Winter 2016 - FL Agency for Health Care Administration...Winter 2016 Quarterly Statewide Medicaid...

Business Intelligence Unit Medicaid Data Analytics

Winter 2016

Quarterly Statewide Medicaid Managed Care Report

Rick Scott, Governor Justin M. Senior, Secretary

Agency for Health Care Administration

Analyzing the Disease Burden of Florida

Medicaid Enrollees Using Clinical Risk Groups

i

Table of Contents List of Figures ................................................................................................................................................ ii

List of Tables ................................................................................................................................................. v

Executive Summary ...................................................................................................................................... vi

Data Sources ............................................................................................................................................. 2

Disease Classifications .............................................................................................................................. 5

Health of the Medicaid Population ............................................................................................................... 6

Top Illnesses of the Medicaid Population ................................................................................................... 13

Overall ..................................................................................................................................................... 13

SSI and Family ......................................................................................................................................... 14

By Age ..................................................................................................................................................... 15

By Sex ...................................................................................................................................................... 18

By MMA Plan ........................................................................................................................................... 19

Top Illnesses by Health Status .................................................................................................................... 26

Health Status 9-Catastrophic Conditions ................................................................................................ 27

Health Status 8-Dominant, Metastatic or Complicated Malignancies ................................................... 31

Health Status 7-Dominant Chronic Disease in Three or More Organ Systems ...................................... 35

Health Status 6-Significant Chronic Disease in Multiple Organ Systems ................................................ 40

Health Status 5-Single Dominant or Moderate Chronic Disease ............................................................ 44

Health Status 4-Minor Chronic Disease in Multiple Organ Systems ....................................................... 50

Health Status 3-Single Minor Chronic Disease ........................................................................................ 54

Health Status 2-Recent History of Significant Acute Illness .................................................................... 58

Conclusions ................................................................................................................................................. 62

ii

List of Figures

Figure 1: Percentage of Medicaid Recipients Categorized as Healthy Compared to Any of the Other Eight

Health Statuses, August 2014-July 2015 .............................................................................................. 6

Figure 2: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status, August

2014-July 2015 ...................................................................................................................................... 6

Figure 3: Percentage of Medicaid Population in the Family-Related Eligibility Group as Compared to the

SSI-Related Eligibility Group, August 2014-July 2015 ........................................................................... 7

Figure 4: Percentage of SSI-Related Eligibility Group and Family-Related Eligibility Group in the Healthy

Category as Compared to One of the Other Eight Health Statuses, August 2014-July 2015 ............... 7

Figure 5: Distribution of Medicaid Population by Age and Eligibility Group, August 2014-July 2015 .................. 7

Figure 6: Percentage of Age Groups Classified as Healthy, August 2014-July 2015 ............................................. 8

Figure 7: Percentage of Age and Eligibility Groups Classified as Healthy, August 2014-July 2015 ...................... 8

Figure 8: Percentage of Females and Males Classified as Healthy, August 2014-July 2015 ................................. 9

Figure 9: Percentage of Medicaid Population by Gender, August 2014 -July 2015 ............................................. 9

Figure 10: Percentage of Medicaid Population in Standard Plan, Specialty Plan, and FFS, August 2014-July

2015 .................................................................................................................................................... 9

Figure 11: Percentage of Specialty Plan Enrollees Classified as Healthy, August 2014-July 2015 ..................... 10

Figure 12: Number of Enrollees in a Specialty Plan, August 2014-July 2015 ..................................................... 10

Figure 13: Percentage of Standard Plan Enrollees Classified as Healthy, August 2014-July 2015 ..................... 11

Figure 14: Number of Enrollees in a Standard Plan, August 2014-July 2015 ..................................................... 11

Figure 15: Percentage of Regions’ Recipients with a Healthy Status, August 2014-July 2015 .......................... 12

Figure 16: Top 10 Non-Healthy CRGs for the Medicaid Population, August 2014-July 2015 ............................ 13

Figure 17: Top 10 Illnesses of the Medicaid Population by Eligibility Group, August 2014-July 2015 .............. 14

Figure 18: Top 10 Illnesses of the Medicaid Population from Birth to 20, August 2014-July 2015 ................... 15

Figure 19: Top 10 Illnesses of the Medicaid Population Twenty-one Years of Age or Over, August 2014-

July 2015 ........................................................................................................................................... 16

Figure 20: Top 10 Illnesses of the Medicaid Population by Sex, August 2014-July 2015 .................................. 18

Figure 21: Top 10 Illnesses of the Fee-for-Service and MMA Populations, August 2014-July 2015.................. 19

Figure 22: Top 10 Illnesses of Standard Plan Enrollees, August 2014-July 2015 ............................................... 20

Figure 23: Top 10 Illnesses of HIV/AIDS Specialty Plan Enrollees, August 2014-July 2015 ............................... 22

Figure 24: Top 10 Illnesses of Children’s Specialty Plan Enrollees, August 2014-July 2015 .............................. 23

Figure 25: Top 10 Illnesses of Severe Mental Illness Specialty Plan Enrollees, August 2014-July 2015 ............ 24

Figure 26: Top 5 Illnesses by Region, August 2014-July 2015 ............................................................................ 25

Figure 27: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status,

August 2014-July 2015 ...................................................................................................................... 26

Figure 28: Number of Recipients with Health Status 9 by CRG and Level of Severity, August 2014-July

2015 .................................................................................................................................................. 27

Figure 29: Top Catastrophic Conditions Compared to All Other Conditions, August 2014-July 2015 ............... 27

Figure 30: Percentage of Eligibility Groups with a Catastrophic Condition, August 2014-July 2015 ................. 28

Figure 31: Percentage of Age Groups with a Catastrophic Condition, August 2014-July 2015 ......................... 28

iii Figure 32: Percentage of Females and Males with a Catastrophic Condition, August 2014-July 2015 ............. 28

Figure 33: Percentage of Specialty Plan Enrollee Months with a Catastrophic Condition, August 2014-

July 2015 ........................................................................................................................................... 29

Figure 34: Percentage of Standard Plan Enrollee Months with a Catastrophic Condition, August 2014-

July 2015 ........................................................................................................................................... 29

Figure 35: Percentage of Regions’ Recipients with a Catastrophic Condition, August 2014-July 2015 ............ 30


2015 .................................................................................................................................................. 31

Figure 37: Top Malignancy Compared to All Other Illnesses, August 2014-July 2015....................................... 31

Figure 38: Percentage of Eligibility Groups with a Malignancy, August 2014-July 2015 ................................... 32

Figure 39: Percentage of Age Groups with a Malignancy, August 2014-July 2015 ........................................... 32

Figure 40: Percentage of Females and Males with a Malignancy, August 2014-July 2015 ............................... 32

Figure 41: Percentage of Specialty Plan Enrollee Months with a Malignancy, August 2014-July 2015 ............ 33

Figure 42: Percentage of Standard Plan Enrollee Months with a Malignancy, August 2014-July 2015 ............ 33

Figure 43: Percentage of Regions’ Population with Malignancies, August 2014-July 2015 .............................. 34


2015 .................................................................................................................................................. 35

Figure 45: Top Dominant Chronic Disease in Three or More Organ Systems Compared to All Other

Illnesses, August 2014-July 2015 ...................................................................................................... 35

Figure 46: Top 10 Individual Diseases, August 2014-July 2015 ......................................................................... 36

Figure 47: Percentage of Eligibility Groups with a Dominant Chronic Disease in 3 or More Organ

Systems, August 2014-July 2015 ....................................................................................................... 37

Figure 48: Percentage of Age Groups with a Dominant Chronic Disease in 3 or More Organ Systems,

August 2014-July 2015 ...................................................................................................................... 37

Figure 49: Percentage of Females and Males with a Dominant Chronic Disease in 3 or More Organ


Figure 50: Percentage of Specialty Plan Enrollee Months with a Dominant Chronic Disease in 3 or More

Organ Systems, August 2014-July 2015 ............................................................................................ 38

Figure 51: Percentage of Standard Plan Enrollee Months with a Dominant Chronic Disease in 3 or More


Figure 52: Percentage of Regions’ Population with a Dominant Chronic Disease in 3 or More Organ

Systems Status, August 2014-July 2015 ............................................................................................ 39

Figure 53: Number of Recipients with Significant Chronic Disease in Multiple Organ Systems by CRG and

Level of Severity, August 2014-July 2015.......................................................................................... 40

Figure 54: Top Significant Chronic Diseases in Multiple Organ Systems Compared to All Other Illnesses,

August 2014-July 2015 ...................................................................................................................... 40

Figure 55: Top 10 Individual Chronic Diseases, August 2014-July 2015 ............................................................ 41

Figure 56: Percentage of Eligibility Groups with Significant Chronic Disease in Multiple Organ Systems,

August 2014-July 2015 ...................................................................................................................... 42

Figure 57: Percentage of Age Groups with Significant Chronic Disease in Multiple Organ Systems, August

2014-July 2015 .................................................................................................................................. 42

iv

Figure 58: Percentage of Females and Males with Significant Chronic Disease in Multiple Organ Systems,

August 2014-July 2015 ...................................................................................................................... 42

Figure 59: Percentage of Specialty Plan Enrollee Months with Significant Chronic Disease in Multiple


Figure 60: Percentage of Standard Plan Enrollee Months with a Significant Chronic Disease in Multiple


Figure 61: Percentage of Regions’ Population with a Significant Chronic Disease in Multiple Organ



2015 .................................................................................................................................................. 45

Figure 63: Top Dominant Chronic Disease Compared to All Other Illnesses, August 2014-July 2015 .............. 45

Figure 64: Percentage of Eligibility Groups with Single Dominant or Moderate Chronic Disease, August

2014-July 2015 .................................................................................................................................. 46

Figure 65: Percentage of Age Groups with a Single Dominant or Moderate Chronic Disease, August

2014-July 2015 .................................................................................................................................. 46

Figure 66: Percentage of Females and Males with a Single Dominant or Moderate Chronic Disease,

August 2014-July 2015 ...................................................................................................................... 46

Figure 67: Percentage of Specialty Plan Enrollee Months with a Single Dominant or Moderate Chronic

Disease, August 2014-July 2015 ........................................................................................................ 47

Figure 68: Percentage of Standard Plan Enrollee Months with a Single Dominant or Moderate Chronic

Disease, August 2014-July 2015 ........................................................................................................ 47

Figure 69: Percentage of Regions’ Population with a Single Dominant or Moderate Chronic Disease,

August 2014-July 2015 ...................................................................................................................... 48

Figure 70: Top 10 Chronic Diseases Across Health Statuses 5, 6, and 7, August 2014-July 2015...................... 49


2015 .................................................................................................................................................. 50

Figure 72: Percentage of Eligibility Groups with Minor Chronic Disease in Multiple Organ Systems,

August 2014-July 2015 ...................................................................................................................... 51

Figure 73: Percentage of Age Groups with Minor Chronic Disease in Multiple Organ Systems, August

2014-July 2015 .................................................................................................................................. 51

Figure 74: Percentage of Females and Males with a Minor Chronic Disease in Multiple Organ Systems,

August 2014-July 2015 ...................................................................................................................... 51

Figure 75: Percentage of Specialty Plan Enrollee Months with Minor Chronic Disease in Multiple Organ


Figure 76: Percentage of Standard Plan Enrollee Months with a Minor Chronic Disease in Multiple Organ


Figure 77: Percentage of Regions’ Population with a Minor Chronic Disease in Multiple Organ Systems,

August 2014-July 2015 ...................................................................................................................... 53


2015 .................................................................................................................................................. 54

Figure 79: Top Single Minor Chronic Disease Compared to All Other Illnesses, August 2014-July 2015 .......... 54

v Figure 80: Percentage of Eligibility Groups with a Single Minor Chronic Disease, August 2014-July 2015 ....... 55

