Evaluating the Iowa Medicaid
Managed Care Program:

Outcomes of Care and
Consumer Assessment

Final Report to the
Iowa Department of Human Services

Elizabeth T. Momany, PhD
Assistant Research Scientist

Peter C. Damiano, DDS, MPH
Professor and Director

Margaret C. Tyler, MA, MSW
Research Assistant

Health Policy Research Program
Public Policy Center
The University of Iowa

January 2003

The Iowa Department of Human Services and the U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services, supported this study. The results and views expressed are the independent products of university research and do not necessarily represent the views of the funding agencies. The source for comparative CAHPS® survey data used in this publication is the National CAHPS® Benchmarking Database (NCBD).  Any analysis, interpretation, or conclusion based on these data is solely that of the authors.  The NCBD is a collaborative initiative of Westat and Shaller Consulting, with funding provided by the Agency for Healthcare Research and Quality.

Outcomes of Care (HEDIS-type measures)

Over the last five years the Iowa Department of Human Services (IDHS) has incorporated outcome measures from the Healthplan Employer Data and Information Set (HEDIS) [1] as part of the quality assurance activities within the Iowa Medicaid program. The University of Iowa Public Policy Center has helped to identify, adapt, and determine the rates for these HEDIS outcomes measures annually. This report provides information regarding annual Medicaid outcomes for the period 1998-2000. There are 14 measures across the three years, although not necessarily in each year. Measures that were used in more than one year allow for year-to-year comparisons. By comparing rates over time we should be able to determine whether the outcomes of care are improving for the Medicaid population. In particular, with intra-HMO comparisons we can determine whether the managed care plans are improving their care over time.

For some measures we also have national level data for comparison. The American Public Human Services Association (APHSA) undertook a project funded by the Commonwealth Fund to analyze data within the National Committee for Quality Assurance to determine rates for specific HEDIS measures for the Medicaid population. These analyses provide national benchmarking data that allow Iowa insights into how the state¹s Medicaid program compares with programs in other states. The APHSA Medicaid HEDIS Database Project, Report for the Third year by Lee Partridge was released in December 2001.

Outcome data should always be interpreted with caution. Limitations of this data may include differential rates of missing data across the claims/encounters, the systematic use of inappropriate codes, or the miscoding or diagnoses. For a more complete discussion of these limitations and a complete provision of all results please see 'Evaluation of the Iowa Medicaid Managed Care Programs and Outcomes of Care', March 2003. Despite these limitations, important knowledge is gained by comparing outcome results over time and between plans. For the purposes of this report, the average across all managed care plans (John Deere, Iowa Health Solutions, Coventry, and MediPASS) for each year in which the measure was utilized are included along with the results for any plan that varied more than 5% from the average for all plans in the given year. 

Ambulatory care for children and adolescents

An ambulatory care visit was defined as any visit to a physician within an office or outpatient clinic setting.  This measure does not include emergency room visits or inpatient physician visits. Though this is a broad measure, it does provide some information regarding utilization of services across age groups and plans. Figures 1-5 indicate the average rate of ambulatory care utilization for 1998 and 1999 for each age group and the rates for Iowa Medicaid health plans that were at least 5% below or above the average for all plans in Iowa in that year. Rates are comparatively lower for 1999 for every age group except children 1 year old. Additionally, for children under 1 utilization of ambulatory care was similar across all plans within both years. This may be attributed to the number of well child visits and vaccinations that are required during this time frame. Providers and parents may be more cognizant of the need for these activities during the first year of life.

Though there is not much variance among plans among children two through six years old, there is a considerable variance for children seven through 11 years of age and adolescents 12 through 16 years of age during 1999. This variance can be seen in Figures 3 and 4.  This measure was not repeated in 2000, however, it should be recalculated in 2001 to ascertain whether the variance and decrease in ambulatory care rates may be indicative of a trend.

