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PolicyReportJune2013Evaluation of theIowaCare Program:Information about the MedicalHome ExpansionPeter C. DamianoSuzanne E. BentlerElizabeth T. MomanyKi H. ParkErin Robinson
June 2013Evaluation of theIowaCare Program:Information about theMedical Home ExpansionPeter C. DamianoDirector, Public Policy CenterProfessor, Preventive & Community DentistrySuzanne E. BentlerResearch SpecialistElizabeth T. MomanyAssistant Director, Health Policy Research ProgramAssociate Research ScientistKi H. ParkResearch SpecialistErin RobinsonGraduate Student Research AssistantPublic Policy CenterThe University of Iowa2Final Report, June 2013
Table of ContentsChapter 1 IowaCare Background . 5Eligibility for IowaCare . 6Enrollment and Premiums . 7Provider Network . 7Covered Services . 9Chapter 2 Research Methods . 12Chapter 3 IowaCare Enrollment, Population Characteristics, and Administration . 15Enrollee Characteristics . 15Previous and Current Insurance Coverage . 17IowaCare Information . 18Chapter 4 Health Status of Enrollees . 19Overall Health . 19Chronic Physical Health Conditions . 19Overall Mental and Emotional Health . 20Chronic Mental Health Conditions . 21Oral Health Status . 22Functional Health . 22Chapter 5 Utilization of and Unmet Need for Care . 24Health Care in the Past Six Months through IowaCare . 24Personal Doctor and Routine Medical Care . 24Urgent and Emergent Medical Care . 25Preventive Care . 26Telephone Medicine . 26Specialty care . 27Hospitalizations . 27Dental Care . 27Mental and Emotional Health Care . 28Prescription Drugs . 28Durable Medical Equipment . 28Chapter 6 Enrollee Experiences with the Medical Home . 30Personal Doctor . 30Communication with Personal Doctor . 31Care Coordination . 323Final Report, June 2013
Access to Care . 33Information about care and appointments . 34Comprehensive Care . 35Self-Management Support . 36Shared Decision Making . 37Chapter 7 Quality of Plan and Care . 38IowaCare Plan Quality . 38Rating of All Health Care . 40Rating Personal Doctors . 40Rating of Hospitals . 41Conclusions . 42Appendices . 444Final Report, June 2013
Chapter 1IowaCare BackgroundThe IowaCare program is a limited-benefit, public health insurance program for Iowaadults with income that does not exceed 200% of the federal poverty level (FPL). Itwas authorized by Iowa House File 841 under a Medicaid expansion program andapproved on July 1, 2005. This program covers some inpatient and outpatientservices, physician, and advanced registered nurse practitioner services, limited dentalservices, routine yearly physicals, smoking cessation, and limited prescription drugbenefits. The program was created, in part, to fill the gap in adult health care coveragethat was expected to occur from the loss of the Iowa Indigent Care Program (a.k.a. theState Papers Program).The 2010 Iowa Legislature modified the program so that an IowaCare Medical Homepilot project was started on October 1, 2010, in part, to prepare for what was expectedto be an influx of new Medicaid enrollees in 2014 resulting from the Medicaidexpansion component of the Patient Protection and Affordable Care Act (ACA). TheIowaCare 1115 waiver will expire on December 31, 2013. As of June 2013, the IowaLegislature passed the Iowa Health and Wellness Plan that will provide coverage toexisting IowaCare members through a combination of an expansion of Medicaid with aslightly different benefit package, based on that of Iowa State Employees, and the1purchase of subsidized insurance on the forthcoming Health Insurance Exchanges.At the beginning of the pilot project in 2005, all IowaCare members, except those livingin Polk County, had to receive services at the University of Iowa Hospitals and Clinics(UIHC) in Iowa City. IowaCare members living in Polk County received services atBroadlawns Medical Center (BMC) in Des Moines. This arrangement continued until2010 when the Iowa Legislature passed Senate File 2356 that authorized theexpansion of the provider network to include a regional primary care provider network,beginning with an approach to phase-in Federally Qualified Health Centers (FQHCs).The bill mandated that the selected FQHCs provide primary health care services to theIowaCare population and to comply with certification requirements of a medical home.The first step was the establishment of 3-4 medical home sites consisting of UIHC inIowa City, BMC in Des Moines, and two FQHCs effective October 1, 2010. SiouxlandCommunity Health Center (SCHC) in Sioux City was chosen to serve IowaCaremembers in twelve counties and Peoples Community Health Clinic, Inc. (PCHC) inWaterloo was chosen to serve members in fourteen counties. Further expansions wereinitially planned for January through March 2011.However, further expansions were put on hold because it became clear very quicklythat PCHC in Waterloo did not have the capacity to handle the demands of all the newSummary of the Iowa Health and Wellness l/CCS446 Introduced.pdf, pp. 190-199.15Final Report, June 2013
