Margaret C. Tyler University of Iowa. Peter C. Damiano University of Iowa. Elizabeth T. Momany University of Iowa. Health Policy

Transcription

1 Health Policy Evaluation of the Iowa Medicaid Managed Care Plans: The Consumer s Perspective. Results from the 2003 Survey of Iowa Medicaid Managed Care Enrollees. Final Report to the Iowa Department of Human Services Margaret C. Tyler University of Iowa Peter C. Damiano University of Iowa Elizabeth T. Momany University of Iowa Copyright 2004 the authors Hosted by Iowa Research Online. For more information please contact: lib-ir@uiowa.edu.

2 Evaluation of the Iowa Medicaid Managed Care Plans: The Consumer s Perspective Results from the 2003 Survey of Iowa Medicaid Managed Care Enrollees 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 Health Policy Research Program Public Policy Center The University of Iowa May 2004 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.

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4 Preface 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 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 consumer report used in this project were modified by researchers at the University of Iowa Public Policy Center in collaboration with the Iowa Department of Human Services and researchers at RAND who are part of the CAHPS team. The core CAHPS survey instrument was modified to include additional questions about access to care, dental care and 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. i

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6 Acknowledgements 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. 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. Ben High, a University of Iowa student research assistant, contributed excellent research support throughout the project. iii

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8 Evaluation of the Iowa Medicaid Managed Care Plans: The Consumer Perspective Results from the 2003 Survey of Iowa Medicaid Managed Care Enrollees EXECUTIVE SUMMARY 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 Iowa s Medicaid HMOs. In Iowa, three private companies John Deere Health, Iowa Health Solutions and Coventry Health Care had contracts to provide services for Medicaid managed care enrollees at the time of this survey (spring/summer 2003). The State of Iowa also administers its own primary care case management program, MediPASS, to provide services in most areas of the state. Two samples (one of adults and one of children) of households with current Iowa Medicaid enrollees were drawn from enrollment data current as of January The samples were stratified by health plan and included 2,644 children and 2,274 adults. Survey data were obtained for 1,325 children and 1,094 adults, yielding adjusted response rates of 51% and 49%, respectively. The 2003 survey was conducted using a mixed-mode methodology, comprised of two mailings and follow-up phone interviews for those who did not respond to the mailed survey. Survey items included the CAHPS 3.0 questionnaire and other items designed to elicit respondents perceptions of their access to medical, dental and behavioral health care, and the quality of their care and health plans. Data on enrollee demographics, current health status, and chronic health conditions were also collected, and children and adults with special health care needs were identified using the FACCT special health care needs screeners. The four Iowa Medicaid Managed Care plans were compared for differences in enrollee demographics, utilization, and performance measures. Plan differences found to be statistically significant are noted throughout the report. To provide a national context, results of comparisons between Iowa and national Medicaid samples conducted by the National CAHPS Benchmarking Database are also summarized. Demographics (see pages 13-14) 1,325 child enrollees 49% female Average age: 7.4 years Child Survey Results Race/ethnicity: 79% Caucasian, 16% African American Hispanic or Latino(a) heritage: 9% 38% had been covered by private health insurance within the last five years 1

9 Children s Health Status (see pages 15-17) Global health rating: 47% excellent, 32% very good, 18% good, 2% fair/poor One quarter (25%) of all children in Medicaid Managed Care had a special health care needs (CYSHCN) as identified by the FACCT screening questions CYSHCN were older and more likely to be male than the total sample To identify children s chronic health conditions, respondents were given a checklist of common pediatric health conditions and indicated which, if any, had affected their child for three months or longer. These chronic conditions may or may not have been the reason the child was identified as having a special health care need. The most common chronic health conditions (identified by parents or guardians) among children and youth in Iowa s Medicaid Managed Care were: Behavioral/emotional problems (other than depression or attention problems): 12% of all children, 38% of CYSHCN Attention problems: 10% of all children, 33% of CYSHCN Asthma: 10% of all children, 28% of CYSHCN Vision problems: 10% of all children, 15% of CYSHCN Dental problems: 10% of all children, 12% of CYSHCN Allergies: 9% of all children, 21% of CYSHCN Chronic ear infections: 7% of all children, 9% of CYSHCN Depression: 5% of all children, 18% of CYSHCN Access to Care and Use of Services 86% of children in Iowa Medicaid Managed Care have a primary care provider 41% got a new primary care physician (PCP) when they enrolled in their current plan Of the 41% who got a new PCP, 20% of parents reported a problem finding a PCP they liked 77% had their last preventive health care visit within the last year, 16% had one 1 to 2 years ago, and 7% over two years ago CAHPS Results: Problem getting needed care: 78% no problem, 17% small problem, 6% big problem Getting care quickly: 58% always, 27% usually, 15% sometimes/never There were no differences among the four plans with regard to getting needed care and getting care quickly In the last six months 65% of parents or guardians had made a routine health care appointment for their child 25% of all children had been treated in an Emergency Room at least once 43% of all children had needed care for an illness, injury or health condition 84% of all children had at least one outpatient visit in the last six months 40% of all children had three or more outpatient visits 65% of parents or guardians had called a doctor s office or clinic during office hours for help or advice regarding their child 72% of those who called said they always got the help they needed 21% of all children had needed specialty care 2