Figure 3. Ambulatory care visits for children 7-11 years old	Figure 4. Ambulatory care visits for adolescents 12-15 years old

Figure 5. Ambulatory care visits for
adolescents 16-18 years old

Preventive care for children and adolescents

The rate of children and adolescents with a well child visit is divided into three age categories: children ages 3-6, children ages 7-11 and adolescents ages 12-19 (Figures 6-8). According to the Iowa Early and Periodic Screening Diagnosis and Treatment (EPSDT) program periodicity schedule, children should receive 7 well child visits by the time they reach 1 year of age, 3 visits up to age 2, annual visits from three through six years of age and biannual visits from age seven up to age 20. Almost 100% of children under age 2 have at least one preventive visit each year. However, this begins to drop at age 3. Figures 6-8 indicate the rate of preventive care for the three age groups during 2000. In addition, comparisons to the APHSA national benchmark are provided for 1999 for the three through six age group and the 12-21 year old group. Within all age groups there is variation among the plans with Iowa Health Solutions having the lowest rates across all three age groups. Additionally, all plans show a pattern of high rates of preventive care for children three through six years of age, low rates of preventive care for children seven through 11 years of age, and moderate rates of preventive care for children 12 through 21 years of age.

The rate of adolescents with at least one preventive visit during 2000 is higher for every managed care plan than it was for children ages seven through eleven. This increased rate of preventive care among adolescents is most likely due to the requirement of the schools that adolescents participating in sports must have a sports physical. Just as in the younger children we see a drop off in the rate of preventive visits after the required pre-school physical, so also we see an increase in the rate as soon as the school requires a preventive visit for participation in sports. School required health care does increase the rate of preventive care in children. It may be useful to consider other time points within the school career at which a preventive visit should be required in order to participate in school activities.

In Figures 6 and 8 we also see the percentage of children ages three through six years of age and the percentage of adolescents 12 through 21 years of age who had a preventive visit within the year 2000 compared with the APHSA benchmark. This comparison puts Iowa in a favorable light with even the HMO with the lowest percentage being equivalent to the APHSA percent. This points up clearly that national numbers do not necessarily provide a target rate. Though the Iowa rates of well child and adolescent visits are higher than the national benchmarks, the rates are still below the guidelines for the EPSDT program. It may be prudent for the IDHS and/or the health plans to educate parents on the importance of the preventive visit, especially as children approach adolescence. Preventive visits do not just address the medical needs of the child, but can also provide an opportunity for anticipatory guidance to parents and children.

Figure 6. Preventive care visits for children 3-6 years old	Figure 7. Preventive care visits for children 7-11 years old

Figure 8. Preventive care visits for adolescents 12-21 years old

Preventive dental care for children and adolescents

In addition to regular preventive medical visits, children are recommended to have regular preventive dental visits. According to the Iowa EPSDT periodicity schedule, children should see a dentist annually at ages one and two and every six months up to age 20. Figures 9-12 indicate the rate of preventive dental visits for children and adolescents for 1998 and 2000. Since dental care is not included within the HMO contract, the rates are not broken out by managed care plan. Over the 2-year period between 1998 and 2000 rates of preventive dental care fell precipitously for children two through six years of age and fell slightly for children seven through 11 years of age. During this same time period the rate remained the same for adolescents 12 through 15 years of age and increased for adolescents 16 through 18 years of age. The decrease in rates among young children may be the result of decreases in dental providers who take children, particularly children under four years of age. These results indicate the need for further research to determine reasons for the drop in rates and continued use of these measures in future outcome analyses to track the trend.

Summary of child and adolescent measures

The Medicaid program has children as its primary enrollee group: over 60% of Medicaid eligible persons are under 19 and the majority of these are under 12. The health outcomes for this group are extremely important in assessing the quality of care provided. Most particularly these data allow us to determine whether children have equal access to services across plans. From an overall perspective, children within the Medicaid program utilize services at rates that appear higher than those seen nationally, however they are not utilizing preventive services at a rate consistent with the established Iowa Medicaid EPSDT guidelines.