Figure 81: Percentage of Age Groups with a Single Minor Chronic Disease, August 2014-July 2015 ............... 55

Figure 82: Percentage of Females and Males with a Single Minor Chronic Disease, August 2014-July

2015 .................................................................................................................................................. 55

Figure 83: Percentage of Specialty Plan Enrollee Months with a Single Minor Chronic Disease, August

2014-July 2015 .................................................................................................................................. 56

Figure 84: Percentage of Standard Plan Enrollee Months with a Single Minor Chronic Disease, August

2014-July 2015 .................................................................................................................................. 56

Figure 85: Percentage of Regions’ Population with a Single Minor Chronic Disease Status, August 2014-

July 2015 ........................................................................................................................................... 57


2015 .................................................................................................................................................. 58

Figure 87: Percentage of Eligibility Groups with a Significant Acute Illness, August 2014-July 2015 ................ 59

Figure 88: Percentage of Age Groups with a Significant Acute Illness, August 2014-July 2015 ........................ 59

Figure 89: Percentage of Females and Males with a Significant Acute Illness, August 2014-July 2015 ............ 59

Figure 90: Percentage of Specialty Plan Enrollee Months with a Significant Acute Illness, August 2014-

July 2015 ........................................................................................................................................... 60

Figure 91: Percentage of Standard Plan Enrollee Months with a Significant Acute Illness, August 2014-

July 2015 ........................................................................................................................................... 60

Figure 92: Percentage of Regions’ Population with a Significant Acute Illness Status, August 1, 2014 - July

31, 2015 ............................................................................................................................................ 61

List of Tables

Table 1: Data Sources ........................................................................................................................................... 2

Table 2: Major Diagnostic Category Description .................................................................................................. 3

Table 3: Health Status Categories ......................................................................................................................... 4

vi

Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information, August 2014-July 2015.

Percentage of Medicaid Recipients Categorized as Healthy Compared to Any of the Other Eight Health

Statuses, August 2014-July 2015

Executive Summary

Medicaid plays an important role in managing the health care of seniors, individuals with disabilities,

and low-income individuals in Florida. According to the 2016 Kaiser Family Foundation State Health

Facts, 18 percent of all Florida citizens were covered by Medicaid in 2015. The Agency for Health Care

Administration administers the Statewide Medicaid Managed Care (SMMC) program which requires

most Medicaid recipients in Florida to receive services through managed care. The SMMC Managed

Medical Assistance (MMA) plans began rolling out in May 2014, and were fully implemented in August

2014. Most recipients eligible for Medicaid are required to enroll in an SMMC MMA plan to receive

medical care. Managed care plans provide preventive health care and are required to enact procedures

to promote disease management and report on quality metrics related to health outcomes.

Individuals with chronic disease or catastrophic illnesses present specific challenges to managing the

health of a population in a managed care system. Because individuals with chronic illnesses generally

use more health resources than healthy individuals, their care is more costly than that of healthy

individuals. For that reason, payments in a managed care system are adjusted for the illness of

enrollees. Understanding the burden of illness of the Medicaid population and its distribution

geographically and across plans is crucial to effective health management in a managed care system.

This report examines the health and illness of Medicaid recipients in Florida using data from August

2014 to July 2015. Clinical Risk Groups (CRGs) are used to classify recipients into one of 1,080 mutually

exclusive clinical risk groups indicating the presence, extent, and severity of specific illnesses. CRGs are

aggregated into nine broad health statuses that range from catastrophic to healthy. The distribution of

illness across health plans, regions, and age, and sex, and eligibility groups is analyzed. The top ten

illnesses in the eight non-healthy statuses are also analyzed. Results are descriptive. Results do not

indicate that a particular plan, program, or region caused their recipients’ health status. Methodological

techniques used in this report do not test causal relationships between aspects of the Medicaid program

and its recipients’ health.

There were 4,026,798 recipients enrolled in Medicaid for

at least 3 months at some point between August 1, 2014

and July 31, 2015.

Recipients whose medical billing data is not received by

the Florida Medicaid Managed Information System

(FLMMIS) are excluded from analyses.

Nearly 70 percent (69%) of recipients were classified as

healthy based on their medical data for the study period.

1,251,794 recipients (31%) were classified in one of eight

health statuses not considered healthy.

Healthy 2,775,004

69%

Any Other Health Status

1,251,794 31%

vii

- 20 40 60 80 100

Asthma

Significant Acute

Significant Acute Procedure

Hypertension

Persistent Signficant Acute

ADHD

2 or More Minor Chronic

Hyperlipidemia

Diabetes

Schizoprenia

Thousands

Level 1 Level 2 Level 3 Level 4 Level 5 Level 6


0%

25%

50%

75%

Healthy SignificantAcute

Disease

Single MinorChronicDisease

MinorChronic

Disease inMultiple

OrganSystems

SingleDominant or

ModerateChronicDisease

SignificantChronic

Disease inMultiple

OrganSystems

DominantChronic

Disease inThree or

More OrganSystems

Dominant,Metastatic

andComplicatedMalignancies

CatastrophicConditions

68.9%

6.3% 5.2% 0.8%

10.2% 6.5%

0.8% 0.3% 0.9%

The three most common health statuses after healthy are Single Dominant or Moderate Chronic

Disease (10.2% of recipients), Significant Chronic Disease in Multiple Organ Systems (6.5% of

recipients), and Significant Acute Illness (6.3% of recipients).

Slightly less than one percent of Medicaid recipients had a Catastrophic Condition.

The most common illnesses

among Medicaid recipients

include asthma, significant

acute illnesses, hypertension,

and attention

deficit/hyperactivity disorder

(ADHD).

Healthy 2,775,004

69%

Top 10 Illnesses 562,092

14%

Other Illnesses 689,634

17%

Top 10 Illnesses of Medicaid Population, August 2014-July 2015

Percentage of Medicaid Recipients Categorized as Healthy, Having a Top Ten Illness, or Having an Illness Not in

the Top Ten, August 2014-July 2015

Higher levels of severity indicate a greater extent and progression of the chronic disease.

Percentage of Medicaid Population by Health Status, August 2014-July 2015

viii


Some recipients are categorized as healthy because they received no services through Medicaid.

Over a third (41%) of FFS recipients are non-users of Medicaid services. The largest portion of

these non-users (69%) are eligible as Qualified Medicare Beneficiaries or SSI recipients for whom

Medicaid receives Medicare claim information but no prescribed drug information likely due to

their Medicare Part D drug coverage. It is possible that if Medicaid received the drug

information, these recipients could be assigned a status other than healthy.

The percentage of each Standard Plan’s enrollees who are classified as healthy varies from 60

percent for Simply to 76.8 percent for Community Care.

The percentage of each Specialty Plan’s enrollees who are classified as healthy varies from a low

of 26 percent for Clear Health to a high of 65 percent for Sunshine Specialty.

Some enrollees in Specialty Plans were classified as healthy because there is insufficient

information in the data related to their illness. Some enrollees’ drug prescriptions were covered

by Medicare Part D. Some enrollees lack hospital or outpatient services that meet the clinical

criteria needed for classification, or lack recent treatment during the study period. During the

analysis period, siblings of enrollees in Children’s Medical Services (CMS) were allowed to enroll

in the plan if the sibling did not meet eligibility criteria for the plan. Magellan enrollees may be

classified as healthy during periods when their illness is in remission.

0%

25%

50%

75%

100%

61

.8%

59

.6%

57

.0%

57

.0%

56

.8%

56

.3%

55

.6%

55

.5%

55

.4%

55

.4%

54

.8%

54

.1%

54

.1%

50

.0%

48

.6%

32

.5%

31

.6%

15.0% 13.0% 14.1% 14.2% 10.2% 13.8% 13.3% 16.0% 14.0% 12.4% 10.9% 11.2% 12.2% 19.8% 11.4%

41

.4%

4.6%

23

.2%

27

.4%

28

.9%

28

.8%

33

.0%

29

.9%

31

.1%

28

.5%

30

.5%

32

.3%

34

.4%

34

.6%

33

.7%

30

.2%

40

.0%

26

.2%

63

.8%

Stan

dar

d P

lan

s

Percentage of Enrollee Months Classified as Healthy Versus Any Other Health Status August 2014 - July 2015

0%

25%

50%

75%

100%

SunshineSpecialty

AggregateStandard

Fee ForService

AggregateSpecialty

CMS Positive Magellan ClearHealth

60

.7%

55

.4%

32

.5%

31

.6%

28

.3%

26

.8%

23

.1%

22

.4%

3.9% 12.4%

41

.4%

4.6% 3.5% 10.0% 7.0% 3.5%

35

.5%

32

.3%

26

.2%

63

.8%

68

.2%

63

.2%

70

.0%

74

.1%

Spe

cial

ty P

lan

s

Healthy Determined by Services-All Standard Plans Healthy Determined by Services-Fee For Service Healthy Determined by Services-All Specialty Plans Healthy No Services (Standard Chart) Healthy Determined by Services-Standard Plans Healthy No Services (Specialty Chart) Healthy Determined by Services-Specialty Plans Status Other than Healthy

Note: See page one for a description of specialty plan populations.

1

Introduction Florida Medicaid pays for medical services for low-income individuals, seniors, and individuals with

disabilities who have limited or no health insurance. In response to legislation mandating that most

Medicaid recipients receive services through a managed care program, the Agency for Health Care

Administration has been providing medical services through the Statewide Medicaid Managed Care

Program since August 2014. Under managed care, health care plans receive capitation payments for

enrollees and contract with health care providers for the provision of medical services to enrollees in

exchange for payment.

Medicaid’s managed care plans are classified as Standard Plans or Specialty Plans. Standard Plans serve

the majority of Medicaid recipients and provide an array of covered medical services. They are Staywell,

Sunshine, Amerigroup, Humana, Prestige, United, Molina, Integral, Better Health, Simply, Coventry,

Community Care, Preferred and First Coast.

Specialty plans serve recipients with a chronic medical condition, specific diagnosis, or specific age group

and are tailored to meet the specific needs of the specialty population. Specialty Plans include Sunshine

Specialty who serves recipients under the age of 21 with an open case for child welfare services;

Magellan who serves recipients diagnosed with a serious mental illness; CMS who serves recipients

under the age of 21 with a serious and chronic condition; and Clear Health Alliance and Positive Health

Care, who serve recipients diagnosed with HIV or AIDS.

In a managed care system, health plans face the challenge of covering the payment for services to

enrollees with the amount received in capitation payments. To ensure that plans can cover the cost of

services for individuals with serious health problems, capitation payments must be adjusted for the

health of each enrollee.

Providing healthcare to individuals who are ill, especially those with serious chronic illness, is more

costly than providing healthcare to healthy individuals. Understanding the disease burden of the

Medicaid population and the distribution of healthy and sick enrollees across health plans and regions is

essential to an efficient and well-functioning managed care system. Health plans with a larger

percentage of individuals with more complex illnesses will have larger medical service expenses per

enrollee than plans with a smaller percentage of enrollees with complex illnesses. Therefore, capitation

rates are adjusted for the burden of illness of each plan’s enrollees to reflect this differential in cost.

This report examines the health status of the Florida Medicaid population. Clinical Risk Groups (CRGs)

are used to categorize enrollees into one of 1,080 clinical risk groups that are aggregated into nine

health statuses that range from catastrophic to healthy. The distribution of health statuses and most

frequent illnesses by health plan, region, sex, age group, and eligibility group is examined. For each of

the eight non-healthy statuses, the top ten illnesses are shown. Results are descriptive. Results do not

indicate that a particular plan, program, or region caused their recipients’ health status. Methodological

techniques used in this report do not test causal relationships between aspects of the Medicaid program

and its recipients’ health.

