medicaid reform pilot transportation references

8/7/2019 Medicaid Reform Pilot Transportation References

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Benefit Plans Requiring Co-PaymentsIType of Service Year 1 Year 2 Year 3

Chiropractic I 10 0 8Hospital Inpatient: Behavioral Health I 11 1 8Hospital Inpatient: Physical Health 7 1 8Podiatrist I 10 0 7Hospital Outpatient Services (Non-Emergency) 7 1 7Hospital outpatient Surgery 7 1 8Mental Health I 7 3 6Home Health I 4 1 8Lab/X-Ray I 5 1 7Dental I 4 4 4Vision I 4 0 5Primary Care Phvsician 0 0 5Specialty Physician I 1 1 6ARNPlPhysician Assistant I 0 0 5Clinic (FOHC, RHC) I 0 0 6Transportation I 5 5 6Total I 82 19 104Total Number of Benefit Packages I 28 30 28Total Number of Benefit Packages Requiring No Copayments 12 16 20Percent of Benefit Packages Requiring No Copayrnents 43% 53% 71%10114/08: Molina Healthcare, Inc., ahnounced that its wholly owned subsidiary, MolinaHealthcare of Florida, Inc., was awarded a Medicaid managed care contract byAHCA. The term of the contract would become effective December 1,2008, at which


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We would like 10 have quick response lith clear cut guidance that is consistent across plans.This is not happening .... different answers depending upon who you talk to .... we have had threetofour contract managers since inception of Reform.Reform is constantly changing; we hat to continually change our processes. Risk adjustmentand encounter data is changing ...everything keeps changing.[L5b Administrative Burden Assoc1ated with ReformOrganizations participating in Reform cited increased administrative burden related toimplementation as a negative aspect of Reform. In particular, plans operating with both Reformand non-Reform members cited mkgnified administrative costs related to participating inMedicaid. IThe short timeline from Reform application to implementation was a major burden forparticipating organizations. The actual application was deemed onerous, and plans alreadyparticipating in the Medicaid program found it to be redundant. Completing the application wasexpensive, and the short timeframe caused staff to be overworked. Many organizations usedexternal resources such as consultants and actuaries to meet the deadline. One plan spokespersonstated that although they successfully Icompletedthe process, it took a lot of "pain" to get there.Systems issues and extra reporting also increased the administrative burden experienced by plansduring Reform development and implementation. Both HMOs and PSNs cited increasedreporting requirements under Refornit, and expressed concern about the related expenses. Thereporting of encounter data is the largest change to reporting and oversight requirements. Gettingthe data has proven to be difficult anq a "big burden." A learning curve also exists with regard tosending and receiving encounter data'jReform implementation resulted in additional training processes and system modifications formany HMOs and PSNs. Many organizations added new employees and new functions.


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Administrative costs with reform: at least 40people spending 8 hours per week from June-December-4 full time people. I .Huge administrative burden associated with Enhanced Benefits- have to create system, enterthe data (scan farms}, create reports, ~orrect the errors (much work associated with this). This isunlike anything we do. II don't think there is anything unreasonable that is requested, anything ... most everything isuseful for us. The only thing that I think just in general is kind of over the top is thetransportation, the contract for transportation and the whole administration aroundtransportation was like 30 pages. IIt is humorous, I mean you look at it and you're like, I mean disease management is three pageslong, and transportation is 20 somethrg pages .... where is our focus here?IL5c The Market is Crowded in Broward County

Many respondents were surprised b~ the number of plans and networks operating in BrowardCounty, suggesting market confusion and a difficult, if not impossible, decision set forbeneficiaries who would choose a plan there. Most respondents complained about the largebenefit matrix and the hard time be1eficiaries would have in reading what was presented, letalone understanding differences among plans.Some plans suggested that the State Ishould have used a more rigorous selection process, or atleast put in place some barriers to entry so that this confusion would not be allowed to gounchecked.Specific Quotes from Informants:The biggest surprise is how these Plax1ers have competed so intensely for this population that no


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Theme [V.2: Barriers to careIn addition to disruptions in long-standing relationships, enrollees reported other challenges inreceiving care such as the lack of trans po rtation, wait time for services, gaps in coverage, limitedprescription drug coverage, and thel Medicaid authorization process. There were significantbarriers to care expressed by participants, including the prior authorization processes, lack ofchoice in providers and difficulty finding specialists, and perceptions of unfair treatment.

