)
* The confidence intervals are presented for hypothetical items with uniformly distributed
responses. These numbers are a worst case generality presented for reference purposes only.


Florida KidCare Evaluation Series, Year 5 DRAFT 8
Medicaid: HMO and Medipass










IV. Demographic Composition, Socioeconomic Status, and Household
Characteristics


Sex of
Enrolled Child












Age of Child





Race and
Ethnicity


The Medicaid HMOs and MediPass programs were compared in
terms of the demographic characteristics of their enrollees.
Respondents were asked a number of questions relating to their
race and ethnicity, the child's race and ethnicity, and family
characteristics.

Overall, there were equal proportions of males and females
enrolled in the Medicaid program, although the distribution was
slightly different among the HMO and MediPass groups. The
MediPass only population was made up of slightly more males
than females with 51% of respondents reporting that their child
was male and 49% reporting the child was female. In counties
that were also served by HMOs, the MediPass choice program
was split more equally between males (49.3%) and females
(50.7%). The HMO group was estimated to be composed of
almost equal shares numbers of males (49.8%) and females
(50.2%). The small differences in gender distribution between the
three programs were not statistically significant.

Overall, enrollees in Medicaid were 8.2 years old. On average,
HMO enrollees were 8.0 years, while MediPass only enrollees
were 8.7 years old and Medipass choice enrollees were 8.5
years old. These differences were statistically significant
(p=.000)1.

In terms of race and ethnicity, the MediPass and HMO groups
differed significantly. Among HMO enrollees, 33% reported they
were Hispanic, 32% reported they were black non-Hispanic, 32%
reported they were white non-Hispanic, and the remaining 3%
reported they were of another racial-ethnic background, or of
mixed race. Among the MediPass only group, 16% reported they
were Hispanic, 23% reported they were black non-Hispanic, 59%
reported they were white non-Hispanic, and the remaining 2%
reported they were of another racial-ethnic background, or of
mixed race. Among the MediPass choice group, 12% reported
they were Hispanic, 24% reported they were black non-Hispanic,
60% reported they were white non-Hispanic, and the remaining
4% reported they were of another racial-ethnic background, or
of mixed race (see Figure 1)**.


1 Hereafter, statistically significant differences between the three programs will be denoted by asterisks. A single asterisk (*) will
denote a significance level of p<=0.05 and two asterisks (**) will denote a significance level of p<=.001.

Florida KidCare Evaluation Series, Year 5 DRAFT 9
Medicaid: HMO and Medipass











The program groups were also examined by age groups 0 to 4
years and 5 to 19 years (see Figure 2). Within their respective
programs, the racial/ethnic compositions of younger children**
and older children** are very similar, but significant differences
in composition remain between programs.

The differences in racial and ethnic makeup of the programs
may affect results. Research has shown that blacks as a group
are more satisfied with their medical care than are whites or
Hispanics. Thus, differences in satisfaction with the program may
be attributable to these demographic differences.


Figure 1. Racial-Ethnic Composition of MediPass and Medicaid HMO Populations


Medipass only


N Hispanic 0 Black O White O Other


HMO


N Hispanic 0 Black O White 0 Other


Florida KidCare Evaluation Series, Year 5 DRAFT 10
Medicaid: HMO and Medipass


Medipass choice


N Hispanic 0 Black O White O Other











Figure 2. Racial-Ethnic Composition of Medipass and Medicaid HMO Populations by
Age


Medipass only 0-4


N Hispanic 0 Black O White O Other


Medipass choice 0-4


" Hispanic N Black O White O Other


HMO 0-4













" Hispanic N Black O White O Other


Medipass only 5-19


* Hispanic N Black O White O Other


Medipass choice 5-19


N Hispanic Black O White D Other


HMO 5-19


N Hispanic 0 Black O White 0 Other


Florida KidCare Evaluation Series, Year 5 DRAFT 11
Medicaid: HMO and Medipass












Parent's
Education,
Primary
Language,
and
Household
Income


Family
Structure


The average education level of HMO and Medipass parents is similar.
About 40% of Medipass choice parents had less than a high school
diploma, while 43% of HMO and Medipass only parents did not have a
degree. A quarter of HMO parents reported having a high school
diploma or GED, compared to 22% of Medipass only parents and 20%
of Medipass choice parents. A third of Medipass choice parents
reported having vocational or technical training or some college
education, while about a quarter of Medipass parents only and HMO
parents had that same training. Only six percent of Medipass parents
and ten percent of HMO parents reported having an Associate's
Degree or higher.

