Outcomes of care for Iowa Medicaidmanaged care enrollees
State Fiscal Year 2005
Final Report to the Iowa Department of Human Services
Elizabeth T. Momany, Ph.D
Assistant Research Scientist
Peter C. Damiano, DDS, MPH
Professor and Director
Knute D. Carter, BSc (Ma&CompSc) (Hons)
Graduate Research Assistant
Health Policy Research Program
Public Policy Center
The University of Iowa
July 1, 2006
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 or The University of Iowa.
Acknowledgments
The authors would like to thank Mr. Dennis Janssen, Bureau Chief Managed Care and Clinical Services, Iowa Medicaid Enterprise, Iowa Department of Human Services for his assistance with the completion of this research.
The University of Iowa Information Technology Services Computing Center provided expert support for the mainframe computer activities necessary to analyze the Medicaid claims, encounter, and enrollment files. The academic Computing Committee was also very generous in their allocation of mainframe computing time for this project.
Special thanks to our colleagues at the Public Policy Center. Professor David Forkenbrock, Director, who provides the valuable resources of the Center to us. A very special thank you to Kevin Sellers for his development and maintenance of the database used to house and analyze the data. Kathy Holeton, administrative assistant, Teresa Lopes, editor, David Svoboda, student research assistant, Cole Grolmus, student computer specialist, and Peggy Waters, secretary all provided valuable assistance to this research.
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Table of Contents
Acknowledgments...... i
Table of Contents...... iii
Figures...... v
Tables...... vii
Introduction...... 1
The study...... 1
The data...... 1
The population...... 2
The measures...... 3
The report...... 4
Well-child visits in the first 15 months of life...... 5
Well-child visits in the third, fourth, fifth, and sixth year of life...... 7
Annual dental visit...... 11
Children’s and adolescents’ access to primary care practitioners...... 14
Use of appropriate medications for people with asthma...... 17
Adult’s access to preventive/ambulatory health services...... 18
Prenatal and postpartum care...... 20
Comprehensive diabetes care...... 23
Appendix A: Summary of outcomes by managed care plan, SFY 2005...... 25
Appendix B: Summary of outcomes by managed care plan, SFY 2004...... 27
Appendix C: Summary of outcomes by managed care plan, SFY 2003...... 29
Appendix D: Technical specifications for outcome measures...... 31
Appendix E: Outcomes for children in the foster care program...... 35
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Figures
1.Map of enrollment options within the Medicaid program by county, SFY 2005...... 3
2.Percent of enrollees by number of months enrolled in Medicaid, SFY 2005...... 4
3.Proportion of children 3 years old with a well-child visit by Medicaid group and year,
SFYs 2003-2005...... 8
4.Proportion of children 4 years old with a well-child visit by Medicaid group and year,
SFYs 2003-2005...... 8
5.Proportion of children 5 years old with a well-child visit by Medicaid group and year,
SFYs 2003-2005...... 9
6.Proportion of children 6 years old with a well-child visit by Medicaid group and year,
SFYs 2003-2005...... 9
7.Proportion of children, adolescents and young adults with a dental visit by age group
and Medicaid group, SFY 2005...... 12
8.Proportion of adults with a preventive/ambulatory care visit by age group and
Medicaid group, SFY 2005...... 19
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Tables
1.Proportion of 15-month-old children with a well-child visit by number of
visits and group, SFYs 2003-2005...... 6
2.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Well-child visits in the
first 15 months of life...... 7
3.Number and percent of children who had a well-child visit by group and year...... 10
4.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Well-child visits in the
3rd, 4th, 5th, and 6th years of life...... 11
5.Percent of children, adolescents and young adults with an annual dental visit
by plan and year using previous HEDIS age categories, SFYs 2003-2005...... 13
6.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Annual dental visits....14
7.Children and adolescents’ access to primary care practitioners by group, SFY 2005...15
8.Children and adolescents’ access to primary care practitioners by year and plan,
SFYs 2003-2005...... 16
9.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Children and
adolescents’ access to primary care practitioners...... 16
10. Rate of persistent asthma by age and Medicaid group, SFY 2005...... 17
11.Use of appropriate medications for people with asthma, SFY 2005...... 18
12.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Use of appropriate
medications for people with asthma...... 18
13.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Adults access to
preventive/ambulatory health services...... 20
14.Rates of early prenatal care, SFYs 2003-2005...... 21
15.Rates of postnatal care, SFYs 2003-2005...... 21
16.Prenatal care rates by managed care plan and year...... 22
17.Postpartum care rates by managed care plan and year...... 22
18.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Prenatal and
postpartum care...... 23
19.Rates of Hemoglobin A1c testing in people 18-64 years old by managed care
plan and year...... 23
20.NCQA Medicaid HEDIS means, percentiles and rates, 2005: Comprehensive
diabetes care, Hemoglobin A1c testing...... 24
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Introduction
The study
The University of Iowa Public Policy Center (PPC) is under contract with the Iowa Department of Human Services (IDHS) to provide Health Plan Employer Data and Information Set (HEDIS) outcome measures for the Medicaid-enrolled population for State Fiscal Year (SFY) 2005 (July 1, 2004-June 30, 2005). HEDIS outcome measures are recommended by the Center for Medicare and Medicaid Services (CMS) as a means for states to provide consistent information to consumers, providers, and the government regarding access and utilization of health services. The recommended HEDIS measures are: Well-child visits in the first 15 months of life, well-child visits at 3, 4, 5, and 6 years of age, adult access to preventive/ambulatory care, children’s and adolescents’ access to primary care providers, early prenatal and postpartum care, comprehensive diabetes care, and use of appropriate medications for people with persistent asthma. In addition, the HEDIS measure for annual dental visits is calculated to inform policy makers as to whether adequate services are available.
