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Title: Florida Medicaid MediPass Program : current issues
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Title: Florida Medicaid MediPass Program : current issues
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The Florida Medicaid MediPass Program: Current Issues


Allyson Hall, PhD
Catherine Aftuck, MHA
Christy Harris Lemak, PhD


Florida Center for Medicaid & the Uninsured
College of Public Health and Health Professions
University of Florida
352/273-5059


Sponsored by
The Agency for Health Care Administration


Florida Center for Medicaid and the Uninsured
Shaping a Heal care a Po icy


June, 2004















TABLE OF CONTENTS

E X E C U TIV E SU M M A R Y ...................................................................... .................... 2
M E T H O D S ...................................................... 5
F IN D IN G S ................................................................................................... . . 6
M ediPass O operations ................................. ......................... 7
Area Office Responsibilities .......... ..... ................ ....... .............. 7
B eneficiary A ssignm ent...................................................................... ................... 8
C redentialing ....................... .............................................................. ............. 9
Disease Management Organizations .................................................................. 10
Provider A iri ............. ................................. .................. ............. 12
Provider Performance .. .... ................................................... .............. 12
Com m unication i Providers ........................................................................... 13
Q quality A assurance ............................................................................. 14
O outreach to Beneficiaries ......................................................... .............. 15
P h ys ic ia n N etw o rk ............................ ................................ 15
Primary Care Physicians........... ......... ................. .............. 15
Case M anagem ent F ee......... ..................................................................... 17
Specialty Physicians............... ..... .... ........ .................. ... ..... ..... 18
P patient Iss ues ............................. .............. ...... 19
Continuity of Care. ........... .................. .......................... 19
S a tisf a c tio n ............................................ .............................. 2 0
Impact of MediPass Demonstration Programs .............. ...................... 22
W ere they Successful? ........... .. ..... .. ... ........................................ ................ .. 22
Demonstration Program Expansion Considerations.............................................. 23
SU M M ARY AN D CON CLU SION S ............................................................................... 24
APPENDIX I: PROTOCOL FOR AREA OFFICE INTERVIEWS ............................. 25
APPENDIX II: PROTOCOL FOR PROVIDER INTERVIEWS.................................. 29















1












EXECUTIVE SUMMARY


This paper is one of three reports that examine specific aspects of the
Florida MediPass program. It summarizes findings from interviews with MediPass
primary care providers and AHCA area office staff on program operations,
including physician and specialty network capacity, patient issues, and the
impact of the pilot programs in South Florida. Providers and staff were asked to
provide recommendations on improving the program. A second report provides
results from the annual Consumer Assessment of Health Plan Survey. A third
report examines the PCP network throughout the state.
Medicaid and MediPass are recognized as critical components of the
healthcare safety net. As such, there was strong support from both providers and
AHCA staff for the program. However, a number of important concerns emerged.
These included:
The unavailability of certain kinds of specialty care within specific regions;
The adequacy and appropriateness of the $3 per member per month
management fee;
Confusion on the role of disease management organizations in patient
care; and
The need to streamline and make more efficient certain operational
procedures such as credentialing and referral authorizations.


Changes to MediPass, however, must occur within the context of finding
solutions to escalating Medicaid costs. Previous evaluations concluded that
MediPass did appear to be controlling costs and utilization. However, since 1998,
the Medicaid budget has grown by about $5.6 billion, or 79 percent. The 2004 -
2005 Medicaid budget is projected to be 13.8 billion, or almost 25 percent of the
state budget. Thus, although MediPass appears to be adequately meeting the









needs of the patients, it currently appears to be less successful at controlling
costs.


Initial analysis has shown that the Minority Physician Network and Provider
Service Network demonstration programs have been somewhat successful in
reducing costs associated with caring for MediPass beneficiaries. Cost savings in
the demonstration programs seemed to be realized through reduction in the
utilization of services relative to MediPass because fewer enrollees used
services. The strong disease management components associated with each of
these programs are more than likely a major reason for the reduction in cost.









INTRODUCTION


MediPass was established in 1991 as a primary care case management
program designed to provide Florida Medicaid recipients with access to adequate
primary care. Since its inception, the program's core element has remained
essentially unchanged. Recipients select, or are assigned, a primary care
provider who manages and coordinates all aspects of that beneficiary's care. The
physician is contracted to provide, to assigned beneficiaries, primary care
services, 24-hour access to health care, and referral and authorization for
specialty and hospital services. In return, the primary care provider receives a $3
per member per month case management fee in addition to reimbursement for
the provision of Medicaid services.


Since 1991 MediPass has grown significantly. The state of Florida
mandates that individuals in certain eligibility categories, Temporary Assistance
to Needy Families (TANF) and Supplemental Security Income without Medicare,
enroll in managed care. As a result, in April 2004, about 50 percent of managed
care eligible beneficiaries, over 700,000, are in MediPass. The other 50 percent
are enrolled in HMOs. In response to increasing expenditures, MediPass has
been subject to a number of policy changes designed to make the program more
efficient. Some notable changes include the implementation of various disease
management programs, the introduction of a preferred drug program, and the
implementation of various pilot programs in South Florida designed to generate
cost savings while ensuring high quality care.