IOh, when I had the surgery, it was, it was a wait. I had to wait. I had to get approved byMedicaid to make sure they coul& do the surgery on me and stuff like that. It was a wait. I mean Ihad to wait 'til the next day befate they could even do the surgery. I had to wait for three days. Ihad to make a couple phone calli' the hospital made a phone call and I made some more phonecalls. The third day that I was inrthere they told me that they got approved for more money to dothe surgery.

The negative that I know of, you L n 'tget all your medicine off Medicaid. You have to pay like 50or 60 percent 'off the Medicaid, Jhen Medicaid don't cover everything. You got a prescription togo to the doctor and the doctor [giVeyou a prescription form, sometimes Medicaid pays half ofyour medicine and you got to pa1 the other half. And other medicine they don't cover at all.

Respondent: I had to take my S ( r to the dentist, because he had a toothache and they wouldn'tsee my son and told me I had to bring him back on a Friday.Interviewer: Why did they tell you you had to bring him back on a Friday?


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1 have had bad experiences J not getting my medication, they would not prescribe mymedications sometime. And 1 would have to call my doctor, and they would have to authorize it sothat I can get my medication.Interviewer: Why is it so hardforlYou to get transportation?Respondent: I call them and the~ refuse me. They say they can't help because I have an HMO. Ihave major problems with transportation.

Almost all of the consumers who ~ere interviewed expressed concerns about finding newphysicians or specialists. I

It was hard (to find a gynecolog,list), because I only had a few to pick from. She was the closestand she told me no.

1 think the hardest part about Medicaid is just finding a doctor that you can communicate with.The good thing is that it (Medibaid) is there for me, although it is like digging a ditch to getsomeone that understands exactl what you mean. .

And everybody you ask, don't take Medicaid. And then you call Medicaid and ask them and theysend their booklet. And there is only one dentist listed in Baker or Duval County that takesMedicaid. I .If I could find me a better doctor, I would love to.


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9) Describe some ofthe ways in which you get information about Medicaid?(Probe: Choice counselor, adverlitements, Fiend?)10) Please tell me about a good and bad experience you had using Medicaid?(Probe: For example with gaininglaccess, quality ofphysicians, or counselors)SECTION 4 - Many of you may al~eady be aware that the state is changing howMedicaidservices are being offered. If you dp not know about these changes, that is fine, what youcan do is tell me how, if at all, your health plan has been changed.11) What have you heard about the c~anges in Medicaid/Medicaid Reform?(Probe: Did any of you receive the "Check it out Package "/ the green and blue envelope?What doYOIl know about this package or about the changes to Medicaidr)12) Talk about some of your concernsl about Medicaid or Medicaid Reform?(Probe: What are some of the barriers to care [long waiting room stay, unhelpful staff]?What are some fi-ustrationslgpod experiences that you have had with Medicaid? What

questions do you think we s1.0uld ask when we want to learn about Medicaid users'issues with Medicaid andlor Medicaid Reform?What would be some good rr= to ask about how Medicaid helps/hinders yourhealth care?) I

13) Is there anything else that you would like to share?THIS IS THE END OF THE SE~U-STRUCTURED QUESTIONS. THE FOLLOWINGQUESTIONS ARE LOGISTIC QiESTIONS.SECTION 5. We are interested inJgiving people the best opportunity to be a part of ourstudy so that they can tell us about their Medicaid health care experiences. Wewould wantthem to participate every 6months/over the next four years.


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Transportation~ Is transportation an issue? Why or why not?~ Based on your recent experiences

rwould you go back to that place for care? Would you return for

the same kind of care?Other services

); > Did you have any other kind of care recently-hospitalizations, lab work, prescription drugs, ER?); > Describe this experience to me. I);> Was it a good or bad experience?

Section 5.Wrap up IIn wrapping up we would now like yo~ to describe your opinions about how the healthcare systemmeets your needs and in what ways. I10) Do you believe that the healthcare ~ystem-doctors, hospitals, ERs, nurses-is designed to helpyou get the best care possible? If so in W I hat way and if no why not? (conceptual)PROBES

);> Describe a specific positive or negative experience? For example with gaining access, quality ofphysicians, or counselors. I

);> What's your perception of how well they healthcare system meets the needs of people onMedicaid, who are low-income o~ are uninsured?