Preventive care for adults

There are no guidelines within the Medicaid program regarding the timing of preventive visits for adults. Providers and enrollees are expected to utilize these services according to the general standard of practice. Figures 13 and 14 indicates the rate of preventive services utilized by for adults 19 through 34 years of age and 35 through 64 years of age. For both age groups, enrollees in Iowa Health Solutions experience the lowest rates of preventive care utilization, while those in Coventry and MediPASS have higher than average utilization rates. Additionally, a previous report (Outcome Assessment: Iowa Medicaid Managed Care Programs, March, 2003) indicated that the rates of preventive care utilization among men is approximately half that of women. Women may be more likely to see a physician due to the use of contraceptives or determination and supervision of pregnancy. In particular, the use of contraceptives requires a well visit yearly, thereby forcing women to make time to visit the doctor. No such incentive exists for men.

Figure 13. Preventive care visits for adults 19-34 years old	Figure 14. Preventive care visits for adults 35-64 years old

Cesarean sections

The rate of Cesarean sections (C-sections) is used to determine the complexity of deliveries within the plans. If this rate is high within a plan and remains high over time it may indicate that action should be taken to determine why C-sections are being performed and develop strategies lower the rate. Figure 15 provides the C-section rates across plans for 1998 and 2000. The rate of C-sections increased across all plans during the 2-year period 1998 through 2000. Additionally, the C-section rate varies across plans during each of the measurement years. Essentially, no clear pattern can be determined except that MediPASS enrollees have the highest rate of births delivered by C-section.

Figure 15. Cesarean section rates

Cervical cancer screenings

The rates for cervical cancer screening (Figure 16) are somewhat low in all health plans. Guidelines indicate that this screening should occur at least once every three years. Plans with a rate of 30% or greater may be considered to be in compliance with this guideline. During the period 1998 through 2000 approximately one-third of women received the screening exams. Iowa Health Solutions and Coventry appear to have extremely low rates during 1998 and 1999. During 2000 more women within these two plans are reflected as having had a screening exam, however Coventry still had below average rates.

Preventive dental care for adults

In addition to well person visits, preventive dental visits play an important role in the over all health of individuals within the Medicaid program. The Iowa Medicaid program provided for comprehensive adult dental services during calendar years 1998 and 2000. Figure 17 indicates that rates of preventive dental care utilization were relatively stable over this 2-year period. The rates were low (less then 50% for both age groups across both years) and appear to be dropping indicating that continued inclusion of this outcome measure in future analyses would be prudent. With the elimination of selective dental services for adults in 2002, the tracking of this measure will be even more important.

Figure 16. Cervical cancer screening for women 21-64 years old

Children	Adults
Figure 21. Ratings of specialists

d)   All health care in past 6 months

Care received by Iowa Medicaid enrollees was rated similarly for all plans in 2002 for both adults and children. Care for children was rated similar to care for children in Medicaid plans nationally however care for adults was rated lower. Care for children in Iowa Health Solutions was rated the same as that provided in other plans in 2002, though it was rated lower than other plans in 2000.

Children	Adults
Figure 22. Rating of all health care received in past 6 months

3)   Access to care

Access to care was evaluated in four ways: 1) the percentage of enrollees with a regular source of care, 2) ability to get needed care, 3) ability to get care quickly and 4) unmet need for services.

Children ---Adults Figure 23. Percent having a regular source of medical care

b)   Ability to get needed care

The ability to get needed care is an average on the following four items, measured on the 3-point problem scale big problem, small problem, and no problem:

v    With the choices your health plan gave you, how much of a problem, if any, was it to find a personal doctor or nurse you are happy with?

v    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?

v    In the last six months, how much of a problem, if any, was it to get the care you or a doctor believed necessary?

v    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?

