Final Report to the
Iowa Department of Human Services
Margaret C. Tyler, MA, MSW
Research Assistant
Peter C. Damiano, DDS, MPH
Professor and Director
Elizabeth T. Momany, PhD
Assistant Research Scientist
February, 2006
This study was supported by the Iowa Department of Human Services and the US 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.
This report presents the results of a study of how Iowa Medicaid managed care enrollees rated
the health plans in which they were enrolled during 2005. 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.
The foundation for the survey instrument is the Consumer Assessment of Health Plans Survey
(CAHPS), which is part of a national effort to develop a standardized 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 reporting format 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 a part of the CAHPS
team. The core CAHPS survey instrument was modified to include additional questions about
access to care, dental care and how 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
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.
The 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 for creating an environment conducive to conducting this evaluation.
Ron Hays, PhD, and Julie Brown, PhD, of RAND provided excellent technical assistance
regarding the development and analysis of the latest version of the CAHPS instrument used in
this study.
Lisa Werner and staff at the University of Iowa Center for Law, Health Policy and Disability
Center conducted the telephone follow-up calls for the enrollee survey in a professional and
efficient manner.
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 in this research. David
Svoboda, a University of Iowa student research assistant, contributed excellent research support
throughout the project.
Results of the 2005 Survey of Iowa
Medicaid Managed Care Enrollees
As part of the ongoing quality assurance activities of Iowa’s Medicaid Managed Care Program,
the Iowa Department of Human Services contracted with researchers at the University of Iowa
Public Policy Center to carry out a survey of adults and children enrolled in the program. As of
February 1, 2005, the State of Iowa maintained a contract with only one private managed care
company, Coventry Health Care, to provide payment for Medicaid health care services. The
Coventry health plan was available in two counties, Black Hawk and Butler. Medicaid Managed
Care enrollees in the rest of the state were covered by the state’s own primary care case
management (PCCM) program, MediPASS.
Random samples of adult and child enrollees were drawn from each of the two health plans
from Medicaid enrollment data current as of March 1, 2005. The samples were comprised of
1,600 children (800 each from MediPASS and Coventry) and 1,284 adults (800 from MediPASS
and 484 from Coventry).
The 2005 survey questionnaire was developed in collaboration with the CAHPS team at RAND.
This year’s survey was part of the piloting of the most recent version of the CAHPS survey
(CAHPS® 4.0H) that was in the final stages of development at the time this instrument was
being developed. It included a number of items from the CAHPS® 4.0 Plan and the CAHPS®
4.0H (HEDIS) questionnaires, as well as other questions addressing respondents’ perceptions of
their access to medical, dental and behavioral health care, and the quality of their care and their
health plans. Respondents also provided demographic information and reported on current
health status and chronic health conditions. The CAHPS® 4.0H instrument retains much of the
content of earlier versions. However, it is designed to obtain more detailed and specific
information regarding patients’ interactions and experiences with their primary care providers.
Survey instrument
The 2005 Survey of Iowa Medicaid Enrollees included items about the following.
• Perceived access to and utilization of health care services, including:
− Primary and specialty medical care
− Dental care
• Behavioral and emotional health care
• Perceptions of health care delivery, including:
− Ratings of overall care, doctors, and specialists
− Communication with personal doctor
− Preventive counseling or guidance
− Treatment by office staff
• Perceptions of the health care plan, including:
− Overall rating of the health plan
− Customer service experiences
− Experience obtaining information about the plan and how it works
• Enrollees’ current health status, including:
− General ratings of current physical, dental and mental health
− Screening for special health care needs
− Checklist of chronic health conditions
Data were tabulated and bivariate analyses (i.e., chi-square, t-test and nonparametric tests for
group differences) were conducted using Stata version 9. CAHPS® ratings and reports were
analyzed using the SAS macro developed by the CAHPS® team. The CAHPS® 3.5 program tests
for differences between health plans using case mix adjusters such as age, education and health
status.
This report provides a summary of findings from the 2005 survey. Differences between plans
and comparisons of Iowa’s results with available national figures are noted where applicable.
Child Survey Results
Response rate
Responses were received for 830 children (52%).