There were significant differences in primary language among the
programs. Only seventy percent of HMO parents spoke English as their
primary language at home; a quarter of HMO parents spoke Spanish
as their primary language. Larger shares of Medipass only parents
(87%) and Medipass choice parents (93%) spoke English as their
primary language at home**.

The HMO group had the lowest household incomes, with 35% reporting
household incomes of less than ten thousand dollars and 62% reporting
incomes of less than twenty thousand dollars. The two Medipass
groups had similar income distributions, each with 30% reporting
household incomes of less than ten thousand dollars. For the Medipass
only group, 58% had household incomes below twenty thousand
dollars, while a slightly larger share of Medipass choice (64%) fell below
that income threshold*.

The family structure of the groups did not vary dramatically. The
majority of HMO enrollees surveyed (55%) reported that they resided in
two-parent families, while 45% reported they resided in single-parent
families. Among MediPass only enrollees, the pattern was similar, with
57% in two-parent families and 43% in single-parent families. Families of
Medipass choice enrollees were almost equally split between single
parent families (48%) and two-parent families (52%) (see Figure 3).

The parent's marital status also did not vary significantly between the
HMO and MediPass groups (see Figure 4). Forty-eight percent of HMO
enrollees reported they were married (including common law), while
52% reported they were not married (including divorced, separated,
single, widowed). Fifty-two percent of Medipass only parents reported
being married while 48% reported they were not married. Medipass
choice parents had the lowest levels of marriage, with 47% being
married and 53% were not married.


Florida KidCare Evaluation Series, Year 5 DRAFT 12
Medicaid: HMO and Medipass











Figure 3. Family Type of MediPass and Medicaid HMO Populations


Medipass only


* Single Parent U Two Parent


Medipass choice


* Single Parent U Two Parent


HMO


* Single Parent U Two Parent


Figure 4. Marital Status of Medicaid HMO Parents and MediPass Parents


6P ~ 6 6P ~
t~~pt 9o


.60
^ ^Sa


O HMO U MediPass only U Medipass choice


Florida KidCare Evaluation Series, Year 5 DRAFT 13
Medicaid: HMO and Medipass









Internet and
Mobile Phone
Access


Families' access to two technologies was measured. Over half (52%) of
HMO parents had a mobile phone, compared to 46% of Medipass only
parents and 50% of Medipass choice parents. Larger shares of parents
reported having a computer in the home (57%, 58%, and 61%,
respectively). Slightly smaller shares of parents reported having access
to the Internet from home (48% of HMO parents, 46% of Medipass only,
and 52% of Medipass choice). Less than a quarter of parents had
access to the Internet at work though (22% of HMO parents, 23% of
Medipass only, and 17% of Medipass choice). Of those parents that
did have Internet access at work, the majority reported that their
employer would allow them to use the Internet to check health care
information (69% of HMO parents, 85% of Medipass only, and 75% of
Medipass choice).