The ability to get needed care was rated slightly higher for both adults and children in Iowa than for Medicaid nationally. In 2002, all Iowa plans received comparable ratings for children. Iowa Health Solutions, however, was rated significantly lower for adults

Children	Adults
Figure 24. Ability to get needed care

c)    Ability to get care without long waits

The ability to get care without long waits is a composite of the following four items indicating how often respondents reported that they received care in a timely manner (scale: never, sometimes, usually or always):

In the last 6 months:

v    when you called the doctor's office or clinic during regular office hours, how often did you get the help or advice you needed?

v    how often did you get an appointment for regular or routine health care as soon as you wanted?

v    when you needed care right away for an illness or injury, how often did you get care as soon as you wanted?

v    how often did you wait in the doctor's office or clinic more than 15 minutes past your appointment time to see the person you went to see? (This is reverse-coded so that a higher score indicates less experience with long waits).

Children	Adults
Figure 25. Ability to get care without long waitsn

d)   Unmet need for services

The ability to get needed services was pursued further by asking if there were any times in the past 6 months when the enrollee needed a specific type of care (medical, dental, behavioral/emotional, and prescription medication) but could not get it for any reason.  Adults were more likely to have reported unmet need for services than children in all service categories except behavioral/emotional (mental health) services. About one in ten children were stopped from receiving dental, behavioral/emotional and prescription medications in 2002. The most common reason reported for unmet dental need was inability to find a dentist who would accept Medicaid enrollees (70%), transportation problems (28%) and trouble getting an appointment (20%). For adults, almost one in five had unmet need for dental care, about one in seven had unmet need for behavioral/emotional care and prescription medications and one in ten had unmet need for medical care. The most common reasons given for unmet need for medical care were the inability to find a doctor who accepts Medicaid patients (33%), trouble getting appointments (23%) and cost (21%). For dental care, the most common reasons were that they could not find a dentist who would accept Medicaid enrollees (59%), cost (30%) and transportation (24%). There were no differences in the proportion with unmet need for any service area by health plan for either adults or children.

Figure 26. Unmet need for services

4)   Health Status

Health status in the Iowa Medicaid survey was evaluated in two ways: using the standard self-perceived health status question (i.e., in general, how would you rate your overall health now) and by using the Foundation for Accountability (FACCT) screening instrument for identifying children and adults with special health care needs. [4] This screener provides a broad definition of special health care need that is being used by the US Bureau of Maternal and Child Health to estimate the percentage of children with special health care needs in a population.

v    Limitations in daily functioning

v    Need or use medicines prescribed by a doctor

v    Above routine need for or use of health and related services

v    Need or use of special therapy such as physical, occupational or speech therapy

v    Need or use of treatment/counseling for emotional, developmental or behavioral problems

Children	Adults
Figure 27. Health status rating

b)   Having a special health care need

More adults (41%) in this TANF population were considered to have a special health care need than children (24%). The proportion of children with special health care needs varied by health plan in 2002 with MediPASS having the largest percentage with a special health care need and Iowa Health Solutions having the smallest. Adults were more likely to report a functional limitation than children and this may account for the increased percentage of adults considered to have a special health care need.

Children	Adults
Figure 28. Percentage with a special health care need

 

5)   Utilization of services

Two different aspects of utilization of health care services are presented from the survey: 1) number of visits to a doctor's office or clinic and 2) number of visits to an emergency room.

a)   Doctor or clinic visits

About four out of five adults and children made a doctor visit in the previous six-month period during both 2000 and 2002. Though the number of children with more than 10 visits to the doctor was negligible in 2000 it rose to 3% in 2002. Additionally, the percent of children for whom one to two doctor visits were reported increased from 45% in 2000 to 49% in 2002. In comparing children to adults, adults with at least one visit make more visits per person than children with a visit.

Children	Adults
Figure 29. Number of doctors visits

b)      Emergency room visits

About one in four children and one in three adults in Iowa had visited an emergency room (ER) in 2000 and 2002. Children in the Iowa Medicaid managed care program were less likely than children nationally to have had a visit to an ER in the past 6 months. Similar proportions of adults in Iowa had an ER visit as adults nationally in 2002.