patients assigned to them. Effective October 1, 2010, 3,382 IowaCare memberstransitioned to PCHC, and within the first six months of PCHC’s establishment as amedical home site, this number increased by another 1,533 members. In order toaddress the capacity issues at PCHC, it was decided that IowaCare members in ten ofthe fourteen counties would be reassigned to new medical home sites effective July 1,2011.On July 1, 2011, three more FQHCs were added as medical home sites to provideservices to the IowaCare members being transitioned from PCHC in Waterloo: Community Health Center of Fort Dodge (CHCFD) – Began providing servicesto members in five counties: Cerro Gordo, Floyd, Franklin, Mitchell, and Worth. Crescent Community Health Center in Dubuque (CCHC) – Began providingservices to members in four counties: Chickasaw, Fayette, Howard, andWinneshiek Counties. Primary Health Care Inc. in Marshalltown (PHC) – Began providing services tomembers in Grundy County.While a plan was being developed to address the capacity issues at PCHC inWaterloo, at the same time BMC in Des Moines and UIHC in Iowa City proposed anew Regional Model. The Regional Model, which was ultimately adopted beginningOctober 1, 2011, divided the state into five geographic areas that would be served bysix FQHCs, BMC, and UIHC. The plan expanded BMC’s role to become a medicalhome site for IowaCare members in Region 5 and a regional primary care hospital formembers in Regions 3, 4, and 5. The plan also expanded UIHC’s role to serve as amedical home site and regional hospital in Regions 1 and 2 and to provide specialtycare to IowaCare members statewide. UIHC also opened satellite offices in Belle Plain,Lowden, Riverside, Muscatine, and Wapello to IowaCare members. All Care HealthCenter in Council Bluffs (ACHC) was added as a medical home site for thesouthwestern region of the state on November 1, 2011.All IowaCare members that had not yet been assigned to a medical home site as ofJanuary 1, 2012 were assigned to one of the above sites based on their county ofresidence. The medical home sites are expected to provide routine care, preventiveservices, and disease management, while referring members needing specialty orhospital care to UIHC in Iowa City or BMC in Des Moines.Eligibility for IowaCareThe population eligible for IowaCare includes: Persons ages 19 through 64 years with a net income at or below 200% of thefederal poverty level (FPL), who are not otherwise eligible for Medicaid. Pregnant women (regardless of age) and their newborns, if their net income isbelow 300% of the FPL, with deductions for medical bills that reduce the familyincome to 200% or less of the FPL.Individuals who have enrolled in other group health insurance plans are not eligible for6Final Report, June 2013
IowaCare. However, an individual is eligible for IowaCare if coverage under othergroup health plans is unaffordable, excludes certain pre-existing medical conditions ordoes not cover needed services. Thus, an individual may be enrolled in both IowaCareand another group health plan if an individual has reached the limits of coveredbenefits under the other plan or if coverage under another health plan appliesexclusions for a pre-existing medical condition or does not cover needed services.Enrollment and PremiumsFollowing the eligibility determination, coverage begins on the first day of the month ofapplication. An individual may request retroactive eligibility of one month at the time ofapplication if they received covered services from a network provider during thatmonth. Eligibility is established for a 12-month period. IowaCare members with incomeequal to or more than 150% of the FPL pay a monthly premium and are required topay for at least four consecutive months of premiums. Premiums are based on asliding scale fee and and cannot exceed more than 5% of family income. Monthlypremiums for a one-person household range from 51 to 63. Premiums forhouseholds with two IowaCare members range from 69 to 86 per month. AnIowaCare member may request and file a hardship declaration for premium paymentson a month-by-month basis by signing a statement included with each monthly billingstatement. The statement must be signed each month that a member wishes todeclare a hardship. Enrollment can be terminated for reasons such as: 1) the 12-monthcertification period ends, 2) the member becomes eligible for Medicaid or Medicare, 3)the member cancels coverage or 4) the member fails to pay their premium.Provider NetworkAs indicated, the IowaCare provider network was changed on October 1, 2010 toinclude two FQHCs, on January 1, 2011 three more FQHCs were added to redistributemembers originally assigned to PCHC in Waterloo, and again on November 1, 2011 toadd another FQHC in Council Bluffs. Members are assigned to a medical home sitebased on their county of residence. The network currently includes: Broadlawns Medical Center (BMC) in Des Moines, Iowa University of Iowa Hospitals and Clinics (UIHC) in Iowa City, Iowa Siouxland Community Health Center (SCHC) in Sioux City, Iowa Peoples Community Health Clinic (PCHC) in Waterloo, Iowa Community Health Center of Fort Dodge (CHCFD) in Fort Dodge, Iowa Crescent Community Health Center (CCHC) in Dubuque, Iowa All Care Health Center (ACHC) in Council Bluffs, Iowa Primary Health Care (PHC) in Marshalltown, IowaA map of the counties participating in the medical home demonstration at the time ofthis survey of enrollees is shown in Figure 1-1.7Final Report, June 2013
Figure 1-1. Medical Home Designations by County of Residenceas of January 1, 2012(Map: Courtesy of the Iowa Department of Human Services)After the sample for this survey was completed, the medical home regions forIowaCare shifted. Effective January 1, 2013, the medical home regions are defined asshown in Figure 1-2.Figure 1-2. Medical Home Designations by County of Residenceas of January 1, 2013(Map: Courtesy of the Iowa Department of Human Services)8Final Report, June 2013