10 80% of those who needed it had received specialty care 20% of those who needed specialty care had at least a small problem getting a referral 3% of the 21% who needed a specialist were unable to see one 4% of all children in Medicaid Managed Care had been unable to receive a needed health service at some point in the last six months Behavioral and Emotional Health Care In the last six months 16% of children in Iowa s Medicaid Managed Care program had needed behavioral or emotional health care 27% of those who needed it had at least a small problem getting behavioral health care 20% of those who needed it were unable to receive behavioral health care at some point in the last six months Prescription Medication In the last six months 16% of children had needed prescription medication 10% of those who needed it had a problem getting their prescription medication 7% of those who needed it were unable to get a prescription medication at some point in the last six months Dental Care Of all children in Iowa s Medicaid Managed Care program 67% had needed dental care in the last six months Of the 67% who needed dental care, 69% needed a routine checkup and cleaning, 22% needed emergency treatment, and 29% needed other treatment (e.g., fillings) Of the 67% who needed dental care, 16% were unable to receive it at some point in the last six months Most common reason: could not find a dentist who accepts Medicaid (67%) Of children age 3 or older 74% saw a dentist in the last year 6% had never been to a dentist 87% were reported to have a single source of dental care Quality of Children s Health Care Care Delivery Average rating of all health care: 8.7 on 0-10 scale, 44% gave a rating of 10 Average rating of primary care provider: 8.8 on 0-10 scale, 50% rated PCP a 10 3

11 Average rating of specialist: 8.4 on 0-10 scale, 39% rated specialist a 10 Health care provider communicates well: 67% always, 23% usually, 10% sometimes/never Got needed information from doctors: 58% always, 29% usually, 13% sometimes/never Courteous and helpful office staff: 77% always, 14% usually, 9% sometimes/never 36% got prevention-oriented advice (e.g., safety, nutrition) from plan or provider The Health Plan Average rating of child s health plan: 8.4 out of 10, 37% gave a rating of 10. Customer service, information and paperwork: 71% no problem, 21% small problem, 8% big problem 43% of parents or guardians were aware of the Medicaid helpline: Of the 43% who knew about the helpline, 17% had called for help or information Of those who called, 67% had no problem getting help, 19% had a small problem, and 15% had a big problem Of the 43% who knew about the helpline, 11% called with a complaint or problem 74% of those whose complaints had been resolved were happy with the outcome Rating of child s Medicaid insurance compared to respondent s perception of private health insurance: 44% excellent, 34% very good, 18% good, 5% fair to poor Comparisons with the 2003 National CAHPS Benchmarking Database 1 Compared to the 2003 national data on children in Medicaid collected and published by NCBD, children in Iowa s Medicaid Managed Care program: Were older (25% ages 12 and up, compared to 14%) Were more likely to be Caucasian (79% vs. 50%) Were in better general health (47% excellent vs. 40%) Had parents with more education (85% graduated high school, vs. 79%) Had parents who were more likely to have called a doctor s office in the last 6 months (65% vs. 58%) Iowa s Child Medicaid Managed Care scored statistically higher than the NCBD 2003 distribution on: Getting needed care Getting care quickly Scores were statistically lower than those of the NCBD 2003 distribution on: Customer service Overall rating of health plan 1 For the complete report, see Westat and Shaller Consulting. (October 2003). National CAHPS Benchmarking Database, NCBD 2003 Child Medicaid Sponsor Report to the Iowa Department of Human Services. US Agency for Healthcare Research and Quality. 4