Florida KidCare Evaluation Series, Year 5 DRAFT 14
Medicaid: HMO and Medipass










V. Presence of Special Health Care Needs among Medicaid HMO Enrollees and
MediPass Enrollees


Background



















CSHCN
Screener
Results


The Children with Special Health Care Needs (CSHCN) Screener was
used to identify the presence of special health care needs among
KidCare Program enrollees. It is based on parent self-report. The
CSHCN Screener contains five items that address whether the child (1)
has activity limitations when compared to other children of his or her
age, (2) needs or uses medications, (3) needs or uses specialized
therapies such as physical therapy and others, (4) has an above
routine need or use for medical, mental health or educational
services, or (5) needs or gets treatment or counseling for an emotional,
behavioral or developmental problem. For any category with an
affirmative response, the parent is then asked if this is due to a
medical, behavioral or other health condition and whether that
condition has lasted or is expected to last at least 12 months. The child
is considered to have a special need if the parent responds
affirmatively to any of the categories.2 The CSHCN Screener has been
tested on several populations of children and the testing supports the
dimensions included in the instrument.

Overall, 25% of respondents met the CSHCN screener. Those enrolled
in the HMO met the screener less frequently than those in MediPass.
About a fifth (21%) of HMO enrollees met the screener, while 30% of
Medipass only and 33% of Medipass choice enrollees did so (see
Figure 5)*.

Results by age show that those in both the MediPass 5-19 groups met
the screener more often than those enrollees in any other groups (see
Figure 6). About 20% of children aged 0-4 in the Medipass choice
group met the screener, a slightly larger share than those in HMOs
(16%) or the Medipass choice (15%). Among older children aged 5-19,
about 40% of Medipass choice enrollees met the screener, while a
third (35%) of Medipass only and a quarter (24%) of HMO enrollees met
the screener.

About 13% of Florida's children have special needs based on
population estimates from the National Survey on Children with Special
Health Care Needs. Thus the percentage of CSHCN enrolled in
Medicaid is substantially higher than the general population estimates.
Moreover, CSHCN are more likely to be enrolled in MediPass than in
the Medicaid HMOs.


2 Bethell C, Read D. Child and Adolescent Health Initiative. Portland, Oregon: Foundation for Accountability; 1999.


Florida KidCare Evaluation Series, Year 5 DRAFT 15
Medicaid: HMO and Medipass










Figure 5. CSHCN Screener Results for Medipass and Medicaid HMO
Enrollees


Medipass only


* Met Screener 0 Did Not Meet


Medipass choice


E Met Screener E Did Not Meet


HMO


* Met Screener U Did Not Meet


Figure 6. Percent of Enrollees by Program and Age Group that Met the
CSHCN Screener


35%
30%
25% -
20%
15%-
20 ---------- --


10% -
5% --
0% "

lo p 0 l op OV


Florida KidCare Evaluation Series, Year 5 DRAFT 16
Medicaid: HMO and Medipass









VI. Families' Satisfaction with the KidCare Program


Background


Primary Care


The Consumer Assessment of Health Plans Survey (CAHPS) was used to
assess family satisfaction with the Medicaid Program. The CAHPS is
recommended by the National Commission on Quality Assurance for
health plans to use when assessing enrollees' satisfaction with the
health care plan.

The CAHPS addresses several care components including:

1. Primary care experiences,
2. Getting health care from a specialist,
3. General health care experiences in the 12 months preceding the
interview,
4. Need for and use of interpreter services,
5. Dental care,
6. A special module for those with special needs that include
questions about home care and other specialized services,
7. Prescription medication use and satisfaction, and
8. Transportation concerns when obtaining health care.

These content areas are addressed in the following sections.

Respondents were asked to rate their usual care provider on a scale
from 0 to 10, with 0 being the worst doctor or nurse possible, and 10
being the best doctor or nurse possible. The mean overall ratings
ranged from 9.1 for HMO respondents to 9.0 for Medipass only
respondents to 9.2 for Medipass choice respondents**.

Fifty-six percent of HMO respondents, 57% of Medipass only
respondents, and 61% of MediPass choice respondents report having
sought routine care in the 12 months previous to interview. About two-
thirds (61% in HMO, 68% in MediPass only, and 66% in Medipass choice*)
of parents reported that they "always" got an appointment for such
care as soon as they wanted.

