business intelligence unit medicaid data analytics winter 2019 · 2016-07-01 · analysis of...

Analysis of Potentially Preventable

Healthcare Events of

Florida Medicaid Enrollees

2016-2017 and 2017-2018

Quarterly Statewide Medicaid

Managed Care Report

Business Intelligence Unit

Medicaid Data Analytics

Winter 2019

Agency for Health Care Administration

i

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

Executive Summary ................................................................................................................................. iv

Introduction .............................................................................................................................................. 1

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

Methodology for PPEs .............................................................................................................................. 2

Risk Adjustment ........................................................................................................................................ 4

Potentially Preventable Hospital Admissions (PPA) ................................................................................. 6

PPAs by Age .............................................................................................................................................. 8

PPAs by Eligibility Group ........................................................................................................................... 9

PPAs by Plan ............................................................................................................................................. 9

PPAs by Region ....................................................................................................................................... 14

Potentially Preventable Readmissions (PPR) .......................................................................................... 16

PPRs by Age ............................................................................................................................................ 18

PPRs by Eligibility Group ......................................................................................................................... 19

PPRs by Plan............................................................................................................................................ 19

PPRs by Region ....................................................................................................................................... 24

Potentially Preventable Emergency Department Visits (PPV) ................................................................ 26

PPVs by Age ............................................................................................................................................ 28

PPVs by Eligibility Group ......................................................................................................................... 29

PPVs by Plan ........................................................................................................................................... 30

PPVs by Region ....................................................................................................................................... 34

Conclusions ............................................................................................................................................. 36

Appendices ............................................................................................................................................. 37

Appendix 1: Technical Specifications ..................................................................................................... 38

Appendix 2: Racial Composition of the Medicaid Population by Region ............................................... 40

Appendix 3: Plan Demographics ............................................................................................................. 42

Appendix 4: List of All Patients Refined Diagnosis Related Groups (APR DRGs) and Enhanced

Ambulatory Patient Grouping (EAPGs) in Top Ten Charts .................................................... 46

ii

List of Figures Figure 1: Total Number of Admissions and Total Number of Admissions Identified as Potentially

Preventable from FY2016/2017 to FY2017/2018 .......................................................................... 6

Figure 2: Risk-Adjusted PPA Rates per 1,000 Enrollee Months by Region, July 2017 to June 2018 ............. 6

Figure 3: Risk-adjusted PPA Rate per 1,000 Enrollee Months Statewide, July 2017 to June 2018 ............... 6

Figure 4: Top Reasons Admissions Are Defined as PPAs Statewide, July 2017 to June 2018 ....................... 7

Figure 5: Top 10 Conditions Leading to PPAs Statewide, July 2017 to June 2018* ...................................... 7

Figure 6: Children-Top 10 Conditions Leading to PPAs, July 2017 to June 2018* ......................................... 8

Figure 7: Children-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018 ................................. 8

Figure 8: Risk-adjusted PPA Rates for Children and Adults per 1,000 Enrollee Months, July 2017 to June

2018 ................................................................................................................................................ 8

Figure 9: Change in PPA Rates for Children and Adults from FY2016/2017 to FY2017/2018 ....................... 8

Figure 10: Adults-Top 10 Conditions Leading to PPAs, July 2017 to June 2018* .......................................... 8

Figure 11: Adults-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018 .................................. 8

Figure 12: Family-Top 10 Conditions Leading to PPAs, July 2017 to June 2018* ........................................... 9

Figure 13: Family-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018................................... 9

Figure 14: Risk-adjusted PPA Rates for Family-Related and SSI-Related Eligibility Categories per 1,000

Enrollee Months, July 2017 to June 2018 ...................................................................................... 9

Figure 15: Change in PPA Rates for Family-Related and SSI-Related Eligibility Categories from

FY2016/2017 to FY2017/2018 ....................................................................................................... 9

Figure 16: SSI-Top 10 Conditions Leading to PPAs, July 2017 to June 2018* ................................................ 9

Figure 17: SSI-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018 ........................................ 9

Figure 18: Risk-adjusted PPA Rates by Plan, July 2016 to June 2017 and July 2017 to June 2018** .......... 10

Figure 19: Top 10 Conditions Leading to a PPA by Specialty Plan, July 2017 to June 2018* ....................... 11

Figure 20: Top 10 PPA Conditions by Standard Plan, July 2017 to June 2018* ........................................... 12

Figure 21: Risk-adjusted PPA Rates per 1,000 Enrollee Months by Region, July 2016 to June 2017 and July

2017 to June 2018 ........................................................................................................................ 14

Figure 22: Top 10 Conditions Leading to a PPA by Region, July 2017 to June 2018* .................................. 14

Figure 23: Total Number of Admissions and Total Number of Readmissions Identified as Potentially

Preventable from FY2016/2017 to FY2017/2018 ........................................................................ 16

Figure 24: Risk-Adjusted PPR Rates per 1,000 Hospital Admissions by Region, July 2017 to June 2018 ..... 16

Figure 25: Risk-Adjusted PPR Rate per 1,000 Hospital Admissions Statewide, July 2017 to June 2018 ...... 16

Figure 26: Reasons for PPRs Statewide, July 2017 to June 2018 ................................................................. 17

Figure 27: Top 10 Conditions Leading to PPRs Statewide, July 2017 to June 2018* ................................... 17

Figure 28: Children-Top 10 Conditions Leading to PPRs, July 2017 to June 2018* ...................................... 18

Figure 29: Children-Reasons for PPRs for Children, July 2017 to June 2018 ................................................ 18

Figure 30: Risk-adjusted PPR Rates per 1,000 Hospital Admissions for Children and Adults, July 2017 to

June 2018 ..................................................................................................................................... 18

Figure 31: Change in PPR Rates for Children and Adults from FY2016/2017 to FY2017/2018 .................... 18

Figure 32: Adults-Top 10 Conditions Leading to PPRs, July 2017 to June 2018* ......................................... 18

Figure 33: Adults-Reasons for PPRs, July 2017 to June 2018 ....................................................................... 18

iii

Figure 34: Family-Top 10 Conditions Leading to PPRs, July 2017 to June 2018* ......................................... 19

Figure 35: Family-Reasons for PPRs, July 2017 to June 2018 ....................................................................... 19

Figure 36: Risk-adjusted PPR Rates per 1,000 Hospital Admissions for Family-Related and SSI-Related

Eligibility Categories, July 2017 to June 2018 .............................................................................. 19

Figure 37: Change in PPR Rates for Family-Related and SSI-Related Eligibility Categories from

FY2016/2017 to FY2017/2018 ..................................................................................................... 19

Figure 38: SSI-Reasons for PPRs, July 2017 to June 2018 ............................................................................. 19

Figure 39: SSI-Top 10 Conditions Leading to PPRs, July 2017 to June 2018* ............................................... 19

Figure 40: Risk-adjusted PPR Rates by Plan, July 2016 to June 2017 and July 2017 to June 2018** .......... 20

Figure 41: Top 10 Conditions Leading to a PPR by Specialty Plan, July 2017 to June 2018* ....................... 21

Figure 42: Top 10 Conditions Leading to a PPR by Standard Plan, July 2017 to June 2018* ....................... 22

Figure 43: Risk-adjusted PPR Rates per 1,000 Hospital Admissions by Region, July 2016 to June 2017 and

July 2017 to June 2018 ................................................................................................................. 24

Figure 44: Top 10 Conditions Leading to a PPR by Region, July 2017 to June 2018* .................................. 24

Figure 45: Total Number of ED Visits and Total Number of ED Visits Identified as Potentially Preventable

from FY2016/2017 to FY2017/2018 ............................................................................................. 26

Figure 46: Risk-adjusted PPV Rates per 1,000 Enrollee Months by Region, July 2017 to June 2018 ........... 26

Figure 47: Risk-adjusted PPV Rate per 1,000 Enrollee Months Statewide, July 2017 to June 2018 ............ 26

Figure 48: Reasons for PPVs Statewide, July 2017 to June 2018 ................................................................. 27

Figure 49: Top 10 Conditions Leading to PPVs, July 2017 to June 2018* .................................................... 27

Figure 50: Children-Top 10 Conditions Leading to PPVs, July 2017 to June 2018* ...................................... 28

Figure 51: Children-Reasons for PPVs, July 2017 to June 2018 .................................................................... 28

Figure 52: Risk-adjusted PPV Rates per 1,000 Enrollee Months for Children and Adults, July 2017 to June

2018 .............................................................................................................................................. 28

Figure 53: Change in PPV Rates for Children and Adults from FY2016/2017 to FY2017/2018 .................... 28

Figure 54: Adults-Top 10 Conditions Leading to PPVs, July 2017 to June 2018* ......................................... 28

Figure 55: Adults-Reasons for PPVs, July 2017 to June 2018 ....................................................................... 28

Figure 56: Family-Top 10 Conditions Leading to PPVs, July 2017 to June 2018 ........................................... 29

Figure 57: Family-Reasons for PPVs, July 2017 to June 2018 ....................................................................... 29

Figure 58: Risk-adjusted PPV Rates per 1,000 Enrollee Months for Family and SSI Eligibility, July 2017 to

June 2018 ..................................................................................................................................... 29

Figure 59: Change for Family and SSI Eligibility Categories from FY2016/2017 to FY2017/2018 ................ 29

Figure 60: SSI-Top 10 Conditions Leading to PPVs, July 2017 to June 2018 ................................................ 29

Figure 61: SSI-Top Reasons for PPVs, July 2017 to June 2018 ...................................................................... 29

Figure 62: Risk-adjusted PPV Rates by Plan from July 2016 to June 2017 and July 2017 to June 2018** .. 30

Figure 63: Top 10 Conditions Leading to PPVs by Specialty Plan, July 2017 to June 2018* ........................ 31

Figure 64: Top 10 Conditions Leading to PPVs by Standard Plan, July 2017 to June 2018* ........................ 32

Figure 65: Risk-adjusted PPV Rates per 1,000 Enrollee Months by Region, FY16/17 to FY17/18 ............... 34

Figure 66: Top 10 Conditions Leading to PPVs by Region, July 2017 to June 2018* .................................... 34

iv

Executive Summary

Background

The Agency for Health Care Administration oversees the provision of healthcare for about 3.8 million low-

income children, adults, seniors, and individuals with disabilities who would otherwise have limited or no health

insurance. Since 2014, the Agency has contracted for the provision of medical services through the Statewide

Medicaid Managed Care (SMMC) program. Most recipients eligible for Medicaid are required to enroll in an

SMMC Managed Medical Assistance (MMA) plan to receive medical care. Managed care plans contract with

providers for healthcare services, including preventive healthcare, and are required to enact procedures to

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

continually seeks to improve access to quality healthcare services for Medicaid recipients and identify

opportunities for healthcare efficiencies that do not compromise quality of care.

One such opportunity lies in identifying and reducing potentially preventable healthcare events (PPEs). PPEs are

healthcare services including hospital admissions, readmissions, and emergency department visits that might

have been prevented with better access to primary care, improved medication management, or better

coordination of care1.

This report examines three types of PPEs:

Potentially Preventable Hospital Admissions (PPAs);

Potentially Preventable Hospital Readmissions (PPRs); and

Potentially Preventable Emergency Department Visits (PPVs).

This report uses data from July 2017 to June 2018, the fourth year of the MMA program, to analyze PPEs. For

comparison, the report includes data from July 2016 to June 2017, the third year of the MMA program, and

displays risk-adjusted rates, the top ten conditions contributing to each PPE, and the reasons PPEs are

considered potentially preventable. Risk-adjusted rates and the top ten conditions contributing to PPEs are also

broken out by plan, region, age, and eligibility group. Differences in the results between the third and fourth

year of the MMA program are also shown. Rounding may affect totals throughout this report.

1 The Agency has contract requirements in place to prevent overpayment for hospital admissions such as case management (Model contract, Attachment II, Section V.E.1.a) and Event Notification Service (ENS) (Model contract, Attachment II, Exhibit II-A, Section VI.A.10.c). The Agency also engages in post payment audits to identify and recoup overpayments (Model contract, Attachment II, Section II.C.12).

v

Total Events and Percentage of Potentially Preventable Events

Results show over 22 percent of all hospital admissions, seven percent of all hospital readmissions, and over 62

percent of all emergency department visits have some potential to be prevented by managing healthcare.

Rates of Potentially Preventable Events

The chart above shows the percentage of PPEs to the total number of events for each category. The remaining

charts show the PPE rates. Risk-adjusted PPA and PPV rates are the number of potentially preventable

admissions and emergency department visits for every 1,000 member months of Medicaid enrollment. Risk-

adjusted PPR rates are the number of potentially preventable readmissions for every 1,000 hospital admissions.

Statewide risk-adjusted rates indicated that for every 1,000 member months, three hospital admissions and 11

emergency department visits had some potential to be prevented. For every 1,000 hospital admissions, 105

readmissions had some potential to be prevented.*

104.9

0

20

40

60

80

100

120

Readmissions

Pe

r 1,

000

In

pat

ien

t A

dm

issi

on

s

2.5

11.4

0

5

10

15

Admissions ED Visits

Pe

r 1,

000

Mem

ber

Mo

nth

s

Percentage and Number of Each Event Identified as Potentially Preventable, July 2017 to June 2018

Risk-adjusted Rates of Potentially Preventable Events, July 2017 to June 2018

*See the technical appendix for changes to the methodology for identifying potentially preventable emergency department visits as compared to

prior issues of this report.

Source: Florida Medicaid Management Information System (FMMIS) Eligibility, Encounter, and Claims Information, July 2017 to June 2018.

101,26922.7%

37,867 7.0%

1,507,26462.2%

0%

25%

50%

75%

100%

Admissions Readmissions ED Visits

vi

Risk-Adjusted Rates

Risk-adjusted rates allow different groups such as plans, regions, and eligibility groups to be compared by

adjusting for differences in the disease burden of each group’s population. Risk adjustment for PPAs and PPVs

also adjusts for differences in cost and resource use among hospital admissions and among emergency

department visits by using national weights that assess the relative value of each event.

By Age

Adults (21 years of age and older) have higher rates of PPAs and slightly lower rates of PPVs than children. The

rates of PPRs are the same for children and adults due to risk-adjustments.

