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the Consumer Perspective Results from the 2002 Survey of Iowa Medicaid Managed Care Enrollees Final
Report to the Peter C. Damiano, DDS,
MPH Margaret C. Tyler, MA,
MSW Elizabeth T. Momany,
PhD Health Policy Research
Program December 2002 This study was supported by the Iowa Department of Human Services and the U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services. The results and views expressed are the independent products of university research and do not necessarily represent the views of the funding agencies. PrefaceThis report presents the results of a study of how Iowa Medicaid managed care enrollees rated their health plans in which they were enrolled during 2000. It was conducted at the request of the Iowa Department of Human Services as part of their continuing quality assurance activities with health plans participating in Medicaid. This study began as part of a demonstration project of the Consumer Assessment of Health Plans Study (CAHPS) that was being conducted in Iowa. CAHPS is a national effort to develop a method to provide consumers and purchasers with information about the quality of health plans. CAHPS is sponsored by the Agency for Health Care Research and Quality. The three primary developers of the CAHPS survey and report are Harvard University, RAND and the Research Triangle Institute. The surveys and aspects of the consumer report used in this project were modified by researchers at the University of Iowa Public Policy Center in collaboration with the Iowa Department of Human Services and researchers at RAND who are part of the CAHPS team. The core CAHPS survey instrument was modified to include additional questions about access to care, dental care and where respondents received information if they had questions about their health plan. Researchers at The University of Iowa Public Policy Center conducted this study with funding provided by the Iowa Department of Human Services and the US Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). Researchers from RAND, who are members of the CAHPS development team, also collaborated and provided technical assistance with this project. Information and conclusions presented in this report are the responsibility of the authors and do not represent the views of the Iowa Department of Human Services, The CMS, the health plans or the University of Iowa. AcknowledgementsThe authors would like to thank Mr. Dennis Janssen, Bureau Chief, Bureau of Managed Care & Clinical Services, Iowa Department of Human Services for his assistance with the completion of this research and creating an environment conducive to conducting this evaluation. The University of Iowa Social Science Institute conducted the telephone follow-up call for the enrollee survey in a professional and efficient manner. The University Of Iowa Information Technology Services¹ Computing Center provided expert support for the mainframe computer activities necessary to analyze the Medicaid claims and eligibility files. The Academic Computing Committee was also very generous in their allocation of mainframe computing time for this project. Researchers associated with the CAHPS project at RAND project excellent technical assistance with the implementation, analysis and reporting of data from the Enrollee Survey. Donna Farley, Ron Hays, Pam Short, David Kanouse, and Marc Elliott were extremely helpful and generous with their time, particularly with questions on short notice. Special thanks to our colleagues at the Public Policy Center. As always, Professor David Forkenbrock, the Center Director, made the valuable resources of the Center available to us. Jean Willard, senior research assistant, Kathy Holeton, administrative assistant, Teresa Lopes, editor, and Peggy Waters, secretary, all provided valuable assistance to this research. Josh Miller, a University of Iowa student research assistant, provided excellent research support throughout the project. Table of Contents Preface........................................................................................................................................ iii Acknowledgements..................................................................................................................... v Executive Summary......................................................................................................................... 1 Chapter 1: Introduction and Survey Methodology........................................................................ 7 Survey Methodology.................................................................................................................... 8 Table 1: Child sample and participation rate............................................................................ 8 Table 2: Adult sample and participation rate............................................................................ 8 Chapter 2: Children¹s Results from the 2002 Medicaid Survey.................................................. 13 Demographics of the 2002 Child Medicaid Sample................................................................. 13 Children's Health Status........................................................................................................... 