6)   Communication with health care providers

To determine how well enrollees believed their doctors communicate, the answers to a series of five questions were averaged together:

In the last 6 months how often did doctors or other health providers:

v    listen carefully to you?

v    show respect for what you had to say?

v    spend enough time with you?

v    explain things in a way you could understand?

v    explain things in a way your child could understand? (Child survey only).

Patient's perceptions of health care provider ability to communicate differs by health plan in 2002 for children, but not for adults. Providers in Coventry were rated as communicating more effectively and those in Iowa Health Solutions were rated as communicating less effectively with respect to children. Perceptions of enrollees in Iowa were similar to those of other Medicaid enrollees nationally. Communication was considered slightly better for children than for adults across both years and nationally.

Children	Adults
Figure 32. Treatment by office staff

8) Customer Service

Experience with customer service, information and paperwork is evaluated with an average of the following three items, measured with the possible responses of big problem, small problem, no problem:

In the last 6 months how much of a problem, if any,

v    was it to find or understand information in the written materials?

v    was it to get the help you needed when you called your health plan's customer service?

v    did you have with paperwork for your health plan?

Overall, Iowa Medicaid health plans scored better regarding customer service than other Medicaid plans nationally. Both MediPASS with child-related care and John Deere for adult-related care were rated better than the state average in 2002.

Children	Adults
Figure 33. Health plan customer service

9) Preventive counseling

Receipt of preventive counseling was evaluated by asking whether, in the last six months, their doctor or health plan:

v    encouraged parents to take any preventive health steps for their child such as watching what their child eats or using a bicycle helmet or car seat

v    encouraged adults to exercise or eat a healthy diet

Adults were significantly more likely to remember receiving preventive counseling for themselves than parents were to remember receiving preventive counseling about their children in 2002.

Figure 34. Preventive counseling received

10) Comparison of Medicaid to private insurance by Iowa Medicaid adult enrollees

Adults were asked whether they had been covered by private health insurance in the past 5 years. They were also asked to compare their Medicaid health insurance with that of private health insurance on several different issues:

v    how well coverage meets their needs

v    rating of the services covered

v    rating of ability to find a doctor who will accept the insurance

v    rating of how well they are treated because of the insurance

v    whether they felt they were ever were treated differently because of being covered by Medicaid

a)   Previous experience with private health insurance

Just over four in ten adult Iowa Medicaid survey respondents had been covered by private health insurance in the previous 5 years.

Figure 35. Percent covered by private insurance in past 5 years

b)    Adequacy of Medicaid coverage

Almost two-thirds of adults rated Medicaid as excellent or very good at meeting their health care needs. Only seven percent rated it as fair or poor. Over 90 percent of adults thought that Medicaid covered the types of services they needed at least as well if not better than private insurance.

Figure 36. Rating how well Medicaid coverage meets needs	Figure 37. Rating the types of services covered by Medicaid compared to private insurance

c)    Ability to find a doctor who accepts Medicaid

About two-thirds of adults thought that their ability to find a doctor was as good, if not better, than that of adults with private insurance. One in four, however, thought their ability to find a doctor who accepts their insurance was worse than for those with private insurance.

Figure 38. Rating the ability to find a doctor in Medicaid compared to private insurance

d)    Treatment as a Medicaid enrollee

There were mixed opinions about whether adults felt they were treated differently by doctors and their staff because they were enrolled in Medicaid. Almost one in four enrollees felt they were treated worse by doctors and their staff compared to those with private insurance, however a similar percentage reported that they believed they were treated better. The remainder (55%) did not see any difference in how they were treated. About one-third of the adults indicated that they thought they had been treated differently at some point because they were on Medicaid. This opinion was supported by numerous comments written on the survey about how adults felt they were treated differently. These are outlined in the full report concerning the survey results.