By Eligibility Category

The Medicaid population is divided into two main types of eligibility groups. The SSI–Related eligibility group

consists of individuals who meet the age, income, and/or disability standards for Supplemental Security Income

(SSI). The Family-Related eligibility group consists of children and families who meet state Medicaid eligibility

standards. The largest percentage of Medicaid recipients are in the Family-Related group.

Recipients in a Supplemental Security Income (SSI)-Related eligibility category have higher rates of PPAs and

PPRs, and lower PPV rates, than recipients in a Family-Related eligibility category.

109.5

89.6

0

20

40

60

80

100

120

Readmissions

Pe

r 1,

00

0 In

pat

ien

t A

dm

issi

on

s


Risk-adjusted Rates of Potentially Preventable Events for Children and Adults, July 2017 to June 2018

Children Adults Children Adults Children Adults

Risk Adjusted Rates of Potentially Preventable Events for Recipients in a Family-Related Eligibility Group and Recipients in an SSI-Related Eligibility Group, July 2017 to June 2018

SSI Family

SSI Family

104.9 104.9

0

20

40

60

80

100

120

ReadmissionsP

er

1,0

00 I

np

atie

nt

Ad

mis

sio

ns

1.2

11.5

2.8

11.3

0

5

10

15


Pe

r 1,

000

Mem

ber

Mo

nth

s

SSI Family

2.9

9.1

1.2

12.6

0

5

10

15


Pe

r 1,

00

0 M

emb

er

Mo

nth

s

vii

By Region

The Agency for Health Care Administration delivers Medicaid care on a regional basis, with health plans being

procured by region.

Risk-adjusted PPA Rates by Region, July 2017 to June 2018

Risk-adjusted PPR Rates by Region, July 2017 to June 2018


Risk-adjusted PPV Rates by Region, July 2017 to June 2018

Region 5 had the highest

rate of PPAs at 3.1 per

1,000 enrollee months.

*See the technical appendix for changes to the methodology for identifying potentially preventable emergency department visits as

compared to prior issues of this report.


rate of PPVs at 14.8 per



rate of PPRs at 115.7 per

1,000 hospital admissions.

2.00 - 2.49

1.79 - 1.99

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

Region 10Ft. Lauderdale

Key West

Region 11

Orlando

Melbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

3.00 - 3.19

2.50 - 2.99

95.00 - 99.99

92.40 - 94.99

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

Melbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

105.00 - 109.99

100.00 - 104.99

110.00 - 115.99

10.00 - 10.99

9.50 - 9.99

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

Melbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

12.00 - 12.99

11.00 - 11.99

14.00 - 14.89

*No region has 13.00 - 13.99

viii

Potentially Preventable Reasons

Reasons identify the rationale for defining some admissions, readmissions, and emergency department visits as

potentially preventable. The rankings of PPA and PPV reasons are based on the most numerous and costliest

conditions associated with each reason. PPR reasons are ranked based on the most numerous conditions

associated with each reason.

Conditions that might be managed through outpatient care or treated in a primary care setting were the reason

almost 80 percent of all PPAs were considered potentially preventable.

Over half (51%) of all PPRs were considered potentially preventable because they involved a continuation or

recurrence of a condition from the initial hospital admission. Another 37 percent of PPRs were considered

potentially preventable because they involved a condition that might have been related to the care received

during or after the initial hospitalization.

More than half (57%) of all PPVs were considered potentially preventable because they were Emergency

Department (ED) visits for conditions that might be treated in a primary care setting. Another 35 percent of

PPVs were considered potentially preventable because they were ED visits for conditions that might be managed

through outpatient care. Over eight percent resulted from trauma while residing in a facility.

Reasons PPAs were Considered Potentially Preventable, July 2017 to June 2018


Primary Care Use/Coordination

79.8%

Potential Area of Overuse

9.3%

Quality5.8%

Mental Health Access/Coordination

4.2%

Patient Safety0.1%

Substance Abuse Access/Coordination

0.8%

Reasons PPRs were Considered Potentially Preventable, July 2017 to June 2018

Continuation or Recurrance of

Condition from Initial Admission

51.2%

May Be Related to Care Rcvd During or

After Initial Admission

37.1%

Requires Outpatient Mgmt During/After

Initial Admission11.6%

Reasons PPVs were Considered Potentially Preventable, July 2017 to June 2018

Treatable in Primary Care

Setting56.8%

Manageable With Outpatient Care

34.8%

Trauma in Facility Setting

8.4%

ix

Potentially Preventable Conditions

Top Conditions Contributing to PPAs Statewide, July 2017 to June 2018

Top Conditions Contributing to a PPR Statewide, July 2017 to June 2018


Top Conditions Contributing to a PPV Statewide, July 2017 to June 2018

Heart Failure10,88511.5%

Top 2 - 10 Conditions

45,44948.2%

All Other Conditions

37,97640.3%

The top condition contributing to

PPAs statewide during the review

period was heart failure. Heart

failure accounted for 12 percent of

all PPAs in the state. The top ten

conditions accounted for 60 percent

of all PPAs.

URI64,194 14.7%


208,907 47.8%


164,108 37.5%

The top condition contributing to

PPRs statewide, schizophrenia,

accounted for 5 percent of all PPRs.

The top ten conditions accounted

for 31 percent of PPRs.

Upper respiratory infections (URI)

were the most common condition

leading to PPVs accounting for 15

percent of all PPVs. The top ten

conditions accounted for 63 percent

of all PPVs.

Results for the top conditions contributing to PPAs and PPVs identify the most numerous and costliest

conditions. For PPRs, the top conditions contributing to PPRs identify the most numerous conditions.

Schizo-phrenia2,223 5.0%


11,676 26.2%


30,722 68.9%

x

Changes in Risk-Adjusted Rates From FY16/17 to FY17/18

This section compares PPEs from the third and fourth years of the MMA program. See the technical

appendix (Appendix 1: Technical Specifications) for changes to the methodology for identifying potentially

preventable ED visits as compared to prior issues of this report.

Risk-adjusted Rates for SSI–Related Eligibility Category from FY2016/2017 to FY2017/2018

Risk-adjusted Rates for Family-Related Eligibility Category from FY2016/2017 to FY2017/2018

16/1782.2

17/1889.6

0

20

40

60

80

100

120

Readmissions

Per

1,0

00 In

pat

ien

t A

dm

issi

on

s

16/17100.6

17/18109.5

0

20

40

60

80

100

120

Readmissions

Per

1,0

00 In

pat

ien

t A

dm

issi

on

s

16/172.2

16/1711.1

17/182.5

17/1811.4

0

5

10

15


Pe

r 1,

00

0 M

emb

er M

on

ths

16/171.0

16/1710.3

17/181.2

17/1811.5

0

5

10

15


Pe

r 1,

000

Mem

ber

Mo

nth

s

16/172.7

16/1711.4

17/182.8

17/1811.3

0

5

10

15


Pe

r 1,

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Mem

ber

Mo

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16/171.1

16/1712.2

17/181.2

17/1812.6

0

5

10

15


Pe

r 1,

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Mem

ber

Mo

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16/1796.1

17/18104.9

0

20

40

60

80

100

120

Readmissions

Pe

r 1,

00

0 I

np

atie

nt

Ad

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16/172.7

16/178.9

17/182.9

17/189.1

0

5

10

15


Pe

r 1,

000

Mem

ber

Mo

nth

s

Statewide Risk-adjusted Rates from FY2016/2017 to FY2017/2018

16/1796.1

17/18104.9

0

20

40

60

80

100

120

Readmissions

Per

1,0

00 In

pat

ien

t A

dm

issi

on

s 16/1796.1

17/18104.9

0

20

40

60

80

100

120

Readmissions

Per

1,0

00 In

pat

ien

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dm

issi

on

s

Statewide rates increased slightly from FY16/17 to FY17/18 for all three types of PPEs, with the largest increase

seen in the PPRs. Changes in rates varied by age and eligibility category.

Risk-adjusted Rates for Adults from FY2016/2017 to FY2017/2018


Risk-adjusted Rates for Children from FY2016/2017 to FY2017/2018

xi


Percentages show each condition’s percentage of all top ten conditions.

0% 5% 10% 15% 20% 25%

COPD

Heart Failure

Septicemia

Other Pneumonia

Kidney & UTI

Seizure

Hip Joint Replacement

Dorsal/Lumbar Fusion

GI Disorders

Cardiac Defibrillator

18.7%

18.3%

13.7%

12.2%

9.2%

6.4%

5.8%

5.6%

5.1%

5.0%

0% 5% 10% 15% 20% 25%

Schizophrenia

Bipolar Disorders

Major Depression

Sickle Cell Anemia

Septicemia

COPD

Heart Failure

Diabetes

Respiratory Failure

Kidney & UTI

22.3%

15.4%

10.7%

10.6%

9.7%

9.6%

8.9%

5.5%

3.6%

3.6%

Changes in Rankings of Top 10 Conditions Leading to a PPV Statewide from FY 2016/2017 to FY 2017/2018

Changes in Potentially Preventable Conditions From FY16/17 to FY17/18

Except for three conditions, the top ten conditions contributing to PPAs, PPRs, and PPVs were consistent from

FY16/17 to FY17/18. Between FY16/17 and FY17/18, septicemia and heart failure became more common in

PPAs and PPRs and COPD became less common in PPAs.

7th Ranked Hip Replacement was removed from the DRG list in 17/18 9th Ranked GI Disorders was 12th in 17/18

10th Ranked Asthma was 11th in 16/17 8th Ranked Infect. & Parasitic Dis. was 12th in 16/17

8th Ranked Pneumonia was 14th in 16/17

16/17

17/18

0% 5% 10% 15% 20% 25%

19.3%

18.0%

14.7%

13.0%

8.2%

6.1%

5.7%

5.4%

4.9%

4.7%

Changes in Rankings of Top 10 Conditions Leading to a PPA Statewide from FY 2016/2017 to FY 2017/2018

9th Ranked Pulmonary Edema/Respiratory Failure was 11th in 17/18 10th Ranked Kidney & UTI was 18th in 17/18

0% 5% 10% 15% 20% 25%

16.0%

15.1%

14.6%

12.6%

11.9%

9.0%

5.5%

5.2%

5.1%

5.1%

17/18

Changes in Rankings of Top 10 Conditions Leading to a PPR Statewide from FY 2016/2017 to FY 2017/2018

16/17

0% 5% 10% 15% 20% 25%

23.5%

14.1%

11.5%

10.2%

9.0%

7.0%

6.6%

6.4%

6.1%

5.5%

0% 5% 10% 15% 20% 25%

URI

GI Disorders

Abdominal Pain

Skin Trauma

Viral Illness

Skin/Tissue/Breast

Musculoskeletal Diag.

Acute UTI

Respiratory, Other

Fever

22.9%

15.5%

12.0%

10.3%

7.7%

7.0%

6.8%

6.5%

5.8%

5.4%

16/17

17/18

1

Introduction The Agency for Health Care Administration oversees the provision of healthcare for about 3.8 million low-

income children, adults, seniors, and individuals with disabilities who would otherwise have limited or no health

insurance. Since 2014, the Agency has contracted for the provision of medical services through the Statewide

Medicaid Managed Care (SMMC) program.

The Agency is responsible for paying for and ensuring that Medicaid recipients receive appropriate and

necessary quality medical services in a timely manner. The Agency must ensure access to healthcare amid

growing healthcare costs in the U.S. and is continually seeking efficiencies and savings that do not compromise

the quality of care.

The Agency has focused on reductions in potentially preventable healthcare events (PPEs) as an area with the

potential to improve care management and reduce waste in healthcare spending. Potentially preventable

events are hospital admissions, readmissions, and emergency department visits that might have been prevented

through accessing primary care, improved medication management, or improved coordination of care. Some

hospital readmissions occur due to premature discharges, quality concerns during a previous hospital stay, or a

lack of necessary services after discharge. By improving care during a hospital stay or improving the continuity

of care after release, patient health can be improved and some hospital readmissions can be prevented. One of

the benefits of managed care is the potential it offers to make healthcare more efficient by coordinating

healthcare for enrollees. By improving access to primary care, managing medication, coordinating care

transitions, and monitoring the use of healthcare resources, managed care has the potential to improve quality

of care and reduce unnecessary use of healthcare resources.

Although not all potentially preventable events can be avoided, PPE rates in populations can be used as a gauge

of failure to access primary care, missed opportunities to manage chronic conditions, and the quality of care

available. Hospitalizations and emergency department visits tend to be costlier than outpatient or primary care

visits. To the extent that hospitalizations and emergency department visits can be reduced by ensuring primary

care is utilized when appropriate and chronic conditions are monitored and managed, healthcare can be more

efficient and less costly.

This report examines three potentially preventable healthcare events: Potentially Preventable Hospital

Admissions (PPAs), Potentially Preventable Hospital Readmissions (PPRs), and Potentially Preventable

Emergency Department Visits (PPVs). Claims and encounter data from the fourth year of Florida’s Statewide

Medicaid Managed Care Managed Medical Assistance program from July 2017 to June 2018 were analyzed for

the three types of events. Risk-adjusted rates, the top ten conditions contributing to each potentially

preventable event, and the reasons that events are considered preventable are included in results, and risk-

adjusted rates and top ten conditions are also analyzed separately by age, eligibility group, plan, and region.

Results from the fourth year of the program are compared to results from the third year of the program.

Changes in PPE rates from the third to the fourth year of the program are shown and changes in top ten

rankings are indicated.

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.

Data Period Source

Enrollment Information

July 1, 2016-June 30, 2018 as of April 2019

Florida Medicaid Management Information System (FMMIS) Eligibility Information

MMA Encounter and Claims Information for

History Period


FMMIS Claims and Encounter Information

MMA Encounter and Claims Information for

Analysis Period


FMMIS Claims and Encounter Information

Medicaid recipients whose medical billing data is incomplete in the Florida Medicaid Management Information

System (FMMIS) are excluded from analyses. This includes recipients dually eligible for Medicaid and Medicare

for whom Medicaid does not receive complete medical billing information, women enrolled only for Family

Planning services, and other recipients without full Medicaid coverage. In addition, recipients who have full

Medicaid coverage for less than 6 months in the analysis period from July 1, 2017 through June 30, 2018, or less

than 3 months in the history period from July 1, 2016 through June 30, 2017 are excluded from the analyses.

Analyses utilized managed care encounters that are paid and submitted to FMMIS and fee-for-service claims

that are paid.