Approximately 33% of those surveyed reported seeking care for an
illness or injury in the 12 months preceding interview. This figure differed
slightly between the three groups, with the 29% of those in the HMO
group reporting they sought such care, compared to 39% of the
MediPass only group and 41% of the Medipass choice group. A large
majority in all groups (75% for HMO, 71% for MediPass only, and 75% for
Medipass choice) reported that they "always" got this care as soon as
they wanted.


Florida KidCare Evaluation Series, Year 5 DRAFT 17
Medicaid: HMO and Medipass









Getting Care
From a
Specialist


General
Health Care
Experiences


A substantial percentage of children needed to see a specialist at
some time in the 12 months preceding the interview. Overall, 27% of
respondents reported that their child needed to see a specialist. HMO
and Medipass choice respondents were more likely than Medipass only
respondents to report that their child needed to see a specialist, with
rates of 28%, 28%, and 26%, respectively.

Most respondents (77%) reported that it was "not a problem" to get a
referral for specialty care for their child. Among HMO enrollees, 75%
reported it was "not a problem" to get a referral while 80% of MediPass
only and 86% of Medipass choice enrollees reported thus. Twelve
percent of HMO enrollees, 8% of Medipass choice enrollees, and 11% of
Medipass only enrollees reported that it was "a big problem" to get a
referral.

After receiving a referral, most respondents did not have problems
actually seeing a specialist. Seventy-five percent of all respondents
reported that it was not a problem to see a specialist. There were no
significant differences by program. Only 13% of HMO parents reporting
a big problem seeing a specialist; a similar share of Medipass only and
Medipass choice parents (15% and 14%, respectively) reported big
problems seeing a specialist.

When asked to rate their specialist physician on a 0 to 10 scale like that
used for the Primary Care Provider (PCP), Medipass choice respondents
rated specialty care at 9.1, higher than the 8.7 rating provided by
Medipass only respondents and the 8.6 rating provided by HMO
respondents**.

The CAHPS contains many questions that measure families' satisfaction
with the overall provision of care their child receives from Medicaid.
Items include measures of wait times, conduct of doctor's office staff,
and whether their primary care provider (PCP) treats them with
courtesy and respect. The HMO and MediPass programs performed
similarly in most of these areas.

Eighty-five percent of respondents reported that it was "not a problem"
to get needed care for their child in Medicaid, while 8% reported it was
"a small problem" and 6% indicated it was "a big problem". There were
significant variations by program component. Ninety percent of
Medipass only respondents did not have a problem getting needed
care compared to 85% of Medipass choice and 84% of HMO parents*.

Sixty percent of families reported that they did not experience delays in
getting plan approval from Medicaid. About a quarter (28%) percent of
parents reported that waiting for plan approval was a small problem,
while 12% of parents reported the delays as being a big problem. There
were no significant variations in delays by program component, but


Florida KidCare Evaluation Series, Year 5 DRAFT 18
Medicaid: HMO and Medipass









there was a large decline in the share of parents from the prior year
(89%) who did not have problems with plan approval.

Enrollees were generally positive regarding their experiences with their
child's doctor and office staff. Eighty-four percent reported that they
were "always" treated with courtesy and respect at their child's
doctor's office, and three-quarters of respondents reported that the
staff at their child's doctor's office was "always" as helpful as they
would like. Eighty-one percent of respondents indicated they their
child's primary care provider "always" listened carefully to them, and
84% reported that their child's doctor "always" explained things in a
way they could understand. Sixty-six percent of enrollees surveyed
indicated that they felt their child's PCP "always" spent enough time
with their child (see Table 3).


Table 3. Medicaid Enrollees' Satisfaction with Their Child's Doctor and Office Staff in Past Year
Never Sometime Usually Always
s
Parent treated with courtesy and respect by PCP's 1 7 7
1.5% 7.0% 7.9% 83.6%
office staff
PCP's office staff was helpful 2.9% 9.7% 12.1% 75.4%
PCP listened carefully 1.7% 7.4% 9.6% 81.3%
PCP explained things so parent could understand 4.7% 4.3% 7.4% 83.7%
PCP explained things so child could understand 8.4% 7.5% 10.3% 73.8%
PCP spent enough time with child 5.6% 13.6% 14.6% 66.3%

When asked if their child's doctor's office kept their appointment
schedule, however, caregivers were substantially less satisfied (see
Figure 7). Only 20% of caregivers reported their child was always taken
to the exam room within 15 minutes of the appointment time.