The Agency for Health Care Administration (AHCA) periodically examines
MediPass in order to assess the extent to which the program is meeting its goals
and objectives. This year, AHCA contracted with the Florida Center for Medicaid
and the Uninsured to conduct satisfaction surveys of MediPass beneficiaries, to
assess the capacity of the existing primary care physician network, to interview
providers about their experiences with the program, and to interview agency staff









about program structure and administration. Both providers and area office staff
were asked to make recommendations to improve the program.


This report summarizes findings from interviews with providers and area
office staff. Two other accompanying reports present findings from the
beneficiary satisfaction survey and the assessment of the primary care physician
capacity.1


METHODS

The research team interviewed MediPass staff at seven AHCA area
offices. The intention of the interviews was to learn about programmatic and
policy changes, administrative challenges associated with the program, and
recommendations for further changes. The list of questions that were used for
the area office interviews are listed in Appendix I. The questions included issues
related to the primary care physician (PCP) network, continuity of care, provider
profiling, beneficiaries, credentialing, case management, specialty care network,
and disease management organizations (DMOs).


Provider offices with a high volume of MediPass patients throughout the
state were selected and contacted for interviews. Physicians or their office
managers answered questions about the office's experience with MediPass,
including issues related to patients, provider procedures, and continuity of care.
A total of 18 in-person or telephone interviews were conducted with providers
throughout the state. One interview was with a health department, six were with
pediatricians' offices, and the remaining eight were with general/family/internal
medicine practice offices. Appendix II contains the office interview protocol.





1 See Hall et al, MediPass Primary Care Physician Network Analysis: Preliminary F,,. iI,i, June 2004 and
Steingraber at el Comparing Satisfaction with Care among MediPass and HMO enrollees in South Florida
June, 2004









FINDINGS


A common theme that emerged throughout the interviews was the value
and importance of Medicaid and the MediPass program in ensuring access to
health care for low-income populations. While MediPass providers and staff
addressed various operational concerns, most of those interviewed expressed a
strong commitment to the program and its patients. For example, many of the
provider offices indicated that their mission was to serve low-income vulnerable
populations, and area offices noted that Medicaid and MediPass exist to serve as
a healthcare safety net for these populations.


"We have a social mission, one of advocacy for sick low-income people."
Physician Office Manager


The program appears to be meeting the needs of its patients, particularly
in terms of assuring that there is an adequate primary care physician network
(although there are a few geographic areas of concern) and overall patient
satisfaction with the program. However, the unavailability of certain kinds of
specialist physicians, confusion about the role of disease management
organizations, and the adequacy and appropriateness of the $3 case
management fee were some of the major concerns among providers and AHCA
personnel. In addition, the overall positive view on the role of MediPass must be
observed within the context of increasing costs associated with the Medicaid
program. Florida spends roughly one quarter of its budget on the Medicaid
program, and costs are expected to continue to grow. As currently configured,
MediPass's ability to curtail costs appear limited.









MediPass Operations


Area Office Responsibilities

The duties of the local office were similar across the state. The responsibilities
included physician recruitment and credentialing, physician training, quality
assurance, and outreach to beneficiaries.


Most offices felt that the roles of the area office were clearly defined and
communicated. The area offices defined the responsibility of the head office as
developing policy and oversight of area offices. These area offices call the head
office when necessary, for questions they have or the clarification of certain
policies. One area office noted that they recently received a handbook from the
head office. However, they had not received a previous updated handbook since
1996.


Area Office Recommendation: The Agency needs to develop standard rules
and regulations for the basic responsibilities of the program. Not all area offices
do things the same way. Send periodic updates of the area office manual.


Most area offices felt that there were not enough people to do the large
amount of work. MediPass-related staffing was not sufficient to support the
program. Some area offices have had to hire contract workers. While this is
helpful in reducing workload, it is not the most optimal solution to the program
since contracted workers are often not committed to program's mission and area
office employees have a "more hands-on feel for the community."


With the exception of credentialing, the area offices did not feel that any of
their responsibilities could be moved to the head office; the area office was more
familiar with the community and it was better to keep the jobs at this level. In
addition to familiarity with Medicaid, they were familiar with community resources
and knew whom to call if they needed any favors.

7











Area Office Recommendation: The Agency should analyze workforce capacity
at the area office level.


Area offices were concerned with the multiple databases in MediPass that
"do not talk to each other." One area office supervisor said that her office was
"forever maintaining databases," so that everyone is working from the same
thing. It was also mentioned that general communication had improved with the
head office. Several offices mentioned the monthly conference calls hosted by
the head office were extremely beneficial.


Area Office Recommendation: AHCA databases need to be simplified and
able to "talk to each other" in order to reduce the amount of time spent
maintaining them.




Beneficiary Assignment

Most area offices are responsible for auto-assignment of beneficiaries to
a managed care arrangement. Only one area office stated that they are not
responsible for auto-assignment. Once the physician is accepted into the
network, MediPass assigns the provider a maximum number of patients. The
office has the option of decreasing this number.


The assignment of beneficiaries (i.e., auto assignment) to primary care
physicians (PCPs) is similar in most of the areas. Beneficiaries have 90 days to
choose a PCP once they have enrolled in Medicaid. If they do not choose a PCP,
a mandatory assignment is made. Mandatory assignment is conducted once a
month for the pool of beneficiaries that have not selected a PCP. They are
assigned based on their geographic location (zip code matrix), age, family unit
(the area tries to keep families at the same provider), specialty, etc.