14 Enrollment and Plan Information.............................................................................................. 14 Access and Utilization.............................................................................................................. 15 Health Care Delivery for Children............................................................................................ 17 Consumer Perceptions of the Health Plans.............................................................................. 18 Chapter 3: Adult Enrollee Results from the 2002 Medicaid Survey........................................... 21 Demographics............................................................................................................................ 21 Health Status............................................................................................................................. 21 Enrollment................................................................................................................................. 22 Access and Utilization.............................................................................................................. 22 Health Care Delivery for Adults............................................................................................... 24 Consumer Perceptions of the Health Plans.............................................................................. 25 Chapter 4: Comparison of Child and Adult Survey Results........................................................ 27 Demographics............................................................................................................................ 27 Health Status............................................................................................................................. 27 Access and Utilization.............................................................................................................. 27 Consumer Perceptions of Health Care Delivery....................................................................... 29 Consumer Perceptions of the Health Plan................................................................................ 30 APPENDIX A: Child Survey Responses by Question 31 APPENDIX B: Adult Survey Responses by Question 51 APPENDIX
C:
Responses to Question 75 (Adult Survey): APPENDIX D: Comments from the Child Survey 87 APPENDIX E: Comments from the Adult Survey 107 APPENDIX F: Child Survey Instrument APPENDIX G: Adult Survey Instrument Evaluating Iowa Medicaid Managed Care Plans:the Consumer PerspectiveResults from the 2002 survey of iowa medicaid managed care enrolleesExecutive Summary As part of the quality assurance activities of Iowa¹s Medicaid Managed Care Program, the Iowa Department of Human Services contracted with the University of Iowa Public Policy Center to conduct a survey of adults and children enrolled in Iowa¹s Medicaid HMOs. Each respondent was enrolled in one of four HMOs: John Deere Health Care, Iowa Health Solutions, Coventry Health Care, or MediPASS (the state-administered Medicaid HMO program). The survey included the CAHPS® 2.0 questionnaire as well as other items designed to elicit respondents' perceptions of their access to medical, dental, and behavioral health care, and the quality of their health care and health plans. Demographic data were also requested. The initial sample was comprised of households with current Medicaid enrollees: 2831 children and 2428 adults. Data were obtained for 953 adults and 1226 children. This represents combined phone and mail survey response rates of 39 percent for adults and 43 percent for children. Approximately two thirds of the responses were received by mail and one third by phone interview. Child Survey ResultsDemographics1226 Child Enrollees § 50% female § Average age: 7 years § 85% Caucasian, 14% African American § Hispanic or Latino heritage: 9% § In school or daycare: 74% § Primary language other than English: 4% § Special health care need: 24% § Current health status: 79% very good to excellent, 18% good, 3% fair to poor § 83% of children were reported to have a primary health care provider (PCP) § 29% had gotten a new primary care provider since enrollment ‹ Of these, 21% had at least some problems finding a PCP § 84% had a preventive health visit within the last year In the last six monthsŠ§ 86% had no problems getting health care for their children, which was better than national averages § Problems Getting Needed Care: 5% big problem, 10% small problem, 86% no problem § 62% said their child always got care as quickly as they wanted, 25% usually did, 13% sometimes or never did. This was also better than national averages § 67% of respondents had made a routine appointment for the child § 21% of the children had needed specialty care § 29% of the children had seen a specialist ‹ Of those who needed a specialist, 14% had an unmet need ‹ 18% of those who needed a specialist had problems getting a referral § 24% of children had been treated in an Emergency Room at least once § 38% of children had needed care for an illness or injury § 83% had at least one outpatient visit in the last 6 months ‹ 34% of all children had three or more outpatient visits § 60% of respondents had called a doctor's office or clinic during office hours for help or advice regarding the child ‹ 