The fee-for-service (FFS) population is included in the data for the calculation of the statewide norms for risk-

adjusted rates. Most of the FFS population consists of Medicaid recipients who are dually eligible for Medicare

and Medicaid and whose medical care is managed by Medicare and are not separately displayed in this report.

Methodology for PPEs

Potentially Preventable Admissions

PPAs are hospital admissions that might have resulted from a failure to access primary care or a failure of

ambulatory care coordination. PPAs include ambulatory sensitive conditions and nursing sensitive conditions.

Ambulatory sensitive conditions are health conditions that require regular treatment that can be managed in an

outpatient setting. Ambulatory sensitive conditions, such as asthma, might be avoided with adequate

monitoring and follow-up care, such as medication management. Nursing sensitive conditions are health

conditions, such as pressure ulcers and urinary tract infections, that rely on quality nursing care for management

or prevention. Nursing sensitive conditions occur in skilled nursing facilities, inpatient psychiatric facilities,

intermediate care facilities, residential substance abuse treatment facilities, psychiatric residential treatment

centers, and comprehensive inpatient rehabilitation facilities.

PPAs are identified by first assigning an All Patient Refined Diagnosis Related Group (APR DRG) to inpatient

claims and encounters for acute care hospitals. If the admission is an APR DRG for one of 43 ambulatory

sensitive conditions or 126 nursing sensitive conditions for patients admitted from a facility, the admission is

considered potentially preventable.

3

Each ambulatory sensitive condition and nursing sensitive condition is associated with a reason that the

condition is defined as potentially preventable. For instance, asthma is defined as potentially preventable

because it is possible to treat it in a primary care setting. Diabetes and COPD are defined as potentially

preventable because they are chronic conditions that may be managed through outpatient coordination.

The reasons below define why ambulatory sensitive conditions and nursing sensitive conditions are considered

potentially preventable. An example of a specific condition that is considered potentially preventable for each

reason is provided.

Primary Care Accessibility, Coordination and Management: Failure to access primary care resulted in a hospital admission (e.g., asthma) or lack of care management of a health condition resulted in a hospital admission (e.g., chronic obstructive pulmonary disease).

Potential Area of Overuse: Hospital admission for a procedure which may not be effective (e.g., dorsal and lumbar fusion except for curvature of the back).

Not Clinically Related: Hospital admission for a procedure not clinically related to the diagnosis (e.g., tonsil and adenoid procedures to address hearing loss).

Patient Safety: Lack of patient safety in a facility resulted in a hospital admission (e.g., contusion, open wound and other trauma to the skin).

Mental Health Accessibility, Coordination and Management: Lack of management of a mental health condition in a facility resulted in a hospital admission (e.g., schizophrenia).

Substance Abuse Accessibility, Coordination and Management: Lack of management of a substance abuse condition in a facility resulted in a hospital admission (e.g., opioid abuse and dependence).

Potentially Preventable Readmissions

A PPR is a return hospitalization within 30 days of an initial hospital discharge that is clinically related to the

initial hospital admission and may have resulted from the process of care and treatment during the prior

admission (e.g., infection of a surgical wound) or from lack of follow up after discharge. PPRs are identified by

first assigning an APR DRG to inpatient claims and encounters for acute care hospitals. For any admission that

follows another admission within 30 days, the APR DRG of each admission is used to determine if the 2

admissions are clinically related. If an admission follows within 30 days of a prior admission and is clinically

related to the initial admission, it is considered potentially preventable.

An admission may be associated with multiple readmissions if a second (or third or more) admission falls within

30 days of the readmission and is clinically related to the initial admission. A chain with multiple readmissions

that are clinically related to an initial admission counts as only one PPR.

Readmissions are considered potentially preventable when the readmission addresses a condition that is likely

to be related to care received during or following a prior hospital admission. The following reasons define why

readmissions are considered potentially preventable:

The readmission was for a continuation or recurrence of a medical condition addressed in the initial admission.

The readmission was for an ambulatory care sensitive condition such as designated by Agency for Healthcare Research and Quality (ARHQ) (e.g., asthma).

4

The readmission was for a chronic problem related to care received during or after the initial admission.

The readmission was for an acute medical condition or complication related to care received during or after the initial admission.

The readmission was for a surgical procedure to address a continuation or recurrence of the problem addressed in the initial admission.

The readmission was for a surgical procedure to address a complication related to or resulting from care received during the initial admission.

The readmission was for a mental health condition following an initial admission for a medical reason.

The readmission was for a substance abuse condition following an initial admission for a medical reason.

The readmission was for a mental health or substance abuse condition following an initial admission for a substance abuse or mental health condition.

Potentially Preventable Emergency Department Visits

PPVs are emergency department visits that may result from a failure to access primary care or a lack of

ambulatory care coordination. PPVs are ambulatory sensitive conditions, such as asthma, which might be

avoided with adequate monitoring and follow-up, or nursing sensitive conditions, such as skin ulcers, which

might be avoided with adequate nursing care. When a PPV occurs shortly after a hospitalization, it may be the

result of actions taken or omitted during the hospital stay or a lack of coordination with physicians after release.

Outpatient claims and encounters for emergency department visits are assigned an Enhanced Ambulatory

Patient Group (EAPG). If an emergency department visit is an EAPG for one of 194 ambulatory sensitive

conditions, or 201 nursing sensitive conditions or 6,617 trauma codes for patients admitted from a nursing

facility, the visit is considered potentially preventable.

The following reasons define why PPVs are considered potentially preventable. An example of a specific

condition that is considered potentially preventable for each reason is provided.

The ED visit was for an acute illness that might be treatable in a primary care setting (e.g., abdominal pain).

The ED visit was for an acute infection that might be treatable in primary care setting (e.g., upper respiratory tract infections).

The ED visit was for a malignancy-related chronic illness that might be manageable via outpatient coordination (e.g., lymphoma, myeloma, and non-acute leukemia).

The ED visit was for a chronic illness (not mental health, substance abuse, or malignancy) that might be manageable via outpatient coordination (e.g., hypertension).

The ED visit was for a mental health or substance abuse condition that might be manageable via outpatient coordination (e.g., acute anxiety).

The ED visit was to treat trauma received while residing in a facility (e.g., contusion, open wound, and other trauma to the skin).

The ED visit was to treat a condition that might not be appropriate for the emergency department (e.g., splint, strapping, and cast removal).

Risk Adjustment Clinical Risk Groups (CRGs) are used to compare actual and expected rates across plans, regions, age groups, and

eligibility groups. CRGs are a categorical clinical model in which each recipient is assigned to a single mutually

exclusive risk category that measures the recipient’s chronic burden of illness. CRGs are constructed using

5

claims and encounter data for the year prior to the analysis year to assess each enrollee’s medical history and

determine the amount and type of healthcare resources the enrollee is likely to consume in the future. The

history year for analyses is July 2016 to June 2017.

The CRG uses diagnosis codes, procedure codes, and national drug codes, singularly or in combination, to build a

disease profile for each person. It also uses information such as the place of service, recency of the service,

persistence of an illness, and the demographic characteristics of the individual. Since CRGs are clinically-based,

they allow a link between the clinical care needed and financial resources required to address health conditions.

Each enrollee is assigned to one of 1,474 CRGs. CRGs are aggregated into 54 predefined categories for risk

adjustment. For more detailed information about CRGs, see the Winter 2017 Quarterly Statewide Medicaid

Managed Care Report.

Some hospital admissions use more medical resources and are costlier than other hospital admissions. The

same dynamic holds for emergency department visits. Using a set of national weights for APR DRGs and EAPGs

provides a measure of relative resource use for hospitalizations and emergency department visits and allows

more resource intensive and costly events to be weighted more heavily.

PPAs and PPVs use a weighted sum in the numerator and the number of enrollee months in the denominator

when calculating the risk-adjusted rate. The population-based rate indicates the number of PPAs or PPVs per


Since weights are used to calculate rates for PPAs and PPVs, the top ten conditions contributing to PPAs and

PPVs are calculated by multiplying the frequency of each APR DRG or EAPG times its weight. The top ten

conditions indicate the most frequent, costliest APR DRGs or EAPGs that lead to a potentially preventable event.

Likewise, reasons for PPAs and PPVs are calculated by multiplying the frequency of each reason times the weight

of the APR DRGs or EAPGs of each condition.

PPRs use APR DRG, severity of illness, age, and mental health status for risk adjustment to compare actual and

expected rates across plans, regions, age groups, and eligibility groups. The PPR rate is calculated by using the

number of initial admissions with one or more clinically-related readmissions in the numerator and the number

of initial admissions at risk for a readmission in the denominator. The PPR rate indicates the number of PPRs per

1,000 hospital admissions.

6

Potentially Preventable Hospital Admissions (PPA)

A potentially preventable hospital admission (PPA) is a hospital admission that might have resulted from a

failure to access care or a lack of ambulatory care coordination. PPAs involving ambulatory sensitive conditions,

such as asthma or diabetes, might be avoided with more effective monitoring and follow-up care, including

medication management. PPAs involving nursing sensitive conditions, such as urinary tract infections or trauma,

might be prevented with more effective quality of care at a nursing facility. These facilities include not only

skilled nursing facilities, but also inpatient psychiatric facilities, intermediate care facilities, residential substance

abuse treatment facilities, psychiatric residential treatment centers, and comprehensive inpatient rehabilitation

facilities.

2.5 Hospital Admissions

Per 1,000 Enrollee Months were Potentially Preventable


The risk-adjusted rate adjusts for

differences in the costliness of

different hospital admissions as well as

for differences in the burden of illness

across plans, regions, and other

populations.

Figure 3: Risk-adjusted PPA Rate per 1,000 Enrollee Months Statewide,

July 2017 to June 2018

Twenty-three percent

(101,269/446,102) of all

hospital admissions during

the FY17/18 review period

were identified as

potentially preventable.

16/17 17/18

Figure 2: Risk-Adjusted PPA Rates per 1,000 Enrollee Months by Region, July 2017 to June 2018

There were 38,269,093

member months from

July 2017 to June 2018.

468,090

100,031

446,102

101,269

0

100,000

200,000

300,000

400,000

500,000

Total Admissions Potentially PreventableAdmissions

Figure 1: Total Number of Admissions and Total Number of Admissions Identified as Potentially Preventable from FY2016/2017 to FY2017/2018

16/17 17/18


rate of PPAs across all

Florida regions.

2.00 - 2.49

1.79 - 1.99

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

Melbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

3.00 - 3.19

2.50 - 2.99

7

Figure 5: Top 10 Conditions Leading to PPAs Statewide, July 2017 to June 2018*

Figure 4: Top Reasons Admissions Are Defined as PPAs Statewide, July 2017 to June 2018

The top ten

conditions make

up 60 percent of

all conditions

resulting in a

PPA.

NS=Nursing Sensitive




Each PPA is associated with an underlying condition that resulted in the PPA. Heart failure accounts for over 19

percent of the top ten conditions that resulted in a PPA, followed by septicemia at 18 percent and COPD at

almost 15 percent.


0% 10% 20% 30% 40% 50%

Outpatient Coordination

Use of Primary Care


NS Quality

NS Mental Health Coordination

NS Use of Primary Care

NS Potential Area of Overuse

NS Care Cordination

NS Substance Abuse Cordination

NS Safety

NS Patient Safety

39.4%

38.7%

8.6%

5.8%

4.2%

1.7%

0.7%

0.7%

0.1%

0.1%

0.1%Ambulatory Sensitive Nursing Sensitive

*Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. Numbers in brackets indicate the group’s corresponding ranking of the condition for FY16/17.

Nearly 87 percent of

PPAs are ambulatory

sensitive conditions.

About 13 percent are

nursing sensitive (NS)

conditions.

0% 10% 20% 30%

(1) Heart Failure [2]

(2) Septicemia [3]

(3) COPD [1]

(4) Pneumonia [4]

(5) Kidney & UTI [5]

(6) Cardiac Defibrillator [10]

(7) Seizure [6]

(8) Infectious Disease [12]

(9) Dorsal/Lumbar Fusion [8]

(10) Asthma [11]

19.3%

18.0%

14.7%

13.0%

8.2%

6.1%

5.7%

5.4%

4.9%

4.7%

Over 39 percent of PPAs were identified as potentially preventable because they were related to outpatient

coordination and over 38 percent were related to the use of primary care.

Ambulatory Sensitive

86.7%

Nursing Sensitive

13.3%

Percentages

show each

condition’s

percentage

of all top ten

conditions.

Numbers in

parentheses

() are current

year’s

statewide

ranking.

Numbers in

brackets []

are previous

year’s

rankings for

that plan,

region,

eligibility, or

age.

Heart Failure10,88511.5%


45,44948.2%


37,97640.3%

8

PPAs by Age

0% 10% 20% 30%

(4) Pneumonia [1]

(10) Asthma [2]

(7) Seizure [3]

(18) Bipolar Disorders [4]

(20) URI [6]

(12) GI Disorders [5]

(24) Major Depression [14]


(19) Cellulitis [7]

(14) Other Digestive [9]

23.4%

20.7%

11.6%

10.1%

8.1%

7.6%

5.3%

4.6%

4.6%

4.0%


COPD, heart failure, and septicemia are the top conditions leading to PPAs for adults. The top three conditions

for adults are the top three conditions for PPAs statewide.

* Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. Numbers in brackets indicate the group’s corresponding ranking of the

condition for FY16/17. Conditions shaded gray do not appear in the statewide top 10 ranking for FY17/18.

0% 20% 40% 60% 80%

Primary Care Use/Coord.

NS Primary Care Use/Coord.


NS Mental Health Access/Coord.


NS Patient Safety

NS Substance Abuse Access/Coord.

Not Clinically Related

NS Not Clinically Related

51.3%

18.9%

0.1%

23.5%

3.4%

2.0%

0.6%

0.2%

0.05%

Ambulatory Sensitive Nursing Sensitive

Figure 8: Adults-Top 10 Conditions Leading to PPAs, July 2017 to June 2018*

Figure 10: Adults-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018

Figure 9: Change in PPA Rates for Children and Adults from FY2016/2017 to FY2017/2018

Child State Adult

1.2

2.5 2.8

0

1

2

3

Child State Adult

Figure 11: Risk-adjusted PPA Rates for Children and Adults per 1,000 Enrollee Months, July 2017 to June 2018

The top conditions resulting in PPAs for children are pneumonia and asthma. Six of the top ten conditions for

children are not in the top ten PPA conditions statewide.