Figure 7. Percent of Enrollees Taken to Exam Room within 15 Minutes of
Appointment Time

40%
35%
30%
25%
20%--


10%
5%
0%
Never Sometimes Usually Always

O HMO U MediPass only U Medipass choice


Florida KidCare Evaluation Series, Year 5 DRAFT 19
Medicaid: HMO and Medipass











Health Plan
Customer
Service


Summary


Overall, 24% of the respondents had called their health plan customer
service number for assistance. Only 16% of Medipass only and 19% of
Medipass choice respondents called, but a larger share (28%) of HMO
respondents called*.


Among those who had called customer service, 62% of Medipass
choice respondents reported that it was "not a problem" to get
information or help from the customer service representative, slightly
less than for parents of HMO and Medipass only enrollees (71% and 66%,
respectively). Additionally, a majority of parents reported that the
health plan paperwork was not a problem (75% of HMO, 77% of
Medipass only, and 81% of Medipass choice).

On a scale of zero (worst) to ten (best), customer service was rated 8.7
overall. There was little variation by program, as HMO parents gave
customer service a 8.6, Medipass only rated the service 8.7, and
Medipass choice rated it 8.8.

Enrollees in both the Medicaid HMO group and the MediPass group are
very satisfied with the care they receive through Medicaid (see Figure
8).












VII. Dental Care


Background







Frequency of
Dental Visits


Satisfaction


Parents of children who were one year of age or older were asked
about their child's dental care prior to interview. In the Year 5 KidCare
evaluation, dental care was the most frequently mentioned unmet
need. Prior to enrollment in KidCare, only 64% of children who needed
to see a dentist actually had that visit, compared to 84% after enrolling
in KidCare.3

About half (49%) of 2003 enrollees saw a dentist in the 12 months prior to
the interview. Similarly, 50% of enrollees saw a dentist in 2002 and 46%
saw a dentist in 2001. There was no variation by program, with 49% of
HMO and Medipass choice enrollees and 50% of Medipass only
enrollees having one or more dental visits in the year prior to interview.

Of the families whose child did have a dental visit, 33% reported that
their child saw a dentist one time during the previous 12 months and
37% reported the child had 2 dental visits during that time. Another 14%
reported their child had 3 visits in the previous year, while 6% reported 4
visits. The remaining 10% reported that they had 5 or more dental visits.

When asked to rate their dental care on a scale of zero (worst) to ten
(best care possible), enrollees in all three program components rated
dental care equally high. The means were almost identical for the three
program components, 8.8 for HMO enrollees, 8.7 for Medipass only
enrollees, and 8.6 for Medipass choice enrollees.


3 The figure on dental care prior to enrollment is based on data collected from the New Enrollee survey
for Medicaid (single-page application) enrollees. Data on experiences since joining KidCare was
calculated from the Established Enrollee data for Medicaid enrollees; this data source is used extensively
for this report.

Florida KidCare Evaluation Series, Year 5 DRAFT 21
Medicaid: HMO and Medipass











VII. Compliance with Preventive Care Guidelines


Well-Child
Visit
Compliance


Immunization
Compliance


The American Academy of Pediatrics (AAP) and others have
established guidelines for the appropriate number of well child visits. In
general, beginning at two years of age, children are expected to have
annual well child visits. There is a brief span in late childhood when visits
are scheduled every other year. Prior to two years of age, multiple visits
are recommended at predetermined intervals. Parents were asked how
many preventive care visits their children had in the preceding year.
This information was used to assess compliance with well-child visit
guidelines for those two years of age and older.

The vast majority of those surveyed with children over 2 years of age
were compliant with AAP well-child visit guidelines. About ninety-seven
percent of Medicaid enrollees were compliant and there not significant
differences by program component.