2

Data Sources The results in this report are based on analyses of data from sources detailed in the table below and

cited with relevant tables and figures.

Table 1: Data Sources

Data Period Source

Enrollment Information

August 1, 2014-July 31, 2015 as of September 21, 2016

Florida Medicaid Managed Information System (FLMMIS) Eligibility Information

MMA Encounter and Claims Information

August 1, 2014-July 31, 2015 as of April 21, 2016

Florida Medicaid Managed Information System (FLMMIS) Claims and Encounter Information

Recipients whose medical billing data is not received by the Florida Medicaid Managed Information

System (FLMMIS) are excluded from analyses. This includes recipients who are dually eligible for

Medicaid and Medicare for whom Medicaid does not receive medical billing information, women who

were enrolled only for Family Planning services, recipients who did not have full Medicaid coverage and

recipients enrolled in Medicaid for less than 3 months in the period from August 1, 2014 through July 31,

2015.

Demographic and medical information present in claims and encounter data for the analysis year is used

to classify each enrollee into a clinical risk group (CRG). Clinical risk groups are a classification system for

describing the health of individuals. Each enrollee is categorized into one of 1,080 CRG codes. CRGs are

assigned using 3M’s CRG grouping software (3M™ Clinical Risk Grouping Software (Version 1.12)

[Software]). The CRG grouping software uses diagnosis codes, procedure codes, and national drug

codes, singularly or in combination, to build a disease profile for each person. It also uses other

information such as the place of service, recency of the service, persistence of the illness, and

demographic characteristics of the individual. The presence or absence of this information can change

the assignment of a health status significantly. For example, some enrollees in illness-based Specialty

Plans are classified as “healthy.” While these individuals would not normally be categorized as healthy,

the claims/encounter data submitted during the study period did not contain information relating to the

illness.

The disease profile is used by the software to group clinical information into 37 major diagnostic

categories based on the organ system involved or the disease etiology. The CRG software uses a set of

detailed clinical criteria to assign a primary chronic disease with corresponding severity level to each

major diagnostic category if any illness is present. Table 2 lists the major diagnostic categories in

hierarchal order beginning with the most severe.

3 Table 2: Major Diagnostic Category Description

Rank Major Diagnostic Category (MDC) Description

1 Catastrophic Respiratory Conditions

2 Catastrophic Neurological Conditions

3 Heart Transplant Status

4 Liver or Pancreas Transplant Status

5 Bone Marrow Transplant Status

6 HIV Infection

7 Secondary Malignancy

8 Malignancies

9 Diseases and Disorders of the Nervous System

10 Diseases and Disorders of the Cardiovascular System

11 Diseases and Disorders of the Respiratory System

12 Diabetes Mellitus

13 Diseases and Disorders of the Digestive System

14 Diseases and Disorders of the Hepatobiliary System and Pancreas

15 Diseases and Disorders of the Kidney and Urinary Tract

16 Disease and Disorders of the Blood and Blood Forming Organs

17 Infectious and Parasitic Diseases

18 Diseases and Disorders of the Eye

19 Diseases and Disorders of the Ear, Nose, Mouth and Throat

20 Peripheral Vascular Disease and Other Non-Cardiac Vascular Diseases

21 Diseases and Disorders of the Musculoskeletal System

22 Connective Tissue Diseases

23 Other Endocrine, Metabolic and Thyroid Disorders

24 Diseases and Disorders of the Male Reproductive System

25 Diseases and Disorders of the Female Reproductive System

26 Newborns and Other Neonates

27 Diseases and Disorders of the Skin, Subcutaneous Tissue, and Breast

28 Mental Diseases and Disorders

29 Substance Abuse

30 Burns

31 Factors Influencing Health Status and Other Contacts with Health Services

32 Pregnancy, Childbirth and the Puerperium

33 Other Trauma

34 Injuries, Poisoning and Toxic Effects of Drugs

35 Neoplasms of Uncertain Behavior

36 Chromosomal Anomalies, Mental Retardation and Other Developmental / Cognitive Diagnoses

37 Craniofacial Anomalies

4

Once the primary chronic illnesses are assigned to each of the major diagnostic categories, the CRG software applies additional detailed clinical criteria to categorize each person into one of 1,080 detailed CRG categories. The CRG categories indicate the presence or absence of specific acute and chronic illnesses, the severity level of illnesses, and the presence of multiple illnesses. Detailed CRG categories can be used to examine the prevalence of specific illnesses in a population and identify the most frequent illnesses experienced by groups within the population. Detailed CRG categories are also aggregated into the following nine health statuses which range from catastrophic to healthy and are used to more broadly summarize the health of a population. Table 3: Health Status Categories

Health Status

Title Description

9 Catastrophic Conditions

Includes long term dependency on a medical technology such as dialysis, respirator, or total parenteral nutrition (TPN), and life-defining chronic diseases or conditions that dominate the medical care required such as persistent vegetative state, cystic fibrosis, AIDS, or a history of heart transplant.

8 Dominant, Metastatic or Complicated Malignancies

Identified by a malignancy that dominates the medical care required such as brain malignancy, or a non-dominant malignancy such as prostate malignancy that is metastatic or complicated (requiring a bone marrow transplant).

7 Dominant Chronic Disease in Three or More Organ Systems

Identified by the presence of three or more dominant chronic diseases, or two dominant and a selected moderate chronic disease. An example is the presence of congestive heart failure, diabetes, and chronic obstructive pulmonary disease.

6 Significant Chronic Disease in Multiple Organ Systems

Identified by the presence of two or more chronic diseases of which at least one is a dominant or moderate chronic disease such as diabetes and hypertension or asthma and hypertension.

5 Single Dominant or Moderate Chronic Disease

Identified by the presence of a single dominant or moderate chronic disease such as asthma, epilepsy, or cerebral palsy.

4 Minor Chronic Disease in Multiple Organ Systems

Identified by the presence of two or more minor chronic diseases such as migraines and depression, or migraines and hyperlipidemia.

3 Single Minor Chronic Disease

Identified by the presence of a single minor chronic disease such as migraines, depression, or hyperlipidemia.

2 Recent History of Significant Acute Disease

Identified by the presence within the most recent six month period of one or more significant acute diseases or procedures. No chronic diseases are present. Examples are: pneumonia, blood transfusion, or bacterial infections.

1 Healthy Identified by the absence of any chronic disease or significant acute disease or procedures. Minor acute disease may be present such as upper respiratory infection, appendicitis, or ear infection.

5

Disease Classifications

The following classifications are used throughout this report to describe a specific type of medical

condition. They are based on the terminology and definitions used to define a CRG.

A Dominant Chronic (DC) disease is a serious lifelong chronic disease which usually leads to the

progressive deterioration of health.

A Moderate Chronic (MC) disease is a serious chronic disease which does not typically lead to the deterioration of health but does contribute to the individual’s overall health and future need for medical care. A Minor Chronic (MinC) disease is a chronic disease that can be managed successfully and has limited effect on the need for future care. A Significant Acute Illness (SA) can be a precursor to, or place the individual at risk for, the development of chronic illness. A Minor Acute (A) illness is limited in duration and does not increase the risk of developing a chronic disease.

6

Healthy 2,775,004

69%

Any Other Health Status

1,251,794 31%


0% 2% 4% 6% 8% 10% 12%

Significant Acute Disease

Single Minor Chronic Disease

Minor Chronic Disease in Multiple OrganSystems

Single Dominant or Moderate Chronic Disease

Significant Chronic Disease in Multiple OrganSystems

Dominant Chronic Disease in Three or MoreOrgan Systems

Dominant, Metastatic and ComplicatedMalignancies

Catastrophic Conditions

6.3%

5.2%

0.8%

10.2%

6.5%

0.8%

0.3%

0.9%

Health of the Medicaid Population

Overall, 69 percent of the Medicaid

population is classified as healthy. A

healthy status is assigned to all individuals

in the population with Medicaid services

that do not meet the clinical criteria

indicating the presence of a significant

acute illness or chronic disease during the

study period as well as those individuals

who have not received any service.

Thirty-one percent of Medicaid’s total population is categorized as other than healthy. The largest

portion of this group (10%) is in the Single Dominant or Moderate Chronic Disease health status.

Figure 1: Percentage of Medicaid Recipients Categorized as Healthy Compared to Any of the Other Eight Health Statuses,

August 2014-July 2015

Figure 2: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status, August 2014-July 2015

7


SSI-Related Eligibility

Group 1,026,575

25% Family-Related

Eligibility Group

3,000,223 75%

The demographic composition of the

Medicaid population plays a role in the

health of the population. The Medicaid

population is divided into two main eligibility

groups. The SSI-Related eligibility group

consists of individuals who meet the age or

disability standards for Supplemental

Security Income (SSI). The Family-Related

eligibility group consists of children and

families who meet Medicaid eligibility

standards. The largest number of Medicaid

recipients (75%) is in the children and

families group.

The Family-Related eligibility group

is typically younger and healthier as

their eligibility is based either on

age for the under 21 population or

the existence of dependent children

for the over 21 population.

By definition, the aged

and disabled population

is older or has a

disability. They

comprise 25 percent of

the Medicaid

population. Overall,

Medicaid’s population is

largely comprised of

children less than 21

years of age.

Figure 5: Distribution of Medicaid Population by Age and Eligibility Group, August 2014-July 2015

Figure 3: Percentage of Medicaid Population in the Family-Related Eligibility Group as Compared to the SSI-Related Eligibility Group,


Figure 4: Percentage of SSI-Related Eligibility Group and Family-Related Eligibility Group in the Healthy Category as Compared to One of the Other Eight Health

Statuses, August 2014-July 2015

0%

25%

50%

75%

SSI-Related Eligibility Group Family-Related Eligibility Group

Healthy 50.4%

Healthy 75.3% Other

49.6% Other 24.7%

0%

20%

40%

60%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

0.1% 3.4% 1.7% 1.7% 3.1% 4.6%

9.1%

1.9% 6.3%

51.0%

8.4% 5.9%

2.4% 0.4% 0.0% 0.0%


8


0%

20%

40%

60%

80%

100%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

73

.2%

78

.0%

65

.2%

55

.6%

43

.3%

35

.4%

64

.9%

50

.0%

26

.8%

22

.0%

34

.8%

44

.4%

56

.7%

64

.6%

35

.1%

50

.0%

Healthy Any Other Health Status

0%

25%

50%

75%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

20

.5%

45

.3%

51

.0%

45

.9%

39

.0%

35

.0%

64

.9%

50

.0%

73

.7%

80

.1%

68

.0%

58

.4%

48

.8%

39

.5%

39

.0%

34

.4%


Typically, the burden of illness increases as the population ages. In Medicaid, the percentage of non-

healthy individuals follows this pattern beginning with the 21-31 age group until it reaches the 65-84 age

group when the burden of illness declines. The decline may be attributed to an increase in number of

individuals in the 65 and older group who, because of age and income, are now eligible to receive both

Medicaid and Medicare. Once that occurs, Medicaid no longer receives pharmacy claims and encounter

data for Medicare Part D recipients, a key component in determining health status. Thus, the CRG

assignments for the 65 and older age groups likely underestimate the true burden of illness for these

age groups. In addition, new entrants to Medicaid who are eligible solely due to age and income rather

than disability status change the composition of the 65 and older group making it relatively healthier.

The increase in the percentage of healthy recipients among 65 to 84 year olds is observed only for

recipients in the SSI-Related eligibility group, suggesting the loss of pharmacy data and the change in

the population’s composition are the likely explanations for the increase in the percentage of healthy

recipients among those 65 and older.