Demographics of 830 child enrollees
• 48% female
• Average age: 7 years
• Race/ethnicity: 80% Caucasian, 19% African American, 6% Latino or Hispanic, 2%
Asian,
2% American Indian, 0.2% Native Hawaiian or Pacific Islander, and 3% Other
• In school or daycare: 75%
• Primary language other than English: 3%
Children’s health status
• Global health rating: 47% excellent, 37% very good, 14% good, 2% fair/poor
• Children with a special health care need: 27% met screening criteria
• Five most common chronic physical health conditions (lasting 3 months or longer):
− Asthma: 12%
− Allergies or sinus problems: 12%
− Skin problems: 9%
− Dental, tooth or mouth problems: 8%
− Frequent ear infections: 7%
• Five most common chronic behavioral and emotional health conditions (lasting 3 months
or longer):
− Attention problems: 10%
− Learning disabilities: 5%
− Emotional problems (other than anxiety or depression): 4%
− Depression: 4%
− Anxiety: 3%
• Need or wear glasses or contacts: 20%
Access to care and use of services
In the last six months…
• Easy to get needed health care for child: 54% always, 28% usually, 19%
sometimes/never
• Care provided quickly: 65% always, 24% usually, 10% sometimes/never
• 5% of children had an unmet need for health care in the last six months
− Most common reasons: trouble finding a doctor who accepts Medicaid (14%), needed
service
not covered by Medicaid (11%)
Personal doctor
• Have a personal doctor (PCP): 92%
− 82% of these visited their personal doctor at least once in the last 6 months
• 75% had made an appointment for non-acute health care for their child
Specialty care
• 21% of all children visited a specialist in the last 6 months
− Of those who saw a specialist, 32% saw more than one
• 4% had an unmet need for specialty care in the last 6 months
• 22% of parents had tried to make an appointment for their child with a specialist
− Of these, 53% said it was always easy to get specialist appointments
Preventive care
• Last preventive health care visit: 43% within last 6 months, 76% within the last year
• Unmet need for preventive care: 2% of all children
Emergency room care
• 26% of children had been treated in an emergency room at least once in the previous 6 months
Use of health care services
• 47% of children had needed care for an illness, injury or condition
• 83% of children had at least one outpatient visit in the last six months
• 38% of all children had three or more outpatient visits
• 56% of respondents had called a doctor’s office or clinic during office hours for help or
advice
regarding their child
− 69% of these always got needed help when they called
• 16% called the doctor’s office for help or advice after regular hours
− 69% of these always got the help they needed
Behavioral and emotional health care
In the last six months…
• 13% of children needed treatment or counseling for a mental or emotional health
problem
− 80% of children who needed care received at least some mental health care
Children who received mental health care were helped:
“a lot” (41%) “somewhat” (32%), a little (19%), and
not at all (9%)
− 15% reported an unmet need for mental health care
Prescription medication
In the last six months…
• 60% of children needed prescription medication
− Of these, 83% reported they were always able to get this medicine through the child’s
Medicaid plan; 5% sometimes or never could
− 9% reported an unmet need for prescription medicine
Dental care
Among all children…
• 35% needed dental care in the last 6 months
− Type of care needed: 80% checkup/cleaning, 8% emergency, 48% other treatment
(e.g., fillings)
− 21% had an unmet need for dental care in the last 6 months
Most common reason: could not find a dentist who accepts Medicaid (90%)
Of children age 3 and older…
• 76% saw a dentist in the last year
• 8% had never been to a dentist
• 90% were reported to have a single source of dental care
Quality of children’s health care
Care delivery
• Average overall rating of child’s health care: 8.5 on 0-10 scale
− 0-4: 3%, 5-7: 18%, 8-9: 37%, 10: 42 %
• Average overall rating of child’s personal doctor: 9.0 on 0-10 scale
− 0-4: 2%, 5-7: 12%, 8-9: 36%, 10: 50%
− Doctor communicates well: 75% always, 16% usually, 9% sometimes/never
− Doctor talks with parent about health promotion and prevention: 59%
− Doctor gives clear treatment instructions: 81% always, 14% usually, 5%
sometimes/never
− Would definitely recommend child’s personal doctor: 70%
− Office staff courteous and helpful: 71% always, 19 % usually, 9% sometimes/never
Coventry higher than MediPASS
• Average overall rating of child’s specialist: 8.3 on 0-10 scale, 37% rated specialist a 10, 0-
4: 7% , 5-7: 17%, 8-9: 40 %, 10: 37%
− Would definitely recommend the specialist: 57%
Health plan
• Average rating of health plan: 8.4 out of 10
− 0-4: 4% , 5-7: 21%, 8-9: 38%, 10: 38%
− Average MediPASS plan rating was significantly higher than Coventry (8.5 vs. 8.2)
− 51% said they would definitely recommend their child’s health plan, while another
35% said they probably would
• 69% of those who tried to get care for their child through their health plan said it was
“always” easy to get the care they wanted
• 8% tried to find a new Medicaid-participating personal doctor for child in last 6 months
− Of these, 36% had a problem finding a personal doctor they liked who was part of
their child’s health plan
• 24% reported needing health plan approval for the child’s care, tests or treatment in the
last 6 months
− Of these, 38% said it was “always” easy to get this approval
• 45% were aware of the Medicaid helpline
− 11% had called the helpline in the last 6 months
− Of those who called, 42% said they always got the help they wanted
• 9% had tried to find information about how their plan works through written materials,
phone calls or the internet
− Of these, 28% were always able to find the information they needed
− Most helpful sources: written plan materials (25%), DHS caseworkers (25%) and the
Medicaid helpline (20%)
• 17% had received paperwork from their health plan
− Of these, 36% said the forms were always easy to fill out
Adult Survey Results
Response rate
Responses were received for 597 adults (47%).