Parent report was used to assess compliance with the AAP's
recommendations for childhood immunizations. The reader should
exercise caution when interpreting data based on parent report, given
that survey respondents may make errors in reporting the services their
child has received. Another consideration in interpreting these data is
the fact that children in Florida who attend school are required to
prove they are compliant with AAP guidelines before they can enroll.
Thus, the vast majority of school-aged children must be compliant,
though their parent may not report this during the interview.

Medicaid enrollees were in compliance with AAP guidelines in the vast
majority of cases (see Table 4). There were no substantial differences
between compliance rates of HMO enrollees and MediPass enrollees.
The reader will notice that compliance for the Pneumococcus vaccine
is markedly lower than that for the other vaccines. This may be due to
the fact that the Pneumococcus vaccine recommendation was new
for 2001. Thus, at the time these surveys were completed, some children
may not yet have visited their health care provider to receive this
vaccine.


Florida KidCare Evaluation Series, Year 5 DRAFT 22
Medicaid: HMO and Medipass











Table 4. Medicaid Enrollees' Compliance with AAP Immunization
Guidelines

HMO Medipass Medipass
% compliant only choice
% compliant % compliant
DTP 78.4 78.6 82.2
Polio 67.5 69.3 69.3
HIB 50.7 52.6 51.3
MMR** 91.6 92.4 95.1
Hepatitis B 69.3 73.3 74.6
Varicella 94.7 91.5 94.7
Tetanus Booster** 97.5 99.5 99.5
Pneumococcus 24.6 36.8 24.7

Note: The Pneumococcus vaccine was not part of the AAP
recommendations until January, 2001.


Florida KidCare Evaluation Series, Year 5 DRAFT 23
Medicaid: HMO and Medipass










VIII. Access to Employer-Provided Insurance Coverage


Background






Findings


As part of the program evaluation, parental access to insurance
coverage through their employer was measured. The original
intent of the KidCare insurance was to cover children without
access to insurance. A substitution effect occurs when parents
enroll their children in publicly-funded insurance even though
they have access to employer-provided family insurance.

A small proportion of all parents have access to family
coverage at their place of work. About 12% of Medipass only
parents, 13% Medipass choice parents, and 13% of HMO parents
are eligible to enroll their children in an employer-provided
family insurance plan (see Table 5). About six percent of parents
in each of the three program components have access to
individual coverage through their employer, but not family
coverage. More than seventy percent of all parents did not
have access to employer-provided coverage for their children
because they are not employed, their employer does not offer
any coverage, or they are ineligible for whatever coverage is
offered.


Table 5: Access to Employer-Provided Insurance for Parents of Medicaid Enrollees

%of
Characteristics of Establis hed N Total
Total number of parents enumerated by the survey, 162,16 100.0
Yes, family coverage is available to the parent through their employer. This
out for parents of Established Enrollees in 21,877 13.4
No, only employee coverage is available to the parent through their 10,72 6.6
Number of parents who are not employed or their employer does not offer
ineligible for employer-provided coverage; they are ineligible to respond 118,83 73.2
Number of parents who did not respond to the item; their eligilibity for this 10,72 6.6

Total number of parents enumerated by the survey, 46,46 100.0
Yes, family coverage is available to the parent through their employer. This
out for parents of Established Enrollees in MediPass in counties 5,63, 12.1
No, only employee coverage is available to the parent through their 3,07 6.6
Number of parents who are not employed or their employer does not offer
ineligible for employer-provided coverage; they are ineligible to respond 33,53 72.1
Number of parents who did not respond to the item; their eligilibity for this 4,22z 9.05

Total number of parents enumerated by the survey, MediPass 36,46 100.0
Yes, family coverage is available to the parent through their employer. This
out for parents of Established Enrollees in MediPass in 4,63j 12.7
No, only employee coverage is available to the parent through their 2,16- 5.9;
Number of parents who are not employed or their employer does not offer
ineligible for employer-provided coverage; they are ineligible to respond 26,88 73.7
Number of parents who did not respond to the item; their eligilibity for this 2.78 7,6

Florida KidCare Evaluation Series, Year 5 DRAFT 24
Medicaid: HMO and Medipass









IX. Summary and Conclusions

Summary Medicaid enrollees in both managed care programs generally
report a high level of satisfaction with the Medicaid program.
Enrollees are generally compliant with preventive care
guidelines. Access to other insurance coverage is very low.

