AHCA Medicaid Analytics Dashboard

Last Updated: May 1, 2025

Key Performance Indicators

Total Medicaid Enrollment

5.2M

↑ 3.2% from previous year

Avg. Monthly Cost Per Member

$642

↓ 1.8% from previous year

Provider Network Adequacy

92.4%

↑ 1.5% from previous year

Quality Measure Compliance

87.3%

↑ 2.7% from previous year

Population Health Insights

Chronic Condition Prevalence

Key Insight:

Diabetes (21.3%) and Hypertension (32.5%) remain the most prevalent chronic conditions among Medicaid recipients. Targeted interventions for these conditions could significantly improve outcomes and reduce costs.

Preventative Care Utilization

Key Insight:

Well-child visits (78.2%) exceed target rates, while adult preventative screenings (62.4%) fall below targets. Member outreach programs could improve adult screening rates.

Social Determinants of Health Impact

Housing Stability

Members with housing instability show 3.2x higher hospital readmission rates. The Behavioral Health and Supportive Housing pilot program has shown a 42% reduction in ED visits among enrolled participants.

Transportation Access

In regions with limited public transportation, missed appointment rates are 27% higher. Mobile health services and telehealth initiatives have reduced this gap by 15%.

Food Security

Members with food insecurity have 2.4x higher rates of uncontrolled chronic conditions. Nutrition benefit programs show a 31% improvement in condition management.

Medical & Pharmacy Claims Analysis

Spending Trends by Service Category

Key Insight:

Specialty pharmacy costs have increased 18.3% year-over-year, primarily driven by new high-cost medications for rare diseases. Implementing expanded rebate programs could save an estimated $42M annually.

Claim Distribution by Member Type

Key Insight:

High-utilization members (top 5%) account for 43.7% of total claims costs. Targeted case management for these members has shown a 12.5% cost reduction in pilot programs.

Pharmacy Utilization & Costs

Generic Utilization Impact

Generic utilization rate is currently 75.2%, while brand drugs (19.2% of claims) account for 91.2% of total expenditures. Increasing generic utilization by 5% could save approximately $124M annually.

Rebate Effectiveness

Combined federal and supplemental rebates return 43.7% of prescription costs. Recent negotiation efforts for supplemental rebates on specialty drugs added $18.4M in annual savings.

Cost Saving Opportunities

Category Estimated Annual Waste Intervention Strategy Potential Savings Implementation Difficulty
Duplicate Claims $37.4M Enhanced Claim Validation $32.1M Medium

Duplicate Claims Pattern Analysis

  • 50.3% from same provider on different dates
  • 32.7% from different providers for same service
  • 17.0% from system coding errors

Implementing real-time duplicate claim detection could prevent 86% of these claims before payment.

Top Providers with Duplicate Claims

  • Memorial Healthcare System (8.2%)
  • BayCare Health (7.5%)
  • Orlando Health (6.3%)
  • Jackson Health System (5.8%)

Targeted provider education could reduce these rates by 64%.
Medication Non-Adherence $62.3M Digital Health Monitoring $43.6M High

Non-Adherence Impact by Condition

  • Diabetes: $18.7M in avoidable hospitalizations
  • Hypertension: $14.2M in avoidable ED visits
  • Mental Health: $22.1M in crisis interventions
  • Asthma: $7.3M in acute exacerbations

Digital Monitoring Pilot Results

  • 42% improvement in adherence rates
  • 37% reduction in hospital admissions
  • 28% reduction in ED visits
  • $1,820 average savings per enrolled member
Inappropriate ED Utilization $58.9M Telehealth & Urgent Care $47.1M Medium

ED Visit Analysis

  • 42.3% of ED visits could have been handled in primary care
  • 18.7% could have been handled via telehealth
  • 24.1% could have been treated at urgent care
  • Average ED visit: $1,240 vs. PCP visit: $120

Regional Variation

  • Region 1: 38.2% inappropriate utilization
  • Region 2: 46.7% inappropriate utilization
  • Region 3: 41.5% inappropriate utilization
  • Region 4: 51.3% inappropriate utilization

24/7 nurse line implementation reduced inappropriate ED visits by 22.4% in pilot regions.
Unnecessary Procedures $42.7M Evidence-Based Guidelines $36.3M High
Fraud & Abuse $28.5M Advanced Analytics $25.6M Medium

Recommended Action:

Implement a phased approach targeting duplicate claims and inappropriate ED utilization first, which offer the lowest implementation difficulty with high potential savings ($79.2M combined).