Demographics
• 87% female
• Average age: 30.5 years
• Race/ethnicity: 83% Caucasian, 13% African American, 5% Latino or Hispanic, 2%
American Indian or Alaskan Native, less than 1% each: Asian, Native Hawaiian or
Pacific Islander, and “other”
• Completed high school or GED: 84%
• Some college or 2-year degree: 38.3%
• Completed college: 5%
Health status
• Global health rating: 43% excellent or very good, 39% good, 18% fair to poor
• Adults with a chronic health condition: 46% met screening criteria
• Five most common chronic physical conditions (lasting three months or longer)
− Allergies or sinus problems: 26%
− Back or neck problems: 23%
− Migraine headaches: 20%
− Dental, tooth or mouth problems: 16%
Somewhat more common in MediPASS than Coventry (185 vs. 12%, p=.051)
− Asthma: 15%
• Most common chronic behavioral or emotional conditions (lasting three months or longer)
− Depression: 30%
− Anxiety: 20%
− Other emotional problems: 8%
Access to care and use of services
• Easy to get needed care: 42% always, 35% usually, 24% sometimes/never
• Got care quickly: 52% always, 31% usually, 16% sometimes/never
• 13% of adults had an unmet need for health care in the last six months
− Most common reasons: needed service not covered by Medicaid (46%), trouble
finding a doctor who accepts Medicaid (28%), distance or transportation problems
(26%)
Personal doctor
• 90% of adult respondents had a personal doctor
− 47% had seen the same personal doctor for at least 3 years
• 86% had visited their personal doctor at least once in the last 6 months
• 62% had called their personal doctor’s office during regular hours for help or advice
− 52% of these always got needed help when they called
Preventive care
• 32% had received preventive health care within the last 6 months, 60% within the last
year
• 7% had an unmet need for preventive care in the last 6 months
Specialty care
• 35% of adults had tried to make an appointment for specialty care
• 33% visited a specialist doctor
− Of these, 36% received care from 2 or more different specialists
• 12% had an unmet need for specialty care
Emergency room care
• 39% of adults had been treated in an emergency room at least once in the last 6 months
Use of health care services
• 82% had made an appointment for routine health care
• 54% of adults had needed care for an illness, injury or condition
• 88% of adults had at least one outpatient visit
• 41% of all adults had three or more outpatient visits
Behavioral and Emotional Health Care
• Self-rated mental health status: 50% excellent/very good, 30% good, 20% fair/poor
In the last six months…
• 25% of adults needed behavioral/emotional health care
− 83% of these received behavioral/emotional care
Adults who received mental health care were helped: a lot (44%), somewhat (31%)
• 20% of those who needed mental health care were stopped from getting it at some point
in the last 6 months
− More likely in MediPASS than in Coventry
Prescription medication
In the last six months…
• 79% of adults needed a new prescription medication or a refill
• Of these, 32% reported an unmet need for prescription medicine
Dental care
• 44% needed dental care in the last 6 months
− Of those who felt they needed dental care:
Care needed: 67% checkup/cleaning, 21% emergency, 60% other treatment (e.g.,
fillings)
Unmet need for dental care: 31%
– Common reasons: Could not find a dentist who accepts Medicaid (54%),
needed service not covered by Medicaid (40%), could not afford it (36%)
• Self-rating of dental health: 37% excellent/very good, 33% good, 30% fair/poor
− Dental health was rated significantly worse than physical health (30% fair/poor vs.
18% fair/poor)
• Last dental checkup: 51% within the last year, 27% over 2 years ago
• Dental care seeking: 37% visit the dentist regularly (at least once a year), 28% only go
“when they have a problem”
• 72% reported a single source of dental care
• Average rating of dental care: 7.2 out of 10
− 0-4: 15%, 5-7: %, 8-9: % 10: 26% 10
− Significantly worse than rating of health care
Quality of health care delivery
• Average rating of all health care: 8.0 out of 10 (CAHPS® 4.0H)
− 0-4: 6%, 5-7: 27%, 8-9 36%, 10: 30%
• Average rating of personal doctor: 8.3 out of 10, 0-4: 4%, 5-7: 18%, 8-9: 36%, 10: 42%
Coventry had significantly higher personal doctor ratings than MediPASS
− 64% would definitely recommend their personal doctor, another 22% probably would
− Personal doctor communicates well: 71% always, 20% usually, 9% sometimes/never
− Personal doctor gives clear instructions: 69% always, 20% usually, 10%
sometimes/never
− Personal doctor talked about prevention: 78%
− Personal doctor’s office staff is helpful and courteous: 56% always, 31% usually, 14%
sometimes/never
Coventry scored better than MediPASS on this composite
• Average rating of specialist: 8.1 out of 10, 40% gave a rating of 10
− 58% would definitely recommend the specialist they saw most often, another 23%
probably would
Quality of health plan
• Overall rating of health plan: 7.8 out of 10 (CAHPS® 4.0H)
− 0-4: 8%, 5-7: 26%, 8-9: 38%, 10: 28%
• 47% would definitely recommend their Medicaid health plan, and another 34% probably
would
• 58% tried to get care, tests or treatment through their Medicaid health plan in the last 6
months
− 54% of these said it was always easy to get this care, 39% said it usually was
• Information and paperwork (CAHPS® 4.0H)
− How often it was easy to get information and do paperwork for the health plan:
35% always, 27% usually, 38% sometimes/never
− 49% were aware of the Medicaid helpline
17% of these had called for information or help
– 30% always got the help they wanted, 20% usually did
Coventry enrollees were more likely to know about the helpline
− 12% had tried to find information about how their plan works
22% were always able to find information they needed, 25% usually were
Most helpful information sources: Medicaid helpline (19%), DHS caseworker
(19%), others in same plan (19%), and written plan materials (15%)
− 24% had received paperwork from their health plans in the last 6 months
More likely in MediPASS
40% said it was always easy to do the paperwork, another 40% said it usually was
Readers who would like to see the tabulated results for each of the questionnaire items are
directed to the appendices. Results from the 2005 Child Medicaid Survey are located in
Appendix A, while Appendix B contains results from the Adult Medicaid Survey. Descriptions
of the CAHPS® composite scales and the chronic condition screener are presented in Appendix C.
Introduction and Survey Methodology
As part of the ongoing quality assurance activities of Iowa’s Medicaid Managed Care Program,
the Iowa Department of Human Services contracted with researchers at the University of Iowa
Public Policy Center to carry out a survey of adults and children enrolled the program. As of
February 1, 2005, the State of Iowa maintained a contract with only one private managed care
company, Coventry Health Care, to provide payment for Medicaid health care services. The
Coventry health plan was available in two counties, Black Hawk and Butler. Medicaid Managed
Care enrollees in the rest of the state were covered by the state’s own primary care case
management (PCCM) program, MediPASS. Results from the 2005 survey are presented and
summarized here. They include data on enrollees’ current health status, perceived need for
health services, and access to and use of medical, dental, and mental health care. Respondents
also reported on how they obtain needed information about their health plans and their overall
rating of their care, their doctors and their plans.