HEDIS data is collected by the National Committee on Quality Assurance (NCQA) on a yearly basis from states and plans that provide managed care services to the Medicaid enrolled population throughout the country. This data allows us to determine how Medicaid enrollees within our state compare with other states and programs. Though NCQA does not compile all outcome measures every year, we include their results whenever possible. Currently, their web site provides a report of Medicaid means, percentiles and rates for Medicaid programs nationally for 2005, as well as and the accreditation targets for 2006. (Available at and
The data
The PPC receives Iowa administrative data directly from Noridian, the current fiscal agent housed within the Iowa Medicaid Enterprise (IME). Institutional, pharmaceutical, medical and dental claims adjudicated by the Medicaid program are received on a monthly basis. These claims reflect all institutional and medical services provided to MediPASS and fee-for-service (FFS) enrollees, as well as dental and pharmacy services for all Medicaid enrollees. Institutional claims reflect all services that occur in an institutional setting, including outpatient visits, and may contain up to 99 discreet lines of information for each occurrence (inpatient stay, emergency room visit, or outpatient visit). Up to nine diagnosis codes are allowed per claim. Medical and dental claims reflect services provided by physicians, dentists, physician assistants, home health care agencies, and a number of other provider types. These claims allow for 50 lines of discreet information related to each visit. Up to 4 diagnosis codes are allowed per claim, however, dentists are not required to provide diagnosis codes. Pharmaceutical claims reflect prescriptions filled and allow for information on only one prescription per claim. In the Medicaid program, each pharmacy claim (i.e., filled prescription) may provide only a one-month supply of medication. No diagnosis codes are given, though one code would be allowed.
Data regarding institutional and medical services provided to HMO enrollees are transmitted quarterly on an encounter basis. Encounters are listed individually, allowing for as many encounters or services per visit or stay as needed. Each encounter is allowed only two diagnosis codes. Institutional and medical encounters have essentially the same structure and contain much less information than claims.
Enrollment data are provided to the PPC on a periodic basis. Enrollment files contain current information on enrollees including demographics, Medicaid identification number, case number, and enrollment history for the past 24 months. Enrollment files include everyone who has a record in the Medicaid program. Even those who are not enrolled during the month that we request information will be included if they have been enrolled within the past 24 months. This allows us to build long-term enrollment datasets. Historical data is particularly important for outcomes research, which requires that we ascertain that enrollees are eligible for a specified time period.
The population
This report provides HEDIS rates for the population eligible for Medicaid managed care. Manage care has been available since 1989. The managed care options available to enrollees have varied over time. At one point, Medicaid enrollees could choose from MediPASS (the primary care gatekeeper program), John Deere HMO, Iowa Health Solutions HMO, and Coventry HMO. However, not all of these programs were available in all counties. At present, MediPASS and Coventry HMO are the only managed care options available for Medicaid enrollees.