Significant differences between the HMO and Medicaid
populations are found in the following areas:

Demographic and socioeconomic composition
There are significant differences in the age distribution
and racial-ethnic compositions of the Medipass enrollee
population and the HMO enrollee population. HMO
enrollees are significantly younger than Medipass
enrollees. Non-Hispanic whites comprise a slight majority
(59%) of the Medipass only population and 60% of the
Medipass choice population. There is no majority racial
group among the HMO enrollees; the population is split
evenly among Hispanic (33%), black non-Hispanic (32%),
and white non-Hispanic (32%). Black non-Hispanic
enrollees comprise 23% of the Medipass only population
and 24% of the Medipass choice population. There were
also significant differences in the primary language
spoken at home by parents, with seventy percent of
HMO parents speaking English, compared to larger
shares of Medipass only parents (87%) and Medipass
choice parents (93%) speaking English. Household
incomes varied across programs as well; thirty-five of
HMO respondents reported household incomes of less
than ten thousand dollars compared with 30% for the two
Medipass groups.


Number of Children with Special Health Care Needs
The MediPass program has a higher percentage of
enrollees with special health care needs than the HMO
program. This finding is not surprising given that extensive
literature has documented that CSHCN are more likely to
be enrolled in fee for service arrangements than in HMOs.


Satisfaction with Care
Although all three groups rated their primary care
providers very highly, there were variations in ratings for
specialist care. Medipass choice respondents rated their
specialist care more highly than HMO or Medipass only
respondents. In general, 90% of Medipass only

Florida KidCare Evaluation Series, Year 5 DRAFT 25
Medicaid: HMO and Medipass









respondents did not have a problem getting health care
for their children, compared to 85% of Medipass choice
respondents and 84% of HMO parents. Larger shares of
HMO enrollees had called their health plan than
Medipass enrollees.


*Well-Child Care
There were significant differences between the Medicaid
program components in compliance with immunization
guidelines for MMR and Tetanus Booster.


Overall, the Medicaid managed care programs perform
comparably. Differences between the programs may be
attributable to race and ethnicity differences, as research has
shown that these attributes effect perception of and satisfaction
with health plans. Further research is needed to determine
what, if any, effect these factors have in this case.


Florida KidCare Evaluation Series, Year 5 DRAFT 26
Medicaid: HMO and Medipass










Appendix A: Medicaid Managed Care Choices by County, October 2003


MediPass only


Alachua
Baker
Bay
Bradford
Charlotte
Collier
Columbia
Desoto
Dixie
Flagler
Franklin
Gilchrist
Glades
Gulf
Hamilton
Hardee
Holmes
Indian River
Jackson
Lafayette
Levy
Monroe
Nassau
Okaloosa
Okeechobee
St. Johns
St. Lucie
Sumter
Suwannee
Taylor
Union
Walton
Washington


Choice of HMO
or MediPass

Brevard
Calhoun
Citrus
Clay
Duval
Escambia
Gadsden
Hendry
Hernando
Highlands
Hillsborough
Jefferson
Lake
Lee
Leon
Liberty
Madison
Manatee
Marion
Martin
Orange
Osceola
Palm Beach
Pasco
Pinellas
Polk
Putnam
Santa Rosa
Sarasota
Seminole
Volusia
Wakulla


Choice of HMO,
MediPass, or PSN

Broward
Miami-Dade


Florida KidCare Evaluation Series, Year 5 DRAFT 27
Medicaid: HMO and Medipass




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