);> Are there enough doctors and hospitals?);> Do the system doctors, nurses, etc., treat you as you should be treated?); > Is the way the health care syste1 set up affecting fulfilling your healthcare needs and in helping

you make health choices?11) Is there anything else that you would like to share?

IComments: Thank you for agreeing tolparticipate in this study. We appreciate your input.The information you have provided will be very relevant and useful.


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MEDICAID ROUND 2

EXECUTIVE SUMMARY

The "Longitudinal Study" component 10fthe Medicaid Reform Evaluation is designed to elicitconsumers' views about their health, their health care, and experience obtaining care as thechanges occur to Florida's Medicaid Ptogram. The study is termed "longitudinal" because it isdesigned to track a subset of enrolleeslthroughout the life ofthe evaluation. Early experiences werereported on in July 2007. This report provides preliminary findings from interviews and focusgroups conducted between July 2007 rd December 2007.A total of 45 enrollees participated in 14 in-depth telephone interviews and four focus groupsconducted between July 2007 and December 2007. To date, nine of these interviews have beentranscribed and coded. The following themes have emerged from this initial analysis:C D The process of plan and primary care provider selection is problematic for some but not

all enrollees. Compared to baselirie findings consumers are more aware of the health planselection process and Choice Counseling. Health plan selection appears to be based onmaintaining relationships with existing providers. Consumers spoke of several problems,notably finding a primary care prq~ider and misinformation or incorrect information providedby the Choice Counselors. I

There is some discontentment with aspects of care once enrolled. Discontentment waslinked with perceived greater rest+ctions associated with referral processes, maintainingcontinuity of care with primary care providers, gaining access to specialty services, limitationson prescription drugs, and transportation barriers.o The Enhanced Benefits Account (EBA) program continues to be a relatively untestedconcept among enrollees. AlthoJgh most enrollees had heard about the EBA program, therewere mixed opinions about whether or not they would participate in the program.


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representations of their own experiences. They express both positive and negative views andinferences should not be drawn about how frequently one might expect to find those positive andnegative views among other enrollees'l

FINDINGS

This interim report is based on data from nine of the 14 in-depth interviews conducted within thisstudy period. The subsequent report will include data from the remaining five in-depth interviews,four focus groups, and additional in-depth interviews and focus groups. Each direct quote has beenitalicized and clarifiers denoted by bdckets have been included to facilitate easier comprehensionby the reader.Overall, this round ofin-depth interviews revealed that enrollees were aware of Medicaid Reformand had both positive and negative experiences with the various Reform elements. While many ofthe comments about Reform were negative, they were not overwhelmingly so. Key concerns raisedby enrollees center around facilitating I adequate choice and selection of primary care and specialtycare providers, greater restrictions associated with specialty care referrals and use of prescriptiondrugs, and transportation barriers to care.I. Some enrollees are having no prbblemsThis new round of focus groups and iili-depth interviews revealed that some enrollees had positiveexperiences with Reform. I

So far we haven't had any=:It's been real good ...I guess I have been pretty lucky.Well, I liked the doctor I was assigned to. Any time I called I didn't have any problems oranything. I was able to get an appointment soon, even like the next day, or whateverdepending on the situation. I

II. The process of plan and primary care provider selection was difficult for some, but not


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IBefore Reform, everyth ing was beautiful.Discontentment was associated with perceived greater restrictions associated with the referralprocesses, maintaining continuity of dre with their primary care providers, gaining access tospecialty services, limitations on prescription drugs, and transportation barriers.Greater restrictions associated with referral processes and use of specialty services-Some ofthe discontentment expressed by enrollees was associated with the increased restrictions imposedby health plans in obtaining specialty Icare referrals.

Before, 1 didn't have to; my doctor would send me to any specialist without any problem,and they in turn would call the specialist, make an appointment, and ljust would go to theappointment. Now the difference is that 1 will have to go to my PI, my primary healthcaredoctor, ... tell them that 1 need to go to whatever specialist 1 need to go to, then they haveto drop the paperwork and give me the referral in order for me to go to [the specialist] andmake the appointment and have my whatever procedure 1 need to be done on that.But now with Reform, even though you pick an insurance, an HMO, you are restricted towhere you are going because this doctor is not working with that doctor, that doctor is notworking with this doctor, and this doctor is not taking that insurance. Then you have aproblem .... the new injection [they give] patients of macular degeneration that goes directly into theeye. Referrals that are givenfrom the doctors,just covers the regular, the check up thatthey want to do ... it doesn't c4ver this injection. So they have to call ... the primary doctorand sometimes they don't answer the phone and they leave the phone on the voice mail,and they still don't call back .....[My doctor] is just a little fru)trated because of my blood work situation. They can nolonger draw blood at the [previous sites}. 1 have to go outside to have my blood drawn ...You are going to an outside laboratory ... So 1 have to travel on a bus to get there .. .I have