The map in Figure 1 provides a visual guide to the counties in which MediPASS is available and indicates the two counties with Coventry HMO. For this report we have divided the population into five groups of enrollees: MediPASS, Coventry, fee-for-service (FFS), Iowa Health Solutions enrollees who switched to MediPASS (IHS to MediPASS), and Iowa Health Solutions enrollees who switched to fee-for-service (IHS to FFS). We have calculated rates for enrollees switching out of IHS to MediPASS or FFS to determine whether the period in which they switched programs made it so difficult to obtain care that outcomes measures were adversely affected. Figure 2 provides a graphic representation of the number of persons within each group by the number of months they were enrolled within the Medicaid program during SFY 2005. There are three groups: enrolled 1-6 months, enrolled 7-10 months, and enrolled 11-12 months. Over 50% of FFS enrollees were eligible for 6 months or less, while on average only about 20% of enrollees in the other groups were eligible for 6 months or less. At the other extreme, only 30% of enrollees in FFS were eligible for at least 11 months, while on average 60% of enrollees in the other groups were enrolled for this period of time. For the purposes of outcomes measurement, enrollees need to be enrolled for at least 11 months of the outcome measurement year. Though this varies across outcome measures, for the FFS group, the majority of enrollees are not included within the outcome analyses. Enrollees are included for all other groups. We are not clear how this bias may affect the measures, however, we should be mindful that the groups are not similar in length of enrollment.
Figure 1. Map of enrollment options within the Medicaid program by county, SFY 2005
The measures
The outcome measures used for this report are derived from the HEDIS 2005 outcome measures. For these measures, higher values are better. The maximum value for each measure is 100%, however, it is unrealistic to believe that we could achieve 100% for any population as we would always have to allow for an enrollee’s right to choose not to obtain health care services. Nevertheless, we can determine optimal performance targets. Optimal performance targets are values for the measures that may be realistically attained within a 3-5 year time frame given some type of intervention to increase service availability and use. To date the values for the measures have remained relatively stable or declined (though some changes have occurred due to programmatic shifts such as the termination of John Deere and Iowa Health Solutions as options), indicating that active intervention is required to maintain or improve the rates. Just informing enrollees of the services available to them and allowing providers to encourage compliance is not enough, in many cases, to improve the measure values.
Figure 2. Percent of enrollees by number of months enrolled in Medicaid, SFY 2005
NCQA provides a benchmarking report on the web as mentioned above. This report provides the average rate for all Medicaid plans that reported data and were audited for accreditation. In addition to the average, the rate for plans that fall into the 10th, 25th, 50th, 75th, and 90th percentile are provided. For example, if the rate at the 90th percentile is 65%, it indicates that 10% of the audited Medicaid plans had a rate higher than 65%. This allows us to estimate how our state Medicaid program is performing compared to others in the country.
The report
This report is organized according to the HEDIS measures used for outcomes analyses. We provide the outcomes related to children-only first, those related to both children and adults second, and those related to adults-only last. Within each measure, we offer an explanation of the enrolled population that comprises the denominator for the measure, an explanation of the enrolled population that comprises the numerator for the measure (always a subset of the denominator), an explanation of any methods that were used to modify the protocols from the original HEDIS specifications, the results for SFY 2005, 2004, and 2003, comparable rates from NCQA database (when available), and a discussion of the optimal performance targets for SFY 2006.
Though results are presented for the last three state fiscal years, the tables and figures providing results may have missing cells or data bars due to the changes in the managed care options available within the last three years. For example, we have included the FFS population for fiscal year 2005, but do not have results for this group for SFYs 2003 and 2004. Therefore, tables and figures will not reflect any results for this group in 2003 or 2004. Appendices A-C provide summary tables of outcome rates by Medicaid group. Appendix D provides the technical specifications that were used to determine the rates.
Well-child visits in the first 15 months of life
The measure
Rate
Seven rates are calculated to determine the percent of children who had 0, 1, 2, 3, 4, 5, and 6 or more well-child visits during their first 15 months of life.
Denominator
All children who turned 15 months of age during fiscal year 2005 and were enrolled in the Medicaid program for at least 14 of their first 15 months are included in the denominator.
Numerator
There are seven numerators for this measure that correspond to the number of children within the denominator who had 0, 1, 2, 3, 4, 5, and 6 or more well-child visits.
The results
The state EPSDT schedule indicates that infants should have a physical exam at 2-3 days, and at 1, 2, 4, 6, 9, 12 and 15 months. We would anticipate that within the claims data we will identify the 6 visits from 1-12 months, therefore providing justification for using 6 visits as the best outcome. We may have children with no well-child visits during this time, because the measure is not designed to identify the visit in the first 2-3 days at the hospital, and this may be the only visit children have. Table 1 presents the percent of children by number of well-child visits by Medicaid program for the last three fiscal years. These figures reflect an increase in the proportion of children who received at least 6 visits for Coventry over the past two years and a marked decrease in the proportion of children who received at least 6 visits for the MediPASS program. Both of these groups had an increase in the proportion of children who received no visits, with MediPASS having 12%, as compared to nearly no children in this category for SFYs 2003 and 2004. Though it is difficult to determine why this may have happened, particularly when the rates for the MediPASS program have been stable over the past few years, it may be related to the increased number of children who must be accommodated in the MediPASS program due to the termination of John Deere and IHS. Since MediPASS providers limit the number of Medicaid enrollees they will allow in their practice, it may be difficult for children to access a MediPASS provider in a timely manner. One indication that this may be happening is the proportion of children that have 4 or 5 visits in the first 15 months. During SFY 2003 and 2004, an average of 6.8% of children had four visits, while 10.7% had five visits. During SFY 2005 11% had four visits and 15% had five visits.