12 Adult Survey Results Demographics 1,094 adult enrollees 87% female Average age: 30 years Race/ethnicity: 88% Caucasian, 8% African American Hispanic or Latino(a) heritage: 3% Completed high school or GED: 83% Adult s Health Status Global health rating: 43% excellent or very good, 38% good, 19% fair to poor Nearly half (47%) of adults in Iowa s Medicaid Managed Care program had a special health care need (ASHCN) as defined by the FACCT screening questions To identify chronic health conditions among adults, respondents were given a checklist of common conditions and asked to indicate which, if any, had affected them for three months or longer. Conditions checked may or may not have been the reasons they were identified as having a special health care need. The most commonly reported chronic health conditions among adults in Iowa s Medicaid Managed Care were: 1. Anxiety, depression, other mental health: 33% of all adults, 58% of ASHCN 2. Back or neck problems: 33% of all adults, 43% of ASHCN 3. Allergy or sinus problems: 35% of all adults, 41% of ASHCN 4. Dental, tooth or mouth problems: 23% of all adults, 26% of ASHCN 5. Migraines: 22% of all adults, 33% of ASHCN 6. Vision problems: 22% of all adults, 28% of ASHCN 7. Asthma: 19% of all adults, 28% of ASHCN 8. Arthritis, bone or joint problems: 18% of all adults, 31% of ASHCN Access to Care and Use of Services 79% reported that they have a primary care provider (PCP) 52% got a PCP when they joined their current plan Of the 52% who got a new primary care provider, 30% had at least a small problem finding a PCP they liked CAHPS 3.0 Composites Getting needed care: 73% no problem, 19% small problem, 8% big problem Getting care quickly: 45% always, 33% usually, 22% sometimes/never Among the four plans in Iowa, MediPASS scored higher than average on getting care quickly 5

13 In the last six months 74% of adults in Iowa Medicaid Managed Care had made an appointment for routine or preventive health care 37% of adults had been treated in an Emergency Room at least once 51% of adults had needed care for an illness, injury or condition 85% of adults had at least one outpatient visit 51% of adults had three or more outpatient visits 69% of adults had called a doctor s office or clinic during office hours for help or advice Of the 69% who called, 59% always got the help they needed 41% of adults in Iowa Medicaid Managed Care had needed specialty care in the last six months Of the 41% who needed specialty care: 87% received specialty care in the last six months 22% had problems getting a referral 9% were unable to get specialty care at some point in the last six months 10% of adults had been unable to receive a needed health service at some point in the last six months Of the 10% who were stopped from getting care, the most common reasons were (1) needing a service not covered by the plan (34%), and (2) trouble finding a doctor who accepted Medicaid (31%) Behavioral and Emotional Health Care Self-rated mental health status: 50% excellent/very good, 29% good, 22% fair/poor In the last six months 24% of adults needed behavioral/emotional health care Of the 24% who needed it: 23% had at least a small problem getting behavioral/emotional care 16% had been unable to receive behavioral/emotional health care at some point Prescription Medication In the last six months 79% of adults in Iowa Medicaid Managed Care needed a new prescription medication or a refill Of the 79% who needed prescription medication: 20% had a problem getting prescription medicine 18% were unable to get a prescription medication at some point Dental Care 68% of adults in Iowa Medicaid Managed Care reported a single source of dental care Self-rating of dental health: 34% excellent or very good, 32% good, 33% fair to poor 6

14 Adults in Iowa Medicaid Managed Care rated their dental health significantly worse than their general physical health Half of adults (51%) had had a dental checkup within the last year 28% of adults had not had a dental checkup in over two years In the last six months 60% had needed dental care Of the 60% who had needed dental care, 35% needed a checkup and cleaning, 26% needed emergency treatment, and 41% needed other treatment (e.g., fillings) 23% of adults in Iowa Medicaid Managed Care had been unable to get needed dental care at some point in the last six months Of the 23% who were stopped from getting dental care, the most common reasons were (1) they could not find a dentist who accepts Medicaid (64%), and (2) Medicaid did not cover the needed service (35%) Dental care was rated significantly lower than general health care among those who rated both. Quality of Adults Health Care Care Delivery Average rating of all health care: 8.0 out of 10, 29% gave a rating of 10 MediPASS was rated better than average Average rating of primary care provider: 8.5 out of 10, 43% rated 10 Iowa Health Solutions had below average ratings of primary care providers Average rating of specialist: 7.8 out of 10, 31% gave a rating of 10 Doctor/nurse communicates well: 55% always, 32% usually, 14% sometimes/never MediPASS was rated better than average Helpful and courteous office staff: 60% always, 28% usually, 12% sometimes/never 40% got prevention advice (e.g., diet and exercise) from plan or provider The Health Plan Average overall rating of health plan: 7.7 out of 10; 27% gave a rating of 10 MediPASS was rated better than the average of the four Iowa Medicaid Managed Care plans About half of adults in Medicaid Managed Care (51%) were aware of the Medicaid helpline Of the 51% who knew about the helpline, 24% had called for information or help Of those who called, 29% had problems getting assistance Of the 51% who knew about the helpline, 10% called with complaint or problem Of those whose complaints had been resolved, 63% were satisfied with the outcome Customer service, information and paperwork: 68% no problem, 25% small problem, 7% big problem 7