Figure 6: Percentage of Age Groups Classified as Healthy, August 2014-July 2015

Figure 7: Percentage of Age and Eligibility Groups Classified as Healthy, August 2014-July 2015

9


0%

25%

50%

75%

Healthy Any Other Health Status

Female 67.9%

Female 32.1%

Male 70.2%

Male 29.8%

Female 56%

Male 44%

The majority of Medicaid recipients were in

enrolled in the managed care program

during the study period. Only 16 percent of

the Medicaid population was in the fee-for-

service program. Medicaid enrollees were

unevenly distributed across MMA health

plans. Eighty percent of the Medicaid

population was enrolled in a Standard Plan

and 3.6 percent was enrolled in a Specialty

Plan.

Figure 9: Percentage of Medicaid Population by Gender,

August 2014 -July 2015

Figure 8: Percentage of Females and Males Classified as Healthy, August 2014-July 2015

The health status of the Medicaid

population varies only slightly by

gender. About 56 percent of the

Medicaid population is female.

Figure 10: Percentage of Medicaid Population in Standard Plan, Specialty Plan, and FFS,


Standard Plans 80.2%

FFS 16.2%

Specialty Plans 3.6%

10

Figure 12: Number of Enrollees in a Specialty Plan, August 2014-July 2015

Figure 11: Percentage of Specialty Plan Enrollees Classified as Healthy, August 2014-July 2015


Healthy and ill enrollees

are unevenly

distributed across

health plans. With the

exception of Sunshine

Specialty, Specialty

Plans are designed to

serve enrollees with a

serious illness and have

a larger percentage of

enrollees with serious

illnesses.

The two HIV/AIDS Specialty plans

have the smallest number of

enrollees among Specialty plans.

Together, they account for less

than nine percent of all Specialty

plan enrollees.

Some enrollees in Positive and Clear Health were classified as healthy because they did not have any HIV

or AIDS related hospital or outpatient medical services, and in some instances, their drug prescriptions

were covered by Medicare Part D and thus were not present in Medicaid encounter data. Information

necessary for a health status determination was thus lacking in the data. The 32 percent of CMS

enrollees who are healthy likely results from the policy in place at the time allowing siblings who did not

meet the CMS criteria to also enroll in CMS plan. Given that mental illness can fluctuate in its severity

and expression, some Magellan enrollees may be classified as healthy during periods when their mental

illness is in remission or is being controlled.

Note: Because enrollees may be in different programs or plans over the course of the study period,

totals by plan or program associate a person’s CRG with the number of member months the person

was enrolled in a plan or the FFS program.

Healthy Determined by Services-All Standard Plans Healthy Determined by Services-FFS Healthy Determined by Services-All Specialty Plans Healthy No Services Healthy Determined by Services-Specialty Plan Status Other than Healthy

0%

25%

50%

75%

100%

SunshineSpecialty

AggregateStandard

Fee ForService

AggregateSpecialty

CMS Positive Magellan ClearHealth

60

.7%

55

.4%

32

.5%

31

.6%

28

.3%

26

.8%

23

.1%

22

.4%

3.9% 12.4%

41

.4%

4.6% 3.5% 10.0% 7.0% 3.5%

35

.5%

32

.3%

26

.2%

63

.8%

68

.2%

63

.2%

70

.0%

74

.1%

-

20,000

40,000

60,000

80,000

CMS Magellan SunshineSpecialty

ClearHealth

Positive

65,599

45,136

22,428

10,050 1,957

Note: See page one for a description of specialty plan populations.

11


Community Care has the largest percentage of healthy enrollees of any Standard plan. The fee-for-

service program has the second largest percentage of healthy recipients. The percentage of healthy

enrollees in a Standard plan ranges from a low of 60 percent for Simply to a high of 77 percent for

Community Care. Some recipients are categorized as healthy because they received no services through

Medicaid. Over a third (41%) of FFS recipients are non-users of Medicaid services. The largest portion

of these non-users (69%) are classified as Qualified Medicare Beneficiaries or SSI recipients for whom

Medicaid receives Medicare claim information but no prescribed drug information likely due to their

Medicare Part D drug coverage. It is possible that if Medicaid received the drug information, these

recipients could be assigned a status other than healthy.

0%

25%

50%

75%

100%

61

.8%

59

.6%

57

.0%

57

.0%

56

.8%

56

.3%

55

.6%

55

.5%

55

.4%

55

.4%

54

.8%

54

.1%

54

.1%

50

.0%

48

.6%

32

.5%

31

.6%

15.0% 13.0% 14.1% 14.2% 10.2% 13.8% 13.3% 16.0% 14.0% 12.4% 10.9% 11.2% 12.2% 19.8% 11.4%

41

.4%

4.6% 2

3.2

%

27

.4%

28

.9%

28

.8%

33

.0%

29

.9%

31

.1%

28

.5%

30

.5%

32

.3%

34

.4%

34

.6%

33

.7%

30

.2%

40

.0%

26

.2%

63

.8%

Figure 14: Number of Enrollees in a Standard Plan, August 2014-July 2015

Fee For Service Standard Plan

Staywell is the largest Standard plan accounting for 23.5 percent of all Standard plan enrollees.

In contrast, Community Care accounts for 1.5 percent of all Standard plan enrollees.

Figure 13: Percentage of Standard Plan Enrollees Classified as Healthy, August 2014-July 2015

Healthy Determined by Services-All Standard Plans Healthy Determined by Services-FFS Healthy Determined by Services-All Specialty Plans Healthy No Services Healthy Determined by Services-Standard Plan Status Other than Healthy

-

250,000

500,000

750,000

75

7,9

31

65

1,9

02

46

8,6

22

37

4,7

50

35

8,4

45

34

9,4

32

30

4,9

55

12


70.0% - 74.9%

65.0% - 69.9%

60.0% - 64.9%Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10Ft. Lauderdale

Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

The map displays the percentage of Medicaid recipients in each region with a status of healthy. A larger

percentage of Medicaid recipients in Regions 9 and 10 as compared to other regions are categorized as

healthy. Regions 1, 2, and 5 have the smallest percentage of healthy recipients in the state.

Note: Because enrollees may be in different regions over the course of the study period, these totals associate

a person’s CRG with the number of member months a person resided in a region.

Figure 15: Percentage of Regions’ Recipients with a Healthy Status, August 2014-July 2015

13

- 20 40 60 80 100

Asthma

SA

SA Procedure

HBP

Presistent SA

ADHD

2+ MinC

HLD

DB

Schizop

Thousands


Healthy 2,775,004

69%


14%


17%

Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims Information,

August 2014-July 2015.

Top Illnesses of the Medicaid Population

Overall

Detailed clinical risk group

categories are ranked in

order of most to least

frequent to identify the

most common illnesses in

the Medicaid population.

Asthma is the most

prevalent illness across all

Medicaid recipients.

Three of the top ten

illnesses are acute rather

than chronic.

Asthma is a chronic

disease affecting the

lungs. It causes episodes

of wheezing,

breathlessness, chest

tightness, and coughing

which may limit a person’s

daily activities. However,

it can be controlled by

medication and

environmental changes.

Figure 16: Top 10 Non-Healthy CRGs for the Medicaid Population, August 2014-July 2015

ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MinC Minor Chronic HLD Hyperlipidemia SA Significant Acute Disease HBP Hypertension Schizop Schizophrenia

Note: Higher levels of severity indicate a greater extent and progression of the chronic disease.

14



0 10 20 30

HBP

DB & HBP

Schizop

SA Procedure

2 MC

DB

HIV

DB & MC

ADHD

SA

Thousands

SSI-Related

0 50 100

Asthma

SA

SA Procedure

Persistent SA

ADHD

HBP

HLD

2+ MinC

2+ SA

Endocrine MC

Thousands

Family-Related

Healthy 517,307

50%


15%


35%

Healthy 2,257,697

75%


15%


10%

SSI and Family

Among individuals in the

SSI-Related eligibility

group, hypertension is the

leading illness and only

one of the top five

illnesses is acute. Among

individuals in the Family-

Related eligibility group

asthma is the leading

illness and three of the

top five illnesses are

acute.

Hypertension is high

blood pressure, a

common and potentially

dangerous condition that

increases the risk of heart

attack and stroke. It

occurs when the pressure

of the blood in a person’s

blood vessels is higher

than it should be.

Hypertension can be

managed to lower the risk

of heart disease and

stroke.

Figure 17: Top 10 Illnesses of the Medicaid Population by Eligibility Group, August 2014-July 2015



ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease HLD Hyperlipidemia MinC Minor Chronic HBP Hypertension SA Significant Acute Disease Schizop Schizophrenia

15



0 50 100

Asthma

ADHD

SA

SA Procedure

Presistent SA

DD

Epilepsy

HLD

Schizop

Endocrine MC

Thousands

Age 1-20

Healthy 188,619

73%


21%


6%

Healthy 1,708,262

78%


14%


8%

0 10 20

SA

SA Procedure

Presistent SA

Asthma

2+ SA

DD

VASD

HLD

Osteo

Endocrine MC

Thousands

Age <1

Figure 18: Top 10 Illnesses of the Medicaid Population from Birth to 20, August 2014-July 2015

By Age

Acute illnesses and

asthma dominate the top

illnesses of newborns

under the age of one.

Asthma, attention deficit /

hyperactivity disorder,

and acute illnesses

dominate the illnesses of

children between the ages

of one and twenty.

An acute illness is

characterized by a rapid

onset and time limited

duration. It does not

place the individual at risk

for development of a

chronic disease.


ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DD Developmental Delay DC Dominant Chronic Disease HLD Hyperlipidemia MC Moderate Chronic Disease Osteo Osteoarthritis SA Significant Acute Disease Schizop Schizophrenia VASD Ventricular and Atrial Septal Defects


16


0 5 10 15

SA

HBP

Presistent SA

SA Procedure

Asthma

2+ MinC

Schizop

HLD

2+ SA

Obesity

Thousands

Age 21-31

0 10 20

HBP

2+ MinC

SA

SA Procedure

HLD

Presistent SA

2 MC

DB

Schizop

DB & HBP

Thousands

Age 32-42

0 5 10 15

HBP

DB & HBP

HIV

2+ MinC

DB

2 MC

HLD

DB & MC

MC & C

Schizop

Thousands

Age 43-53

Healthy 170,775

56% Top 10

Illnesses 59,860

19%


25% Healthy 95,890

43%


24%


33%

Figure 19: Top 10 Illnesses of the Medicaid Population Twenty-one Years of Age or Over, August 2014-July 2015

Among adults 21 years and older, acute illness becomes less prevalent as individuals age, and hypertension becomes more prevalent, dominating illnesses for adults in Medicaid through their 30s, 40s, 50s, 60s, 70s, and mid-80s. Chronic illnesses such as diabetes, HIV, and Chronic Obstructive Pulmonary Disease become more common for adults in their 40s and older. Dementing illnesses and Alzheimer’s become the dominant illnesses for adults 85 and over. Alzheimer’s disease involves parts of the brain that control thought, memory, and language and over time can seriously affect a person’s ability to carry out daily activities. Although the cause is still unknown, it is believed to be influenced by a mix of genetic, environmental, and lifestyle factors.