Table 1. Proportion of 15-month-old children with a well-child visit
by number of visits and group, SFYs 2003-2005
of visits / 0
n (%) / 1
n (%) / 2
n (%) / 3
n (%) / 4
n (%) / 5
n (%) / 6+
n (%) / Totals
Coventry
2005 / 5 / (2.1) / 9 / (3.8) / 10 / (4.3) / 21 / (9.0) / 34 / (14.5) / 51 / 104 / (44.4) / 234 (100)
2004 / 0 / (0.0) / 0 / (0.0) / 2 / (4.3) / 7 / (14.9) / 9 / (19.1) / 18 / (38.3) / 11 / (23.4) / 47 (100)
2003 / 0 / (0.0) / 1 / (1.1) / 2 / (2.2) / 9 / (9.7) / 27 / (29.0) / 23 / (24.7) / 31 / (33.3) / 93 (100)
MediPASS
2005 / 664 / (11.9) / 360 / (6.4) / 326 / (5.8) / 407 / (7.3) / 630 / (11.3) / 838 / (15.0) / 2357 / (42.2) / 5582 (100)
2004 / 2 / (0.2) / 7 / (0.7) / 20 / (2.0) / 26 / (2.6) / 67 / ( 6.7) / 100 / (10.1) / 772 / (77.7) / 994 (100)
2003 / 6 / (0.3) / 40 / (1.8) / 50 / (2.2) / 99 / (4.3) / 158 / (6.9) / 264 / (11.6) / 1668 / (73.0) / 2285 (100)
Fee-for-service
2005 / 114 / (8.1) / 71 / (5.0) / 95 / (6.7) / 117 / (8.3) / 169 / (12.0) / 214 / (15.2) / 631 / (44.7) / 1411 (100)
IHS
2005 IHS to MediPASS / 29 / (1.9) / 57 / (3.7) / 74 / (4.8) / 162 / (10.5) / 204 / (13.3) / 219 / (14.2) / 792 / (51.5) / 1537 (100)
2005 IHS to FFS / 14 / (2.0) / 18 / (2.6) / 36 / (5.1) / 53 / (7.5) / 80 / (11.4) / 134 / (19.1) / 368 / (52.3) / 709 (100)
2004 / 6 / (1.0) / 16 / (2.6) / 43 / (7.1) / 82 / (13.6) / 141 / (23.3) / 160 / (26.4) / 157 / (26.0) / 605 (100)
2003 / 2 / (0.2) / 36 / (4.0) / 47 / (5.2) / 81 / (8.9) / 114 / (12.6) / 173 / (19.1) / 455 / (50.1) / 908 (100)
John Deere
Not in 2005 / — / — / — / — / — / — / — / —
2004 / 13 / (3.1) / 35 / (8.5) / 26 / (6.3) / 48 / (11.6) / 66 / (15.9) / 82 / (19.8) / 144 / (34.8) / 414 (100)
2003 / 20 / (1.5) / 116 / (8.7) / 120 / (9.0) / 134 / (10.0) / 169 / (12.6) / 213 / (15.9) / 564 / (42.2) / 1336 (100)
Combined
2005 / 864 / (8.8) / 541 / (5.5) / 562 / (5.7) / 798 / (8.1) / 1161 / (11.8) / 1529 / (15.5) / 4419 / (44.8) / 9874 (100)
2004 / 21 / (1.0) / 58 / (2.8) / 91 / (4.4) / 163 / (7.9) / 283 / (13.7) / 360 / (17.5) / 1084 / (52.6) / 2060 (100)
2003 / 28 / (0.6) / 193 / (4.2) / 219 / (4.7) / 323 / (7.0) / 468 / (10.1) / 673 / (14.6) / 2718 / (58.8) / 4622 (100)
Performance targets
The combined proportion of children with at least six visits in the first 15 months of life is 45%. This proportion matches the mean for all Medicaid programs within the NCQA HEDIS benchmarking data. For SFYs 2003 and 2004, the proportion of children with at least six visits in the first 15 months of life was 58% and 52%, respectively, both at the 75th percentile for audited Medicaid plans within the benchmarking database for these years (see Table 2). It is recommended that the performance target for this measure should be set at 60% in an attempt to bring the proportion back up to the previous levels and surpass the 75th percentile results for 2005.