0% 10% 20% 30%


(2) Septicemia [3]

(3) COPD [1]

(4) Pneumonia [4]





(11) Cardiac Cath. [11]

(7) Seizure [10]

20.6%

19.1%

15.7%

10.3%

8.1%

6.4%

5.8%

5.0%

4.7%

4.3%

Figure 6: Children-Top 10 Conditions Leading to PPAs, July 2017 to June 2018*

Figure 7: Children-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018

0% 20% 40% 60% 80%







NS Patient Safety


78.4%

3.0%

0.04%

16.4%

1.9%

0.1%

0.1%

0.05%


NS=Nursing

Sensitive

NS=Nursing

Sensitive

NS=Nursing

Sensitive

NS=Nursing

Sensitive

NS=Nursing

Sensitive

NS=Nursing

Sensitive

NS=Nursing

Sensitive

NS=Nursing

Sensitive

9


0% 10% 20% 30%

(4) Pneumonia [1]

(10) Asthma [2]


(7) Seizure [5]


(19) Cellulitis [6]




(20) URI [10]

22.0%

20.6%

8.7%

8.2%

7.9%

6.7%

6.6%

6.6%

6.3%

6.2%

0% 20% 40% 60% 80%






NS Patient Safety



NS Not Clinically Related

51.8%

16.9%

0.1%

24.4%

3.9%

2.1%

0.6%

0.2%

0.05%


PPAs by Eligibility Group

0% 20% 40% 60% 80%






NS Patient Safety


70.4%

17.2%

11.1%

0.7%

0.4%

0.1%

0.1%


The top conditions for recipients in a family-related eligibility category are pneumonia and asthma. Five of the

top ten conditions are not present in the statewide top ten conditions for PPAs. The top ten conditions for

individuals in a family-related eligibility group are similar to the top ten conditions for children.

Figure 13: Family-Top 10 Conditions Leading to PPAs, July 2017 to June 2018*

Figure 12: Family-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018

Figure 14: Risk-adjusted PPA Rates for Family-Related and SSI-Related Eligibility Categories per 1,000 Enrollee Months,


1.2

2.52.9

0

1

2

3

4

Family State SSI

Figure 16: SSI-Top 10 Conditions Leading to PPAs, July 2017 to June 2018*



Figure 15: Change in PPA Rates for Family-Related and SSI-Related Eligibility Categories from FY2016/2017 to

FY2017/2018

Figure 17: SSI-Reasons Admissions Are Defined as PPAs, July 2017 to June 2018

The top conditions for recipients in an SSI-related eligibility group are heart failure and septicemia. The top

ten conditions for individuals in an SSI-related eligibility group are similar to the top ten conditions for adults.

NS=Nursing

Sensitive

NS=Nursing

Sensitive

Family State SSI

0% 10% 20% 30%


(2) Septicemia [3]

(3) COPD [1]

(4) Pneumonia [4]




(7) Seizure [7]



20.4%

19.4%

15.6%

10.8%

7.9%

6.2%

5.8%

4.9%

4.6%

4.4%

10

PPAs by Plan

Figure 18: Risk-adjusted PPA Rates by Plan, July 2016 to June 2017 and July 2017 to June 2018**

Change from 2016/2017 to 2017/2018


Rates vary by plan ranging from 1.1 to 3.8 PPAs per 1,000 enrollee months during the review period. PPA

rates increased for all but five plans from FY16/17 to FY17/18. For more information on plans’ service

regions, market share, and populations served, see Appendix 3.

Seven of the top ten conditions for Magellan, the specialty plan for serious mental illness, are among the top

ten conditions statewide. Three of Magellan’s top ten conditions are mental health conditions.

Pneumonia is the most common condition leading to a PPA for Children’s Medical Services (CMS) but ranks

fourth statewide. Many of the top ten conditions for CMS, the specialty plan for children with chronic

conditions, are conditions common in children: asthma, upper respiratory infections (URIs), and

gastrointestinal (GI) disorders.

Seven of the top ten conditions contributing to PPAs for Sunshine Specialty, the specialty plan for children in

child welfare, are not among the top ten conditions statewide. Six of Sunshine Specialty’s top ten conditions

are mental health conditions.

The most common conditions leading to a PPA for both Clear Health and Positive, the specialty plans for

enrollees with HIV/AIDS, are heart failure and COPD.

**The fee-for-service (FFS) population is included in the calculation of the statewide norms for risk-adjusted rates. Most of the FFS population

consists of Medicaid recipients who are dually eligible for Medicare and Medicaid and whose medical care is managed by Medicare. Therefore results

for FFS are not separately displayed in this report.

Risk-adjusted PPA Rates per 1,000 Enrollee Months




2.1

1.6

1.3

1.3

1.7

2.1

2.4

2.5

2.1

1.2

1.5

1.5

2.0

2.6

1.8

2.6

2.2

2.3

1.8

1.3

1.3 1

.6

2.0

2.0

2.6

2.1

1.1

1.7

1.5

2.7

3.8

2.6

3.0

2.5

0

1

2

3

4

Am

eri

gro

up

Be

tte

r H

ealt

h

Cle

ar H

eal

th

CM

S

Co

mm

un

ity

Car

e

Co

ven

try

Hu

man

a

Mag

ella

n

Mo

lina

Po

siti

ve

Pre

stig

e

Sim

ply

Sta

ywe

ll

Sun

shin

e

Sun

shin

e S

pe

cial

ty

Un

ited

Sta

te

11


* Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. Numbers in brackets indicate the group’s corresponding ranking

of the condition for FY16/17. Conditions shaded gray do not appear in the statewide top 10 ranking for FY17/18.

Figure 19: Top 10 Conditions Leading to a PPA by Specialty Plan, July 2017 to June 2018*

0% 10% 20% 30%

(2) Septicemia [1]

(13) Schizophrenia [2]


(3) COPD [3]


(4) Pneumonia [8]


(7) Seizure [6]



31.3%

12.1%

10.8%

9.9%

8.8%

6.8%

6.5%

4.9%

4.8%

4.1%

Magellan

0% 10% 20% 30%

(4) Pneumonia [1]

(7) Seizure [2]

(20) URI [4]

(10) Asthma [5]



(25) Minor Respiratory [9]



(28) Low Blood Circu. [10]

24.5%

21.0%

9.9%

8.9%

8.4%

7.5%

6.3%

5.2%

4.3%

4.0%

CMS Network

0% 10% 20% 30%


(43) Behavioral Disorders [2]

(44) Mood Disorders [7]


(10) Asthma [5]

(4) Pneumonia [3]

(7) Seizure [8]


(55) Depression [13]


35.9%

17.7%

15.5%

8.1%

6.6%

5.8%

3.1%

2.6%

2.5%

2.3%

Sunshine Specialty

0% 10% 20% 30%


(3) COPD [1]

(4) Pneumonia [3]




(21) Hypertension [8]

(15) Coronary Bypass [10]


(7) Seizure [7]

25.1%

24.9%

11.5%

8.0%

6.2%

5.2%

5.2%

4.8%

4.7%

4.3%

Clear Health

0% 10% 20% 30%

(3) COPD [1]



(4) Pneumonia [6]


(7) Seizure [12]

(8) Infectious Disease [-]




24.6%

21.0%

12.4%

11.6%

6.7%

6.0%

5.5%

5.0%

3.7%

3.5%

Positive

12


The top condition leading to a PPA for all but three plans is heart failure. Gastrointestinal Disorders,

ranked 12th statewide, appears among the top ten conditions for five standard plans.

0% 10% 20% 30%


(3) COPD [1]

(2) Septicemia [4]

(4) Pneumonia [3]


(10) Asthma [6]

(7) Seizure [7]




19.9%

13.9%13.5%

13.2%

8.9%

7.5%

6.6%

6.0%

5.8%4.9%

Amerigroup

0% 10% 20% 30%


(4) Pneumonia [2]

(2) Septicemia [5]

(3) COPD [4]


(10) Asthma [9]

(7) Seizure [12]



(20) URI [17]

27.3%

20.6%

12.4%

11.4%

7.1%

4.9%

4.8%

4.6%

3.6%

3.3%

Coventry

Figure 20: Top 10 PPA Conditions by Standard Plan, July 2017 to June 2018*

0% 10% 20% 30%

(4) Pneumonia [1]


(3) COPD [3]

(10) Asthma [4]


(7) Seizure [6]


(20) URI [13]

(2) Septicemia [5]


17.7%

16.5%

13.4%

11.8%

8.7%

7.3%

6.9%

6.1%5.8%

5.7%

Better Health

* Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. Numbers in brackets indicate the group’s corresponding

ranking of the condition for FY16/17. Conditions shaded gray do not appear in the statewide top 10 ranking for FY17/18.

0% 10% 20% 30%


(2) Septicemia [3]

(3) COPD [2]

(4) Pneumonia [4]



(10) Asthma [8]

(7) Seizure [7]



20.3%

14.7%

14.1%

14.1%

8.9%

7.8%

5.4%

5.2%

4.9%

4.6%

Humana

0% 10% 20% 30%

(4) Pneumonia [1]


(10) Asthma [4]

(3) COPD [3]

(7) Seizure [5]


(15) Coronary Bypass [-]


(2) Septicemia [17]

(20) URI [6]

17.7%

17.6%

13.9%

13.4%

11.3%

5.6%

5.5%

5.4%

5.0%

4.7%

Community Care

13


COPD, heart failure, and pneumonia are among the top ten conditions for every plan. Two infectious

conditions, septicemia and infectious diseases, are also among the top ten conditions contributing to PPAs

for many plans.



0% 10% 20% 30%


(3) COPD [2]

(4) Pneumonia [3]

(2) Septicemia [4]



(10) Asthma [6]


(7) Seizure [10]


19.7%

15.7%

13.7%

12.6%

7.6%

7.4%

7.3%

5.8%

5.3%

5.0%

Molina0% 10% 20% 30%


(3) COPD [1]

(4) Pneumonia [3]

(2) Septicemia [4]


(10) Asthma [6]

(7) Seizure [7]




21.0%

16.7%

15.5%

15.2%

7.2%

6.9%

5.0%

4.2%

4.1%

4.1%

Prestige

0% 10% 20% 30%


(3) COPD [1]

(2) Septicemia [4]

(4) Pneumonia [3]



(10) Asthma [8]



(7) Seizure [7]

19.1%

15.9%

13.0%

12.9%

8.5%

6.8%

6.5%

6.4%

5.6%

5.3%

Staywell0% 10% 20% 30%


(3) COPD [1]

(4) Pneumonia [3]





(17) Cardiac Procedure [17]

(2) Septicemia [16]


20.4%

18.7%

14.8%

11.5%

7.4%6.9%

5.6%5.3%

4.9%

4.5%

Simply

0% 10% 20% 30%


(2) Septicemia [3]

(4) Pneumonia [4]

(3) COPD [2]





(7) Seizure [10]


19.5%

18.9%

13.1%

13.1%

8.5%

6.6%6.1%

5.5%4.4%

4.1%

United0% 10% 20% 30%

(2) Septicemia [1]


(3) COPD [3]

(4) Pneumonia [4]




(7) Seizure [8]

(23) Urogenital Malfunc. [19]

(22) Respiratory Failure [13]

28.5%16.0%

11.5%

10.5%

8.8%8.4%

5.0%

4.2%

3.9%

3.3%

Sunshine

14

PPAs by Region

Figure 21: Risk-adjusted PPA Rates per 1,000 Enrollee Months by Region, July 2016 to June 2017 and July 2017 to June 2018


*Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. Numbers in brackets indicate the group’s corresponding ranking of the condition for FY16/17. Conditions shaded gray do not appear in the statewide top 10 ranking for FY17/18.

0% 10% 20% 30%

(2) Septicemia [3]


(4) Pneumonia [4]

(3) COPD [2]






(7) Seizure [7]

22.4%

22.1%

12.2%

11.9%

8.7%

5.3%

4.8%

4.7%

4.2%

3.8%

Region 2

PPA rates increased in all regions except Regions 1, 10, and 11 from FY16/17 to FY17/18. Region 5 has the

highest rate of PPAs in the state with septicemia accounting for over 26 percent of the top ten conditions

leading to a PPA in the region. The top condition contributing to PPAs in all 11 regions is either heart failure

or septicemia.

Change from FY2016/2017 to FY2017/2018

Figure 22: Top 10 Conditions Leading to a PPA by Region, July 2017 to June 2018*

0% 10% 20% 30%


(2) Septicemia [3]

(3) COPD [1]

(4) Pneumonia [5]



(7) Seizure [7]


(10) Asthma [12]


17.6%

16.5%

16.4%

13.1%

8.9%

6.5%

5.7%

5.5%

5.0%

4.7%

Region 1

0% 10% 20% 30%


(3) COPD [1]

(2) Septicemia [3]

(4) Pneumonia [4]






(7) Seizure [8]

18.4%

17.8%

17.6%

10.9%7.2%

6.7%

5.6%

5.4%

5.2%

5.2%

Region 3

2.2

2.2

2.3

2.2

2.5

2.2

2.4

2.0

2.2

2.0

2.2

2.2

1.8

2.9

2.8

2.7 3

.1

2.4 2

.8

2.3

2.3

2.0 2.1 2

.5

0

1

2

3

4

01 02 03 04 05 06 07 08 09 10 11 State

15

Five conditions appear in the regional top ten lists that do not appear in the statewide top ten conditions.