Figure 1-1. Medicaid managed care plans by county, May 2005
(Click to view full size image)
Survey Methodology
The 2005 Survey of Iowa Medicaid Managed Care Enrollees was conducted during the spring
and summer of 2005 using a mixed-mode mail and telephone methodology. Questionnaires
were mailed to plan-stratified random samples of Medicaid enrollees who had been in their
current plan for at least the previous six months. Random samples of adult and child enrollees
were drawn from each of the two health plans from Medicaid enrollment data current as of
March 1, 2005. Only one person was selected per household to reduce the relatedness of the
responses and respondent burden. The samples were comprised of 1,600 children (800 each
from MediPASS and Coventry) and 1,284 adults (800 from MediPASS and 484 from Coventry).
The number of adults in Coventry was smaller because only persons from only 1,284
households were enrolled in Coventry, thus there were only 484 adults left after the child
sample was selected.
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 initial mailing was sent to 1,285 adult and 1,600 child enrollees,
followed by a reminder postcard ten days later. A second survey packet was sent to nonrespondents
two weeks following the reminder card mailing.
In an effort to maximize response rates for the mailed survey, both a premium and an incentive
were used during the first mailing. Each survey packet included a 20-minute long-distance
phone card (a $1.50 value), which the recipient could use whether or not he or she chose to fill
out the survey. In addition, ID code numbers of respondents who completed and returned the
questionnaire within the first two weeks of the study were entered into a random drawing for
one of three $100 Wal-Mart gift cards. The three winners were contacted by phone and the
cards were mailed to them in October, 2005.
The Public Policy Center contracted with the University of Iowa’s Center for Law, Health Policy
and Disability to conduct telephone surveys with enrollees who had not responded to either of
the two mailings. The telephone interview script was essentially identical to the mailed survey.
Overall, the telephone survey accounted for 16% of the total number of completed surveys.
Survey data were obtained for 830 children and 597 adults, for unadjusted response rates of
52% for children and 46% for adults. Final response rates were 52% for the child survey and
47% for the adult survey (Table 1-1).
Description of the Survey Instrument
The survey instrument used in this study was based on the most recent version of the
Consumer Assessment of Health Plan Study (CAHPS®) 4.0H, available as of December, 2004
(see Appendix C for details about the CAHPS Survey). The use of CAHPS in Iowa is part of a
national demonstration of the instrument, an effort to develop and implement standardized
measures for assessing the quality of health plans from the consumer perspective. The
instrument also included items from National Health Interview Survey (NHIS). The Special
Health Care Needs screening instrument was developed by the Child and Adolescent Health
Measurement Initiative (CAHMI). To better define the types of chronic conditions experienced
by children and adults in Medicaid, we also included checklists of chronic physical and mental
health conditions.
The 2005 Survey of Iowa Medicaid Enrollees included items about the following.
• Enrollees’ current health status, including:
− General ratings of current physical, dental and mental health
− Special health care needs
− Chronic physical or mental health conditions
• Perceived access to and use of health services, including:
− Personal doctors or primary care providers
− Medical specialists
− Dental care
− Behavioral and emotional health care
• Perceptions of health care delivery, including:
− Ratings of overall care, personal doctors, and specialists
− Communication with personal doctors
− Receipt of preventive counseling or guidance
− Treatment by office staff
• Perceptions of the health care plan, including:
− Overall rating of the health plan
− Customer service experiences
− Experience getting information about the plan
Data were tabulated and bivariate analyses (i.e., chi-square, t-test and nonparametric tests for
group differences) were conducted using Stata version 9 for the Macintosh. CAHPS® 4.0 ratings
and CAHPS® 3.0 and 4.0H reports were analyzed with a SAS macro program specifically
developed for this purpose by the CAHPS® team. This program generates CAHPS® results
adjusted for case-mix variables such as age, education and health status. More detail about the
CAHPS® data is presented in Appendix E. The macro and accompanying programs and
documentation are available for download from the CAHPS® Survey Users Network web site.
This report is intended to provide a summary of findings from the 2005 survey. Differences
between plans and comparisons with findings from the 2003 survey are noted where available
and applicable.
Child Survey Results
The following is a summary of results from the 2005 Survey of Iowa Medicaid Enrollees: Child
Survey. Responses to each item in the questionnaire are in Appendix A.
Demographics
Overall, boys and girls were roughly equally represented in the survey responses; however,
Coventry had proportionally more girls than MediPASS (Table 2-1). Overall, nearly 80% of
child enrollees were Caucasian. Coventry had a significantly higher proportion of African
American children than MediPASS. Children ranged in age from 6 months to 18 years, with an
average of 7 years. Children in Coventry were slightly younger (6.6 vs. 7.4 years).
The vast majority of respondents to the child survey were female. Eighty-five percent of all
respondents were the child’s mother, and 5% were the child’s father (Table 2-2). One out of five
was under age 25; three out of five were under 35. Over half of the children (56%) had been in
their current Medicaid health plan for two years or more.
Children’s Health Status
Children’s health status was evaluated in several ways: (1) using a global rating scale (excellent
to poor), (2) using the special health care needs screening instrument, and (3) asking about any
chronic health conditions that have lasted for at least three months.
Global health rating
Respondents rated their child’s current health status on a one-to-five scale where 1 = excellent
and 5 = poor health (Table 2-3). Nearly half were in excellent health, while 8 out of 10 were in
very good or excellent health.