Healthy 262,926

65%


17%


18%

17


0 5 10 15

HBP

DB & HBP

DB & MC

2 MC

HIV

DB

DB & HBP & DC

2+ MinC

COPD & MC

MC & C

Thousands

Age 54-64

0 5 10 15

HBP

SA Procedure

DB & HBP

DB

Dementia & MC

2 MC

DB & MC

SA

Alzheimer's

DB & DC

Thousands

Age 65-84

0 2 4

Dementia & MC

Alzheimer's

SA Procedure

HBP

CHF

Presistent SA

DB & DC

COPD & DC

2 MC

DB

Thousands Age 85+

Healthy 38,252

50%


20%


30% Healthy 71,843

35%


24%


41% Healthy 238,437

65%


13%


22%



CHF Congestive Heart Failure 2+ Two or More COPD Chronic Obstructive Pulmonary Disease C Chronic DB Diabetes DC Dominant Chronic Disease HLD Hyperlipidemia MC Moderate Chronic Disease HBP Hypertension MinC Minor Chronic Schizop Schizophrenia SA Significant Acute Disease

18



0 20 40 60

SA

HBP

Asthma

SA Procedure

Presistent SA

2+ MinC

HLD

DB

ADHD

2 MC

Thousands

Female

0 20 40 60

Asthma

ADHD

SA

SA Procedure

Presistent SA

HBP

Schizop

HLD

DD

2+ MinC

Thousands

Male

Healthy 1,241,662

70%


15%


15%

Healthy 1,533,342

68%


14%


18%

By Sex

Acute illnesses, asthma,

and hypertension are the

most common illnesses

for girls and women in

Medicaid. Acute illnesses

are also among the most

common illnesses for boys

and men in Medicaid,

however asthma and

attention deficit/

hyperactivity disorder are

the leading illnesses for

boys and men.

ADHD is a chronic

condition characterized by

an inability to focus, over-

activity, and/or an

inability to control

behavior which can

interfere with normal

functions and

development. It can be

treated with medications

and therapies.

Figure 20: Top 10 Illnesses of the Medicaid Population by Sex, August 2014-July 2015



ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease DD Developmental Delay MinC Minor Chronic HLD Hyperlipidemia SA Significant Acute Disease HBP Hypertension

Schizop Schizophrenia

19



0 100 200

SA Procedure

SA

HBP

DB

Persistent SA

Asthma

Schizop

2 MC

DB & HBP

DB & MC

Thousands

FFS

Healthy 6,115,807

74%


9%

Other llnesses

1,398,859 17%

0 500 1000

Asthma

SA

ADHD

Presistent SA

SA Procedure

HBP

2+ MinC

HLD

Schizop

Endocrine MC

Thousands

MMA Plans

Top 10 Illnesses

5,443,232 16%

Other Illnesses

6,113,859 18%

By MMA Plan

Asthma and attention

deficit / hyperactivity

disorder are the only non-

acute illnesses among the

top 5 illnesses for MMA

Plans. In contrast,

hypertension and

diabetes are the only non-

acute illnesses among the

top 5 illnesses for the Fee-

for-Service population.

Figure 21: Top 10 Illnesses of the Fee-for-Service and MMA Populations, August 2014-July 2015



ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease HLD Hyperlipidemia MinC Minor Chronic HBP Hypertension SA Significant Acute Disease Schizop Schizophrenia

Note: Because enrollees may be in different programs or plans over the course of the study period,

totals by plan or program associate a person’s CRG with the number of member months the person was

enrolled in a plan or the FFS program.

Healthy

22,705,103

66%

20


0 500 1000

Asthma

SA

Presistent SA

SA Procedure

HBP

ADHD

2+ MinC

HLD

Endocrine MC

DB & HBP

Thousands

Aggregated Standard


0 100 200 300

Asthma

SA

ADHD

Presistent SA

HLD

Thousands Staywell

0 50 100 150

Asthma

SA

SA Procedure

ADHD

Presistent SA

Thousands Sunshine

0 50 100 150

Asthma

SA

Presistent SA

SA Procedure

ADHD

Thousands Amerigroup

0 50 100 150

Asthma

HBP

SA

SA Procedure

Presistent SA

Thousands Humana Healthy

22,127,888 68%

Top 10 Illnesses

5,145,217 16%

Other Illnesses

5,394,281 16%

Figure 22: Top 10 Illnesses of Standard Plan Enrollees, August 2014-July 2015

Maximum axis values and population sizes vary

between the MMA Plans.

Asthma, acute illness, and hypertension are among

the top illnesses for Standard plans although the order

of prevalence varies from plan to plan.


ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More DB Diabetes MC Moderate Chronic Disease HLD Hyperlipidemia MinC Minor Chronic HBP Hypertension SA Significant Acute Disease

21


0 50 100

Asthma

SA

HBP

ADHD

Presistent SA

Thousands Prestige

0 20 40 60 80

Asthma

SA

HBP

ADHD

Presistent SA

Thousands United

0 20 40 60

Asthma

SA

SA Procedure

Presistent SA

HBP

Thousands Molina

0 10 20 30 40

Asthma

HBP

SA Procedure

SA

Presistent SA

Thousands Simply

0 10 20 30

Asthma

SA

SA Procedure

Presistent SA

HBP

Thousands Better Health

0 10 20 30

Asthma

SA

Presistent SA

ADHD

HBP

Thousands Integral

0 5 10 15 20

SA Procedure

Asthma

SA

HBP

Presistent SA

Thousands Coventry

0 5 10 15

Asthma

SA

SA Procedure

ADHD

Presistent SA

Thousands Community Care

0 5 10

HBP

Asthma

SA

SA Procedure

Presistent SA

Thousands Preferred

0 5 10

Asthma

ADHD

SA

HBP

Presistent SA

Thousands First Coast

Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or

program associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS

program.

22


Healthy 7,795 37%


59%

Other Illnesss

827 4%

Healthy 28,164

26%


68%

Other Illnesses

6,477 6%

0 20 40 60 80

HIV

Dial w/o DB

SA Procedure

SA

HBP

Persistent SA

Asthma

DB

Dial w DB

Endocrine MC

Thousands Clear Health

0 5 10 15

HIV

HBP

Dial w/o DB

Endocrine MC

Dial w DB

SA

Persistent SA

SA Procedure

Asthma & MC

Schizop

Thousands Positive

DB Diabetes MC Moderate Chronic Disease Dial Dialysis SA Significant Acute Disease HBP Hypertension Schizop Schizophrenia

The population size is significantly

higher in Clear Health than in Positive

Health Care.

HIV is the predominant disease among enrollees

in Clear Health and Positive, the two HIV/AIDS

Specialty Plans.



Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or program

associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS program.

Figure 23: Top 10 Illnesses of HIV/AIDS Specialty Plan Enrollees, August 2014-July 2015

23

Healthy 165,103

65%


25%


10%

0 5 10 15

ADHD

Asthma

DD

SA

Schizop

Persistent SA

SA Procedure

DBD

CMH Dx

DOP

Thousands

Sunshine Specialty


0 20 40 60

ADHD

Asthma

DD

PDD

Epilepsy

DC & MC

Asthma & DC

CQDH

Persistent SA

SA

Thousands

CMS

Healthy 238,113

32%


33%

Other Illnesss

265,712 35%

Attention deficit / hyperactivity disorder, asthma, and developmental delay are the predominant diseases

among enrollees in CMS, the Specialty Plan for children with chronic conditions, and Sunshine Specialty,

the Specialty Plan for Child Welfare.

CMH Dx Chronic Mental Health Diagnoses - Moderate DC Dominant Chronic Disease CQDH Congenital Quadriplegia, Diplegia or Hemiplegia MC Moderate Chronic Disease DOP Depressive and Other Psychoses SA Significant Acute Disease DD Developmental Delay PDD Pervasive Development Disorder Schizop Schizophrenia

Figure 24: Top 10 Illnesses of Children’s Specialty Plan Enrollees, August 2014-July 2015


24

0 10 20 30 40

Schizop

Dementia & DC

Schizop & MC

HBP

Dep

2+ MinC

DOP

ADHD

BiP

PsyD & MC

Thousands Magellan


Healthy 138,040

30%


34%


36%



Figure 25: Top 10 Illnesses of Severe Mental Illness Specialty Plan Enrollees, August 2014-July 2015

The most common diseases among enrollees in Magellan, the Specialty Plan for serious mental illness, are schizophrenia, dementia, hypertension, and depression. Schizophrenia is a chronic severe mental disorder which requires lifelong treatment. It is characterized by abnormal behavior and an inability to understand what is real. Symptoms include hallucinations, delusions, and extremely disordered thinking and behavior.




program.

ADHD Attention Deficit / Hyperactivity Disorder 2+ Two or More BiP Bi-Polar Disorder DC Dominant Chronic Disease Dep Depression MC Moderate Chronic Disease DOP Depressive and Other Psychoses MinC Minor Chronic HBP Hypertension PsyD Psychiatric Disease Excluding Schizophrenia Schizop Schizophrenia

25


Asthma, attention deficit / hyperactivity disorder, significant acute illness, and

hypertension, are among the most common illnesses in most Florida regions. The order

of prevalence varies slightly from region to region.

Note: Because enrollees may be in different regions over the course of the study period, these totals associate a

person’s CRG with the number of member months a person resided in a region.

Figure 26: Top 5 Illnesses by Region, August 2014-July 2015

26


0% 2% 4% 6% 8% 10% 12%

Significant Acute Disease

Single Minor Chronic Disease

Minor Chronic Disease in Multiple OrganSystems

Single Dominant or Moderate Chronic Disease

Significant Chronic Disease in Multiple OrganSystems

Dominant Chronic Disease in Three or MoreOrgan Systems

Dominant, Metastatic and ComplicatedMalignancies

Catastrophic Conditions

6.3%

5.2%

0.8%

10.2%

6.5%

0.8%

0.3%

0.9%

Top Illnesses by Health Status Each of the 8 non-healthy health statuses is defined by a specific set of illnesses. Within each health

status, detailed CRG categories are ranked in order of most to least frequent to examine which illnesses

dominates each health status. This allows us to see which illnesses are most common among Medicaid

recipients with chronic illnesses.

Figure 27: Percentage of Medicaid Population Classified in a Non-Healthy Status by Health Status, August 2014-July 2015

27

Top Illness 16,235

44%

Illnesses 2-11

20,872 56%

- 5 10 15 20

HIV Disease

Dialysis without Diabetes

Dialysis with Diabetes

Congenital Quadriplegia, Diplegia orHemiplegia

Spina Bifida

Acquired Quadriplegia or PermanentVegetative State

Cystic Fibrosis

History of a Major Organ Transplant

Dependence on a Mechanical Ventilator

Progressive Muscular Dystrophy or SpinalMuscle Atrophy

Total Parenteral Nutrition

Thousands

Level 1 Level 2 Level 3 Level 4



Health Status 9-Catastrophic Conditions

A Catastrophic Conditions

health status is assigned

to an individual when one

of eleven chronic illnesses

is present. The chart to

the left lists each of the

illnesses and displays its

prevalence across the

population. It also

displays the number of

people within each

severity level.

HIV is the most prevalent

disease affecting 44

percent of those with a

catastrophic condition.

Fifty-six percent of people

with HIV are categorized

as severity level 1 or the

least severe.

Figure 29: Top Catastrophic Conditions Compared to All Other Conditions, August 2014-July 2015

Figure 28: Number of Recipients with Health Status 9 by CRG and Level of Severity, August 2014-July 2015


28

0%

1%

2%

3%

4%

5%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

0.3% 0.3%

0.9%

1.7%

4.0% 4.1%

1.1%

0.5%


0%

2%

4%

SSI-Related EligibilityGroup

Family-RelatedEligibility Group

3.1%

0.2%

0.0%

0.5%

1.0%

1.5%

Female Male

0.8%

1.1%

He

alth

Sta

tus

9 –

Cat

astr

op

hic

Co

nd

itio

ns

A larger percentage of recipients that

are eligible for Medicaid because they

are aged or disabled have a

catastrophic condition as compared to

recipients in the Family-Related

eligibility group.

A larger percentage of

recipients between the

ages of 43 and 64 have a

catastrophic condition

compared to recipients in

other age groups.

A slightly larger percentage of males

than females have a catastrophic

condition.