72% of these always got needed help when they called the clinic § 3% of children had an unmet need for health care in the last 6 months ‹ Most common reasons: trouble finding a doctor who accepted Medicaid (34%), trouble getting appointments (31%) Dental Care § 58% saw a dentist in the last year, compared to 74% statewide § 83% had a single source of dental care § 37% of children needed dental care in the last 6 months ‹ Common reasons: couldn¹t find a dentist who accepted Medicaid (70%), transportation problems (28%) ‹ Of the 37% who needed dental care in the last six months, 18% had an unmet need. This is higher than the statewide figure of 8%. Care Delivery Issues§ Average Quality of Care Rating: 8.6 on a 0 to 10 scale § Average Rating of Primary Care Provider: 8.8 on a 0 to 10 scale § Average Rating of Specialist: 8.3 on a 0 to 10 scale § Health Care Provider Communicates Well 10% never/sometimes, 22% usually, 68% always ‹ Below average: Iowa Health Solutions ‹ Above average: Coventry Health Care § 32% reported getting prevention advice for their children (e.g, nutrition, car seats or bicycle helmets) from their plan or provider in the last 6 months ‹ Of the 84% who had a preventive visit in the last year, 37% had gotten prevention advice for their children. § Medical Office Staff is Courteous and Helpful: 8% never/sometimes, 18% usually, 74% always ‹ below average: Iowa Health Solutions ‹ Above average: Coventry Health Care Health Plan Issues§ Average Overall Plan Rating: 8.4 on a 0 to 10 scale § 48% of respondents were aware of the Medicaid helpline, ‹ 15% of these had called the helpline for information or help ‹ 33% had problems getting needed assistance from helpline ‹ 9% had called with a complaint or problem ‹ 63% of those whose complaints had been resolved were happy with the outcome § Problems with Customer Service, Information or Paperwork: 10% big problem, 29% small problem, 71% no problem. Behavioral and Emotional Health Care In the last six monthsŠ § 14% of children had needed behavioral health care ‹ 25% of these had problems with access ‹ 15% of those who needed behavioral health care had an unmet need for care Prescription Medication In the last six monthsŠ § 55% of children needed prescription medication ‹ 14% had problems getting prescriptions § 55% of these received help in getting prescriptions § 11% had unmet need for prescription medication Demographics953 Adult Enrollees§ 87% female § Average age: 29 years § 87% Caucasian, 10% African American § Hispanic or Latino heritage: 5% § Completed high school: 85% Health Status§ Current health status: 43% very good to excellent, 39% good, 18% fair to poor § Chronic health condition: 41% Access to Care and Use of Services§ 76% had a primary health care provider (PCP) § 35% had gotten a new primary care provider since enrollment ‹ Of these, 27% had at least some problem finding a PCP § 75% had a preventive health care visit within the last year In the last six monthsŠ- 80% had no problem getting needed care, 12% had a small problem, 8% a big problem ‹ More problems than average: Iowa Health Solutions § 18% never or only sometimes got care as quickly as they wanted, 32% usually did, 50% always did § 69% had made an appointment for routine health care § 33% had been treated in an Emergency Room at least once § 44% had needed care for an illness or injury § 80% had at least one outpatient visit (excluding emergency room visits) ‹ 44% of all respondents had three or more outpatient visits § 66% had called a doctor's office or clinic during office hours for help or advice for themselves ‹ 61% always got the help they needed when they called the clinic § 32% of all respondents had seen a specialist - 36% had needed specialty care - 83% of those who had a need for specialty care did see a specialist ‹ 23% of those who needed a specialist experienced some problem getting a referral ‹ 19% of those who needed it had an unmet need for specialty care at least once Quality of Adult's Health CareCare Delivery Issues§ Average Quality of Care Rating: 8.1 on a 0 to 10 scale § Average Rating of Primary Care Provider: 8.4 on a 0 to 10 scale § Average Rating of Specialist: 8.1 on a 0 to 10 scale § 43% received prevention advice (diet or exercise) from their doctor or health plan in the last six months § Health Care Provider Communicates Well: 14% never/sometimes, 29% usually, 57% always § Medical Office Staff is Courteous and Helpful: 9% never/sometimes, 27% usually, 64% always Health Plan Issues§ Average Overall Plan Rating: 7.8 on a 0 to 10 scale § 53% of adults were aware of the Medicaid helpline ‹ 29% of these had called it for information § 29% of callers had problems getting assistance from the helpline ‹ 16% of those who were aware of the helpline had called with a complaint or problem § 75% of those whose complaints had been resolved were satisfied with the result § Problems with Customer Service, Information or Paperwork: 11% big problem, 26% small problem, 63% no problem. ‹ Fewer problems than average: John Deere Health Care Dental Care§ Dental health status: 38% very good to excellent, 34% good, 28% fair to poor § 76% had a single source of dental care § 56% had a dental checkup within the last year, 26% had not had one for 2 years or more § 39% needed dental care in the last 6 months § 18% of