Special health care needs
Children and youth were classified as having a special health care need (CYSHCN) based on a
series of 14 screening questions. Children met criteria as CYSHCN if their parents indicated that
one of the conditions listed in Table 2-4 was the result of a health condition that had lasted at
least 12 months. Based on this instrument, 27% of children in this survey had special care needs.
This is similar to the 2003 figure of 25%.
Chronic health conditions
Respondents were given a list of chronic health conditions that can affect children and were
asked to identify which, if any, their child had experienced for three months or more. Forty-five
percent indicated that the child had at least one chronic physical health condition, while 19%
had a behavioral or emotional health concern. The most common chronic physical conditions,
affecting between seven and 12 percent of children, were asthma, allergies, skin problems, ear
infections and dental problems (Table 2-5). Twenty percent of all children needed or wore
eyeglasses or contact lenses. Children in Coventry were significantly more likely than those in
MediPASS to suffer from chronic skin problems (11% vs. 7%), while those in MediPASS were
more likely to need corrective lenses (25% vs. 14%).
1 Child and Adolescent Health Measurement Initiative, January 2000.
Nineteen percent of all children were reported to have at least one behavioral or emotional
health condition lasting three months or more. Attention problems were the most common,
affecting 10% of all children and half of those with a behavioral or emotional condition (Table
2-6).
Access to Care and Use of Services
Two of the CAHPS® 4.0H composites, getting needed care and getting care quickly, are general
or global measures of access to care. Getting needed care reflects the parent’s report of how
often it was easy to get care for the child, get approval for care from the plan, and make
appointments with specialists if needed. Over half said it was always easy to get health care for
their child, while another 28% said it usually was (Table 2-7). Scores for Coventry and
MediPASS were not significantly different from each other.
Half (51%) tried to get care for their child through the child’s health plan. Of these, 69% of those
who tried to get care for their child through their health plan said it was always easy to get the
care they wanted. Nearly one quarter (24%) reported needing health plan approval for the
child’s care, tests or treatment in the last 6 months. Of these, 38% said it was always easy to get
this approval.
The CAHPS® 4.0H getting care quickly composite combines responses to items regarding phone
calls to the personal doctor’s office and getting acute care and routine appointments as soon as
wanted. Nearly two thirds reported that their child always received needed care quickly, while
another one fourth usually did (Table 2-8). Again, the two health plans had very similar
distributions on this measure.
Ninety-two percent of children were reported to have a personal doctor (Table 2-9). Most (81%)
had seen the same doctor for at least a year. Over three quarters (79%) had a personal doctor
visit at least once in the previous six months.
Over 80% of respondents who had spoken with the doctor about health concerns regarding the
child said the doctor always gave clear treatment instructions. Nearly 60% indicated that their
child’s personal doctor talked with them about specific ways to prevent illness or injury and
improve the child’s health, such as wearing helmets, using car seats or supervising eating
habits. Respondents from Coventry were more significantly likely than those from MediPASS to
report getting such prevention advice from their child’s doctor (65% vs. 55%, χ2(1)=6.98,
p=.008).
Forty-three percent of respondents had called their child’s personal doctor’s office during
regular hours for help or advice. Nearly 70% said they always got the help they needed when
they called during regular hours, while another 23% usually did. Sixteen percent had called the
office after regular hours; of these 64% always and 23% usually got the help they needed.
Delays in the start of appointments caused by having to wait in the waiting room and/or exam
room are the subject of a new composite in CAHPS® 4.0 (Table 2-10). About 35% of respondents
always had brief waiting times, whereas a quarter (24%) never or only sometimes waited less than
15 minutes.
Routine and preventive health care
Sixty-five percent of respondents had made an appointment for their child to get routine health
care (such as vaccinations or checkups) in the previous six months. Nearly three-fifths (58%) of
those who made appointments said they always got these appointments as soon as they wanted,
and another 30% usually did. Twelve percent said they sometimes or never got routine
appointments as soon as they wanted.
Over three quarters (76%) reported that their child had had some type of preventive visit during
the previous year. Another 16% had a preventive visit between one and two years ago, and 7%
more than two years ago. Two percent indicated their child had needed a preventive visit
within the last six months but was unable to get one.
Specialty care
Twenty-one percent of all children had seen a specialist in the last 6 months. Of these, over twothirds
(68%) saw only one specialty doctor, while another 22% saw two different specialists.
About 1 out of 5 respondents (22%) had tried to make an appointment with a specialist in the
previous six months. Over half (53%) said it was always easy to get an appointment, and another
25% said it was usually easy.
Illness or injury care
Nearly half (47%) of children in Medicaid had needed care right away for an illness or injury in
the six months prior to the survey. Nearly three quarters (72%) of these respondents said their
child always got this care as soon as they wanted, and another 21% said they usually did. Seven
percent never or only sometimes got acute care as soon as they wanted it. In 78% of cases, acute
care was provided the same day, 14% waited one day, and 7% waited two days.
Office visits and emergency room visits
Eighty-four percent of children had at least one visit to a clinic or doctor’s office in the last six
months. Of those who had an office visit, over half (54%) had only one or two visits, while 15%
had five or more.
About one fourth of the respondents (26%) indicated their child had visited a hospital
emergency room (ER) in the last six months. Of those who used an ER, over two thirds (68%)
had only one visit, another 22% had two, 6% had three and 4% had four or more visits.
Unmet need for health care
Overall, 4.6% reported that their child had experienced an unmet need for medical care (i.e., had
been stopped from receiving care) at some point in the previous six months. This rate did not
differ significantly by plan.
Behavioral and emotional health care
A little over half (51%) said their child’s current emotional health was excellent, and another
26% rated it as very good. Six percent were in poor or only fair emotional health. Children’s
emotional health was rated significantly worse than their general health (t[815]=3.20, p=.0014).