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You walk in and you can't get 1 medicine. You know you couldn't get it with this Reformchange. IThe Medicaid Reforms is a system that was designed that is not working. Now we can't getcertain medications. I

Transportation Barriers-As health plans contract with new transportation providers, someenrollees are reporting logistical issues associated with those companies. While these concernsreflect perceptions of Longitudinal Study enrollees, it should be noted that during the early phaseof Medicaid Reform several non-Medicaid Reform events occurred in Broward County such as thesudden change to a new non-emergency transportation vendor. These issues may have beenincorrectly attributed to Medicaid Reform.

Transportation had been given to me for the last 11years .... It was working wonderfully.Then all of a sudden, this Medicaid Reform came in and I received a letter that I was beingtransferred to a company in B~evard County. I called the company as the letter said. Theyknew nothing about what was going on and they told me to call back after the Christmasholidays. 1 called back and they said they didn't know yet, but they would let me know. Icalled back and they said they Iwere not accepting patients from the South FloridaCommunity Network. January, 1 had to cancel my doctor's appointment.At the time, they told me I would be receiving a bus pass every month. So I mailed them theform the first month-the fax number at the bottom of the form was not the right faxnumber. The next month when I sent off the form, I got [a} fax transmission, that it wasreceived by them. Well, 1 am at the end of the month and I don't receive a bus pass andagain1had to cancel my appolintment.Yeah, I take the transportation and it is not always that good because sometimes they mightschedule two different people at the same time in two different directions, miles apart.

One individual indicated that transportation under Reform was working well.


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CONCLUSlbN AND ISSUES TO WATCH

During the past year, as would be expected, awareness and knowledge of the changes to theMedicaid programs have increased sighificantly among enrollees. Many enrollees have played anactive role in selecting health plans and primary care providers. However, it does appear thatmaintaining continuity of care with primary and specialty care providers is problematic. Inaddition, some plan formularies have placed restrictions on access to prescription drugs and certainkinds oftherapy.For some Medicaid enrollees, this restriction in access may have a detrimental impact on theirhealth. For others, changes to the Medicaid program may have no impact at all. This first year ofthe demonstration represents a period of time in which enrollees were learning to adjust to thechanges, and AHCA was making programmatic modifications in response to enrollee needs andconcerns. Thus, it is still too early to make conclusions about Medicaid Reform and its impact onenrollee access to care. Nevertheless, AHCA and the University of Florida must continue tomonitor key issues over the long term. These issues include:

the ability of the Choice Counseling program to provide accurate and up-to-dateinformation on primary care provider availability to enrollees; the availability of an appropriate and adequate distribution of primary care and specialtycare providers;

the impact of drug formulary restrictions on the health of enrollees; the availability of transportation providers; enrollee participation in the enhanced benefit program; and the extent to which there are differences across health plans in enrollee experience with

care.NEXT STEPS


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How did you decide where to g b for care? Is [insert location mentioned] the place whereyou have always gone?

What are some of the barriers r care [long waiting room stay, unhelpful staff]?When to go (or care

Aside from when you (or YOUrlkidS) are sick, what other factors determine when you seekcare? .

Getting an appointment The last time you went to this place did you make an appointment? How hard was it to getthat appointment? Did you have to wait in the waiting room fo r a long time?

I What about the attitude of ther:':

Were the office and nursing staff polite? Helpful?Your doctor

What do you like about your current doctor?Why is that important to stay with that doctor?

Any issue with referrals or going to specialists? Finding a doctor that takes Medicaid?Are you treated differently bec~use you are on Medicaid, because of your ethnicity, age?How do you know this? I

Have you had any issues with the care you received? If so what were they?IDid you understand what they said? Were they respectful? Did they answer yourquestions?


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(No) N questions

/

(Yes) Y questions How did you hear about them?Did you see billboard ads?Where they helpful?What about the written material?How did you end up making a choice?