The list of MediPass patient assignments is updated once per month by
Affiliated Computer Services (ACS) Medicaid's fiscal agent, and a hard copy is
mailed to providers. Providers also can access the list via the Internet. These
monthly beneficiary enrollment lists supplied to providers are useful. Providers
mentioned that they routinely contacted patients who were unknown to them but
appeared on their beneficiary list.


Some providers expressed concern about their ability to routinely verify
patient eligibility and provider assignment. Providers can verify eligibility either by
using the services of an outside vendor (e.g., MediFax), accessing the Internet or
calling a toll-free telephone number. However, providers in small or solo
practices complained that they do not have access to the Internet and that using
the services of an outside vendor is often cost prohibitive. In addition, providers
complained that the toll-free number is frequently busy.


Area Office Recommendation: The Agency should streamline the MediPass
application process by asking providers if they are interested in MediPass up
front (i.e., when they apply to become a Medicaid provider). Time and resources
are wasted when providers have to apply for Medicaid and then MediPass.


Credentialing

The area offices are responsible for credentialing providers. This process
used to be performed by the head office in Tallahassee. For the initial
credentialing of new doctors, the doctor must submit a resume, DEA certificate,
DOH license, and proof of hospital privileges (or something showing that they
have a "buddy doctor" that will admit for them). Other factors considered when
accepting a new physician into the network include positive results from a site
visit (proper handicap parking, posted patient rights, record review, etc.), office
hours, and a National Practitioner Database inquiry. This information is then sent
to the head AHCA office.









The initial credentialing process takes approximately one month. Area
offices complained that it is a long, drawn out process that involves a lot of
paperwork. Offices would like to be able to streamline the process, but they were
unsure how to do this. Re-credentialing is done every two years and generally
area offices thought that this timeframe is adequate. However, one office
mentioned that they were looking at changing this to every three years. As a
result of re-credentialing, providers are rarely dropped from the program.
Instances in which a provider was not re-credentialed included the provider not
believing it was beneficial to be re-credentialed and a physician leaving town
without ensuring that patients had access to on-call services.


Disease Management Organizations

MediPass beneficiaries who have been diagnosed with diabetes,
HIV/AIDS, asthma, congestive heart failure, hemophilia, congestive heart failure,
and end-stage renal disease are enrolled in disease management programs. As
stipulated by the 1997 Florida legislature, the disease management program was
designed to "promote and measure: health outcomes, improved care, reduced
inpatient hospitalization, reduced emergency room visits, reduced costs, and
better educated providers and patients". The program was also to bring an
enhanced connection between the patient and the provider, thereby making a
significant impact on health outcomes and improved quality of life for patients
with chronic disease.2 The MediPass disease management program focuses
broadly on patient care management, including medical services and lifestyle
counseling for specific diseases.3 The Agency contracts with disease
management organizations (DMO) for these services.


Providers and area office staff expressed mixed views on the value of the
disease management programs to the MediPass program. Overall, it appeared

2 Agency for Health Care Administration, Disease Management
www.fdhc.state.fl.us/Medicaid/Disease Management/index.shtml, downloaded on June 21, 2004
3 Wheatley B Disease Management: Findings from Leading State Programs State Coverage Initiatives,
Vol. III (3) December 2002









as if there were a lack of knowledge on the precise role of the DMO in patient
care. Providers recalled that they received lists indicating which of their patients
were enrolled in a DMO. However, several of the providers said that neither they
nor their patients could recall any encounter with a DMO caseworker. Physicians
recalled receiving very little educational materials or other programmatic
information from the DMOs. One physician's office mentioned that it is confusing
to elderly patients when they receive communication from both their DMO and
MediPass.


Providers that did have some experience with the disease management
programs acknowledged that the program seemed to enhance patient
satisfaction, but there was no evidence that the overall quality of care had
improved. Finally, providers questioned why "outsiders" are necessary in the
management of their patients. These providers felt that they could "manage their
own patients." They viewed disease management as a duplicated effort that was
expensive and time consuming.


Area offices believed that DMOs added to the overall "confusion" of
MediPass for providers. One area office was particularly concerned that the
DMOs may not understand that MediPass patients are often "hard to reach and
were difficult to serve," and that significant resources were needed to meet their
needs. In addition, area offices were concerned that patients appeared to be
arbitrarily assigned to a DMO, often without a clear demonstration of need. Area
offices reported not seeing any measurable changes as a result of DMOs,
although they could recount anecdotal stories of patients who have benefited
from the program.


There was also some concern among area offices about providing DMO
case workers with relevant medical documents. This confusion was intensified
with the implementation of the Health Insurance Portability and Accountability Act
of 1996 (HIPAA).










Area Office Recommendation: The roles of DMOs need to be better defined
and communicated to both providers and beneficiaries. Policies should be
established and DMOs should somehow be included in the initial MediPass
training.


Provider Authorizations

Specialists and other providers must seek authorization from the PCP in
order to be reimbursed for services delivered to a PCP's patient. Several provider
offices complained about the time involved in the authorization process. It was
time consuming and in some instances, an additional employee had to be hired
to handle authorizations. This was of particular concern to the health department.
Large numbers of people seek STD, HIV, and family planning services from the
health department because they did not wish to be seen by their regular PCP.
Hence, the health department has to seek authorization from the PCP for a large
percentage of their patient visits.