adults had an unmet need for dental care ‹ Most common reasons: problems finding a participating dentist (60%), expense (30%), transportation problems (25%) § 26% had a problem accessing dental care § Average Dental Care Rating: 7.6 on a 0-to-10 scale. (Only adults rated dental care) Behavioral and Emotional CareIn the last six monthsŠ§ 18% had needed behavioral health care ‹ 20% had problems with access § 41% of these received help from their plan or clinic to get behavioral health services Prescription Medication In the last six monthsŠ § 73% had needed prescription medication ‹ 19% had problems accessing prescription medicine ‹ 16% had an unmet need for prescription medication Evaluating Iowa Medicaid Managed Care Plans:the Consumer PerspectiveResults from the 2002 Survey of Iowa Medicaid Managed Care EnrolleesChapter 1:Introduction and Survey MethodologyAs part of the quality assurance activities of Iowa's Medicaid managed care program, the Iowa Department of Human Services (IDHS) contracted with researchers at the University of Iowa Public Policy Center to conduct a survey of adults and children enrolled in Iowa's Medicaid managed care plans. The Iowa Medicaid managed care program includes three private Health Maintenance Organizations (HMOs) and the Primary Care Case Management (PCCM) program, MediPASS. The three HMOs that coordinate health care services under contracts with the IDHS are: John Deere Health Care, Iowa Health Solutions, and Coventry Health Care. The State of Iowa administers the MediPASS program, utilizing physician case managers, in most areas of the state. This report presents results from the 2002 Survey of Iowa Medicaid Enrollees. The survey addressed health status, access to and use of health care, and ratings of the quality of care for both adults and children in Iowa's Medicaid HMO program. The 2002 Survey of Iowa Medicaid Enrollees included questions about:
Ratings of overall care, primary care providers and specialists
This report will provide a summary of findings from the 2002 survey as well as detailed results for each question in the survey for members of each of the health plans. Findings for children and adults are presented in Chapters 2 and 3 of this report. In Chapter 4, results for children and adults are compared. Significant differences between the health plans and between adults and children for each question are noted. Results for Iowa¹s Medicaid managed care plans are compared to results for Medicaid programs nationally provided by the National CAHPS® Benchmarking Database [1] . Readers who wish to examine the survey results in greater detail are directed to the appendices. Results from the 2002 Child Medicaid Survey are found in Appendix A. Appendix B provides detailed results from the Adult Medicaid Survey. Appendix C contains written responses to question 75 on the Adult Survey (³Do you think you have ever been treated differently because you were covered by Medicaid? If yes, please tell us how you were treated differently.²) Additional comments from survey respondents are presented in Appendix D for the Child Survey and in Appendix E for the Adult Survey. Survey MethodologySample and participation rateThe 2002 Medicaid survey was conducted in the fall of 2001 and winter of 2002 with a random sample of Medicaid managed care enrollees who had been in their managed care plan for at least six months in row. A modified Dillman survey methodology [2] was used. Questionnaires were mailed to enrollees selected from administrative data provided by the Iowa Department of Human Services. Only one person per household was selected to participate in this study. Surveys were initially mailed to 2831 parents or guardians of child enrollees and 2428 adult enrollees in four health plans. A reminder postcard was sent out two weeks after the first mailing. A second survey mailing to nonrespondents was conducted three weeks after the initial mailing. Those who did not respond to the mailings were attempted to be reached by telephone to complete the survey up to five times. Table 1: Child sample and participation rate
* adjusted for surveys returned undeliverable and ineligibles Table 2: Adult sample and participation rate
* adjusted for surveys returned undeliverable and ineligibles For the child sample, in households with more than one child enrolled in Medicaid, one child was selected at random as the "target" child. The survey was addressed to the parent or guardian with instructions to complete the survey based on their experiences obtaining health care for this child only. The information presented in this report is based on responses for 953 adult and 1226 child enrollees. These figures represent combined mail and phone response rates of 39 percent for adults and 43 percent for children. About 2/3 of the responses were received by mail and 1/3 were completed by telephone. Description of the Survey Instrument The foundation for the survey instrument used in this study was the CAHPS® 2.0 Questionnaire [3] . The use of CAHPS® in Iowa is part of a national demonstration of the Consumer Assessment of Health Plans Study (CAHPS® 2.0), an effort to develop standardized measures for assessing the quality of health plans from the consumer perspective. The instrument also included questions from the Foundation for Accountability (FACCT) and the National Health Interview Survey (NHIS). Questions developed by FACCT called the 'Living with Illness' measures were included in the child survey. The Adult Survey contained a section on adult enrollees¹ experience with their Medicaid health plan in comparison with their perception of private health coverage. CAHPS® 2.0 SurveyThe CAHPS® 2.0 survey is designed to evaluate access to health care and the quality of health plans and care from the consumer's perspective. In order to examine consumer perspectives on both adult and child health care, two versions of the survey were developed. The child version differs from the adult version in that it addresses child-specific areas, such as the child's ability to communicate with providers, providers' support of caregivers' efforts, education of caregivers about children's health needs, and items addressing cooperation between health care personnel and daycare or schools. In addition to the individual questions in the survey, the CAHPS survey includes two ways to more broadly evaluate the health plans: 1) global ratings and 2) composites or scale scores. For the global ratings, a 010 scale is used to evaluate the health plan overall, the health care overall, the primary health care provider (if they have one), and the specialist (if they have one). Several questions are scored together to develop a composite score for five topic areas: 1) ability to get needed care, ability to get care quickly, 3) doctors' ability to communicate, 4) experience with medical office staff and 5) the plan's customer service. The composites getting needed care and customer service are measured on a 3-point scale indicating how much of a problem the respondent had in obtaining care or assistance (1=a big problem, 2=a small problem, and 3=not a problem). Getting care without long waits, doctors' ability to communicate, and courtesy and helpfulness of office staff are evaluated in terms of how often the respondent had positive experiences in these areas (1=never, 2=sometimes, 3=usually, and 4=always). Thus, for all composites a higher score is preferable. ('Sometimes' and 'never' responses are combined in the tables for display purposes, but average scores are reported based on a range of one to four). Each composite and the questions included in that topic area is described below: 1) Getting care when you need it is an average of scores on the following four items, measured on the 3-point problem scale described above: · In the last six months, how much of a problem, if any, was it to get a referral to a specialist that you needed to see? · In the last six months, how much of a problem, if any, was it to get the care you or a doctor believed necessary? · In the last six months, how much of a problem, if any, were delays in health care while you waited for approval from your health plan? 2) Getting care quickly is a composite of the following four items indicating how often respondents reported that they received care in a timely manner (never, sometimes, usually or always). In the last 6 months: · when you called the doctor's office or clinic during regular office hours, how often did you get the help or advice you needed? · how often did you get an appointment for regular or routine health care as soon as you wanted? · when you needed care right away for an illness or injury, how often did you get care as soon as you wanted? 3) How well doctors communicate is comprised of the following items: In the last 6 months: · how often did doctors or other health providers listen carefully to you? · how often did doctors or other health providers show respect for what you had to say? · how often did doctors or other health providers explain things in a way you could understand? 4) Courtesy and helpfulness of office staff is measured by two items: In the last 6 months: · how often did office staff treat you with courtesy and respect? · how often were office staff as helpful as you thought they should be? 5) Experience with customer service, information and paperwork is evaluated with a composite of the following three items, measured on the 3-point problem scale: In the last 6 months: · how much of a problem, if any, was it to find or understand information in the written materials? · how much of a problem, if any, was it to get the help you needed when you called your health plan¹s customer service? · how much of a problem, if any, did you have with paperwork for your health plan? CAHPS® 2.0 items were analyzed with the SAS statistical package using the CAHPS® 2.0 protocol, which takes into account any plan differences in enrollees' current health status, age, and educational level. Differences among health plans were analyzed using the CAHPS® 2.0 methodology. The statistical methods used by the CAHPS® 2.0 program are described in some detail in the CAHPS® 2.0 Survey and Reporting Kit. [4] Briefly, plan differences on the composite scores and the global ratings are evaluated for statistical significance using t- and F-tests for differences in means (averages). For statistical significance, the probability level was set at .05; that is, the probability that an observed difference is due solely to sampling error is less than five percent. Practical significance was evaluated according to the CAHPS® 2.0 protocol. For this