There is one exception to the IowaCare provider network for the covered services.That is, qualified pregnant women who live in Cedar, Clinton, Iowa, Johnson, Keokuk,Louisa, Muscatine, Scott or Washington Counties must receive pregnancy-relatedservices and newborn care at UIHC in Iowa City. Pregnant women in all other countiesmay receive pregnancy-related services and newborn care from any Iowa Medicaidprovider. Originally, any Iowa Medicaid provider in a member’s local area could providepreventive health visits. However, with the implementation of the medical homeconcept, preventive visits must now be provided by the member’s medical home site.Covered ServicesIowaCare provides coverage for most inpatient and outpatient services. Some limitedcoverage is also available for other services such as:Preventive VisitsA preventive health visit assesses overall health and health behaviors that promote anindividual’s wellbeing. The primary focus is on the prevention and early detection ofdisease. Preventive health visits are now covered under IowaCare. An annual physicalexamination must be provided by the member’s assigned medical home. If additionalservices or follow-up care is indicated as a result of the annual physical, an approvedIowaCare provider must perform these services.Durable Medical EquipmentIowaCare provides a very limited durable medical equipment benefit. UIHC in IowaCity provides some additional durable medical equipment to IowaCare enrollees on acase-by-case basis.DentalIowaCare covers only limited dental services, including extractions at IowaCareproviders. More comprehensive dental care is available at BMC in Des Moines forresidents of Polk County.TransportationIowaCare does not cover transportation services. However, a transportation servicewas provided by UIHC in Iowa City to help IowaCare members travel from their homesto UIHC and back. This transportation service was available by appointment only andmembers called to schedule transportation. IowaCare did not cover lodging and mealcosts that resulted from overnight stays at UIHC. UIHC ended this transportationservice to IowaCare patients on December 31, 2012.thDuring the 4 quarter of SFY12, the Department of Transportation (DOT) secured agrant of 50,000 to assist IowaCare members with transportation for medical care andpharmacy visits. The funds became available for access on April 1, 2012. However,9Final Report, June 2013
DOT notified the state that funds were expected to run out as early as September2012; therefore, they would have to terminate the program on October 1, 2012. Theprogram was replaced with a similar system, but the new funding limits coverage to 80percent of transportation costs per trip, and the number of participating transit agenciesdecreased from 16 to 8.PrescriptionsAlthough IowaCare does not have a prescription drug benefit, there are someprescription drugs provided by both UIHC and Broadlawns. For example, patients inthe UIHC medical home may receive up to a 60-day supply of some genericprescription medicine for a 4 copayment with multiple refills. And, they provide a 10day supply of any prescriptions associated with an inpatient or outpatient DRG. Somemedication administered in the hospital outpatient clinic is also provided. Broadlawnsprovides some limited medications through its community care program. There is alsoa volunteer drug program from which some members can receive prescriptionmedications.The 2011 Iowa General Assembly passed House File 649 to establish a 4 million poolfor IowaCare members receiving outpatient prescription drugs, podiatry and optometryservices at Broadlawns Medical Center (region 5 members only). This pool wasapproved by CMS for utilization on November 1, 2011. The 2012 Iowa GeneralAssembly reauthorized utilization of this pool for SFY 2013.IowaCare members are eligible for the same tobacco cessation benefit as Medicaidmembers where they can access cessation counseling through Quitline Iowa andreceive pharmacotherapy prescribed by their primary care provider.All of the IowaCare providers also work to assist members with their prescription needsby making 340B drug prices available (reduced costs are based on a sliding feeschedule), helping to them enroll in Prescription or Medication Assistance Programsoffered by pharmaceutical manufacturers, and connecting them with the variouspharmaceutical access programs administered by the Iowa Prescription DrugCorporation Program.Emergency ServicesIn SFY 2010, Senate File 2356 authorized an additional 2 million in funds to beaccessible for non-IowaCare hospitals to pay for emergency services that result in aninpatient stay. These funds were made available beginning October 1, 2010. However,hospitals reported that the administrative requirements presented a barrier toaccessing the funds. As a result, the Iowa Medicaid Enterprise (IME) proposed astatutory change to ease these restrictions. The Iowa legislature supported the bill,Administrative Rules were adopted, and these went into effect on Septemb
The first step was the establishment of 3-4 medical home sites consisting of UIHC in Iowa City, BMC in Des Moines, and two FQHCs effective October 1, 2010. Siouxland Community Health Center (SCHC) in Sioux City was chosen to serve IowaCare members in twelve counties and Peoples