Doctors mentioned that they themselves were not involved in the
authorization process-consequently it had evolved into a system of office clerks
simply "exchanging authorization numbers." As such, the role of the PCP in
monitoring utilization has become relatively minor. One doctor mentioned that he
received calls from other providers requesting his authorization number for
approval of services for patients he did not know or for services he did not
request.


Provider Performance

Area offices reported that the fiscal intermediary, ACS, develops utilization
reports that are mailed to providers. These reports compare physicians'
performances to their "peer group." Some area offices also received more
detailed reports that enabled them to identify over- and under-utilizers.











Although some offices were familiar with profiles they received from other
health plans, very few office managers or physicians recalled receiving reports
from ACS or MediPass. Among those who did, none found the reports
particularly useful or meaningful. In particular they were concerned about
whether the comparisons with the peer group were appropriate. The "o" (for over
some threshold or relative to their peers) and "u" (for under some threshold or
relative to their peers) indications provided no sense of how much they differed
from their peers and why. When asked about the kinds of information they would
want to have on a profile, most mentioned that pharmaceutical/drug utilization
information would be very important.


In South Florida, several of the physicians reported being in MediPass for
one office and in one of the pilot programs in another location.4 When asked
about performance reports, these physicians spoke favorably of the reports
supplied by the minority physician network pilot programs. These reports alerted
providers to patients who may be seeing other physicians, who may have been
hospitalized, or who may be on medications not prescribed by the PCP.


Communication with Providers

The level of communication between area offices and providers appears
to vary by area. Both physicians and staff in areas with small numbers of
providers have more ongoing telephone contact with each other relative to areas
with a large number of providers. Physician contact with area offices in larger
areas seems to be limited to specific problem solving, quality control, and general
training activities. For example, in one area with several PCPs, providers were
visited only once every two years. In contrast, one office manager in an area with
a small number of providers reported that she is on a first-name basis with her
area office and that she "loves them to death." But, overall, most providers

4 In one location, a provider appeared to be both in MediPass and the MPN pilot program. It was unclear
whether the MediPass number was retained exclusively for patients in disease management programs
13









indicated that they have relatively little interaction with the area offices and it was
usually via telephone. However, when they needed to communicate with the area
offices, they generally had no problems. Other forms of communication included
mail-outs (e.g., outreach materials and invitations to training) and quarterly
newsletters that inform providers of training and changes in the program.


All of the area offices have similar procedures for training providers. They
all provide on-site training for new providers. In one area, monthly training were
held at the area office and were mandatory for new providers. If it seemed that a
provider was not doing what they were supposed to do, the area office required
that the provider participate in additional training.


Area Office Recommendation: The Agency needs to continue and perhaps
improve its communication efforts to ensure that beneficiaries and providers are
receiving correct information and have a strong understanding of how the
MediPass program operates. Training of participating specialty physicians in
MediPass billing practices is particularly important since this group tends to have
a higher rates of claims denials. Additional training on billing has the potential to
lead to less physician dropout and more new physicians entering the program.


Quality Assurance

A number of area offices are involved in quality assurance activities. For
example, in one office each month 10 providers are selected for in-depth
reviews. These providers are selected based on their performance and are
generally outliers. Selected physician offices are requested to pull certain charts,
which are mailed to the area office. If nurse reviewers detect a problem,
providers are asked to send a letter documenting how they intend to correct the
problem. The area offices will then follow-up periodically to ensure that corrective
action has been taken. This office also conducts periodic checks to ensure that
offices provide 24-hour access to their patients. This periodic check generally









begins within 30 days after a provider has been accepted into the network. The
area office will call after hours to see if the doctor responds within 30 minutes. If
the doctor fails to comply, they will check the doctor again within three months.
The area office reports that only about five percent of the physicians fail the
access test. However, among physicians participating in the Minority Physician
Network pilot program, the percentage of providers failing the access test is
much higher.


Outreach to Beneficiaries

Area offices conducted a great deal of community outreach programs to
teach patients about the MediPass program. However, there was a general
sense that patients did not understand the program. This problem stemmed from
many different sources: patients did not receive or read communication mailed to
them from area offices and the Department of Children and Families (DCF), and
physician offices provided a great deal of misinformation. As one area office
staffer stated, "The only people that understand Medicaid is Medicaid" and "this
is why all inquires about the program should be directed to Medicaid offices".


Physician Network

Primary Care Physicians

Area office coordinators generally felt that the sizes of the PCP network in
their areas are adequate. However, many stated that within their jurisdiction there
are areas that are problematic and could use more PCPs. Munroe County,
located in South Florida, has a shortage of primary care physicians, mostly
because the cost of living is high and doctors report that they cannot afford to
practice there. Consequently, the area office proactively recruits providers in
Munroe County, but not in any other part of their area. Volusia and Flagler
Counties also do not have an adequate network size. This is especially









problematic in Flagler County because it is one of the fastest growing counties in
the state, but currently has only two PCP providers with open panels.5


Although most providers do not place caps on enrollment, they are
allowed to and often do place limits on the kinds of patients they see (e.g.,
children or women only). As a result, composition of the PCP network varies from
area to area. Therefore, while the overall number of PCPs may appear adequate,
certain segments of the population may not have quality access to a provider.
For example, in one area, older patients have difficulty finding a PCP because
most of the providers have decided to only accept children. Some areas stated
that the majority of the network's doctors are pediatricians and others said that
they lack pediatricians and the majority of the network is family practice. One
provider's office did report that they had to stop taking new MediPass patients
because of its inability to handle the volume. This office was the only pediatrician
in that area that accepted MediPass and had become overwhelmed.