15 Comparisons with the 2003 National CAHPS Benchmarking Database 2 Compared to 2003 national data on adults in Medicaid compiled and published by NCBD, adults in Iowa s Medicaid Managed Care program: Were more likely to be female (88% vs. 77%) Were younger (72% age 18-34, vs. 42%) Were more likely to be Caucasian (88% vs. 58%) Were in better health (47% excellent/very good vs. 34%) Had more education (83% high school graduates, vs. 68%) In the last six months, adults in Iowa s Medicaid Managed Care were more likely to have: Called a doctor s office for help or advice (69% vs. 60%) Made a routine preventive care appointment (74% vs. 67%) Needed care for an illness, injury or condition (51% vs. 46%) Had at least one outpatient visit (85% vs. 78%) Iowa s Adult Medicaid Managed Care Program scored statistically better than the NCBD 2003 distribution on: Getting needed care Getting care quickly None of the Iowa Medicaid Adult CAHPS scores were below the NCBD 2003 distribution 2 For the complete report, see: Westat and Shaller Consulting (October 2003). National CAHPS Benchmarking Database, NCBD 2003 Adult Medicaid Sponsor Report to the Iowa Department of Human Services. US Agency for Healthcare Research and Quality. 8

16 Chapter 1 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 in Iowa s Medicaid HMOs. In Iowa, three private companies John Deere Health, Iowa Health Solutions and Coventry Health Care had contracts to provide services for Medicaid managed care enrollees at the time of this survey (spring/summer 2003 see Figure 1-1). The State of Iowa also administers its own primary care case management program, MediPASS, to provide services in the most areas of the state. Lyon Osceola Dickinson Emmet Kossuth Winnebago Worth Mitchell Howard Winneshiek Allamakee Sioux O'Brien Clay Palo Alto Hancock Cerro Gordo Floyd Chickasaw J Fayette Clayton Plymouth Cherokee Buena Vista Pocahontas Humboldt Wright Franklin Butler J,C Bremer J J J,I Woodbury Ida Sac Calhoun I Webster Hamilton I Hardin I Grundy J Black Hawk J,C Buchanan J,I Delaware J Dubuque J,I Monona Crawford Carroll Greene Boone I Story Marshall Tama I I I Benton J,I Linn J,I Jones J Jackson J,I Clinton Cedar Harrison Pottawattamie Shelby Audubon Cass Guthrie Adair Dallas J,I Madison Polk J,I Warren Jasper J Marion Poweshiek Mahaska Iowa Keokuk Johnson Washington J Muscatine J,I Scott J,I J,I J,I J,I I Louisa Mills Fremont Montgomery Page Adams Taylor Union Ringgold Clarke Decatur Lucas I Wayne Monroe Appanoose Wapello J Davis Jefferson J Van Buren Henry I Des Moines I J I Lee I MediPASS Option Only MediPASS & HMO Options Available * HMO Option Only * J = John Deere Health Plan, Inc. (Formerly Heritage) I = Iowa Health Solutions C = Coventry Health Care of Iowa (formerly Principal) Figure 1-1. Medicaid managed care plans by county, March 2003 Results from the 2003 Survey of Iowa Medicaid Enrollees are presented in this report. The survey addressed enrollees access to and use of health care and their perceptions of the quality of that care. Respondents also reported on their health status, including special health care 9

17 needs. This year, a checklist of types of chronic health conditions was added to both the adult and child surveys in order to help identify any particular areas of concern. The 2003 Survey of Iowa Medicaid Enrollees included questions about the following: Enrollees current health status Screening for special health care needs using the Foundation for Accountability (FACCT) screening instrument Checklist of common chronic health conditions Effects of health conditions on functional status Perceived access to and utilization of health care services, including: Medical care Dental care Behavioral and emotional health care Perceptions of health care delivery, including: Ratings of overall care, primary care providers, and specialists Communication with health care providers Receipt of preventive counseling or guidance Receipt of adequate information regarding children s health conditions (child survey only) Treatment by office staff Experiences with the health care plan, including Overall rating of the health plan Customer service experiences This report contains a summary of findings from the 2003 survey including (a) any differences found between plans, and (b) comparisons of Iowa Medicaid results with available statewide and national figures. The national figures were obtained from the CAHPS National Benchmarking Database, a collection of data from Medicaid programs nationally. 3 These differences are noted where applicable. Readers who wish to examine the results in greater detail are directed to the appendices. Appendix A contains tables with responses to each question by health plan for the 2003 Child Medicaid Survey; responses to the 2003 Adult Medicaid Survey are presented in Appendix B. Descriptions of the CAHPS 3.0 composite scales and the FACCT chronic condition screener are included in Appendix C. Appendices D and E contain general comments written by respondents at the end of the survey. Detailed responses to the question Do you think you and your child have ever been treated differently because your child was covered by Medicaid? are in Appendix F. 3 The source for national comparative CAHPS 3.0 survey data used in this publication is the National CAHPS Benchmarking Database (NCBD) Any analysis, interpretation, or conclusion based on these data is solely that of the authors. The NCBD is a collaborative initiative of Westat and Shaller Consulting, with funding provided by the Agency for Healthcare Research and Quality. The source for statewide comparative data is Damiano PC, Willard JC, Momany ET, Tyler MC, Schor E, Hageman GA, Lobas J, Penziner A, Kahl B. The 2000 Iowa Child and Family Household Health Survey. University of Iowa Public Policy Center, Iowa City, IA, October