Figure 30: Percentage of Eligibility Groups with a Catastrophic Condition, August 2014-July 2015

Figure 31: Percentage of Age Groups with a Catastrophic Condition, August 2014-July 2015

Figure 32: Percentage of Females and Males with a Catastrophic Condition, August 2014-July 2015

29

0%

2%

4%

6%

8%

7.9%

1.2% 0.9%

0.8% 0.8% 0.7% 0.7% 0.6% 0.5% 0.5% 0.5% 0.5% 0.5% 0.5% 0.4% 0.3%


0%

25%

50%

75%

ClearHealth

Positive AllSpecialty

CMS Magellan FFS AllStandard

SunshineSpecialty

64.7%

56.7%

7.9% 4.9%

1.3% 1.2% 0.6% 0.2%

Only 0.9 percent of Medicaid recipients are classified in the Catastrophic Conditions health status.

Almost eight percent of all Specialty Plans’ enrollees are classified with a Catastrophic Conditions health

status. Sunshine Specialty Plan has the smallest percentage of enrollees with this health status

category. Positive and Clear Health, the two HIV Specialty Plans, have the largest percentage of

enrollees with a Catastrophic Conditions health status.

A very small percentage of Standard Plans’ enrollees have a health status of Catastrophic Conditions.

Overall, only 0.6 percent of the enrollees in a Standard plan are in this health status. A little over one

percent of recipients in the fee-for-service program are classified in the Catastrophic Conditions

category.

Figure 34: Percentage of Standard Plan Enrollee Months with a Catastrophic Condition, August 2014-July 2015

He

alth Statu

s 9 – C

atastrop

hic C

on

ditio

ns



program.

Aggregated Specialty Plans Specialty Plan Aggregated Standard Plans Fee-for-Service

Standard Plan Aggregated Specialty Plans Fee-for-Service

Figure 33: Percentage of Specialty Plan Enrollee Months with a Catastrophic Condition, August 2014-July 2015

30


1.00% - 1.40%

0.70% - 0.99%

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Regions 4, 9, 10, and 11 are the only regions where more than 1 percent of the region’s recipients are

classified with a catastrophic condition.

Figure 35: Percentage of Regions’ Recipients with a Catastrophic Condition, August 2014-July 2015

Note: Because enrollees may be in different regions over the course of the study period, these totals associate a person’s

CRG with the number of member months a person resided in a region.

He

alth

Sta

tus

9 –

Cat

astr

op

hic

Co

nd

itio

ns

31

Top Illness 2,348 17%

Illnesses 2-10

9,292 67%

Other Illnesses

2,247 16%



0.0 0.5 1.0 1.5 2.0 2.5

Lung Malignancy

Digestive Malignancy

Other Malignancies

Breast Malignancy

Colon Malignancy

Brain and Central Nervous System Malignancies

Acute Lymphoid Leukemia

Kidney Malignancy

Pancreatic Malignancy

Ovarian Malignancy

Thousands


Health Status 8-Dominant, Metastatic or

Complicated Malignancies

A Dominant, Metastatic or

Complicated Malignancies

health status is assigned

when an individual has

one of 22 dominant or

chronic malignancies.

Each of the malignancies

is divided into one of four

severity levels.

The following chart

depicts the ten most

prevalent malignancies

along with the severity

levels of individuals in this

health status. Most of the

individuals in this health

status are Severity Level 2

and 3. Digestive

Malignancy has the

largest number of

individuals in Severity

Level 4.

Lung malignancies are the

top illness with 17 percent

or nearly 3,000

individuals. Eighty-two

percent of the individuals

in this category have one

of the top ten chronic

illnesses.

Figure 37: Top Malignancy Compared to All Other Illnesses, August 2014-July 2015


32


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

0.0% 0.1% 0.1% 0.3%

1.1%

2.3%

1.0%

0.7%

0.0%

0.5%

1.0%

1.5%

SSI-Related Eligibility Group Family-Related EligibilityGroup

1.2%

0.0%

0.0%0.1%0.2%0.3%0.4%0.5%

Female Male

0.3% 0.4%

He

alth

Sta

tus

8 -

Do

min

ant,

Me

tast

atic

or

Co

mp

licat

ed M

alig

nan

cie

s

There is little difference by gender in

the percentage of recipients in the

metastatic health status.

Figure 38: Percentage of Eligibility Groups with a Malignancy, August 2014-July 2015

Figure 39: Percentage of Age Groups with a Malignancy, August 2014-July 2015

Figure 40: Percentage of Females and Males with a Malignancy, August 2014-July 2015

The percentage of

recipients with a metastatic

health status increases

among 43 to 53 year olds

and reaches its maximum

among 54 to 64 year olds.


recipients in the SSI-


than Family-Related

eligibility group have a

dominant, metastatic,

or complicated

malignancy. From

Health Status 9 through

Health Status 4, a larger

percentage of recipients

in the SSI-Related

eligibility group have

the health status than

the Family-Related

eligibility group.

33



0.00%

0.25%

0.50%

0.75%

0.58%

0.42% 0.40%

0.33% 0.30%

0.28% 0.28% 0.27% 0.27% 0.22% 0.21% 0.21% 0.20% 0.19% 0.19%

0.16%

Only 0.3 percent of the Medicaid population is classified in Dominant, Metastatic, or Complicated

Malignancies. On average, Specialty Plans had 0.4 percent of their enrollees in this health status. CMS

had the largest percentage of enrollees of all the Specialty Plans. Fee-for-service has the largest

percentage of recipients in this category.

Overall, 0.3 percent of Standard Plans’ enrollees are in this category. United has the largest percentage

of Standard Plan enrollees in this health status with 0.42 percent.

0.00%

0.25%

0.50%

0.75%

FFS CMS Magellan All Specialty All Standard Clear Health Positive SunshineSpecialty

0.58% 0.56%

0.43% 0.40%

0.25%

0.11% 0.08%

0.04%

Figure 41: Percentage of Specialty Plan Enrollee Months with a Malignancy, August 2014-July 2015



program.

He

alth Statu

s 8 - D

om

inan

t, Me

tastatic or C

om

plicated

Malign

ancie

s


Standard Plan

Aggregated Specialty Plans

Fee-for-Service

Figure 42: Percentage of Standard Plan Enrollee Months with a Malignancy, August 2014-July 2015

34


0.40% - 0.42%

0.30% - 0.39%

0.20% - 0.29% Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

A larger percentage of recipients in Regions 5 than any other region are in the dominant metastatic

health status. Regions 6, 7, 8, and 9 have the smallest percentage of recipients in this health status.

Note: Because enrollees may be in different regions over the course of the study period, these totals

associate a person’s CRG with the number of member months a person resided in a region.

He

alth

Sta

tus

8 -

Do

min

ant,

Me

tast

atic

or

Co

mp

licat

ed M

alig

nan

cie

s

Figure 43: Percentage of Regions’ Population with Malignancies, August 2014-July 2015

35

0 3 6 9

Diabetes - Hypertension - Other Dominant ChronicDisease

Diabetes - 2 or More Other Dominant ChronicDiseases

Diabetes - COPD - Other Dominant Chronic Disease

Congestive Heart Failure - Diabetes - COPD

Chronic Renal Failure - Diabetes - Other DominantChronic Disease

Diabetes - Advanced Coronary Artery Disease -Other Dominant Chronic Disease

COPD - 2 or More Other Dominant ChronicDiseases

Congestive Heart Failure - Diabetes - OtherDominant Chronic Disease

Congestive Heart Failure - COPD - Other DominantChronic Disease

3 or More Other Dominant Chronic Diseases

Thousands


Top Illness 8,204 27%

Illnesses 2-10

17,404 56%

Other Illnesses

5,152 17%

Source: Florida Medicaid Managed Information System (FLMMIS) Eligibility, Encounter, and Claims

Information, August 2014-July 2015.

Health Status 7-Dominant Chronic Disease in Three

or More Organ Systems

Dominant Chronic Disease

in Three or More Organ

Systems is assigned when

an individual has one of

21 dominant or moderate

chronic illnesses in three

or more organ systems.

The combination of

illnesses is divided into

one of six severity levels.

The chart displays the top

ten combinations of

illnesses among this group

along with severity levels.

Diabetes and

hypertension are the most

common chronic illnesses

in this health status.

Diabetes has the most

individuals classified as

Severity Level 6, the most

severe. Less than 1

percent of the Medicaid

population is in this

category.

The top ten illnesses are

present in 83 percent of

the individuals in this

health status. Only 17

percent have a CRG below

the top 10.


Figure 45: Top Dominant Chronic Disease in Three or More Organ Systems Compared to All Other Illnesses,


36


- 10 20 30

Diabetes

Hypertension

Chronic Obstructive Pulmonary Disease

Congestive Heart Failure

Chronic Renal Failure

Advanced Coronary Artery Disease

Cerebrovascular Disease

Peripheral Vascular Disease

Other Dominant Chronic Disease

Thousands

Individuals in this health status by definition have more than one disease. The most frequent individual

illnesses among the combinations are shown in the following chart. Aside from the “other dominant

disease” category, diabetes is the most prevalent disease affecting 22 percent of this group.

He

alth

Sta

tus

7 -

Do

min

ant

Ch

ron

ic D

ise

ase

in T

hre

e o

r M

ore

Org

an S

yste

ms

Figure 46: Top 10 Individual Diseases, August 2014-July 2015

37


0%

1%

2%

3%

4%

5%

6%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

0.0% 0.0% 0.2% 0.7%

2.8%

5.6%

2.0%

2.9%

0%

1%

2%

3%


Family-Related EligibilityGroup

2.8%

0.1%

0%

1%

Female Male

0.8% 0.7%

He

alth

Sta

tus

7 -

Do

min

ant

Ch

ron

ic D

ise

ase

in T

hre

e o

r M

ore

Org

an S

yste

ms

Figure 49: Percentage of Females and Males with a Dominant Chronic Disease in 3 or More Organ Systems,



recipients in the SSI-Related

eligibility group than Family-

Related eligibility group are

classified in this health

status.

The percentage of

recipients with a

dominant chronic

disease in three or

more organ systems

increases among 43 to

53 year olds and

reaches its maximum

among 54 to 64 year

olds.

There is little difference by

gender in the percentage of

recipients with a dominant

chronic disease in three or more

organ systems.

Figure 47: Percentage of Eligibility Groups with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015

Figure 48: Percentage of Age Groups with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015

38


Only 0.8 percent of the Medicaid population is classified in this health status. Magellan, the serious

mental illness (SMI) Specialty Plan, has the largest percentage of enrollees in this category among the

Specialty Plans. Although mental health disease does not appear as one of the top ten illnesses, it is

included in the “other dominant chronic disease category.”

Simply and Humana are the Standard Plans with the largest percentage of enrollees in this category.

0%

1%

2%

3%

4%

5%

Magellan All Specialty FFS All Standard CMS Positive Clear Health SunshineSpecialty

4.79%

1.60%

0.89% 0.75% 0.44%

0.19% 0.15% 0.02%

0.0%

0.5%

1.0%

1.5%

2.0%

1.6%

1.4%

1.1% 1.0% 1.0% 0.9% 0.9%

0.7% 0.6% 0.6% 0.6% 0.6% 0.6% 0.5% 0.5%

0.4%

Figure 50: Percentage of Specialty Plan Enrollee Months with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015

Figure 51: Percentage of Standard Plan Enrollee Months with a Dominant Chronic Disease in 3 or More Organ Systems, August 2014-July 2015



program.

He

alth

Sta

tus

7 -

Do

min

ant

Ch

ron

ic D

ise

ase

in T

hre

e o

r M

ore

Org

an S

yste

ms



39


1.00% - 1.09%

0.60% - 0.99%Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Regions 1, 5, and 11 are the only regions where more than one percent of recipients are classified as

Dominant Chronic Disease in Three or More Organ Systems.