Reasons for PCP shortages in other areas included disenrollment due to
dissatisfaction with reimbursement and problems with billing and authorization. In
the northeastern region of Florida, one area office cited recent malpractice
insurance difficulties as a cause of physicians dropping from the network. With
rising premiums, providers reported that they were no longer able to afford
malpractice insurance. Not having malpractice insurance could affect their
credentialing status. Providers also left the network because they had retired or
had moved from the area. However, discussions with office staff revealed that
there does not seem to be a significant amount of physician turnover throughout
the state. Physicians tend to remain loyal to the Medicaid program. When a
physician drops from the network, another physician is usually added, and overall
the network remains balanced.




5 See Hall et al MediPass Primary Care Network Analysis: Preliminary F,,. I,,1 i. June 2004
16









The area offices offered several reasons why physicians joined the
network. These included trying to build up their practice (i.e., new practices), the
$3 per member per month (PMPM) case management fee as an incentive, and
legitimately wanting to assist Medicaid patients and make a difference.


Case Management Fee

Providers who participate as PCPs are required to agree to provide
primary care services, referrals for specialty care, follow the results of the
referral, and maintain overall responsibility for the health of the beneficiaries on
their panel. Specific responsibilities include contacting new enrollees to arrange
for an initial preventive screening appointment, maintain patient records, and to
provide 24-hour coverage. In return providers receive a $3 case management fee
in addition to fee for service reimbursement.


Views on the adequacy of the case management fee are mixed. Some
providers and area office staff thought the fee is sufficient and should not be
increased or decreased. Others maintained that some upward adjustment is
needed, especially if the provider has a large number of chronically ill patients or
is in a rural area. Several physicians noted that the $3 fee does not sufficiently
cover the patient case management services they are expected to provide. As
one physician office manager noted, "It isn't even close enough to cover all of the
work involved." Another commented that their office was "giving all it has got to
support the patients and $3 was not enough to cover this." These comments
were heard mostly at physician practices where the largest proportions of
patients were on MediPass.


Area offices were concerned that many physicians do not appropriately
manage their patients and therefore should not be eligible for a case
management fee. They argued that MediPass does very little to hold physicians
accountable for ensuring that appropriate case management and primary care
services are delivered.



















Specialty Physicians

Access to specialty care is a problem statewide. Every area stated that
more specialists are needed. However, the extent of the problems varies
considerably across the state. Not all specialties are uniformly unavailable
throughout the state. In general, specialties that are problematic include:
orthodontics, dermatology, neurology, dental, orthopedics, ENT, oral surgery,
and pain management. In one area, there are only two orthodontists for the
seven counties. Patients that are able to secure a specialist appointment are
often placed on long wait lists. Area offices were quick to point out that they did
not believe that PCPs were referring heavily to specialists.


In getting patients appointments with specialists, both area offices and
providers rely on established relationships. Providers rely on professional
relationships developed with other privately insured patients in establishing
specialist contacts for their Medicaid patients. One provider noted that he would
refer a Medicaid patient to a specialist only if he had referred at least five
privately insured patients to that provider. AHCA staff said that they "begged and
pleaded" when necessary. They also called other area offices for the names of
specialty providers. Area offices with established relationships with some
providers in specialty offices are careful not to bombard one office with too many
MediPass patients.


Often patients must be transported great distances to receive specialty
care. Travel distance is especially problematic when patients have to return for


Area Office Recommendation: The monthly fee paid to participating providers
should be performance based. Physicians who meet some pre-established
performance criteria would receive a higher case management fee.









follow-up appointments. One area office mentioned that it was bothersome that a
doctor could be paid $35, but instead MediPass spent $110 to transport patients
to another area. The money is expended, but in the wrong place. Physicians'
offices reported that patients may have to pay out of pocket if MediPass specialty
providers are unavailable in their area. Alternatively, patients may go through
emergency rooms to obtain needed care. Specialists that do accept MediPass
patients generally have a two- to three-month wait time for an appointment.


The problem with access to specialty care was referred to as a "crisis."
Area offices and physicians speculate that the reimbursement offered by
MediPass to specialists is not sufficient. Additionally, specialists do not like the
paperwork (claims and billing) involved with the program and often find the
patients "difficult to manage." These issues are generally beyond the control of
area offices. One staff member noted, "Specialty care is there; we just can't
access it." The few specialists that initially agree to accept MediPass patients are
often left with no choice but to refuse new MediPass patients because their
practices are at capacity levels.


Area Office Recommendation: The Agency should consider the feasibility of
setting standards for the specialty care network and actively recruiting to meet
these standards. An analysis needs to be conducted to understand how to
encourage specialist participation in the MediPass program.


Patient Issues

Continuity of Care

Overall, the area offices felt that seeing the same provider every time and
having continuity of care was important. One response was that continuity of care
was what "MediPass is for." One area office staff member stated that MediPass
provides a great advantage in terms of continuity compared to the old fee-for-
service Medicaid because "it puts someone in charge of the patient."