Emerging Risk Identification

Predicted High-Cost Members

Key Insight:

Predictive modeling identifies 8,743 members (0.17% of population) at high risk of becoming high-cost within the next 6 months. Early intervention could reduce costs by $103.5M annually.

Utilization Anomaly Detection

Key Insight:

Three service areas show significant utilization surges: Behavioral Health (+18.7%), Home Health (+14.2%), and Specialty Pharmaceuticals (+22.3%). These warrant immediate investigation for potential overutilization.

Risk Stratification by Patient Cohort

High-Risk Patient Characteristics

Multiple Chronic Conditions

23,458 members have 3+ chronic conditions with poor management metrics. These members average 3.2x higher costs than the general population.

Mental Health + Physical Comorbidities

18,324 members have both mental health diagnoses and physical health comorbidities, with 42% showing medication non-adherence.

Recent Hospital Discharge

12,683 members were recently discharged from inpatient stays with high readmission risk scores. Targeted follow-up care reduced readmissions by 38% in pilot programs.

External Risk Factor Integration

External Factor Current Status Projected Impact Risk Level Mitigation Strategy
Hurricane Season Forecasts Above Average Activity Potential disruption to care access High Emergency Preparedness

Historical Impact Analysis

Previous severe hurricane seasons showed:

  • 42% increase in ED utilization during storms
  • 28% medication adherence reduction
  • 60% increase in crisis mental health services post-storm
  • $28.5M in additional costs during last major hurricane

Recommended Preparedness Actions

  • Early prescription refill exceptions (30-day supply)
  • Out-of-network coverage waivers during emergencies
  • Expanded telehealth coverage during evacuation periods
  • Dedicated case management for high-risk, electricity-dependent members
Infectious Disease Outbreaks Moderate Influenza Activity Increased hospitalizations Medium Vaccination Campaigns
Provider Market Changes Regional Hospital Consolidation Potential price increases Medium Contract Renegotiation
Pharmaceutical Pipeline 7 High-Cost Drugs Expected $43M annual cost increase High Alternative Treatment Pathways
Legislative Changes Pending Federal Changes Eligibility expansions possible Medium Scenario Planning

Risk Alert System

The dashboard provides automated alerts for unusual cost or utilization patterns that may indicate emerging risks.

ALERT: Region 3 Behavioral Health Utilization Spike

42.3% increase in behavioral health service utilization detected in Region 3 over the past 30 days, primarily for adolescent services. This exceeds the expected seasonal variation by 28.7%.

ALERT: Specialty Pharmacy Cost Trend

Specialty pharmacy costs for oncology medications increased 17.8% above projections in the past quarter. Analysis shows a 23.2% increase in utilization rather than price increases.

ALERT: Provider Network Change Impact

The exit of Southeast Medical Group from the network is projected to affect 12,475 members, with potential disruptions in primary care access for 8,231 members in rural counties.

Provider Network Analysis

Provider Performance Ranking

Key Insight:

27.3% of providers exceed quality and cost expectations, while 18.5% fall below thresholds on both metrics. Implementing a tiered network could incentivize higher-performing providers and save $86.3M annually.

Network Adequacy Analysis

Key Insight:

Significant provider shortages exist in behavioral health (72.4% adequacy) and dental care (78.1% adequacy). Telehealth expansions improved access by 15.3% in rural regions.