18 Survey Methodology The 2003 Medicaid survey was conducted during the spring and summer of 2003 using a mixed-mode mail and telephone methodology. 4 Questionnaires were mailed to Medicaid enrollees selected at random from administrative data provided by the Iowa Department of Human Services. 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 2,300 adult and 2,459 child enrollees. A second mailing to nonrespondents took place two weeks later. 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. To increase response rates, both a premium and an incentive were used during the first mailing. Each survey included a 20-minute long-distance phone card, and respondents who completed and returned their survey within the first two weeks of the study were eligible for one of three $100 gift certificates to Wal-Mart. After adjusting for non-eligibles, the response rates were 51.4 percent for the child survey, and 48.9 percent for the adult survey (Tables 1-1 and 1-2). Plan Table 1-1. Child sample and participation rate Number Sampled Adjusted Sample Size Number of Respondents Response Rate John Deere % Iowa Health Solutions % Coventry % MediPASS % Total % Table 1-2. Adult sample and participation rate Plan Number Sampled Adjusted Sample Size Number of Respondents Response Rate John Deere % Iowa Health Solutions % Coventry % MediPASS % Total % 4 Dillman DA Mail and Internet Surveys. New York: Wiley and Sons. 11

19 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 3.0) (see Appendix C for details about the CAHPS 3.0 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 questions from the Foundation for Accountability (FACCT) and National Health Interview Survey (NHIS). The FACCT Special Health Care Needs screening instruments were included to screen for children and adults with Special Health Care Needs. To better define the types of chronic conditions experienced by children and adults in Medicaid, we included checklists of chronic health conditions in both the child and adult surveys. A unique module of questions was used in both the child and adult surveys. In the adult survey, we used questions developed in consultation with the University of Iowa Center for Law, Disability and Health Policy to address the effects of physical and mental health conditions on day-to-day functioning and ability to maintain employment. In the child survey, parents or guardian respondents were asked a series of questions regarding their experiences with their Medicaid plan compared to their experiences with private health insurance coverage. 12

20 Chapter 2 SUMMARY OF CHILD SURVEY RESULTS The following is a summary of findings from the 2003 Survey of Iowa Medicaid Enrollees for Children. Responses to each item in the survey questionnaire are presented in Appendix A. Demographics The survey sample represented an even split between boys and girls, with 49% of the sample being female (Table 2-1). The average age of the children surveyed was 7.4 years. Four-fifths were Caucasian, 16% African American, and 13% indicated other ethnic identities; 9% indicated Spanish or Hispanic heritage. Seventy-three percent of children were currently enrolled in school or a childcare program. About 1% spoke a language other than English at home. Children in the Iowa Medicaid survey were more likely to be white (74% vs. 50%) and adolescent (ages 12 and up: 25% vs. 14%) than those in the National NCBD 2003 child Medicaid sample. Table 2-1. Child demographics by health plan John Iowa Health Variable Deere Solutions Coventry MediPASS Total % female 51% 50% 52% 45% 49% Mean age of child in years * (std. dev) Child race (marked one or more) 6.9 (5.2) 7.1 (5.2) 7.9 (5.3) 7.8 (5.4) 7.4 (5.3) % Caucasian 81.5% 79.5% 64.1% 85.3% 79.1% % African American 16.0% 13.2% 33.8% 9.0% 16.3% % Asian 1.4% 2.1% 1.7% 1.5% 1.7% % Pacific Islander/Native Hawaiian % American Indian/ Alaska Native % Hispanic only (no other ethnicity noted) 0.0% 1.0% 0.0% 0.3%.03% 2.0% 2.1% 1.7% 2.5% 2.1% 1.7% 2.5% 3.4% 2.0% 2.3% % Other 6.6% 8.3% 4.7% 5.7% 6.4% % with Hispanic/Latino heritage 7.9% 11.4% 8.0% 8.7% 9.0% Avg. number of people in family (standard deviation) Household size % in school or daycare 69.7% 72.3% 77.3% 75.4% 73.4% % primary language not English 0.9% 2.2% 0.4% 1.8% 1.4% Total N