0% 10% 20% 30%


(4) Pneumonia [3]

(3) COPD [2]

(2) Septicemia [4]



(7) Seizure [7]


(10) Asthma [12]


22.3%15.8%

13.8%

13.6%10.4%

7.0%5.3%

4.0%4.0%

3.9%

Region 110% 10% 20% 30%


(4) Pneumonia [2]

(2) Septicemia [4]

(3) COPD [3]

(7) Seizure [6]



(10) Asthma [7]



18.0%16.9%

14.0%12.2%

7.7%7.4%7.4%

7.2%5.0%

4.1%

Region 10

0% 10% 20% 30%


(2) Septicemia [3]

(3) COPD [1]

(4) Pneumonia [4]





(10) Asthma [10]

(7) Seizure [8]

18.7%18.6%

15.5%12.3%

7.0%6.4%6.1%

5.9%4.8%4.7%

Region 8

0% 10% 20% 30%


(2) Septicemia [2]

(3) COPD [3]

(4) Pneumonia [4]


(7) Seizure [6]




(10) Asthma [7]

20.4%19.0%

12.8%11.4%

6.9%6.5%6.5%

5.8%5.6%5.2%

Region 7

0% 10% 20% 30%

(2) Septicemia [2]


(3) COPD [1]

(4) Pneumonia [6]




(7) Seizure [8]



26.1%

15.2%14.7%

9.0%8.6%

7.3%5.6%

4.9%4.5%4.2%

Region 5

0% 10% 20% 30%

(2) Septicemia [4]


(4) Pneumonia [3]

(3) COPD [1]


(7) Seizure [6]

(10) Asthma [7]




18.9%

17.7%

14.8%

13.1%8.6%

6.6%

5.7%5.1%

4.8%

4.8%

Region 9

0% 10% 20% 30%


(3) COPD [1]

(2) Septicemia [3]

(4) Pneumonia [4]


(7) Seizure [10]



(10) Asthma [8]


20.4%17.2%

14.0%13.2%

8.9%5.6%5.6%5.2%5.1%

4.7%

Region 6

0% 10% 20% 30%

(2) Septicemia [2]


(3) COPD [1]

(4) Pneumonia [4]





(7) Seizure [7]


19.5%16.6%

13.9%12.1%

7.8%6.8%6.2%6.0%5.6%5.6%

Region 4

16

95.00 - 99.99

92.40 - 94.99

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

Melbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

105.00 - 109.99

100.00 - 104.99

110.00 - 115.99

Potentially Preventable Readmissions (PPR)

A potentially preventable readmission (PPR) is a hospitalization that occurred within 30 days of a prior hospital

admission and is clinically related to the initial hospital admission. PPRs might result from the process of care

and treatment during the initial admission (e.g., infection of a surgical wound) or from lack of follow up after

discharge. PPRs can also indicate incomplete resolution of the illness during the initial stay.

104.9 Hospital Readmissions

Per 1,000 Admissions were Potentially Preventable

Figure 25: Risk-Adjusted PPR Rate per 1,000 Hospital Admissions Statewide,


The risk-adjusted rate

adjusts for differences in

the burden of illness

across plans, regions, or

other populations.

Figure 24: Risk-Adjusted PPR Rates per 1,000 Hospital Admissions by Region, July 2017 to June 2018


About seven percent

(37,867/539,900) of all

hospital admissions were

followed by a potentially

preventable hospital

readmission in FY17/18.

Figure 23: Total Number of Admissions and Total Number of Readmissions Identified as Potentially Preventable from FY2016/2017 to FY2017/2018

16/17 17/18 16/17 17/18

544,296

33,775

539,900

37,867

0

200,000

400,000

600,000

Total Admissions Potentially PreventableAdmissions

Regions 2 and 3 had the

highest rate of PPRs across all

Florida regions.

17

0% 5% 10% 15% 20% 25% 30%

Medical Condition / Complication Related to InitialAdmit

Continuation or Recurrance of Initial Medical Cond.

MH or SA Readmit following initial SA or MA Admit

Chronic Problem Related to Care During or AfterInitial Admit

Surgical Procedure for Continuation/Recurrance ofInitial Problem

Mental Health Readmit Following Initial MedicalAdmit

Surgical Procedure for Complication Related to InitialCare

Ambulatory Care Sensitive Conditions

Substance Abuse Readmit Following Initial MedicalAdmit

27.3%

26.1%

23.9%

7.9%

7.9%

6.1%

6.1%

5.2%

0.3%

Figure 26: Reasons for PPRs Statewide, July 2017 to June 2018

Over three-quarters (77%) of PPRs were considered potentially preventable because they were complications

related to care provided during the initial hospitalization or after discharge (27%), were a continuation or

recurrence of a medical condition addressed in the original hospitalization (26%), or were a continuation or

recurrence of a mental health or substance abuse condition following an initial hospitalization for substance

abuse or a mental health condition (24%).

Figure 27: Top 10 Conditions Leading to PPRs Statewide, July 2017 to June 2018*

0% 10% 20% 30%


(2) Septicemia [5]




(6) COPD [6]

(7) Sickle Cell Anemia [4]

(8) Pneumonia [14]


(10) Diabetes [8]

16.0%

15.1%

14.6%

12.6%

11.9%

9.0%

5.5%

5.2%

5.1%

5.1%

The top ten

conditions

leading to PPRs

make up over 30

percent of all

PPRs statewide.

Three of the top five conditions for the initial admission that resulted in a PPR are mental health conditons.

Schizophrenia accounts for 16 percent of the top ten PPRs, followed by septicemia (15%) and bipolar

disorders (15%).

MH=Mental Health SA=Substance Abuse

Schizo-phrenia2,223 5.0%


11,676 26.2%


30,722 68.9%Percentages

show each

condition’s

percentage

of all top ten

conditions.

Numbers in

parentheses

() are current

year’s

statewide

ranking.

Numbers in

brackets []

are previous

year’s

rankings for

that plan,

region,

eligibility, or

age.

* Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. A dash indicates the condition was not present in FY17/18. Numbers in brackets indicate the group’s corresponding ranking of the condition for FY16/17. Conditions share the same ranking when the value of the percentage for each condition is the same.


Medical41,69969.6%

MH/SA18,19130.4%

18

Bipolar disorders account for nearly a third of children’s top ten PPRs. Five of the top ten PPRs for children are

mental health conditions accounting for over 74 percent of top ten PPAs.

PPRs by Age

0% 20% 40% 60%

Medical Condition / Complication Relatedto Initial Admit

Continuation or Recurrance of InitialMedical Cond.

MH or SA Readmit following initial SA orMA Admit

Chronic Problem Related to Care During orAfter Initial Admit

Mental Health Readmit Following InitialMedical Admit


Surgical Procedure forContinuation/Recurrance of Initial Problem

Surgical Procedure for ComplicationRelated to Initial Care

Substance Abuse Readmit Following InitialMedical Admit

30.5%

28.0%

16.6%

8.6%

6.3%

6.1%

2.2%

1.3%

0.4%

0% 20% 40% 60%

MH or SA Readmit following initial SA or MAAdmit

Continuation or Recurrance of Initial MedicalCond.

Medical Condition / Complication Related toInitial Admit





Surgical Procedure for Complication Relatedto Initial Care

57.2%

17.7%

12.4%

5.3%

4.6%

1.0%

1.0%

0.8%


*Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. A dash indicates the condition was not present in FY16/17. Numbers in brackets indicate the group’s corresponding ranking of the condition for FY16/17. Conditions shaded gray do not appear in the statewide top 10 ranking for

FY17/18. Conditions share the same ranking when the value of the percentage for each condition is the same.

Figure 32: Adults-Top 10 Conditions Leading to PPRs, July 2017 to June 2018*

Schizophrenia is the top condition leading to a PPR for adults accounting for a fifth (18%) of top ten PPAs.

Figure 33: Adults-Reasons for PPRs, July 2017 to June 2018

MH=Mental Health

SA=Substance Abuse

Figure 31: Change in PPR Rates for Children and Adults from FY2016/2017 to FY2017/2018

PPRs for Children and Adults are the same due to risk adjustment.

Figure 30: Risk-adjusted PPR Rates per 1,000 Hospital Admissions for Children and Adults, July 2017 to June 2018

Child State Adult

MH=Mental Health

SA=Substance Abuse

Figure 28: Children-Top 10 Conditions Leading to PPRs, July 2017 to June 2018*

Figure 29: Children-Reasons for PPRs for Children, July 2017 to June 2018

104.9 104.9 104.9

0

25

50

75

100

125

Child State Adult

0% 10% 20% 30% 40% 50%




(26) Adjustment Disorders [12]


(20) Depression [5]

(52) Bronchiolitis & RSV [13]

(16) Medicinal Poisoning [10]

(14) Seizure [6]

(8) Pneumonia [11]

31.7%

18.8%

11.2%

7.4%

7.4%

5.3%

4.8%

4.7%

4.6%

4.1%

0% 10% 20% 30% 40% 50%


(2) Septicemia [3]


(6) COPD [2]




(11) Pulmonary Edema [12]

(10) Diabetes [8]

(8) Pneumonia [16]

18.1%

17.4%

14.2%

10.7%

9.8%

8.5%

5.8%

5.3%

5.2%

5.0%

19

PPRs by Eligibility Group

0% 20% 40% 60%








Surgical Procedure for Complication Relatedto Initial Care


28.2%

28.0%

19.8%

8.5%

6.0%

5.9%

2.1%

1.2%

0.3%

MH=Mental Health

SA=Substance Abuse

*Numbers in parentheses indicate the statewide ranking of the condition for FY17/18. A dash indicates the condition was not present in FY16/17. Numbers in brackets indicate the group’s corresponding ranking of the condition for FY16/17. Conditions shaded gray do not appear in the statewide top 10 ranking for FY17/18. Conditions share the same ranking when the value of the percentage for each condition is the same.


Mental health conditions are the top two PPRs for enrollees in a family-related eligibility group. Delivery-related conditions are the top third and fourth conditions for enrollees in a family-related eligibility group.

Figure 35: Family-Reasons for PPRs, July 2017 to June 2018

Mental health conditions were three of the top six PPRs for enrollees in an SSI-related eligibility group. Schizophrenia was the top PPR for enrollees in an SSI-related eligibility group accounting for almost 18 percent of top ten PPAs.

Figure 34: Family-Top 10 Conditions Leading to PPRs, July 2017 to June 2018*

0% 20% 40% 60%








Surgical Procedure for Complication Related toInitial Care


41.9%

24.1%

16.9%

7.0%

5.2%

1.9%

1.7%

1.1%

0.2%

Figure 39: SSI-Top 10 Conditions Leading to PPRs, July 2017 to June 2018*

Figure 38: SSI-Reasons for PPRs, July 2017 to June 2018

Figure 37: Change in PPR Rates for Family-Related and SSI-Related Eligibility Categories from FY2016/2017 to FY2017/2018

Family State SSI

Figure 36: Risk-adjusted PPR Rates per 1,000 Hospital Admissions for Family-Related and SSI-Related Eligibility Categories, July 2017

to June 2018

89.6104.9 109.5

0255075

100125

Family State SSI

MH=Mental Health

SA=Substance Abuse

MH=Mental Health

SA=Substance Abuse

MH=Mental Health

SA=Substance Abuse

MH=Mental Health

SA=Substance Abuse

0% 10% 20% 30% 40% 50%



(13) Cesarean Delivery [3]

(21) Vaginal Delivery [4]




(20) Depression [8]

(2) Septicemia [9]

(10) Diabetes [5]

21.9%

19.6%

15.2%

10.2%

6.0%

6.0%

5.9%

5.3%

5.0%

4.9%

0% 10% 20% 30% 40% 50%


(2) Septicemia [6]



(6) COPD [4]





(8) Pneumonia [13]

17.8%

16.4%

13.7%

10.6%

10.4%

8.9%

5.9%

5.7%

5.4%

5.2%

20

PPRs by Plan

Risk-adjusted PPR Rates per 1,000 Hospital Admissions

Change from 2016/2017 to 2017/2018

Three plans experienced a decrease in PPR rates from FY16/17 to FY17/18. With the exception of Positive,

specialty plans had the highest rates of PPRs. Community Care and Staywell were the only standard plans

with a higher PPR rate than the statewide average.

Four of the top ten conditions leading to a PPR for Magellan were mental health conditions.

Sickle cell anemia was the top condition leading to a PPR for Children’s Medical Services. Two of the top ten

conditions for CMS were mental health conditions although only one mental health condition was among the

top five. The top six conditions for Sunshine Specialty were mental health conditions, accounting for 95

percent of the top ten PPRs for the plan. Bipolar disorders accounted for almost half of the top ten PPRs for

Sunshine Specialty.

Clear Health and Positive are the Specialty Health Plans for enrollees with an HIV diagnosis. Four of the top

ten conditions leading to a PPR for Clear Health are mental health conditions.

88

.7

93

.1

11

1.0

11

6.1

10

5.3

85

.9

10

5.3

11

8.1

88

.9

58

.2

82

.3

94

.4

85

.7

86

.5

13

5.0

84

.8

96

.1

98

.2

94

.5

11

0.7

11

7.2

10

7.2

97

.5

97

.8

11

2.0

90

.0

69

.3 86

.5

10

1.7 1

34

.8

10

6.9 1

38

.8

10

1.2

10

4.9

0

50

100

150A

me

rigr

ou

p

Be

tte

r H

ealt

h

Cle

ar H

eal

th

CM

S

Co

mm

un

ity

Car

e

Co

ven

try

Hu

man

a

Mag

ella

n

Mo

lina

Po

siti

ve

Pre

stig

e

Sim

ply

Sta

ywe

ll

Sun

shin

e

Sun

shin

eSp

ecia

lty

Un

ited

Sta

te


Figure 40: Risk-adjusted PPR Rates by Plan, July 2016 to June 2017 and July 2017 to June 2018**

21

Figure 41: Top 10 Conditions Leading to a PPR by Specialty Plan, July 2017 to June 2018*

0% 10% 20% 30% 40% 50%


(82) HIV w/Maj. Cond. [5]



(121) HIV w/Sig. Cond. [4]


(91) HIV w/Mult. Maj. Cond. [7]

(6) COPD [6]


(27) Musculoskeletal Diag. [-]

25.2%

15.1%

10.5%

9.7%

9.7%

8.0%

8.0%

5.9%

4.2%

3.8%

Clear Health



0% 10% 20% 30% 40% 50%




(2) Septicemia [8]


(6) COPD [6]

(27) Musculoskeletal Diag. [25]

(10) Diabetes [11]


(20) Depression [5]

36.3%

18.2%

16.1%

7.9%

4.1%

3.9%

3.5%

3.4%

3.4%

3.3%

Magellan

0% 10% 20% 30% 40% 50%





(20) Depression [5]



(52) Bronchiolitis & RSV [19]


(76) Respiratory Failure [13]

45.9%

18.8%

12.2%

10.2%

5.3%

2.3%

2.0%

1.7%

1.0%

0.7%

Sunshine Specialty0% 10% 20% 30% 40% 50%



(14) Seizure [3]

(8) Pneumonia [10]



(10) Diabetes [4]


(41) URI [12]

(47) GI-tube Malfunc. [7]

28.0%

14.3%

13.8%

9.7%

7.0%

6.8%

6.3%

5.3%

4.6%

4.3%

CMS

0% 10% 20% 30% 40% 50%

(82) HIV w/Maj. Cond. [6]

(22) Pancreatic Disorders [8]

(6) COPD [5]

(2) Septicemia [6]

(91) HIV w/Mult. Maj. Cond. [31]

(44) Post-Op Infection [20]

(121) HIV w/Sig. Cond. [7]

(17) Stroke w/Infarc. [12]

(55) Peripheral Disorder [-]

(41) URI [-]

23.1%

15.4%

11.5%

11.5%

11.5%

7.7%

7.7%

3.8%

3.8%

3.8%

Positive

22



0% 10% 20% 30%



(2) Septicemia [8]



(6) COPD [5]




(10) Diabetes [7]

16.4%

14.4%

14.3%

11.8%

10.9%

7.7%

6.5%

6.3%

6.1%

5.5%

Amerigroup

A mental health condition was the top condition resulting in a PPR for four standard plans. Another top

condition leading to a PPR was sickle cell anemia. Sickle cell anemia was the top condition for Community Care

and the second condition for Better Health. Community Care operates exclusively in Region 10, and Better

Health operates in Regions 6 and 10. Region 10 has the largest percentage of Black Medicaid recipients (42%).