What factors lead you to make the Idecisions?What additional kind of informationwould you like to have had?

Does the incentive need to be higher?Choice counselorsPicking a health plan is a personal decision.Florida Medicaid Reform enrollees can now talkwith a Choice Counselor for free. The ChoiceCounselor will provide information that can helpyou pick a plan that is best for you.

Would using the services of ChoiceCounselors encourage you to engage in thehealthy behaviors we talked about earlier? Why or why not? Do you think the Choice Counselors wouldhelp you make a choice? If not what otherfactors would lead you to make thedecisions? What other kinds of information wouldyou like to have to help you with yourchoices?

Have you participated in any of the newprograms or used any ofthe new services?Opt-Out Program? IEnhanced Benefits Program?ChoiiceCounseling Program?Why or why not?

Would you participate in any of the newprograms that I explained earlier such asthe Opt-Out program? The Enhanced Benefits? Or contact a Choice Counselor for help? Why or why not?

Describe your experiences with the new Medicaidsystem, such as length oftime on it, problems youhave had, good experiences you've had. Are you looking forward to experiencingthese new changes with Medicaid?


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Ms. Young's poster presentation suggests that Medicaid enrollees' beliefs may havesome impact on their ability and willingness to control, manage, and participate in their

Ihealthcare decision making and behaviors.A copy of this presentation is included in Appendix E.

HEALTHCARE EXPERIENCES OF MEDICAID ENROLLEES INFLORIDADr. Rada Dagher was invited to present a poster at the AcademylIealth Annual ResearchMeeting, on June 29,2009, in Chicago, IL .Dr. Dagher's poster discussed enrollee experiences with Medicaid. Study participantsreported problems they experienced, such as.difficulty with


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Evaluating MedicaidReform in Florida--{---/t l,I '

I

IMPLICATIONS FOR POLICY,PRACTICE, OR DELIVERY

Healthcare Experiences ofMedicaid Enrollees in Florida

RESULTSStudy participants reported a n umber of problems they exp erienced as participants in the demonstration.These included difficulty with access and referral 10 specialists. having to switch primary Cafe providers,inadequate prescription drug coverage, lack of dental care, transportation barriers, lengthy wait times forservices. and perceptions of discrimination under Medicaid. However, they also repor ted pos itiveexperiences such as being thankful for Medicaid and the services it provides them and being satisfied withtheir doctors.

E n ro ll ee E x p er ie nc e s w it h C a reUnde r th e M e dic aid D em o ns tr at io n P ilo t1

r::!::-

of Medicaid

Rada Dagher, PhD, MPH;l Allyson Hall, PhD, MBA, MHSI

I , Dep artm ent of Hea lth Ser vic es Rese arch , Ma nagement and Policy , Co llege of Public H ealth and He alth Pr ofe ssi ons, Un iversity of Florida

INTRODUCTIONIn recent years, a number of states (Florida, Idaho, Kentucky,and West Virginia) have experimented with modifying theirMedicaid benefit packages and/or adopting elements ofconsumer choice. There is surprisingly little qualitativedocumentation of patients' experiences with Medicaid in theresearch Iirerature. In FIOJida, a demonstration project targetedto a competitive consumer choice model carne into effect onJuly 1,2006, following CMS approval of a Section 1115Research and Demonstration Waiver. This study examined thehealth care experiences of Medicaid enrollees under the FloridaMedicaid demonstration in Broward and Duval Counties.

METHODSThis study employed purposive sampling of Medicaid eruolleesthroughout two waves of data collection. The firs t waveincluded 10 in-depth telephone interviews with Med icaidenrollees and three focus groups (27 enrollees) all conductedbetween October 2006 a nd May 20 07.Interviewees constituted mainly of African Americans (60%)and Caucasians (20%) a nd were primarily female (70%). Focusgroup participants were mostl y Af ri can Americans (63%) andHispanics (26 1' 0) and predominantly female (9 7%) . The secondwave included 23 in-depth telephone interviews with Medicaidenrollees and four focus groups (30 enrollee s) condu ct edbetween July 2007 and June 2008. Interviewees constitutedmainly of African Americans (48%) and Caucasians (38%) andslightly more males (52%). Focus g roup participants weremostly Caucasians ( 53%) and African Americans (40%) andconstituted primarily offemales (80%).Th e smdy team reviewed transcripls and developed a codingalgorithm to identify and veri fy ove rarching themes/findings.In-depth interviews were coded using Atlas.ti 5. 0 software andfocus group findings were coded using NVivo 2.0 software.Eight global themes were identified based on the focus groupand in-depth interview instruments including MedicaidExperience and General Experience with Care.