Thirteen percent of respondents indicated that their child had needed behavioral or emotional
health care in the last six months. Of these, 80% had received treatment or counseling for mental
health problems in the last six months. Most believed the child received at least some benefit
from the mental health care. Forty-one percent thought the counseling or treatment helped a lot,
32% somewhat, 19% a little and 9% not at all. Ten percent of the children who needed mental
health care were unable to receive it at some point in the previous six months.
Prescription medications
Sixty percent of children in Medicaid needed a prescription medication at some point in the six
months prior to the survey. Of these, 83% said they were always able to get the child’s
prescriptions through his or her Medicaid health plan, and another 13% usually were. Nine
percent had been unable to get a needed prescription at least once during the last six months.
Dental care
Ratings of children’s dental health were significantly worse than ratings of their general
physical health(t[754]=-10.27, p=.0000). Only 30% thought their child had excellent dental
health, compared to 47% with excellent physical health Eighty-eight percent of all children were
reported to have a usual source of dental care. Sixty-one percent had a dental checkup within
the last year. More than a quarter (27%) had never been to a dentist; however, 77% of these were
under age 3.
The remaining dental questions were only analyzed for children age 3 and over. While many
professional dental associations recommend that children see a dentist earlier, the utilization of
dental services among Medicaid-enrolled children under age 3 is so low that it is more relevant
from a program evaluation perspective to focus the evaluation of access and use of dental
services for children age 3 and over. Among children age three or older at the time of the
survey, 90% had a usual source of dental care (Table 2-11). Overall, 44% had needed some type
of dental care within the previous six months. Of these, more than 1 out of 5 (21%) had been
unable to get the care they needed. There were often several different reasons for this, but the
most commonly cited reason for unmet need was the inability to find a dentist who accepts
Medicaid (90%). Other common problems with access to dental care included needing care not
covered by Medicaid (73%), other problems getting appointments (74%), and cost (70%).
Children age 3 and older were more likely to have unmet dental needs (21%) than medical (5%)
or mental health (10%) needs. Children in MediPASS were more likely to have an unmet dental
care need than those in Coventry.
About three quarters of children age three or older (76%) had a dental visit within the last year
and another 12% last saw a dentist between one and two years ago. Eight percent of children
age three and older had never been to a dentist.
Quality of Health Care Delivery
Respondents rated overall the quality of their child’s care and doctors using the CAHPS® 0-10
scale. They also reported on experiences and interactions with the child’s doctors and plan.
Each of the CAHPS® composite scales are comprised of a combination of two or more items
reflecting these experiences and interactions.
The average rating on the 0-10 scale for overall health care was 8, with over 40% rating care a 10.
The two health plans had very similar distributions on this score (Table 2-12).
Among those children who visited their personal doctor in the last 6 months, the average
personal doctor rating was 9.0 out of 10 (Table 2-13). Half the respondents in each plan gave
their child’s personal doctor a rating of 10.
The “doctor communication” composite represents how often the respondent felt the child’s
personal doctor listened carefully, spent enough time with the child, showed respect for the
parent and provided understandable explanations for the parent and child. Overall, three
quarters of respondents felt their child’s personal doctor always communicated well. Coventry
had significantly higher scores on this composite than MediPASS (Table 2-14).
Over 70% reported that the staff in their child’s personal doctor’s office were always helpful and
treated them with respect and courtesy, while 9% said they never or only sometimes had this
experience (Table 2-15). Respondents enrolled in Coventry gave significantly higher scores on
this measure than those in MediPASS.
Respondents were asked if they would recommend their child’s personal doctor to friends or
relatives with children. Seven out of 10 said they would definitely recommend him or her, and
another 21% probably would. Only 3% would not recommend their child’s doctor.
Specialty care
If the child had seen a specialist within the previous six months, the respondent rated the
specialist their child seen most often. Average rating of the specialist the child saw most often
was 8.3 on 0-10 scale. Thirty-seven percent of those who rated a specialist gave him or her a 10
(Table 2-16).
When asked if they would recommend this same specialist to others with children, 57% said
they definitely would, while another quarter probably would. On the other hand, ten percent
would not recommend this specialist.
Quality of Health Plan
Overall, respondents rated their child health plan an average of 8.4 on the 0-10 scale, with
nearly 40% rating it a 10 (Table 2-17). MediPASS had significantly higher mean scores than
Coventry.
Plan information and paperwork
The CAHPS® 4.0H information and paperwork composite reflects how often the respondent
thought it was easy to get plan information and fill out forms, as well as the quality of the tollfree
Medicaid help line (Table 2-18).
About one fourth of all respondent had experience trying to find information or completing
paperwork regarding their child’s health plan in the previous six months. Of these, nearly 40%
said they always had an easy time doing these things, while over one quarter never or only
sometimes thought these were easy. Average plan scores were not significantly different.
Less than half (45%) of respondents were aware of the toll-free Medicaid helpline. Of these, 11%
had called the helpline in the last 6 months. Of those who called, 42% said they always got the
help they wanted.
Nine percent had tried to find information about how their plan works through written
materials, phone calls or the internet. Of these, 28% were always able to find the information
they needed. Written plan materials (25%), DHS caseworkers (25%) and the Medicaid helpline
(20%) were most frequently cited as the best sources of information. Fewer than one out of five
respondents (17%) had needed to complete paperwork for their child’s health plan within the
previous six months. Of these, 36% said the forms were always easy to fill out.