This population is more prone to sickle cell anemia (see Appendix 2).

0% 10% 20% 30%




(2) Septicemia [8]



(8) Pneumonia [15]




22.6%

13.9%

13.9%

10.9%

10.9%

7.3%

5.8%

5.1%

5.1%

4.4%

Coventry

0% 10% 20% 30%





(6) COPD [4]




(37) Asthma [18]

(2) Septicemia [6]

16.6%

14.2%

12.4%

11.8%

8.9%

8.9%

8.3%

8.3%

5.3%

5.3%

Better HealthFigure 42: Top 10 Conditions Leading to a PPR by Standard Plan, July 2017 to June 2018*

0% 10% 20% 30%


(6) COPD [4]





(12) Cellulitis [11]

(2) Septicemia [18]


(14) Seizure [8]

27.0%

14.0%

13.0%

8.0%

8.0%

7.0%

6.0%

6.0%

6.0%

5.0%

Community Care

0% 10% 20% 30%

(2) Septicemia [6]





(6) COPD [3]


(8) Pneumonia [15]


(10) Diabetes [10]

15.3%

13.9%

12.0%

10.6%

10.5%

9.5%

8.1%

7.8%

6.5%

5.7%

Humana

23

COPD is among the top ten conditions resulting in a PPR for ten standard plans, and among the top five

conditions resulting in PPRs for five of the 11 plans. Cesarean delivery is among the top ten conditions

resulting in PPRs for nine of the 11 plans.



0% 10% 20% 30%

(2) Septicemia [3]




(6) COPD [6]





(8) Pneumonia [17]

18.0%

13.4%

13.4%

13.0%

9.5%

9.3%

6.2%

5.9%

5.7%

5.6%

United

0% 10% 20% 30%



(2) Septicemia [5]



(6) COPD [3]





21.1%

18.0%

13.7%

10.2%

9.2%

7.9%

5.8%

5.1%

4.6%

4.4%

Staywell

0% 10% 20% 30%

(2) Septicemia [1]






(6) COPD [6]

(10) Diabetes [9]


(18) Heart Attack [19]

18.1%

13.2%

12.7%

11.3%

9.0%

8.9%

7.5%

7.1%

6.5%

5.7%

Prestige0% 10% 20% 30%

(2) Septicemia [7]







(6) COPD [4]

(10) Diabetes [9]


13.9%

12.4%

12.2%

11.7%

11.3%

10.9%

8.8%

8.5%

5.3%

5.1%

Molina

0% 10% 20% 30%




(6) COPD [4]




(2) Septicemia [9]

(8) Pneumonia [11]


26.8%

14.1%

11.7%

9.9%

9.4%

7.0%

6.6%

5.2%

4.7%

4.7%

Simply

0% 10% 20% 30%

(2) Septicemia [3]




(6) COPD [7]




(8) Pneumonia [12]


19.7%

13.0%

11.9%

11.5%

10.3%

8.9%

7.5%

5.9%

5.8%

5.6%

Sunshine Standard

24


PPRs by Region

PPR rates increased in 9 regions from FY16/17 to FY17/18. A mental health condition is the top condition

leading to a PPR in Regions 3, 5, 7, 10, 11. COPD is in the top five conditions leading to a PPR in five of the 11

regions.

93

.2

92

.7

90

.8

93

.3

91

.5

89

.6

92

.3

81

.4

11

1.1

10

4.8

10

4.4

96

.192

.5 11

5.7

11

1.3

99

.4

10

6.4

98

.3

10

3.5

92

.7

10

9.1

11

0.0

10

9.7

10

4.9

0255075

100125

01 02 03 04 05 06 07 08 09 10 11 State

Figure 44: Top 10 Conditions Leading to a PPR by Region, July 2017 to June 2018*


Figure 43: Risk-adjusted PPR Rates per 1,000 Hospital Admissions by Region, July 2016 to June 2017 and July 2017 to June 2018

Change from FY2016/2017 to FY2017/2018

0% 10% 20% 30%



(2) Septicemia [2]



(6) COPD [3]



(10) Diabetes [9]


18.2%

15.8%

15.0%

10.1%

9.2%

8.8%

7.3%

6.6%

4.7%

4.3%

Region 3

0% 10% 20% 30%

(2) Septicemia [3]

(6) COPD [1]






(10) Diabetes [6]



16.8%

12.6%

11.5%

10.4%

9.9%

9.5%

8.4%

7.7%

6.6%

6.6%

Region 1

0% 10% 20% 30%

(2) Septicemia [1]



(8) Pneumonia [8]

(6) COPD [3]


(10) Diabetes [4]




23.4%

18.2%

10.7%

10.2%

9.1%

6.9%

6.0%

5.5%

5.3%

4.9%

Region 2

25


Septicemia is the leading medical condition followed by a PPR in six regions. It is the second most

common condition in one region.


0% 10% 20% 30%





(2) Septicemia [9]


(6) COPD [5]

(8) Pneumonia [11]



17.8%14.1%

12.9%12.0%

10.0%9.1%

7.4%5.9%5.9%

4.9%

Region 10

0% 10% 20% 30%

(2) Septicemia [6]





(6) COPD [5]


(8) Pneumonia [14]

(10) Diabetes [10]


14.6%14.6%

13.5%13.1%

11.8%8.8%

7.8%5.4%5.3%

5.0%

Region 9

0% 10% 20% 30%

(2) Septicemia [3]





(6) COPD [7]

(10) Diabetes [8]



(8) Pneumonia [13]

17.2%17.1%

14.6%10.9%10.5%

7.9%5.7%5.6%5.5%5.0%

Region 4

0% 10% 20% 30%

(2) Septicemia [3]


(6) COPD [1]






(8) Pneumonia [34]

(10) Diabetes [7]

21.1%15.2%

12.7%11.3%

7.5%7.4%7.1%

6.3%5.7%

5.7%

Region 8

0% 10% 20% 30%

(2) Septicemia [6]




(6) COPD [5]



(10) Diabetes [8]



16.5%

15.1%13.5%

10.5%10.2%

8.8%7.1%

6.7%5.9%

5.7%

Region 60% 10% 20% 30%




(2) Septicemia [4]


(6) COPD [8]


(10) Diabetes [6]



22.3%

19.7%12.7%

12.6%9.7%

6.9%4.7%4.6%

3.8%3.2%

Region 7

0% 10% 20% 30%




(2) Septicemia [7]


(6) COPD [6]


(8) Pneumonia [10]



27.3%13.2%

11.3%11.0%

9.6%

7.7%6.0%

5.2%4.8%

4.0%

Region 11

0% 10% 20% 30%


(2) Septicemia [3]



(6) COPD [5]




(10) Diabetes [9]

(12) Cellulitis [7]

17.3%15.2%15.0%

11.5%9.4%8.5%

6.5%6.1%5.5%4.9%

Region 5

26

Potentially Preventable Emergency Department Visits (PPV) Potentially preventable emergency department visits (PPVs) are emergency department visits that may result

from a failure to access primary care or a lack of ambulatory care coordination. PPVs are ambulatory sensitive

conditions, such as asthma, which may be avoided with adequate monitoring and follow-up, such as medication

management. When a PPV occurs shortly after a hospitalization, it may be the result of actions taken or omitted

during the hospital stay or poor coordination with physicians after release. PPVs may also be nursing sensitive

conditions such as a hip fracture because of a fall. These trauma events are considered potentially preventable.

11.4* Emergency Department Visits

Per 1,000 Enrollee Months were Potentially Preventable


The risk-adjusted rate adjusts for

differences in the costliness of different

ED visits as well as for differences in the

burden of illness across plans, regions, or

other populations.


rate of PPVs.

Figure 46: Risk-adjusted PPV Rates per 1,000 Enrollee Months by Region, July 2017 to June 2018

Figure 45: Total Number of ED Visits and Total Number of ED Visits Identified as Potentially Preventable from

FY2016/2017 to FY2017/2018

Figure 47: Risk-adjusted PPV Rate per 1,000 Enrollee Months Statewide,


*See the technical appendix for changes to the methodology for identifying potentially preventable emergency department visits as

compared to prior issues of this report.

There were 38,269,093

member months from

July 2017 to June 2018.

16/17 17/18

16/17 17/18

16/17 17/18

16/17 17/18

During the FY17/18 review

period, 62 percent

(1,507,264/2,424,631) of all ED

visits were identified as

potentially preventable as

compared to 61.9 percent in

FY16/17. 16/17 17/18

16/17 17/18

16/17 17/18

16/17 17/18

2,445,390

1,513,587

2,424,631

1,507,264

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

Total ED Visits Potentially PreventableED Visits

10.00 - 10.99

9.50 - 9.99

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

Melbourne

Region 3

Gainesville

Ocala

Region 1

Region 6

Region 7

12.00 - 12.99

11.00 - 11.99

14.00 - 14.89

*No region has 13.00 - 13.99

27

Percentages

show each

condition’s

percentage

of all top

ten

conditions.

0% 10% 20% 30%

(1) URI [1]


(3) Abdominal Pain [3]

(4) Skin Trauma [4]

(5) Viral Illness [5]


(7) Skin/Tissue/Breast [6]

(8) Acute UTI [8]


(10) Fever [10]

23.5%

14.1%

11.5%

10.2%

9.0%

7.0%

6.6%

6.4%

6.1%

5.5%

Figure 48: Reasons for PPVs Statewide, July 2017 to June 2018

Almost 57 percent of PPVs

are acute episodes that

might have been treated in

a primary care setting.

Over 43 percent are related

to care management.

More than 31 percent of PPVs were considered potentially preventable because management of a chronic

illness might have prevented the ED visit. About 54 percent of PPVs were considered potentially preventable

because they addressed an acute illness (29%) or an acute infection (25%) that might have been treated in a

primary care setting.

Upper respiratory infections (URI) account for more than 23 percent of the top ten conditions leading to a PPV,

14 percent of all PPVs were gastrointestinal disorders (GI Disorders), followed by abdominal pain. Together

these three conditions account for almost 50 percent of the top ten conditions that lead to an ED visit.

Figure 49: Top 10 Conditions Leading to PPVs, July 2017 to June 2018*

The top ten

conditions account

for 63 percent of all

conditions leading

to a PPV.



URI64,194

14.7%


208,907 47.8%


164,108 37.5%

Numbers in

parentheses

() are current

year’s

statewide

ranking.

Numbers in

brackets []

are previous

year’s

rankings for

that plan,

region,

eligibility, or

age.

0% 15% 30% 45%

ED Visit Preventable with Managementof Chronic Illness

Acute Illness Treatable in Primary CareSetting

Acute Infection Treatable in PrimaryCare Setting


ED Visit Preventable with Managementof Mental Health/Substance Abuse

Not Appropriate for ED, Treatable inPrimary Care Setting

ED Visit Preventable with Managementof Malignancy-Related Illness

31.4%

28.9%

24.8%

8.4%

3.4%

3.1%

0.1%

ED Preventable with Care

Management43.2%

Acute Episode

Treatable by Primary Care

56.8%

28

PPVs by Age

Figure 51: Children-Reasons for PPVs, July 2017 to June 2018

Figure 50: Children-Top 10 Conditions Leading to PPVs, July 2017 to June 2018*

Forty one percent of children’s PPVs involved acute infections that might have been treated in a primary care

setting as compared to 18 percent of adults.

The top two conditions resulting in a PPV for children were upper respiratiory infections (URIs) and gastrointestinal

(GI) disorders. The top two conditions for adults were abdominal pain and musculoskeletal diagnosis.