21 Ninety-one percent of respondents to the child survey were parents, and 93% were female (Table 2-2). Respondents ranged in age from under 18 to 75 or older, with a median age of 25 to 34. Forty-one percent had graduated from high school or had a GED, and over one third had some college or a two-year degree. Sixteen percent had less than a high school education. Variable Relationship to child Table 2-2. Parent/guardian respondents John Deere Iowa Health Solutions Coventry MediPASS Total % mother or father 92% 91% 91% 89% 91% % grandparent 7% 5% 4% 6% 6% % aunt or uncle 1% 2% 2% 2% 2% % older brother or sister 0% 0% 0% 0.3% 0.1% % other relative 0% 1% 0.4% 0.3% 0.3% % legal guardian 0.3% 2% 1% 1% 1% % other 0.3% 0.3% 1% 1% 1% % female 94% 93% 96% 92% 93% Respondent age group % under 18 yrs 1% 0.3% 1% 1% 1% % % 18% 18% 17% 17% % % 41% 35% 39% 40% % % 28% 36% 28% 28% % % 9% 6% 11% 9% % % 3% 3% 3% 3% % % 1% 2% 1% 1% % 75+ 0% 0.3% 0% 0.3% 0.2% Highest educational level % 8 th grade or less 2% 2% 2% 3% 3% % some high school or less 11% 11% 14% 15% 13% % high school graduate or GED 42% 41% 42% 40% 41% % some college/2-year degree 38% 38% 35% 34% 36% % college graduate or more 9% 7% 7% 8% 7% Total N Enrollment in current plan About half of respondents (49%) had been in their current plan for two years or less, and 6 % reported being in their plan for over ten years. 14

22 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). Forty-seven percent said their child was in excellent health, and nearly 80 percent rated their child s health as either very good or excellent. Fair to poor health was reported for 2.7% of children. There were no differences between the health plans with regard to reported child health status. Table 2-3. Health status of child as reported by parent/guardian Health Status Percent Excellent 47% Very Good 32% Good 18% Fair 2% Poor 0.3% Total N 1312 Special health care needs For a child to meet the criteria of the FACCT instrument for having a special health care need, parents had to confirm that one of the conditions listed in Table 2-4 was the result of a health condition that had lasted at least 12 months. One quarter (25.1%) of respondents met the FACCT criteria for classification as a child or youth with special health care needs (CYSHCN). This is higher than the statewide figure of 17% CYSHCN. 5 Table 2-4. Children and Youth with Special Health Care Needs For a health condition that has lasted or is expected to last at least twelve months... N Percent* Needs or gets prescription medication % Needs or gets more medical, educational or other services than others % Has functional limitations, i.e., difficulty with daily tasks % Needs specialized therapy such as physical, occupational or speech % Has a mental health issue expected to last 12 months or more % Meets CYSHCN Criteria % * of the 1,318 who responded to these questions. 5 Foundation for Accountability, Child and Adolescent Health Measurement Initiative, January

23 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. Half (50.3%) indicated that the child had had at least one chronic health condition lasting three or more months. Behavioral or emotional problems other than depression or attention problems affected 12% of children overall. Asthma, attention problems, dental problems, vision problems, and other chronic conditions were each identified for 10% of the children. Chronic allergies or sinus problems affected 9%, while frequent ear infections affected 7%. Other issues included depression (5%), speech or language problems (4%), back, bone, neck or muscle problems (3%), developmental delays or mental retardation (2%), failure to thrive or eating disorders (2%). Hearing impairment, physical disabilities, and substance abuse problems each affected 1%. The following table (Table 2-5) lists each condition and its prevalence among children who were identified as CYSHCN, those who were not, and the sample as a whole. Table 2-5. Chronic conditions among CYSHCN and Non-CYSHCN Condition lasting 3 months or longer Behavioral/emotional problems (not depression or attention problems) All children %/(N) CYSHCN %/(N) Non-CYSHCN %/(N) 11.8% (155) 39.4% (130) 2.5% (25) Attention problems 10.2% (134) 33.4% (110) 2.4% (24) Asthma 10.2% (134) 27.5% (91) 4.4% (43) Allergies 9.4% (123) 20.9% (69) 5.5% (54) Depression 5.2% (68) 17.5% (58) 1.0% (10) Vision problems 9.6% (127) 15.4% (51) 7.7% (76) Dental problems (n.s.) 9.7% (128) 12.1% (40) 8.9% (88) Chronic ear infections (n.s.) 6.8% (90) 8.8% (29) 6.2% (61) Speech problems 3.9% (51) 7.6% (25) 2.6% (26) DD/MR 1.9% (25) 6.4% (21) 0.4% (4) Bone, joint or muscle problems 2.7% (36) 6.0% (20) 1.6% (16) Bowel or bladder problems 2.8% (37) 6.3% (21) 1.6% (16) Failure to thrive or eating disorder 1.6% (21) 3.3% (11) 1.0% (10) Hearing impairment or deafness 1.1% (15) 2.7% (9) 0.6% (6) Substance abuse 0.6% (8) 2.1% (7) 0.1% (1) Physical disability 0.7% (9) 1.8% (6) 0.3% (3) Diabetes 0.2% (3) 0.9% (3) 0.0% (0) Other condition (specified) 4.8% (63) 11.8% (39) 2.4% (24) Other condition (not specified) 2.7% (35) 6.3% (21) 1.4% (14) Total N As could be expected despite the different time limits (3 months for the condition list, 12 months for CYSHCN) most conditions were more prevalent among children with special health 16