project, differences between plans were determined to have substantive significance if the plan¹s mean score varied from the overall mean by an amount equal to 15 percent or more of the absolute difference between the overall mean and the nearest extreme score. (In our sample, the nearest extreme was always the highest possible score, (i.e., 10 on a 010 scale, 3 on a 13 scale, and 4 on a 14 scale). In order for a plan to rate above or below average on a CAHPS® 2.0 measure, the difference between the plan mean and the overall mean was required to meet criteria for both statistical and substantive (practical) significance. As suggested in the CAHPS® 2.0 manual, we used age, educational level (for children, this was the parent's or guardian's educational level), and current health status as case mix adjusters. This technique holds constant the effects of the adjuster variables to allow a clearer picture of the main effects of plan membership on respondents' assessment of their health care experiences. Special needs screening instrument and barriers to careBoth the adult and child versions of the survey included an instrument developed by the Foundation for Accountability (FACCT) to identify individuals with a special health care need. [5] Individuals are classified as having special health care needs if they are reported to have: a) a health condition, that b) has lasted or is expected to last at least one year, and c) has resulted in either 1) use of prescription medication, 2) functional limitations, or 3) need for or use of specialized (e.g., PT, OT, etc.) therapies mental health services, or more medical or other services than usual for people of the same age. Questions about barriers to care and unmet need for care were based on questions in the National Health Interview Survey (NHIS). [6] Unmet need is defined as any time when a person was unable to get needed care in the last 6 months. Chapter 2:Children's Results from the 2002 Medicaid SurveyBelow is a summary of the results of the 2002 Survey of Iowa Medicaid Enrollees for children enrolled in the four Medicaid managed care plans: the three Medicaid HMOs and MediPASS . Responses for children to each item in the survey questionnaire are presented by plan in Appendix A. Demographics of the 2002 Child Medicaid SampleChild respondentsThe children on who survey data were obtained ranged in age from under one to 17 years, with an average age of 7 years. The sample was evenly divided between boys and girls. The majority of children (85%) were Caucasian, with 14 percent Black, and 0 to 2 percent other ethnic identifications. Nine percent were of Hispanic or Latino heritage. Four percent spoke a language other than English as their primary language in the home. Three quarters (74%) were attending school or day care at the time of the survey. Table 3: Child respondent demographics by health plan
* statistically significant difference (p < .05) Compared to the National CAHPS® Benchmarking Database Medicaid samples, children in the Iowa Medicaid sample were more likely to be Caucasian, more likely to be age 12 and older, and were in better overall health. There were some demographic differences between respondents for each of the plans. Children in MediPASS were a little older than the average (7.8 vs. 7.1). Coventry had a higher proportion of African American children than average for all plans combined (35% vs. 14%) and children in Iowa Health Solutions were less likely to be attending school or day care. Parent/guardian respondentsMost child survey respondents were either the child's mother (89%) or a grandparent (7%). A fifth were under age 25 and 57 percent were under 35. Eighteen percent had less than a high school diploma. Demographic characteristics were similar to those of respondents of CAHPS surveys nationally, except that parents in Iowa were more likely to be Caucasian. Children's Health StatusGlobal Health RatingMost children (79%) in Iowa's Medicaid program were reported to be in excellent or very good health. Three percent were in fair to poor health. This is slightly better than children nationally where 72 percent of children were in very good to excellent health, and seven percent were in fair to poor health. Special Health Care NeedsBased on the FACCT screening instrument, 24 percent of the children in the Iowa Medicaid sample were identified as having a special health care need. This is greater than the 17 percent of children found to have a special health care need statewide using the FACCT instrument in the Iowa Statewide Child and Family Household Health Survey conducted in 2000. [7] It is important to note that the Medicaid managed care population only includes children from the TANF program and does not include children enrolled through the Supplemental Security Income (SSI) Program who are more likely to become eligible in part because of a special health care need. There were differences in the proportion of children with a special care need between the health plans. Children in Iowa Health Solutions were a little less likely than average to meet the criteria for having a special health care need (18% vs. 24%), while those in MediPASS were a little more likely (29% vs. 24%). Table 4. Children with Special Health Care Needs, by health plan
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