Over half (51%) said they would definitely recommend their child’s health plan to friends or
relatives who have children, while another 35% said they probably would. Only four percent
would not recommend their child’s health plan. Respondents with children in MediPASS were
more likely to say they would definitely recommend the child’s health plan (t[822]= -2.34,
p=.019).
Adult Survey Results
The following is a summary of results from the 2005 Survey of Iowa Medicaid Enrollees: Adult
Survey. Responses to each item in the questionnaire are in Appendix B.
Demographics
A total of 597 adult Medicaid enrollees completed the 2005 survey (Table 3-1). Respondents
ranged in age from 18 to 55, and were primarily female and Caucasian. Eighty-four percent had
at least a high school diploma, but only 5 percent had a bachelor’s level degree or higher. Over
half (56%) had been in their current health plan for two years or longer.
Adults’ Health Status
Current health status of the adults was measured in several ways: (1) a five-level global rating
scale (excellent to poor), (2) the Special Health Care Needs screening instrument, and (3)
checklists of chronic health conditions—defined as conditions that had lasted or were expected
to last for at least three months. In addition, female respondents were asked whether they had
been pregnant or given birth within the previous six months, and if so, if they were currently
pregnant.
Global health rating
Respondents rated their overall health status on a one-to-five scale where 1 = excellent and 5 =
poor health (Table 3-2). Twelve percent rated their health as excellent, and 43% rated their
health as either very good or excellent. Nearly one fifth (18%) rated their health as only fair or
poor.
Chronic health condition
Adults are classified as having a chronic health condition based on a series of 14 screening
questions, similar to the CSHCN screening instrument. Chronic health needs criteria are met if
the respondent indicates that one of the conditions listed in Table 3-3 was the result of a health
condition lasting at least 12 months. Based on this instrument, 46% of adults in this survey had
chronic care needs. This is somewhat higher than the 40% identified in the 2003 survey.
Respondents were also given a list of chronic health conditions common among adults and
were asked to identify which, if any, they had experienced for three months or more. Sixty-two
percent reported at least one chronic physical health problem, while 39% had a chronic mental
health concern (Table 3-4). The five most common chronic physical conditions, affecting
between 15 and 26 percent of adults, were allergies or sinus problems, back or neck problems,
migraine headaches, dental problems, and asthma. In addition, three out of five respondents
needed or wore eyeglasses or contact lenses. MediPASS enrollees were more likely than those in
Coventry to have chronic oral health problems, while those in Coventry were more likely to
report diabetes. Coventry enrollees were also somewhat more likely to suffer from lung
problems, however this difference was not significant at the .05 level.
Nearly two in five (39%) adult respondents indicated they had at least one chronic behavioral or
emotional condition (Table 3-5). Depression and anxiety were the most common, affecting 30%
and 20% of all adults, respectively, and 76% and 51% of those with a behavioral or emotional
health condition.
Pregnancy
Twenty-one percent of female respondents had been pregnant or given birth in the previous six
months. Of these, 28% were pregnant at the time they completed the survey.
Access to Care and Use of Services
The two CAHPS® 4.0H general access to care composites measure how often respondents were
able to get needed care easily and quickly over the previous six months. Coventry and
MediPASS did not differ from each other on either of these measures. Forty-two percent in both
plans reported it was always easy to get the care they needed (Table 3-6).
Over half of adult enrollees in both Coventry and MediPASS said they had always gotten health
care quickly when they needed it, and another third (31%) usually did (Table 3-7).
Personal Doctor
Ninety percent of adult Medicaid respondents had a personal doctor. Most (79%) had seen the
same doctor for at least a year, while nearly half (47%) had seen the same doctor for three years
or more.
More than 4 out of 5 (85%) adult respondents had visited their personal doctor at least once in
the previous six months (Table 3-8). During these visits, 85% talked to their doctor about health
problems or symptoms, and 76% said the doctor spoke with them about prevention.
Of those who talked with their doctor about symptoms, 71% said he or she always gave clear
treatment instructions. Of the 85% who had a personal doctor visit, 76% said the doctor talked
with them about how to improve their health or prevent illness. Of those whose doctors talked
about this subject, 84% said the doctor usually or always talked about prevention.
Sixty-two percent had called their doctor’s office during regular hours in the last six months.
About half (52%) of those who called said they always got the help they needed, and another
third (33%) said they usually did.
A new composite introduced with CAHPS® 4.0H indicates how often respondents felt they had
reasonably brief (i.e., less than 15 minutes) waiting times in the clinic waiting room and in the
exam room prior to seeing their doctor. About a quarter always had short waiting times, while
30% never or only sometimes got to see their personal doctor without long waits (Table 3-9).
These did not differ by plan.
Routine and preventive health care
Eighty-two percent of adults had made an appointment for routine (non-acute) health care in
the previous six months. About half of those who had made appointments said they always got
these appointments as soon as they wanted, and another third usually did. Eighteen percent
said they sometimes or never got routine appointments as quickly as they wanted.
Sixty percent reported having a preventive visit such as a check-up, exam, mammogram or Pap
smear within the last twelve months. Another 27% had a preventive visit between one and three
years ago, while 11% had not had one in the last 3 years. Seven percent said they’d needed
preventive care within the last six months but were unable to get it.
Specialty care
Overall, a third of adult Medicaid respondents had seen a specialist in the last 6 months. Most
of those who did saw only one specialist (64%), while another 28% saw two different specialists.
Over a third (35%) had tried to make an appointment to see a specialist in the last 6 months. Of
these, 42% said it was always easy to get these appointments, a third (34%) said it was usually
easy. Nearly a quarter (24%) said it was sometimes or never easy to get specialist appointments.
Twelve percent said that at some point in the previous six months they had needed to see a
specialist but were unable to do so.