Area offices reported that "doctor shopping" appears to be on the decline
because very few beneficiaries change providers unless something drastic
happens or unless the patient is trying to hide something.


Doctor's offices complained that mandatory assignments can disrupt
continuity. Patients fail to select their original PCP upon reenrollment in the
Medicaid program. These patients are then assigned to another provider by the
area office. One office mentioned that they worked particularly hard at making
sure their existing patients were reassigned to them upon re-enrollment in
Medicaid.


Within large group practices, most offices make an effort to assign a
specific physician who sees the patient at each visit. Providers feel that this is
important because it creates a better line of communication between the patient
and provider. There are some cases (i.e., group practices) in which the patient is
not assigned to an individual doctor within the group. Some reasons for this
included shorter waiting times for the patient and familiarizing patients with each
of the doctors in the office. In these instances, patients who were assigned to the
group see different doctors, physicians assistants, or ARNPs at each visit. The
area offices may sometimes receive complaints from beneficiaries if they are not
seeing "their" physician.


Satisfaction

Providers and area office staff reported that the MediPass program is well
liked by patients. Area offices commented that many beneficiaries speak highly
of their provider and are satisfied with the care they receive. Positive comments
that the area offices receive about the program include provider accessibility,
patients can see the doctors when needed, and availability of doctors after hours.










Providers and some area offices said that beneficiaries that have been

assigned to a HMO want to return to MediPass. Recent survey findings revealed

that of 353 patients who switched managed care options within the last year, 45

percent switched from an HMO to MediPass, 22 percent switched from MediPass

to an HMO, and 33 percent switched from one HMO to another.6 Providers and

area offices said that the patients switching from MediPass to an HMO perceived

that MediPass has a better choice of primary care and specialty care provider

within the MediPass program. Survey results showed that this statement was

generally true for all beneficiaries regardless of the kind of managed care

arrangement they left (Figure 1).





Figure 1: Reasons for Switching Managed Care
Arrangement


All switchers 4 HMO to MediPass O MediPass to HMO U HMO to HMO
100 Percent of switchers
77 78 82 76
80 70 72 70
6062 64 63 56 60

40
20


A specific provider was Better overall selection Old plan too restrictive
not on old plan of providers in new plan regarding provider
choice

2004 Medicaid Switcher Survey



Negative comments heard by both area and physician's offices included

long waits to get an appointment and being assigned to the wrong provider.

Physicians' offices complained that Medicaid patients were often not compliant,

and that there were a lot of no-show appointments with this population.


6 Hall et al, MedicaidManaged Care i, ,. '. Characteristics and Reasonsfor Switching, June 2004
21









Furthermore, a few providers speculated that some Medicaid patients might
actually be ineligible for programs based on known income and available assets.


Providers' offices have developed a number of innovative ways to
enhance the services provided to their MediPass patients. One office, for
example, provided a bus that traveled into the community to collect patients and
bring them in for care. Several offices said that they used outreach workers to
locate no-show and non-compliant patients. Another office strived to prescribe
what they referred to as "simpler medication" and worked hard to get patients
involved in their treatment plans. Finally, many providers sent welcome letters to
new patients encouraging them to make an appointment.


Impact of MediPass Demonstration Programs

Several MediPass pilot programs are in operation in Miami-Dade and
Broward Counties. These pilot programs include the Provider Service Network
(PSN), the Minority Physician Networks (MPN) and the Pediatric Associates
program. The PSN and MPN programs are fairly similar in principle. Essentially,
these programs are designed to shift MediPass administrative and other
functions to third parties such as health plans and large physician group
practices (in the case of the MPN) and safety-net providers (as in the case of the
PSN). The premise is that by providing incentives, these third parties would be
encouraged to achieve cost savings for the Medicaid program. Both programs
are characterized by strong disease management or care management
components.7



Were they Successful?



SSee Duncan R. P., et al., F ,,iolar,, Florida's Medicaid Provider Service Network (i .) Demonstration
Project Summary Report, Department of Health Services Administration, University of Florida,
forthcoming, and Lemak, et al., Evaluation of Florida's Minority Physician Network Final Report, Florida
Center for Medicaid and the Uninsured, University of Florida, April 6, 2004.
22









Initial analysis has shown that the MPN and PSN innovations have been
somewhat successful in reducing costs associated with caring for MediPass
beneficiaries. Cost savings in the demonstration programs seemed to be realized
through reduction in the utilization of services relative to MediPass because
fewer enrollees used services. (However, among utilizers, expenditures were not
significantly impacted). The MPNs appear to make MediPass better by (1)
offering providers timely beneficiary utilization and (2) by managing the networks
at a local level.


Demonstration Program Expansion Considerations

These programs have had important consequences for MediPass in South
Florida. First, by definition, these programs exclude several categories of
Medicaid beneficiaries (e.g., dual eligibles, CMS children, etc.). As increasing
numbers of providers become involved in these programs, their eligible patients
become enrolled in the pilot program networks. Generally speaking, chronically ill
patients enrolled in MediPass disease management organizations remained
outside the pilot programs, as did some other beneficiaries with complex medical
and social needs. The result was that the South Florida area offices defined
themselves (that is, MediPass) as the "plan that cared for the sickest patients."
They emphasized the increasing needs for true case management and
coordination of medical and social services for "regular MediPass" beneficiaries.