Note: Because enrollees may be in different regions over the course of the study period, these totals

associate a person’s CRG with the number of member months a person resided in a region.

He

alth Statu

s 7 - D

om

inan

t Ch

ron

ic Dise

ase in

Thre

e o

r Mo

re Organ

System

s

Figure 52: Percentage of Regions’ Population with a Dominant Chronic Disease in 3 or More Organ Systems Status, August 2014-July 2015

40

0 5 10 15 20 25

Diabetes and Hypertension

Two Other Moderate Chronic Diseases

Diabetes and Other Moderate Chronic Disease

One Other Moderate Chronic Disease and OtherChronic Disease Level 2

Schizophrenia and Other Moderate ChronicDisease

One Other Dominant Chronic Disease and One orMore Moderate Chronic Disease

Asthma and Other Moderate Chronic Disease

Dementing Disease and Other Moderate ChronicDisease

Dementing Disease and Other Dominant ChronicDisease

Psychiatric Disease (Except Schizophrenia) andOther Moderate Chronic Disease

Thousands


Top Illness 23,866

9%

Illnesses 2-10

122,952 47%


44%



Health Status 6-Significant Chronic Disease in Multiple

Organ Systems

Significant Chronic

Disease in Multiple Organ

Systems is assigned when


22 combinations of

dominant, moderate or

minor chronic illnesses

present in multiple organ

systems. 6.5 percent of

Medicaid recipients are in

this Health Status. It is

the third most prevalent

Health Status.

The top ten conditions are

present in 56 percent of

the individuals in this

Health Status. 44 percent

have one of the other

combinations of

conditions.

Figure 53: Number of Recipients with Significant Chronic Disease in Multiple Organ Systems by CRG and Level of Severity, August 2014-July 2015

Figure 54: Top Significant Chronic Diseases in Multiple Organ Systems Compared to All Other Illnesses, August 2014-July 2015

41


- 25 50 75

Diabetes

Asthma

Hypertension

Chronic Obstructive Pulmonary Disease

Dementing Disease

Schizophrenia


Psychiatric Disease (Except Schizophrenia)


Advanced Coronary Artery Disease

Thousands

Individuals in this health status by definition have more than one disease. The most frequent individual

illnesses among the combinations are shown in the following chart. Diabetes is the most prevalent

disease among Medicaid recipients in this category. Thirty-three percent of the individuals have

diabetes in combination with another chronic disease. Diabetes was also prevalent among recipients in

the previous Health Status 7. Mental illnesses are in the top ten illnesses in this health status but were

not uniquely identified in Health Status 7.

He

alth Statu

s 6 - Sign

ificant C

hro

nic D

isease

in M

ultip

le O

rgan Syste

ms

Figure 55: Top 10 Individual Chronic Diseases, August 2014-July 2015

42


0%

10%

20%

30%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

1.2% 1.6%

5.6%

11.2%

20.8%

29.4%

13.0%

19.8%

0%

10%

20%



18.4%

2.5%

0%

5%

10%

Female Male

7.3% 5.6%

He

alth

Sta

tus

6 -

Sig

nif

ican

t C

hro

nic

Dis

eas

e in

Mu

ltip

le O

rgan

Sys

tem

s

A slightly larger percentage of females

than males are classified with a

significant chronic disease in multiple

organ systems.

The percentage of

recipients with a

significant chronic

disease in multiple organ

systems increases with

age reaching its

maximum among 54 to

64 year olds.


recipients in the SSI-Related

eligibility group than Family-

Related eligibility group are

classified in this health status.

Figure 56: Percentage of Eligibility Groups with Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015

Figure 57: Percentage of Age Groups with Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015

Figure 58: Percentage of Females and Males with Significant Chronic Disease in Multiple Organ Systems,


43


0%

5%

10%

15%

15.2%

10.4%

8.0% 7.7% 7.2% 6.9% 6.8% 6.6% 6.3% 6.2% 5.6% 5.3% 5.1% 5.1% 4.8%

3.5%

0%

10%

20%

30%

Magellan AllSpecialty

CMS FFS AllStandard

SunshineSpecialty

ClearHealth

Positive

26.7%

15.2% 14.6%

6.8% 6.5%

2.9% 2.1% 1.6%

Magellan, the serious mental illness (SMI) Specialty Plan, has the largest percentage of enrollees with a

significant chronic disease in multiple organ systems among the Specialty Plans with over a quarter of its

enrollees classified in this health status.

Simply and Humana are the Standard Plans with the largest percentage of enrollees with a significant

chronic disease in multiple organ systems. On average, 15 percent of Specialty Plan enrollees as

compared to 6.5 percent of Standard Plan enrollees are classified in this health status.

Figure 59: Percentage of Specialty Plan Enrollee Months with Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015

Figure 60: Percentage of Standard Plan Enrollee Months with a Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015



program.

He

alth Statu

s 6 - Sign

ificant C

hro

nic D

isease

in M

ultip

le O

rgan Syste

ms



44


0.0% - 5.9%

8.0% - 8.9%

7.0% - 7.9%

6.0% - 6.9% Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Regions 1, 2 and 5 have the largest percentage of recipients classified with a Significant Chronic Disease

in Multiple Organ Systems.

Figure 61: Percentage of Regions’ Population with a Significant Chronic Disease in Multiple Organ Systems, August 2014-July 2015



He

alth

Sta

tus

6 -

Sig

nif

ican

t C

hro

nic

Dis

eas

e in

Mu

ltip

le O

rgan

Sys

tem

s

45

Top Illness 93,284

23%

Illnesses 2-10

206,346 50%


27%



- 20 40 60 80 100

Asthma

Hypertension

Diabetes

Schizophrenia

Chronic Endocrine, Nutritional, Fluid, Electrolyteand Immune Diagnoses - Moderate

Developmental Delay NOS / NEC / Mixed

Epilepsy

Chronic Obstructive Pulmonary Disease andBronchiectasis

Depressive and Other Psychoses

Obesity

Thousands


Health Status 5-Single Dominant or Moderate

Chronic Disease

Single Dominant or

Moderate Chronic Disease

is assigned when an

individual has one of 107

dominant or moderate

chronic illnesses. 10.2

percent of Medicaid

recipients are in this

Health Status. It is the

second most prevalent

Health Status after

healthy. Asthma and

hypertension are the most

common illnesses in this

health status. There are

slightly more individuals

with asthma and

hypertension than all the

other eight illnesses

combined. The largest

number of individuals

with a severity level two

has asthma.

73 percent of the

individuals in this health

status had one of the top

ten illnesses.

Figure 63: Top Dominant Chronic Disease Compared to All Other Illnesses, August 2014-July 2015


46


0%

5%

10%

15%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

6.4%

8.2%

11.5%

14.9%

16.7% 15.6%

11.5%

17.4%

0%

5%

10%

15%


Family-RelatedEligibility Group

15.1%

8.6%

0%

5%

10%

15%

Female Male

10.3% 10.2%

A larger percentage of recipients in

the SSI-Related eligibility group than

Family-Related eligibility group are

classified in this health status.

The percentage of

recipients with a single


chronic disease is

largest among the 85

and older age group,

although only by a

small amount

compared to 43 to 53

year olds.

There is little difference by gender in the

percentage of recipients with a single

dominant or moderate chronic disease.

Figure 64: Percentage of Eligibility Groups with Single Dominant or Moderate Chronic Disease, August 2014-July 2015

He

alth

Sta

tus

5 -

Sin

gle

Do

min

ant

or

Mo

de

rate

Ch

ron

ic D

ise

ase

Figure 66: Percentage of Females and Males with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015

Figure 65: Percentage of Age Groups with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015

47


0%

10%

20%

30%

CMS AllSpecialty

Magellan SunshineSpecialty

AllStandard

FFS ClearHealth

Positive

29.0%

23.0% 22.8%

16.3%

10.5% 8.7%

3.3% 2.8%

0%

5%

10%

15%

20%

25% 23.0%

12.9%

11.0% 10.9% 10.8% 10.5% 10.1% 9.9% 9.9% 9.9% 9.7% 9.5% 9.5% 9.4% 8.7% 8.7%

Among Specialty Plans, CMS has the largest percentage of enrollees with a Single Dominant or moderate

chronic disease. Clear Health and Positive have the smallest percentage.

On average, 23 percent of Specialty Plan enrollees are classified in this health status as compared to 11

percent of Standard Plan enrollees. Simply and Humana are the Standard Plans with the largest

percentage of enrollees classified in this health status.



program.

He

alth Statu

s 5 - Sin

gle Do

min

ant o

r Mo

de

rate C

hro

nic D

isease



Figure 67: Percentage of Specialty Plan Enrollee Months with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015

Figure 68: Percentage of Standard Plan Enrollee Months with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015

48


9.0% - 9.9%

12.0% - 12.9%

11.0% - 11.9%

10.0% - 10.9% Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Region 2 has the largest percentage of recipients with a Single Dominant or moderate chronic disease.

Regions 9 and 10 have the smallest percentage of recipients with this health status.

Note: Because enrollees may be in different regions over the course of the study period, these totals associate a person’s CRG

with the number of member months a person resided in a region.

He

alth

Sta

tus

5 -

Sin

gle

Do

min

ant

or

Mo

de

rate

Ch

ron

ic D

ise

ase

Figure 69: Percentage of Regions’ Population with a Single Dominant or Moderate Chronic Disease, August 2014-July 2015

49



- 50 100 150

Asthma

Diabetes

Hypertension

Chronic Obstructive Pulmonary Disease andBronchiectasis

Schizophrenia


Chronic Endocrine, Nutritional, Fluid,Electrolyte and Immune Diagnoses - Moderate

Dementing Disease

Developmental Delay NOS / NEC / Mixed


Thousands

Health Status 5 Health Status 6 Health Status 7

Comparing Health

Status 5, 6, and 7

Health Status categories

5, 6, and 7 include

individuals who have one

or more dominant or

moderate illnesses. 17.5

percent of the Medicaid

population is categorized

in the three health

statuses combined. The

top ten individual illnesses

across all three health

statuses are shown in the

chart. Asthma, diabetes,

and hypertension are the

most prevalent illnesses

among Medicaid

recipients with a


chronic disease alone or in

combination.

Figure 70: Top 10 Chronic Diseases Across Health Statuses 5, 6, and 7, August 2014-July 2015

50



- 10 20 30 40

Multiple Minor ChronicPCDs

Thousands


Health Status 4-Minor Chronic Disease in Multiple Organ

Systems

Note: The CRG software does not identify the specific illnesses associated with the individuals in this

health status.

Minor Chronic Disease in

Multiple Organ systems is

assigned when an

individual has two or

more minor chronic

illnesses such as attention

deficit hyperactivity

disorder, hyperlipidemia,

or depression. The level

of severity corresponds to

the number of Minor

Chronic illnesses present

and their severity. Less

than one percent of

Medicaid recipients are

classified in this Health

Status.


51


0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

0.1%

0.4%

1.4%

2.5%

2.1%

1.4%

0.5% 0.6%

0.0%

0.5%

1.0%



1.0%

0.7%

0.0%

0.5%

1.0%

Female Male

1.0%

0.6%



recipients with a minor chronic

disease in multiple organ

systems.

The percentage of

recipients with a

minor chronic

disease in multiple

organ systems is

largest among 32 to

53 year olds.


recipients in the SSI-


than Family-Related

eligibility group are

classified in this health

status.