24 care needs. The two exceptions to this were dental problems and chronic ear infections, which were found in statistically equivalent proportions between CYSHCN and non-cyshcn. Nearly 5% of respondents (63 children) wrote in a chronic condition that was not provided in the list (Table 2-6). These included blood or immune disorders (12 cases), skin problems (9 cases), chronic bronchitis (7 cases), gastrointestinal problems (6 cases), chronic sore throat or frequent strep (5 cases), seizures (5 cases), kidney problems (3 cases), obesity (3 cases), heart problems (3 cases), migraine (3 cases), thyroid disorders (2 cases), hydrocephalus (2 cases), hypertension (1 case), Ehlers-Danlos syndrome (1 case), fetal alcohol syndrome (1 case), neurofibromatosis (1 case), and chronic vertigo (1 case). Table 2-6. Additional chronic conditions mentioned by respondents (number of children) Condition CYSHCN Non-CYSHCN TOTAL Blood or immune disorders Skin problems Bronchitis Gastrointestinal Sore throat/strep Seizure disorders Kidney problems Overweight/obesity Heart problems Migraine Thyroid disorders Hydrocephalus Hypertension Ehlers-Danlos Syndrome Fetal Alcohol Syndrome Neurofibromatosis Vertigo Access and Utilization Primary care providers Eight-six percent of all respondents said their child had a personal doctor or nurse. Those in Coventry were slightly less likely to report a personal doctor or nurse (80%, p=.05). Forty-one percent of respondents switched doctors when they enrolled the child in their current plan. Of these, 20% had at least some problem finding a participating primary care provider they liked. 17

25 Phone calls to provider In the last six months, two thirds (64.7%) had called a doctor s office or clinic during regular hours for help or advice about their child. The majority (72.3%) of those who called said they always got the help they needed from these calls, and another 21% usually did. About 7% said they only sometimes or never got the help they needed. Routine and preventive health care Sixty-five percent of respondents had made an appointment for their child to get routine health care in the previous six months. Sixty-three percent of those with appointments said they always got these appointments as soon as they wanted, and another 29% usually did. Eight percent said they sometimes or never got routine appointments as quickly as they wanted. Thirty-nine percent reported getting in for non-acute care the same day, 25% waited one day, 19 percent waited 2-3 days, and 10% waited 4 to 7 days. Eight percent waited more than a week for non-acute care. Over three quarters (77%) reported that their child had had a preventive visit sometime in 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. In addition to preventive health visits, receiving prevention-oriented advice (i.e., anticipatory guidance) is an important part of overall health care. Respondents were asked if their health care provider or health plan had encouraged them to take any kind of preventive health steps, such as watching what their child eats or using bicycle helmets or car seats. Overall, just over one third of respondents (36%) remembered getting this type of guidance. Of those who did, 65% got it from their health care provider, 13% from their plan, and 21% from both their provider and their plan. Those in Coventry were more likely to remember getting prevention advice from both their plan and their provider. Specialty care Twenty-one percent of respondents reported that their child had needed to see a specialist at some point in the previous six months. Twenty percent had at least some problem getting a referral, with 5% reporting a big problem. Beyond getting the initial referral from the primary care provider, similar proportions reported problems getting in to see the specialist. Among the four health plans, children in Iowa Health Solutions were least likely to have problems getting in to see a specialist (p=.039). Of those who reported needing a specialist, 80% actually did see one, with 19.5% of the children having seen a specialist in the last six months. Three percent said that at some point in the previous six months their child had needed to see a specialist but was unable to do so. Acute care Forty-three percent of children in Medicaid needed care for an acute illness or injury in the previous six months. About 71% of respondents said their child always got this care as soon as they wanted, and another 24% said they usually did. Five percent never or only some times got acute care as soon as they wanted it. In 81% of cases, acute care was provided the same day, 12% waited one day, and 5% waited two days. 18