Second, as pilot programs were developed and implemented, area offices
struggled with the coordination and management of different programs with
different rules and oversight requirements. Providers were often confused about
the different programs and the appropriate way to manage and bill different types
of beneficiaries. For example, when providers had DMO patients and were
members of the Minority Physician Network (MPN), they received two lists of
MediPass members. Since the DMO patients are not part of the MPN pilots,
providers must bill using the MPN "SuperGroup ID" for the MPN beneficiaries
and bill for the DMO patients using their own unique Medicaid provider
23









identification number. In some pilot programs, credentialing is done by the pilot
organization. In other programs, credentialing is done by the Agency.


Because of complexities such as this, the area offices must conduct
extensive training and hand-holding with providers (and beneficiaries) before,
during, and after physicians join pilot programs. Ironically, the pilot programs
were designed to reduce administrative hassles for the Agency. However, area
offices are usually the first place that providers and beneficiaries call when they
are confused about what to do or how to do it. These and other factors
associated with Medicaid pilot programs must be understood and anticipated as
the pilots expand to other parts of the state (e.g., Tampa and Jacksonville).


SUMMARY AND CONCLUSIONS

Medicaid and MediPass are recognized as critical components of the
healthcare safety net. As such there was strong support from both providers and
AHCA staff for the program. However, a number of important concerns emerged.
These include:
The unavailability of certain kinds of specialty care within specific regions;
The adequacy and appropriateness of the $3 per member per month
management fee;
Confusion on the role of disease management organizations in patient
care; and
The need to streamline and make more efficient certain operational
procedures such as credentialing and referral authorizations.


However, in light of increasing costs associated with the Medicaid program,
these concerns must be addressed as part of an overall strategy to reduce
expenditures while maintaining and enhancing quality of care. Existing payment
structures and mechanisms do little to encourage physicians to engage in cost
saving and quality improvement activities.









APPENDIX I: PROTOCOL FOR AREA OFFICE INTERVIEWS


Evaluation of Florida's Medicaid MediPass Program
Questions for AHCA Area Offices

The Florida Center for Medicaid and the Uninsured has been contacted through
AHCA to conduct an evaluation of the MediPass program. The most recent
evaluation conducted three years ago concluded the following:
MediPass consumes fewer resources than expected;
Excess capacity exists within the primary care network;
The need to implement enhanced utilization review procedures to hold
providers responsible for practice patterns; and
High rates of satisfaction.

The purpose of this evaluation was to build on this information and to gather
information about the challenges, successes and changes in the MediPass
program in the last three years. It will also offer an opportunity to give any
thoughts on MediPass.

PCPs
This set of questions will focus on PCPs. We are interested in learning about the
PCP network, relations with providers and PCP training and education.

How would you characterize the size of the PCP network in your area?
Too large or too small to manage?
Any changes needed?
Any changes over time?
Are PCPs more/less reluctant to join the PCP network?

Describe the PCPs in the area network.
Who are they (family practice, pediatricians, internal medicine, etc.)?
Lack of /too much of any kind?

How long do PCPs generally serve in the MediPass network?

Do you know why PCPs join and leave the MediPass program?

What kinds of comments do you hear about the program and the patients from
PCPs?

What forms of communication does the area office use to communicate
with/educate/ train/provide feedback to PCPs?

What forms of communication does you use to inform providers (and their office
staff) of changes in the MediPass program?









How extensive is PCP orientation and training for MediPass? What's involved?

Is there ever a need for additional PCP training? Do you monitor this?

Continuity of Care
One of the areas we have been investigating through the evaluation is continuity
of care. We have asked providers whether or not patients see the same provider
every time and if they feel continuity of care is important.

How easy is it to maintain continuity of care for patients in the program?

Provider Profiling
The head office has asked us to investigate the feasibility of provider profiling
within the program. Provider profiling uses performance reports of providers to
compare to peers and identify outliers and improve provider performance.

To your knowledge, are there any provider profiling activities that are now
ongoing within the agency?

Do you think that profiling activities could be implemented into MediPass?

What performance measurements do you feel are needed?

Do you think MediPass PCPs would be influenced by performance reports? Why
or why not?

Beneficiary Assignment
What factors are used in making PCP assignments?

How often are the patient lists updated (i.e., list of patients that are assigned to
each doctor)?

What is the current system in place for providers to verify eligibility? What could
be done to improve this system for providers?

How are patients educated about the MediPass program? Are they assisted with
selecting a doctor and informed of the purpose of MediPass?

Credentialing
What is the current PCP credentialing process? Does it include all needed
elements?

Are there ways to streamline the process?

What should headquarter/area office roles be with regard to credentialing? (What
currently happens? What would be most efficient?)










Is Medicaid successful in attracting top-tier PCPs in the community?

How often are PCPs credentialed? How often should PCPs be credentialed?

On average, how many PCPs are dropped from the program each year? For
what reasons?

To what extent are PCP performance standards set, communicated, and
measured?

Is PCP quality of care used in the credentialing process?

Case Management Fee
Do you think that providers understand what is expected for the $3 PMPM fee?

Do you feel that $3 PMPM is sufficient?

Specialists
Through our provider interviews, we have heard that access to specialty care is a
problem statewide.