Illness or injury care
Over half (54%) of the adult respondents had needed care right away for an illness, injury or
condition in the last 6 months. Of these, two thirds reported getting in for illness or injury care
the same day, 17% waited one day, 12% waited 2 to 3 days, and 4% waited 4 to 7 days.
Office visits and emergency room visits
Eighty-eight percent of adults had at least one visit to a clinic or doctor’s office in the last six
months. Of those who did visit a doctor, 54% had only one or two visits, while 15% had five or
more.
Thirty-nine percent had visited a hospital emergency room (ER) in the previous six months. Of
those who used the ER, 68% had one visit, another 22% had two, 6% had three, while less than
4% had four or more visits.
Unmet need for health care
Overall, 13% had experienced unmet need for medical care (i.e., had been stopped from
receiving care, tests or treatment) at some point in the previous six months. The most common
reason for this (46%) was needing care not covered by Medicaid. Trouble finding doctors who
accept Medicaid was a problem for 28% of those with unmet needs, and distance or
transportation problems were a concern for 26%.
Behavioral and emotional health care
One out of five respondents felt their mental health was currently only fair or poor, while half
thought it was very good or excellent. Self-ratings of current mental or emotional health were
significantly better than physical health ratings (z=-3.17, p=.0002).
Twenty-five percent had needed behavioral or emotional health care in the last six months. Of
these, 83% did get counseling or other treatment. Seventy-five percent thought it helped
somewhat or a lot. One fifth of those who needed it had been unable to get mental health care at
some point.
Prescription medications
Seventy-nine percent of respondents had needed a prescription medication at some time in the
six months prior to the survey. Of these, 38% had an unmet need for prescription medicine
during this time.
Dental care
Self-rated dental health was significantly worse than physical health (z=-4.17, p=.0000). Only
14% rated their dental health excellent and 23% rated it very good. Nearly a third (30%) said their
dental health was fair or poor. Adult MediPASS enrollees reported significantly worse dental
health than their counterparts in Coventry (t=2.23, p=.0264).
Only half (51%) had a dental checkup in the last year, while 27% had not had one in over 2
years (Table 3-10). Only 37% said they visited the dentist regularly (i.e., at least once per year)
and 28% reported that they only go to the dentist when they have a problem.
Overall, 44% of adults reported needing some type of dental care within the previous six
months. Of these, two thirds (67%) needed routine care (cleaning and checkup), 21% needed
emergency dental care, and 60% needed other dental treatment such as fillings. Of those who
had needed it, 31% had been unable to get dental care at some point in the last six months. The
most common reason for this (54%) was the inability to find dentists who accept Medicaid.
Needing care not covered by Medicaid (40%) was another problem leading to unmet dental care
needs.
Care delivery
Respondents rated the overall quality of their care and their doctors using the CAHPS® 0-10
rating scale (Table 3-11). They also reported on their experiences interacting with their doctors.
Adult respondents rated their health care an average of 8 on the 0-10 scale. The two plans did
not have significantly different average scores.
The average rating for personal doctors was 8.3, with 42% rating him or her a 10 (Table 3-12).
Adults in Coventry rated their personal doctors significantly higher than those in MediPASS.
Respondents who had visited their personal doctor in the previous 6 months reported on how
well their doctor communicated with them. Seventy-one percent said their personal doctor
always communicated well (Table 3-13). The two health plans had similar distributions of
scores on this measure.
Respondents indicated how often the office staff at their personal doctor’s office or clinic were
as helpful and courteous as they expected them to be. This composite was included in CAHPS
3.0 but is not part of 4.0 or 4.0H. Based on this measure, adult Coventry enrollees reported
significantly better by office staff than did those in MediPASS (Table 3-14).
Nearly two thirds (64%) said they would definitely recommend their personal doctor, and
another 22% probably would. Although doctor ratings were higher in Coventry, respondents in
the two plans were equally likely to say they would recommend their doctor.
Specialists
The 33% of enrollees who saw a specialist in the previous 6 months were asked to rate the
specialist they saw most often. The average rating was 8.3, and 37% gave a rating of 10 (Table 3-
15). Average ratings were not significantly different between the two plans.
Over half (54%) would definitely recommend the specialist they saw most often, and another
25% probably would.
Quality of Health Plan
The average overall rating for the health plan as a whole was 7.8, with 28% rating it a 10. The
mean 0-10 ratings were not significantly different by plan (Table 3-16).
Overall, 58% reported that they tried to get health care through their Medicaid plan in the
previous 6 months. Of these, 54% of these said it was always easy to get the care they wanted,
while another 39% usually had an easy time getting care. Forty-one percent reported needing
health plan approval for care, tests or treatment in the last 6 months. Of these, 29% said it was
always easy to get approval from their health plan, and another 39% said it usually was.
Overall, about half (49%) the respondents knew about the Medicaid helpline. Coventry
enrollees were more likely than MediPASS enrollees to know about the helpline. Seventeen
percent of those who knew about it had called the helpline in the last 6 months.
Twelve percent had tried to find information about how their plan works through written
materials, phone calls or the Internet. Of these, 22% were always able to find the information
they needed (Table 3-17). Written plan materials (25%), DSH caseworkers (25%) and the
Medicaid helpline (20%) were most frequently cited as the most helpful sources of information.
Seventeen percent had needed to complete paperwork for their health plan. Of these, 36% said
the forms were always easy to fill out.
Nearly half (47%) said they would definitely recommend their health plan to friends or
relatives, while another 34% said they probably would. Those in MediPASS were significantly
more likely to say they would definitely recommend their health plan to others (t[591]=-3.45,
p=.0006).