Figure 72: Percentage of Eligibility Groups with Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015

Figure 73: Percentage of Age Groups with Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015

He

alth Statu

s 4 - M

ino

r Ch

ron

ic Dise

ase in

Mu

ltiple

Organ

Systems

Figure 74: Percentage of Females and Males with a Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015

52


0%

1%

2%

3%

Magellan AllSpecialty

CMS AllStandard

FFS SunshineSpecialty

ClearHealth

Positive

2.5%

1.4% 1.2%

0.9%

0.4% 0.2% 0.2%

0.0%

0.00%

0.50%

1.00%

1.50% 1.4%

1.2%

1.1%

1.0% 1.0% 0.9% 0.9% 0.9%

0.8%

0.7% 0.7% 0.6% 0.6%

0.4% 0.4%

0.3%

Magellan and CMS have a larger percentage of enrollees with minor chronic disease in multiple organ

systems than other Specialty Plans at 2.5 percent and 1.2 percent respectively.

One percent or less of enrollees in each Standard Plan has a minor chronic disease in multiple organ

systems.

Note: Because enrollees may be in different programs or plans over the course of the study period, totals by plan or program

associate a person’s CRG with the number of member months the person was enrolled in a plan or the FFS program.

He

alth

Sta

tus

4 -

Min

or

Ch

ron

ic D

ise

ase

in M

ult

iple

Org

an S

yste

ms


Figure 75: Percentage of Specialty Plan Enrollee Months with Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015

Figure 76: Percentage of Standard Plan Enrollee Months with a Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015


53


1.00% - 1.19%

0.40% - 0.99%Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Regions 1, 2, 3, and 5 have 1 percent or more of recipients with a minor chronic disease in multiple

organ systems. Less than 1 percent of recipients in other regions are in this health status.



He

alth Statu

s 4 - M

ino

r Ch

ron

ic Dise

ase in

Mu

ltiple

Organ

Systems

Figure 77: Percentage of Regions’ Population with a Minor Chronic Disease in Multiple Organ Systems, August 2014-July 2015

54

Top Illness 57,426

28%

Illnesses 2-10

113,875 54%


18%



- 20 40 60

Attention Deficit / Hyperactivity Disorder

Hyperlipidemia

Osteoarthritis

Depression

Chronic Thyroid Disease

Chronic Neuromuscular and Other NeurologicalDiagnoses - Minor

Chronic Joint and Musculoskeletal Diagnoses -Minor

Developmental Language Disorder

Chronic Pain

Psoriasis

Thousands

Level 1 Level 2

Health Status 3-Single Minor Chronic Disease

Single Minor Chronic

Disease is assigned when


41 minor chronic illnesses

present. 5.2 percent of

Medicaid recipients are in

this Health Status. The

most common single

minor chronic disease is

attention deficit /

hyperactivity disorder.

Depression is the only

disease among the top

ten with a larger

percentage of individuals

in severity level two than

severity level one.

82 percent of recipients in

this health status have

one of the top ten

illnesses.

Figure 79: Top Single Minor Chronic Disease Compared to All Other Illnesses, August 2014-July 2015


55

0%

2%

4%

6%

8%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

3.1%

5.5%

6.7%

7.4%

5.5%

3.3%

2.4% 2.9%

0%

2%

4%

6%



4.3%

5.5%

0%

2%

4%

6%

Female Male

5.1% 5.4%


This is the first Health

Status where a larger

percentage of recipients in

the Family-Related

eligibility group than SSI-


are classified in the health

status.

He

alth Statu

s 3 - Sin

gle Min

or C

hro

nic D

isease

The percentage of

recipients with a

single minor chronic

disease is largest

among 1 to 53 year

olds.



recipients with a single minor

chronic disease.

Figure 80: Percentage of Eligibility Groups with a Single Minor Chronic Disease, August 2014-July 2015

Figure 81: Percentage of Age Groups with a Single Minor Chronic Disease, August 2014-July 2015

Figure 82: Percentage of Females and Males with a Single Minor Chronic Disease, August 2014-July 2015

56


0%

5%

10%

CMS AllSpecialty

SunshineSpecialty

Magellan AllStandard

FFS ClearHealth

Positive

11.8%

9.3% 8.8%

7.8%

5.9%

2.9%

1.3% 0.8%

0%

2%

4%

6%

8%

10% 9.3%

7.1% 7.0%

5.8% 5.7% 5.7% 5.6% 5.5% 5.5% 4.9% 4.7% 4.5% 4.3% 4.2%

3.8% 2.9%

CMS has the largest percentage of enrollees with a single minor chronic disease. Twelve percent of

CMS’ enrollees are classified in this health status. On average, nine percent of Specialty as compared to

six percent of Standard Plan enrollees is classified in this health status.

Staywell and Amerigroup are the Standard Plans with the largest percentage of enrollees with a single

minor chronic disease.



program.

He

alth

Sta

tus

3 -

Sin

gle

Min

or

Ch

ron

ic D

ise

ase



Figure 83: Percentage of Specialty Plan Enrollee Months with a Single Minor Chronic Disease, August 2014-July 2015

Figure 84: Percentage of Standard Plan Enrollee Months with a Single Minor Chronic Disease, August 2014-July 2015

57


3.0% - 3.9%

7.0% - 7.9%

6.0% - 6.9%

5.0% - 5.9%

4.0% - 4.9%

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Regions 1, 2, and 3 have a larger percentage of recipients than other regions classified in the single

minor chronic disease health status.



He

alth Statu

s 3 - Sin

gle Min

or C

hro

nic D

isease

Figure 85: Percentage of Regions’ Population with a Single Minor Chronic Disease Status, August 2014-July 2015

58



- 25 50 75 100

Significant Acute Illness Excluding ENT

Significant Acute Procedure

Persistent Significant Acute IllnessExcluding ENT

Two or More Significant Acute Illnessesfrom Different MDCs Excluding ENT

Persistent Significant Acute ENT Illness

Significant Acute ENT Illness

Thousands

Health Status 2-Recent History of Significant Acute

Illness

Significant Acute Illness is

assigned when an

individual has a significant

acute illness present.

Only 6 categories of acute

illness are defined by the

3M grouper. 6.3 percent

of Medicaid recipients are

in this Health Status. It is

the fourth most prevalent

Health Status.

Examples of Significant

Acute Illnesses include

pneumonia, blood

transfusions, and bacterial

infections.


59


0%

5%

10%

15%

20%

<1 1-20 21-31 32-42 43-53 54-64 65-84 85+

15.7%

5.9%

8.4%

5.8%

3.6% 2.8% 3.5% 5.2%

0%

2%

4%

6%

8%



3.7%

7.2%

0%

2%

4%

6%

8%

Female Male

6.5% 6.0%

He

alth Statu

s 2 – R

ece

nt H

istory o

f Significan

t Acu

te Illn

ess



recipients with an acute

illness.

The percentage of

recipients with a

significant acute

illness is largest

among children

under the age of one.


recipients in the Family-


than SSI-Related eligibility

group are classified in this

health status.

Figure 87: Percentage of Eligibility Groups with a Significant Acute Illness, August 2014-July 2015

Figure 88: Percentage of Age Groups with a Significant Acute Illness, August 2014-July 2015

Figure 89: Percentage of Females and Males with a Significant Acute Illness, August 2014-July 2015

60


0%

2%

4%

6%

8%

SunshineSpecialty

AllStandard

CMS AllSpecialty

FFS Magellan ClearHealth

Positive

7.1% 6.9%

5.7%

5.0% 4.6%

3.6%

2.2%

1.0%

0%

2%

4%

6%

8%

10%8.1%

8.0% 7.9% 7.3%

7.0% 6.9% 6.7% 6.6% 6.5% 6.4% 6.3% 6.2% 6.1%

5.5% 5.0%

4.6%

Figure 91: Percentage of Standard Plan Enrollee Months with a Significant Acute Illness, August 2014-July 2015

Sunshine Specialty is the specialty plan with the largest percentage of enrollees classified in the Acute

Illness health status. On average, five percent of Specialty Plan enrollees are categorized in this health

status.

On average, seven percent of standard plan enrollees are categorized in this health status. Coventry,

Amerigroup, and Simply Healthcare have the largest percentage of enrollees in this health status with

about eight percent each.



program.

He

alth

Sta

tus

2 –

Re

cen

t H

isto

ry o

f Si

gnif

ican

t A

cute

Illn

ess



Figure 90: Percentage of Specialty Plan Enrollee Months with a Significant Acute Illness, August 2014-July 2015

61


6.0% - 6.9%

5.0% - 5.9%

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonville

Tallahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama City

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

M elbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

Only 3 regions, Regions 2, 4, and 10, have less than 6 percent of recipients classified with a health status

of Significant Acute Illness.



He

alth Statu

s 2 – R

ece

nt H

istory o

f Significan

t Acu

te Illn

ess

Figure 92: Percentage of Regions’ Population with a Significant Acute Illness Status, August 1, 2014 - July 31, 2015

62

Conclusions Almost 70 percent of all Medicaid recipients are classified as healthy. However, a smaller percentage of

recipients in an SSI-Related eligibility group as opposed to Family-Related eligibility group, adults as

opposed to children, Specialty Plan enrollees as opposed to Standard Plan enrollees and recipients in the

fee-for-service program, and recipients in more rural as opposed to urban regions of Florida are healthy.

A larger percentage of recipients in the fee-for-service program are categorized as healthy than

Standard Plan enrollees and Specialty Plan enrollees. Community Care is the only Standard Plan with a

larger percentage of enrollees categorized as healthy as compared to recipients in the fee-for-service

program. Among Specialty Plans, Sunshine Specialty has the largest percentage of enrollees categorized

as healthy. These results are descriptive and are not indicative of causal relationship.

The most common illnesses among Medicaid recipients are asthma, acute illness, and hypertension. The

prevalence of disease is highly related to age and eligibility group. Asthma and acute illness is common

among recipients in a Family-Related eligibility group and children under the age of 21. Hypertension is

common among recipients in an SSI-Related eligibility group and adults 21 and over. Attention deficit/

hyperactivity disorder is also common among recipients in a Family-Related eligibility group and children

under the age of 21. Other common illnesses among recipients in an SSI-Related eligibility group and

adults include diabetes, schizophrenia, and hyperlipidemia. Dementing illnesses and Alzheimer’s are the

most common illnesses among recipients 85 and older. Asthma, acute illness, hypertension, attention

deficit / hyperactivity disorder, and hyperlipidemia are among the top illnesses among Standard Plans

although the order of prevalence shifts some among the plans. These are also the top illnesses in every

region with the order of prevalence shifting slightly among the regions. Because the Specialty Plans,

with the exception of Sunshine Specialty, are designed to serve populations with specific illnesses, the

top illnesses vary among Specialty Plans. The most common disease among enrollees in Clear Health

and Positive, the two HIV/AIDS Specialty Plans, is HIV. Schizophrenia is the most common disease

among enrollees in Magellan, the Specialty Plan for serious mental illness. Enrollees in CMS, the

Specialty Plan for children with chronic disease, and Sunshine specialty, the Specialty Plan for Child

Welfare, share the same 3 most common illnesses – attention deficit/hyperactivity disorder, asthma,

and developmental disability.

Thirty-one percent of the Medicaid population is categorized as other than healthy. Ten percent have a

single dominant or moderate chronic disease, 6.5 percent have a chronic disease in multiple organ

systems, 6.3 percent have a history of significant acute illness, and 5.2 percent have a single minor

chronic disease. Less than a percent have a catastrophic illness. HIV/AIDS is the dominant disease

among recipients with a catastrophic illness. Diabetes, hypertension, and asthma are the most frequent

illnesses among dominant chronic illnesses. Attention deficit/hyperactivity disorder and hyperlipidemia

are the most common illnesses among minor chronic illnesses.

Winter 2016 - FL Agency for Health Care Administration...Winter 2016 Quarterly Statewide Medicaid...

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