How do you feel about the specialty care network available to MediPass
beneficiaries?
What can the Agency do to improve this situation?
Do you have any ideas for improving the specialty care network?

Do PCPs use specialists appropriately?
Is this a problem?
Are PCPs relying too heavily on specialists?

To what extent do PCPs help patients locate specialists?

Disease Management
What disease management programs are offered in your area?

Do you believe that the disease management organizations offered to MediPass
patients have been effective in reducing costs and improving health outcomes?

To what extent has the disease management program enhanced the MediPass
program?

Patients
How satisfied do you think patients are with the care they receive from MediPass
providers?









What kinds of complaints and/or compliments have you received from patients?

Any specific challenges related to racial/ethnic diversity among the patient
population?

Any other kinds of challenges associated with patients.

MediPass Organized Structures/Staffing/Functions
We are interested in learning more about the roles of the area office and the
division of labor between the head office and the area offices.

General responsibilities of the area offices: Tell us about the responsibility of the
area office in relation to MediPass.

Would you discuss the organization of the area office?

Are headquarters and area office roles properly defined and communicated?
Is there a clear understanding of roles of the head office and the area office?

Is MediPass-related staffing appropriate/sufficient to support the program?

Is there a need for shifting any roles between the head and state offices?

Closing
What are some of the changes/improvements that have recently been made to
the program?

What can be done to build upon successes or improve MediPass?
Recommendations for future changes?

What are some of the challenges?

Is MediPass meeting the needs of consumers?

Is there anything else you would like to tell us about the program?









APPENDIX II: PROTOCOL FOR PROVIDER INTERVIEWS


Evaluation of Florida's Medicaid MediPass Program
Questions for Providers/Office Staff

Introduction
The Florida Center for Medicaid and the Uninsured (FCMU) at the University of
Florida is conducting an evaluation of the MediPass program on behalf of the
Agency for Health Care Administration. The evaluation will be conducted under
the direction of Dr. Allyson Hall who is the research director for FCMU.

Your participation in this research is voluntary and you do not have to answer
any of the questions you choose not to.

The main goal of this evaluation is to:
Examine program practices and procedures;
Examine the primary and specialty care capacity of the physician network; and
Examine provider profiling activities within the program.

In order to accomplish these objectives, FCMU will be conducting either in-
person or telephone interviews with MediPass providers with a large number of
Medicaid patients. The interviews will mainly focus on policies and procedures
associated with MediPass. Through this process, FCMU hopes to learn about the
challenges and success of MediPass. The interviews will provide an opportunity
for those interviewed to suggest changes to the program. Please note that the
individual interviewee's identities will be kept confidential.


General Questions

Tell us about your practice
Population Served
Number of Providers- Do they all serve MediPass patients?
Payer Mix
Number of patients seen from MediPass?
Office Hours

Your position at the office

Are you taking new MediPass patients? Why or why not?
Why does your office take MediPass patients? How did your office get involved?
How long have you accepted MediPass?

Tell us about your experience with MediPass.
Good things
Problems









Recommendations


Patient/Provider

What is your experience with getting specialty referrals?

Do you agree with the patient/PCP caps?
If patient/PCP cap were decreased how would it affect business? Would it give
other players a chance to play?
Increased?

Talk about the process of managing patients.
How frequently do they change PCPs.
Problems with data (phone numbers, ID numbers)

What is the process for verifying eligibility of MediPass patients?

Medicaid is interested in innovative approaches that your office uses to better
manage MediPass patients and the needs of the patients (e.g., extended hours,
quality issues). Do you have any that you would be interested in sharing with us?

Continuity of Care
Is the patient assigned to a specific physician?
Do they see same physician every time they visit the office?

Physician Profiling
AHCA is considering implementing physician profiling. We are interested in what
you think about physician profiling.

Currently...
What measurements do you use to track quality of care?
Do you compare quality measures with other doctors?

If MediPass were to institute provider profiling...
What do you think the effects would be?
What measurements would be helpful to compare in order to change behavior?
What incentives would be necessary to change physician behavior?

Have you participated in physician profiling with any other insurers?

May we contact you in the future for further assistance with developing physician
profiling (i.e., questionnaire)?

MediPass Program









Tell us about your experience and relationship with AHCA staff? (supportive, not
supportive?)

What are the administrative challenges associated with being involved with
MediPass?
Positive things?
Has PCP practice management changed in any way to accommodate MediPass
requirements?

Would you talk about your experience with the following areas of MediPass:

Billing and claims processing (claims submission, payments, levels of
reimbursement, etc.)

Case management

Is the $3/month case management fee sufficient to achieve adequate member
case management?
Has the Agency properly explained the PCP case management role to you?
Do you know what is expected for the $3 fee?

Patient Issues

Patient issues (including access to specialists, access to ancillary services, care
coordination, other patient care issues)

Disease Management
Are any of your patients in DMOs?


Do you believe that the disease management organizations offered to MediPass
patients have been effective in reducing costs and improving health outcomes?
Do disease management organizations (DMOs) aid the MediPass PCPs?


Closing

Is MediPass meeting your expectations?

Is MediPass a good way to provide care to low-income families?

Is MediPass meeting the needs of consumers?

To what extent do PCPs rely on Medicaid business?

Are there any new problems?









Have you noticed any changes to the program in the last 3 years?

Any suggestions you can offer to improve MediPass in the future?




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