Provider Value Assessment

Provider Type Quality Score Cost Efficiency Member Satisfaction Overall Value Action
Primary Care 87.3% 76.5% 92.1% 85.3%

Top Performing Primary Care Providers

  1. Sunshine Family Medicine (97.8% value score)
  2. Florida Health Partners (94.2% value score)
  3. Coastal Primary Care (92.7% value score)
  4. Central Florida Physicians (91.3% value score)
  5. Miami Medical Group (90.8% value score)

Performance Differentiators

  • High performers average 2.4 more preventative care visits per member
  • 42% higher screening rates for chronic conditions
  • 68% better medication adherence among patients
  • 54% fewer avoidable ED visits
  • 37% lower overall cost per attributed member
Specialists 82.4% 68.9% 87.3% 79.5%

Specialty Performance by Type

Specialty Value Score Network Adequacy
Cardiology 86.3% 93.2%
Oncology 88.7% 87.8%
Neurology 76.4% 68.3%
Psychiatry 71.5% 58.7%
Endocrinology 82.3% 76.2%

Improvement Opportunities

  • Psychiatry: Critical shortage and low performance scores; telehealth expansion recommended
  • Neurology: Standard care pathway implementation could improve cost efficiency by 18%
  • Gastroenterology: 32% variation in procedure costs; standardization opportunity
  • Orthopedics: High imaging utilization (28% above benchmark); appropriate use criteria needed
Hospitals 78.6% 72.1% 81.5% 77.4%
Behavioral Health 74.2% 83.7% 79.8% 79.2%
Skilled Nursing 81.3% 79.4% 76.2% 79.0%

Provider Network Optimization Opportunities

Value-Based Contract Expansion

Currently 32.4% of provider payments are tied to value-based arrangements. Expanding to 50% could improve quality metrics by 14.7% and reduce costs by 8.3%, based on pilot program results.

Telehealth Integration

Telehealth utilization varies widely across regions (8.3%-27.4%). Standardizing telehealth integration into care pathways could improve access by 23.7% and reduce transportation barriers.

Specialty Network Redesign

Creating Centers of Excellence for high-cost procedures could concentrate volume at high-performing facilities, improving outcomes by 18.2% and reducing costs by 12.7%.

Digital Health Program Integration

Remote Patient Monitoring

Members enrolled in RPM programs for diabetes and hypertension show 32.4% fewer hospitalizations and 27.8% better medication adherence. Expanding from current 8,743 participants to 25,000 eligible members could save $28.3M annually.

Behavioral Health Apps

Digital behavioral health interventions show 19.6% reduction in crisis service utilization. Integration with provider workflows improved engagement by 42.3% in pilot regions.

Dashboard Summary & Recommendations

Key Findings

  1. Population health metrics reveal significant opportunities in chronic condition management, particularly for diabetes and hypertension. The data shows that addressing social determinants of health has measurable impacts on health outcomes and costs.
  2. Medical and pharmacy claims analysis identifies $229.8M in potential annual savings through targeted interventions in duplicate claims, medication adherence, and inappropriate ED utilization.
  3. Predictive analytics have identified 8,743 members at high risk of becoming high-cost utilizers, with early intervention potential to reduce costs by $103.5M.
  4. Provider network analysis demonstrates substantial variation in provider performance, with significant opportunities to improve value through network optimization and value-based contracting.
  5. Digital health program integration shows promising results, particularly in remote patient monitoring and behavioral health applications.

Recommended Actions

Short-Term Priorities (0-6 months)

  • Implement enhanced claims validation to reduce duplicate payments ($32.1M opportunity)
  • Expand telehealth access in behavioral health shortage areas
  • Deploy case management for predicted high-risk members
  • Launch medication adherence program targeting highest-risk populations
  • Expand behavioral health and supportive housing pilot program to additional regions

Medium-Term Initiatives (6-18 months)

  • Implement tiered provider network based on performance metrics
  • Expand value-based contracting to 50% of provider payments
  • Develop Centers of Excellence program for high-cost procedures
  • Scale remote patient monitoring to 25,000 eligible members
  • Implement comprehensive SDOH screening and referral system

Anticipated Benefits

Projected Annual Cost Savings

$412.6M

Implementation cost: $67.3M

ROI: 6.1:1

Quality Measure Improvement

+14.3%

Key HEDIS measures average

Across all measures

Avoidable Utilization Reduction

-27.8%

ED visits, readmissions

And preventable admissions

AHCA Medicaid Analytics Dashboard | Developed for AHCA | Generated on May 1, 2025

This dashboard identifies areas for improvement to enhance Medicaid quality of service and reduce costs.