0% 15% 30% 45%

ED Visit Preventable with Management ofChronic Illness


Acute Infection Treatable in Primary CareSetting


ED Visit Preventable with Management ofMental Health/Substance Abuse


ED Visit Preventable with Management ofMalignancy-Related Illness

24.2%

17.6%

2.7%

44.5%

5.5%

5.3%

0.2%

Acute EpisodeTreatable byPrimary CareED Preventablewith CareManagement

Figure 55: Adults-Reasons for PPVs, July 2017 to June 2018

Figure 53: Change in PPV Rates for Children and Adults from FY2016/2017 to FY2017/2018

Figure 52: Risk-adjusted PPV Rates per 1,000 Enrollee Months for Children and Adults, July 2017 to June 2018

Figure 54: Adults-Top 10 Conditions Leading to PPVs, July 2017 to June 2018*

10.9 11.4 11.3

0

5

10

15

Child State Adult



0% 10% 20% 30%


(6) Musculoskeletal Diag.[2]

(8) Acute UTI [4]

(11) Back/Neck [3]

(4) Skin Trauma [6]

(1) URI [5]



(13) Dental/Oral [9]

(12) Headaches [10]

19.0%

12.7%

10.1%

10.0%

9.9%

9.9%

9.3%

7.3%

6.2%

5.7%

Child State Adult

0% 15% 30% 45%








41.4%

23.7%

0.4%

26.0%

7.5%

1.1%

0.02%

Acute EpisodeTreatable byPrimary Care

ED Preventablewith CareManagement

0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]

(10) Fever [5]




(8) Acute UTI [9]

(15) Constipation [10]

28.9%

15.5%

11.8%

9.6%

7.6%

7.0%

6.8%

5.0%

4.1%

3.7%

29

PPVs by Eligibility Group

SSI State Family

The top two conditions resulting in a PPV for the Family-Related eligibility group were upper respiratiory

infections (URIs) and gastrointestinal (GI) disorders. The top two conditions resulting in a PPV for the SSI-Related

eligibility group were abdominal pain and musculoskeletal diagnoses. Figure 57: Family-Top 10 Conditions Leading to PPVs,


0% 15% 30% 45%








36.5%

24.3%

0.5%

30.5%

6.6%

1.5%

0.02%






Figure 59: Change for Family and SSI Eligibility Categories from FY2016/2017 to FY2017/2018

Figure 60: SSI-Top 10 Conditions Leading to PPVs, July 2017 to June 2018

Figure 61: SSI-Top Reasons for PPVs, July 2017 to June 2018

0% 15% 30% 45%

ED Visit Preventable with Managementof Chronic Illness




ED Visit Preventable with Managementof Mental Health/Substance Abuse


ED Visit Preventable with Managementof Malignancy-Related Illness

22.8%

16.4%

3.8%

43.5%

6.7%

6.6%

0.2%



Figure 56: Family-Reasons for PPVs, July 2017 to June 2018

Figure 58: Risk-adjusted PPV Rates per 1,000 Enrollee Months for Family and SSI Eligibility, July 2017 to June 2018

0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [4]


(10) Fever [7]

(8) Acute UTI [8]


(6) Musculoskeletal Diag.[10]

26.6%

14.7%

10.4%

9.7%

9.3%

6.8%

6.3%

5.7%

5.5%

5.0%

0% 10% 20% 30%



(4) Skin Trauma [3]


(1) URI [5]

(11) Back/Neck [6]

(8) Acute UTI [7]


(14) Other Symptoms [9]

(22) Physical Therapy [12]

16.8%

13.6%

12.3%

10.4%

10.0%

9.2%

8.4%

7.6%

6.5%

5.3%

12.6 11.49.1

0

5

10

15

Family State SSI

30

PPVs by Plan

PPV rates increased for 8 of the 16 plans from FY16/17 to FY17/18. Magellan had the highest rate of PPVs of

any plan.

The top conditions contributing to a PPV for every specialty plan except the two specialty plans for children are

abdominal pain and musculoskeletal diagnosis.

The top condition contributing to a PPV for the two specialty plans for children is the same as for all children,

upper respiratory infections (URIs).

The top two conditions contributing to a PPV for the two specialty plans for enrollees with an HIV diagnosis are

abdominal pain and musculoskeletal diagnosis.


Risk-adjusted PPV Rates per 1,000 Enrollee Months

Figure 62: Risk-adjusted PPV Rates by Plan from July 2016 to June 2017 and July 2017 to June 2018** 1

1.4

12

.6

13

.1

9.6

12

.2

10

.7

11

.8

16

.1

12

.2

11

.0

11

.9

9.4

11

.9

10

.8

8.9

11

.3

11

.1

11

.9

12

.5

13

.0

10

.4

10

.4

11

.6

11

.8 14

.4

14

.0

10

.3 11

.9

9.2 1

2.4

11

.4

9.2 1

2.5

11

.4

0

5

10

15

20A

me

rigr

ou

p

Be

tte

r H

ealt

h

Cle

ar H

eal

th

CM

S

Co

mm

un

ity

Car

e

Co

ven

try

Hu

man

a

Mag

ella

n

Mo

lina

Po

siti

ve

Pre

stig

e

Sim

ply

Sta

ywe

ll

Sun

shin

e

Sun

shin

eSp

ecia

lty

Un

ited

Sta

te

** The fee-for-service (FFS) population is included in the calculation of the statewide norms for risk-adjusted rates. Most of the FFS population

consists of Medicaid recipients who are dually eligible for Medicare and Medicaid and whose medical care is managed by Medicare. Therefore

results for FFS are not separately displayed in this report.

31

Figure 63: Top 10 Conditions Leading to PPVs by Specialty Plan,

July 2017 to June 2018*

0% 10% 20% 30%



(4) Skin Trauma [3]

(1) URI [4]


(8) Acute UTI [6]

(11) Back/Neck [7]


(27) Alcohol Abuse [9]

(13) Dental/Oral Cond. [10]

18.2%

11.8%

10.5%

10.4%

10.2%

9.6%

9.0%

8.3%

6.3%

5.7%

Magellan

0% 10% 20% 30%

(1) URI [1]


(4) Skin Trauma [3]



(10) Fever [6]



(15) Constipation [9]


25.0%

17.0%

11.2%

9.9%

7.6%

7.1%

6.0%

5.8%

5.7%

4.8%

CMS

0% 10% 20% 30%

(1) URI [1]

(4) Skin Trauma [3]





(10) Fever [7]


(8) Acute UTI [8]


29.1%

14.3%

12.6%

10.2%

7.4%

6.6%

6.5%

5.0%

4.7%

3.7%

Sunshine Specialty

0% 10% 20% 30%




(11) Back/Neck [4]


(8) Acute UTI [7]

(1) URI [6]

(4) Skin Trauma [8]



17.7%

15.8%

10.0%

9.7%

9.4%

8.8%

8.2%

7.6%

6.7%

6.2%

Clear Health0% 10% 20% 30%



(11) Back/Neck [4]



(8) Acute UTI [10]

(4) Skin Trauma [6]




18.6%

15.3%

11.3%

10.9%

9.2%

7.6%

7.6%

7.4%

6.2%

5.9%

Positive



32



0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]




(8) Acute UTI [8]


(10) Fever [10]

24.2%

14.7%

11.8%

9.6%

8.8%

6.6%

6.4%

6.4%

5.8%

5.6%

Humana

0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [5]



(10) Fever [7]

(8) Acute UTI [8]



26.0%

15.9%

10.0%

9.9%

9.4%

6.7%

6.0%

5.5%

5.5%

5.0%

Better Health

0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [5]

(10) Fever [6]




(8) Acute UTI [10]

25.3%

17.7%

11.8%

10.1%

7.1%

6.5%

6.1%

5.4%

5.3%

4.7%

Coventry0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [5]

(10) Fever [6]




(8) Acute UTI [10]

25.2%

16.2%

10.4%

9.5%

8.7%

7.7%

6.3%

5.7%

5.4%

5.0%

Community Care

Upper respiratory infections (URIs), gastrointestinal (GI) disorders and abdominal pain are the top three

conditions resulting in a PPV for nine of the 11 standard plans.

Figure 64: Top 10 Conditions Leading to PPVs by Standard Plan, July 2017 to June 2018*

0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]


(10) Fever [7]



(8) Acute UTI [8]


23.7%

15.3%

11.4%

9.8%

9.1%

6.7%

6.4%

6.2%

5.8%

5.7%

Amerigroup

33


0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]




(8) Acute UTI [7]


(10) Fever [9]

24.2%

13.9%

11.2%

9.9%

9.6%

6.8%

6.5%

6.2%

5.9%

5.8%

Staywell0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [5]



(8) Acute UTI [9]


(10) Fever [10]

23.2%17.5%

11.4%

10.5%

7.7%

7.0%

5.9%

5.8%

5.6%

5.4%

Simply


URIs were not only the top condition statewide but were the top condition for each standard plan and each

region.

0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [4]


(8) Acute UTI [7]



(10) Fever [10]

25.7%14.4%

10.5%

10.0%

9.6%6.9%

6.2%5.9%

5.5%

5.3%

Molina0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]




(8) Acute UTI [8]


(10) Fever [11]

25.5%

12.8%

10.5%

10.4%

9.4%

6.9%

6.9%

6.2%

6.2%

5.3%

Prestige

0% 10% 20% 30%

(1) URI [1]


(4) Skin Trauma [4]





(8) Acute UTI [7]

(10) Fever [9]


24.3%

13.8%

10.6%

10.3%

9.4%

6.9%

6.4%

6.4%

6.0%

5.7%

Sunshine Standard0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]





(8) Acute UTI [8]

(10) Fever [10]

23.6%

13.6%

11.5%

9.7%

9.4%

7.1%

6.7%

6.6%

6.5%

5.5%

United

34

PPVs by Region


Figure 65: Risk-adjusted PPV Rates per 1,000 Enrollee Months by Region, FY16/17 to FY17/18


Figure 66: Top 10 Conditions Leading to PPVs by Region, July 2017 to June 2018*

All but four regions experienced an increase in PPV rates from FY16/17 to FY17/18. Region 4 has the highest

rate of PPVs of any region. Upper respiratory infections (URIs), GI disorders, and abdominal pain are among

the top three conditions contributing to a PPV in seven of the 11 regions.

0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]


(8) Acute UTI [6]




(11) Back/Neck [8]

26.0%

11.9%

11.6%

10.8%8.8%

6.7%

6.6%

6.5%

5.6%

5.4%

Region 1

0% 10% 20% 30%

(1) URI [1]


(4) Skin Trauma [3]



(8) Acute UTI [5]




(11) Back/Neck [11]

25.7%

12.1%

11.2%

9.4%

8.9%

7.4%

7.2%

6.9%

6.6%

4.5%

Region 20% 10% 20% 30%

(1) URI [1]

(4) Skin Trauma [4]





(8) Acute UTI [6]



(11) Back/Neck [10]

24.0%

11.4%

11.3%

11.1%

8.7%

7.3%7.2%

6.8%

6.7%

5.5%

Region 3

14

.6

12

.4

11

.3

12

.4

10

.2

11

.5

11

.8

10

.3

10

.1

11

.7

9.5

11

.114

.5

12

.6

11

.8 14

.8

10

.4

11

.5

12

.0

9.9 9.9

11

.6

9.6

11

.4

0

10

20

01 02 03 04 05 06 07 08 09 10 11 State

35


The top nine conditions resulting in a PPV statewide are consistently among the top ten conditions in all 11

regions of the state.

0% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]




(8) Acute UTI [8]


(10) Fever [10]

24.6%12.4%

10.4%

10.4%10.0%

7.6%6.9%

6.7%6.2%

5.0%

Region 40% 10% 20% 30%

(1) URI [1]

(4) Skin Trauma [4]





(8) Acute UTI [6]



(11) Back/Neck [9]

18.5%

13.8%13.4%13.4%

7.8%

7.7%7.2%

7.0%5.9%

5.3%

Region 5

0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [4]

(10) Fever [5]




(8) Acute UTI [9]

20.5%

14.3%13.3%

9.4%8.6%

7.7%7.5%

6.4%6.3%

5.9%

Region 70% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]


(8) Acute UTI [5]



(10) Fever [9]


24.6%

14.1%12.0%

10.5%

7.5%6.6%

6.6%6.5%

5.8%

5.7%

Region 6

0% 10% 20% 30%

(1) URI [1]


(4) Skin Trauma [3]



(8) Acute UTI [6]




(11) Back/Neck [10]

24.6%14.2%

11.8%10.6%

8.6%6.9%

6.4%6.4%

6.1%4.3%

Region 90% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [4]


(8) Acute UTI [7]


(10) Fever [9]


25.0%13.8%

11.1%10.9%

10.2%

6.8%6.0%

5.7%5.3%5.3%

Region 8

0% 10% 20% 30%

(1) URI [1]




(4) Skin Trauma [5]


(10) Fever [8]



(8) Acute UTI [10]

22.9%17.6%

11.3%10.1%

7.7%6.7%

6.2%6.1%6.0%

5.4%

Region 110% 10% 20% 30%

(1) URI [1]



(4) Skin Trauma [4]




(10) Fever [8]

(8) Acute UTI [10]


23.4%15.6%

11.1%

10.1%8.7%

6.5%6.3%

6.2%6.2%5.9%

Region 10


36

Conclusions The statewide risk-adjusted PPE rates show that three hospital admissions and 11 ED visits were potentially

preventable for every 1,000 member months during the review period. Over the same period, 105 hospital

readmissions were potentially preventable for every 1,000 hospital admissions. Overall, PPA, PPR and PPV rates

increased from FY16/17 to FY17/18.

Heart failure, septicemia, and COPD, all serious health conditions, were the top three conditions resulting in a

PPA statewide. The top three conditions resulting in a PPR statewide were septicemia, schizophrenia, and heart

failure. Upper respiratory infections (URIs), gastrointestinal (GI) disorders, and abdominal pain, all acute

conditions, were the top conditions resulting in a PPV statewide. The top ten conditions contributing to each

PPE statewide changed very little from FY16/17 to FY17/18. More changes were apparent when examining the

top ten conditions by age, eligibility group, plan, and region.

While there is further work needed to understand the underlying causes of PPEs among Florida Medicaid

enrollees, the details here lay a foundation for health plans, hospitals, and other providers to work with the

Agency to reduce the number of PPEs, thereby improving quality of care and reducing costs.

37

Appendices

38

Appendix 1: Technical Specifications

Changes in the Methodology for Identifying Potentially Preventable Emergency Department Visits

(PPVs)

Grouper Versions

Analyses of Potentially Preventable Admissions (PPAs) and Potentially Preventable Emergency Room Visits

(PPVs) utilize versions 2.0 and 2.1 of the 3M™ Population Focused Preventable (PFP) grouper. Analyses for

FY17/18 utilize version 2.0 and analyses for FY16/17 utilize version 2.1 of the grouper. Analyses of Potentially

Preventable Readmissions (PPRs) utilize version 35.0 of the 3M™ PPR grouper for FY16/17 and version 35.0 for

FY17/18.

Version changes for groupers typically include changes to the clinical logic the grouper uses to assess what

conditions are considered potentially preventable. Following is a partial list of changes in clinical logic for each

grouper version that are noteworthy because they may have impacted results in this report.

PPAs

Noteworthy changes in the clinical logic for PPAs from version 1.3 to version 2.0 of the PFP grouper:

Sickle cell anemia crisis, inflammatory bowel disease, and intervertebral disc excision & decompression

were changed to not potentially preventable for the general population but are considered potentially

preventable for persons admitted to a hospital from a facility setting.

Noteworthy changes in the clinical logic for PPAs from version 2.0 to version 2.1 of the PFP grouper:

Diagnosis Related Groups (APR DRGs) for Coronary bypass without Acute Myocardial Infarction (AMI) or

complex primary diagnosis (PDX), Dorsal and Lumbar Fusion Procedure except for Curvature of Back,

and procedures for obesity were added to the list of potentially preventable conditions for the general

population;

Diagnosis codes were removed from being considered potentially preventable for many APR DRGs.