l 1Difficulty Accessing

SpecialistsProblems AccessingPrescription Drugs

Lengthy WaitTimes

~w~have a problem wi th the I I "My med ication is a p roblemI speeallst endcerinoloqist , It's as well. Wh en I go101ill a-- -bard to find endocrinologist- - prescription, they ----

for Medicai d." automatically, after Ihavebeen taking itfora couple ofyears, change it to gener ic a ndgeneric."

"Sometimes Iknow i t i s n oteasytogetthroughtotheMedicaid office . Yo u have.tocal l a n d c a ll and the n whenyou d o g et through you get puton hold and then y ou getthose representa tive s, [wh osay] "I don' t know ", "I don'tknow .""

"I love the Medicaid. Wi thMed ica id y ou c an goanywhe re, ycudon'thave anyproblems, a ny c it y o r state,caus e s om etimes I tra vel." !"W o l lt o me I t is scary if I don 't Ih av o a n yM edicaid. Th at i swh at makes thi s very s cary. Imean , t h ad a good job all mylife unti l I go t in that caraccident,"

-It's hardto find,Onlyonespecialist fo r the who leJack sonville and how manypeople in Jacksonville. Do youknow how man y? Irs m illions." "Be fo re y ou

aa decide torefo rm things , Id id n't have toworry a bout m e dl ca lions .ldon't have to wo rry abou t noneof that , Y ou reformedeverything, you know what rmsa yi ng ? N ow I got to dowithout some of mymedi catio ns. Medicat io ns thatI'vo bee n o n f or a lmos t two orthr ee decadc s."

"N ot e nough doct o rs. No tenough doctors. Th ere are lowIncome people, no t e noughdoc tors who on Medicaid,notenough:'

"I romember going to I hi sdoctor. I got there about 9 or10 o'clock . I didn't get waitedon until about, Id idn ' t even getwa ited on. I t wa s abo u t 12o'c l oc k a nd Istil l had n't got te nseen by a doc tor. Ij ust walkedo ut a nd l eft,''

"V ery difficult , very diffic ult tof ind . They send us HealthEase,they send us a book let wi thspecialist. Wh en it's time tocaD 1I1edoctor, they say, Wedon' t a ccept""

"Ca use lh avc a l ot (If anx ietyand dep re ss io n a ndwh en youa re me ssing w ith thatmedic in e, you knowwhatl 'msaying?"

"If you are no t in Medicaid,y ou are soon quick."

U F I F L O R I D A 2.~ 1 f r ' ~ - - 'Cwlu.Q1;lnIJ Mttclllc.ldn.rorm In no,ldD ,j J .~ .~, p' 'r This re se a r c h (UFP roject # 58750) was funded by the Florida Agc ncy for Health Care A dm ini s trat ion (AReA) through contract f MED027,

Pervasive problems with Medicaid continue to exist. Key issues ofacce ss to c are remain such a s d ifficulty ac ces si ng specialists, problemsmaintain in g con ti nuity of care through primary care providers, andinadequate prescription drug coverage. Study findings suggest 3 need forpo licym ake rs to address the underlying issues that prevent Medicaidpatients from having access to timely and quality health care.

LIMITATIONSThese findings primarily highlight the results of qualitative in-depthinterviews an d focus g roups w ith small samples of enrolleesthroughout the duration of tile study. Thus, these findings are notrepresentative of the larger Medicaid popularion.Different samples of enrollees were interviewed over t ime; thus,

------clianges in enrollee expenen-- c-es over time could nocbe examined= ---In addition, the study participants had varied levels of exp erience withMedicaid. For example, individuals who had participated 111 Medicaidfor a longer time period were more expressive of their experiences andpercepti ons than enro lle es w ith shorter partici pat ion periods.For both positive and negative experiences, enrollees did not alwaysdistinguish the Medicaid program in general from the demonstrationini ti at iv e being undertaken in F lorida. These preliminary findingsindicate that future research, employing, longitudinal design and largesample sizes, is necessary to capture the longstanding factors that maybe attributed to changes ill Florida's Medicaid program.

medicaid reform pilot transportation references

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