While these APR DRGs remain on the list of PPAs, fewer diagnosis codes trigger a PPA; and

Additional diagnosis codes were considered potentially preventable for many APR DRGs. For these APR

DRGs, more diagnosis codes trigger a PPA.

PPRs

Noteworthy changes in the clinical logic from version 32.0 to 35.0 of the PPR grouper:

Renal Failure as an initial admission in combination with many conditions for a readmission was

removed from the list of PPRs.

Medicinal poisoning as an initial admission in combination with some conditions for a readmission were

removed from the list of PPRs

Kidney and urinary tract infection (UTI) as an initial admission in combination with some conditions for a

readmission were added to the list of PPRs.

39

PPVs

Noteworthy changes in the clinical logic for PPVs from version 1.3 to version 2.0 of the PFP grouper

Diagnosis codes were removed from being considered potentially preventable for many EAPGs. While

these EAPGs remain on the list of PPVs, fewer diagnosis codes trigger a PPV.

Additional diagnosis codes were considered potentially preventable for many EAPGs. For these EAPGs,

more diagnosis codes trigger a PPV.

Noteworthy changes in the clinical logic for PPVs from version 2.0 to version 2.1 of the PFP grouper

Diagnosis codes were removed from being considered potentially preventable for many EAPGs. While

these EAPGs remain on the list of PPVs, fewer diagnosis codes trigger a PPV.

Additional diagnosis codes were considered potentially preventable for many EAPGs. For these EAPGs,

more diagnosis codes trigger a PPV.

Groupers Used by the PFP and PPR Groupers

The PPR grouper uses an APR DRG grouper to assign an APR DRG to each hospital admission. The PFP grouper

uses an APR DRG grouper to assign an APR DRG to hospital admissions for PPAs, an EAPG grouper to assign an

EAPG to emergency department visits for PPVs, and a CRG grouper to assign a CRG to each enrollee for PPAs and

PPVs. Following is a list of the grouper versions embedded within the PFP and PPR groupers used in this report.

PFP Grouper version 2.0

3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Classification System for ICD-10-CM, version 33.0

3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Classification System for ICD-9-CM, version 32.0

3M™ Enhanced Ambulatory Patient Grouping (EAPG) System, version 3.10

3M™ Clinical Risk Groups (CRG) Classification System, version 2.0

PFP Grouper Version 2.1

3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Classification System, version 34.0

3M™ Enhanced Ambulatory Patient Grouping (EAPG) System, version 3.12

3M™ Clinical Risk Groups (CRG) Classification System, version 2.1

PPR Grouper Version 32.0

3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Classification System, version 32.0 PPR Grouper Version 35.0

3M™ All Patient Refined Diagnosis Related Groups (APR DRG) Classification System, version 35.0

40

Region 2Pensacola

Tallahassee

Panama City

Region 1

White 51.6% Black

28.2%

No Response 7.4%

Asian 1.6%

Native American 0.6%

Other Race 5.6% Hispanic 5.0%

White 43.8%

Black 37.3%

8.7% 5.0%

4.0%

0.8%

0.4%

No Response

Hispanic

Other Race

Asian

Native American

Appendix 2: Racial Composition of the Medicaid Population by Region


Region colors are based on the racial/ethnic group representing the largest

percentage of Medicaid recipients in the region. Whites are the largest

percentage of Medicaid recipients in six of the 11 regions. Hispanics are the

largest percentage of Medicaid recipients in Regions 6, 7, and 11. Blacks are

the largest percentage of Medicaid recipients in Regions 9 and 10.

Region 10 (Broward County) has experienced recent immigration from

Caribbean countries including Haiti and Jamaica. One-third of Region 10’s

Black population is foreign-born (first generation immigrants), compared

to only one-quarter of Florida as a whole.

41


Region 9Region 8

Region 4

Jacksonville

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Daytona Beach

Tampa

Region 5

West Palm Beach


Key West

Region 11

Orlando

Melbourne

Region 3

Gainesville

Ocala

Region 6Region 7

White 51.7% Black

21.7%

12.5%

8.1%

4.9%

0.8%

0.3%

No Response

Other Race

Asian

Native American

White 39.7%

Black 34.5%

10.4%

7.4%

6.0%

1.7%

0.3%

No Response

Other Race

Asian

Native American

8.8%

5.4%

1.0%

0.2%

No Response

Other Race

Asian

Native American

White 49.7%

Black 19.1%

14.2%

8.5%

6.3%

1.9%

0.3%

No Response

Other Race

Asian

Native American

Hispanic 33.4%

Black 25.1%

White 24.0%

8.8%

6.8%

1.7%

0.2%

No Response

Other Race

Asian

Native American

Black 31.1%

Hispanic 28.0%

White 25.9%

7.6%

6.1%

1.2%

0.2%

No Response

Other Race

Asian

Native American

White 36.2%

Hispanic 33.2%

15.5%

8.1%

5.9%

0.8%

0.2%

No Response

Other Race

Asian

Native American

Black 42.3%

Hispanic 24.0%

White 15.4%

9.6%

7.0%

1.6%

0.2%

No Response

Other Race

Asian

Native American

Hispanic 54.2%

Black 20.8%

15.0%

6.2%

3.2% 0.5%

0.1%

No Response

White

Other Race

Asian

Native American

31.3% Hispanic

28.7%

Black 24.5%

White

Hispanic

Hispanic

Hispanic

Black

42

*Percentages for Children in Clear Health

and Positive are too small to be visible.

6.91

5.54

4.87

Number of Member Months (in Millions) by Plan and FFS Program, July 2017 to June 2018

3.38 3.30 3.26

Source: Florida Medicaid Management Information System (FMMIS) Eligibility Information, July 2017 to June 2018.

3.52

Appendix 3: Plan Demographics

Stay

we

ll

FFS

Sun

shin

e

Mo

lina

Am

eri

gro

up

Pre

stig

e

Hu

man

a

Un

ite

d

All

Spe

cial

ty

Better Health

Simply Coventry Community CareChildren Adults

2.71

1.94

1.02 0.81

0.57

Number of Member Months (in Thousands)

by Specialty Plan, July 2016 to June 2017

0.45

Magellan CMS SunshineSpecialty

ClearHealth

Positive

846.5

584.9

379.1

106.123.0

Children Adults

Standard Plans Children58.94%

Standard Plans Adults21.53%

Specialty Plans Children

3.02%

Specialty Plans Adults2.05%

FFS Children1.47%

FFS Adults13.00%

CMS Children30.16%

Sunshine Specialty Children19.54%

Clear Health Children

0.16%

Clear Health Adults5.31%

Positive Children

0.02%

Positive Adults1.17%

Magellan Children

9.75%

Magellan Adults33.90%

43

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Plan Serves Region Plan Does Not Serve Region

FFS serves Medicaid

recipients excluded from

or voluntary for the MMA

program such as those

who are Medically Needy,

enrolled in the iBudget

Waiver, or only receiving

Family Planning services.

FFS serves recipients in all

regions.

Magellan Complete Care

serves Medicaid enrollees

diagnosed with

Schizophrenia, Bipolar

Disorder, Major

Depressive Disorder, or

Obsessive Compulsive

Disorder.

Children’s Medical Services

Network

Clear Health

Magellan

Sunshine Specialty

serves Medicaid

enrollees under the age

of 21 who have an open

case for child welfare

services with the

Department of Children

and Families or who

were adopted from

foster care.

Positive Healthcare

serves Medicaid

enrollees diagnosed

with HIV or AIDS.

Sunshine Specialty

Positive

Children's Medical Services

Network serves Medicaid

enrollees under the age of 21

who meet the Department of

Health’s clinical screening

criteria for chronic conditions.

Clear Health Alliance

serves Medicaid

enrollees diagnosed

with HIV or AIDS.

Fee for Service

Regions Served by Specialty Plan and the Fee-For-Service Program, July 2017 to June 2018

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

44

Community Care

Standard plans serve Medicaid

enrollees enrolled in the

Medicaid Managed Medical

Assistance Program.

Humana

Coventry

Better Health

Regions Served by Standard Plan, July 2017 to June 2018

Amerigroup


Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

45

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Sunshine

Staywell

Simply

Molina

United

Prestige


Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

Pensacola

Jacksonvi l le

Tal lahassee

St. Petersburg

Naples

Ft. Myers

Sarasota

Miami

Panama Ci ty

Daytona Beach

Tampa

Region 5

West Palm Beach

Region 10

Ft. Lauderdale

K ey West

Region 11

Orlando

Melbourne

Region 3

Gainesvi l le

Ocala

Region 1

Region 6

Region 7

Region 9

Region 8

Region 4

Region 2

P ensacol a

Jacksonvi l l e

Tal l ahassee

S t . P et er sbur g

N apl es

Ft . M yer s

S ar asot a

M i am i

P anam a C i t y

D ayt ona B each

Tam pa

Region 5

West P al m B each

Region 10

Ft . Lauder dal e

K ey West

Region 11

Orlando

Melbourne

Region 3

G ai nesvi l l e

O cal a

Region 1

Region 6

Region 7

46

Appendix 4: List of All Patients Refined Diagnosis Related Groups (APR DRGs)

and Enhanced Ambulatory Patient Grouping (EAPGs) in Top Ten Charts

Labeled in Report Charts APR DRG APR DRG Description

Adjustment Disorders 755 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNOSIS

Asthma 141 ASTHMA Behavioral Disorders 758 CHILDHOOD BEHAVIORAL DISORDERS Bipolar Disorders 753 BIPOLAR DISORDERS Bronchiolitis & RSV 202 BRONCHIOLITIS & RSV PNEUMONIA Cardiac Cath. 192 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS Cardiac Defibrillator 161 CARDIAC DEFIBRILLATOR & HEART ASSIST IMPLANT Cardiac Procedure 175 PERCUTANEOUS CORONARY INTERVENTION W/O AMI Cellulitis 383 CELLULITIS & OTHER SKIN INFECTIONS Cesarean Delivery 540 CESAREAN DELIVERY COPD 140 CHRONIC OBSTRUCTIVE PULMONARY DISEASE Coronary Bypass 166 CORONARY BYPASS W/O AMI OR COMPLEX PDX Depression 754 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER Diabetes 420 DIABETES Dorsal/Lumbar Fusion 304 DORSAL & LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK GI Disorders 201 OTHER GASTROENTERITIS, NAUSEA & VOMITING GI-tube Malfunc. 252 MALFUNCTION, REACTION & COMPLICATION OF GI DEVICE OR PROCEDURE Heart Attack 190 ACUTE MYOCARDIAL INFARCTION Heart Failure 194 HEART FAILURE HIV w/ Maj. cond. 892 HIV W MAJOR HIV RELATED CONDITION HIV w/ Mult. Maj. cond. 890 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV w/ Sig. cond. 894 HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND Hypertension 199 HYPERTENSION

Infectious Disease 710 INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE Kidney & UTI 463 KIDNEY & URINARY TRACT INFECTIONS Low Blood Circu. 422 HYPOVOLEMIA & RELATED ELECTROLYTE DISORDERS Major Depression 751 MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES Medicinal Poisoning 812 POISONING OF MEDICINAL AGENTS Minor Respiratory 166 RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES Mood Disorders 755 ADJUSTMENT DISORDERS & NEUROSES EXCEPT DEPRESSIVE DIAGNO

Musculoskeletal Diag. 351 OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES

Other Digestive 254 OTHER DIGESTIVE SYSTEM DIAGNOSES

Pancreatic Disorders 282 DISORDERS OF PANCREAS EXCEPT MALIGNANCY Peripheral Disorder 300 PERIPHERAL & OTHER VASCULAR DISORDERS Pneumonia 139 OTHER PNEUMONIA Post-Op Infection 856 POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS Respiratory Failure 133 PULMONARY EDEMA & RESPIRATORY FAILURE Schizophrenia 750 SCHIZOPHRENIA Seizure 53 SEIZURE

Septicemia 720 SEPTICEMIA & DISSEMINATED INFECTIONS

The following is a list of the APR DRGs that appear in at least one of the top ten graphics for PPAs or PPRs in this

report. The APR DRG code and full description are shown in the table.

47

Sickle Cell Anemia 662 SICKLE CELL ANEMIA CRISIS Stroke w/Infarct. 45 CVA & PRECEREBRAL OCCLUSION W INFARCT URI 113 INFECTIONS OF UPPER RESPIRATORY TRACT Urogenital Malfunc. 466 MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC

Vaginal Delivery 560 VAGINAL DELIVERY

48

The following is a list of the EAPGs that appear in at least one of the top ten graphics for PPVs in this report. The

list is in alphabetical order based on the label used in the charts. The EAPG code and full description are shown

in the table.

Labeled in Report Charts EAPG Description

Abdominal Pain 628 ABDOMINAL PAIN

Acute UTI 727 ACUTE LOWER URINARY TRACT INFECTIONS

Alcohol Abuse 842 ALCOHOL ABUSE & DEPENDENCE

Back/Neck Diag. 656 BACK & NECK DIAGNOSES EXCEPT LUMBAR DISC DIAGNOSES

Constipation 630 CONSTIPATION

Dental/Oral Cond. 563 DENTAL & ORAL DIAGNOSES & INJURIES

Fever 807 FEVER

GI Disorders 627 NON-BACTERIAL GASTROENTERITIS, NAUSEA & VOMITING

Headaches 530 HEADACHES OTHER THAN MIGRAINE

Signs/Symp & Other 871 SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS

Minor Respiratory 576 LEVEL I OTHER RESPIRATORY DIAGNOSES

Musculoskeletal Diag. 661 LEVEL II OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES

Physical Therapy 271 PHYSICAL THERAPY

Schizophrenia 820 SCHIZOPHRENIA

Skin Trauma 674 CONTUSION, OPEN WOUND & OTHER TRAUMA TO SKIN & SUBCUTANEOUS TISSUE

Skin/Tissue/Breast 675 OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DIAGNOSES

URI 562 INFECTIONS OF UPPER RESPIRATORY TRACT & OTITIS MEDIA

Viral Illness 808 VIRAL ILLNESS

49

Ron DeSantis, Governor

Mary C. Mayhew, Secretary

business intelligence unit medicaid data analytics winter 2019 · 2016-07-01 · analysis of...

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