26 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 did visit a doctor, over half (53%) had only one or two visits. One-quarter of children in Medicaid (24.5%) were reported to have visited a hospital emergency room (ER) in the previous six months. Of those who used the ER, 68% had one visit, another 21% had two, 7% had three and 4% had four or more visits. Ability to get needed health care (CAHPS 3.0 composite measure) Most respondents (78%) reported having no problem getting health care for their child (Table 2-7). Seventeen percent reported a small problem, and 5% had a big problem. There were no statistically significant differences between the plans. Iowa Medicaid overall and Iowa Health Solutions individually scored better than the national (NCBD 2003) average on this measure. Table 2-7. Problems getting needed care Plan Big Small No Average N problem problem problem Score Comparison John Deere 266 6% 17% 77% 2.70 Average Iowa Health Solutions 247 6% 10% 84% 2.77 Average Coventry 172 5% 20% 75% 2.71 Average MediPASS 292 5% 20% 75% 2.71 Average Total 977 6% 17% 78% 2.72 Average Getting care quickly (CAHPS 3.0 composite) Nearly six out of ten respondents (58%) reported that their child always got needed health care as soon as they wanted, and another 27% said they usually did (Table 2-8). There were no differences between plans within the state. Iowa Medicaid as a whole, and each plan individually, scored better than the NCBD 2003 average. Fifteen percent in Iowa reported their children only sometimes or never got care quickly, compared to 21 percent in the total NCBD 2003 sample. Table 2-8. How often child got care quickly Plan N Never/ Sometimes Usually Always Average score Comparison John Deere % 28% 54% 3.52 Average Iowa Health Solutions % 26% 59% 3.86 Average Coventry % 27% 57% 3.37 Average MediPASS % 26% 59% 3.39 Average Total % 27% 58% 3.37 Average 19

27 Access problems and unmet need for health care Overall, 4% reported that their child had experienced unmet need for medical care (i.e., had been stopped from receiving care) at some point in the previous six months. There were no differences between plans. About half (52%) of children with one or more outpatient visits in the last six months had needed some type of care, tests or treatment. Of these, about 12% had at least some problem getting the care, tests or treatment they needed. Although only 11% reported that their plan required approval for care, tests or treatment, 35% of those who needed prior approval indicated this had resulted in delays in needed care. Dental care Eighty-four percent of all children were reported to have a usual source of dental care. Of the 987 children who were age three or older at the time of the survey, 87% had a usual source of dental care. Overall, 58% had needed some type of dental care within the previous six months, with 16% of these having an unmet need for dental care or treatment. Among children age three or older, 67% needed dental care in the last six months and 16% had unmet dental care needs. About three quarters of children age three or older (74%) had a dental visit within the last year. Another 15% last saw a dentist between one and two years ago, and 5% had not seen a dentist in over two years. Six percent had never been to a dentist. Mental health care Sixteen percent of respondents indicated that their child had needed behavioral or emotional health care in the last six months. Of these, 20% experienced unmet need for mental health care. When asked how much trouble it was to get this care for their child, 12% said it was a big problem, 15% said a small problem, and 73% had no trouble getting care. 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, 7% had an unmet need for prescription medicine during this time. Ten percent reported problems getting prescription medication for their child. Consumer Perceptions of Health Care Delivery Overall rating of child s health care Ratings of children s health care in the last six months were generally high (Table 2-9). Scores averaged 8.7 on the CAHPS 0-10 rating scale, with 44% giving a rating of 10. There were no statistically significant differences between the plans, and Iowa s scores were similar to the national NCBD 2003 benchmark ratings. 20

28 Table 2-9. Rating of child s health care (CAHPS 3.0) Plan N Comparison John Deere 342 2% 16% 42% 40% Average Iowa Health Solutions 319 3% 16% 37% 44% Average Coventry 223 4% 16% 32% 48% Average MediPASS 398 2% 16% 38% 44% Average Total % 16% 28% 44% Average Overall rating of primary care provider The majority of respondents thought highly of their child s personal doctor or nurse, rating them an average of 8.8 on the 0-10 scale (Table 2-10). Half of the respondents rated their child s doctor or nurse a 10, and another third gave ratings of eight or nine. There was no significant variation between plans on primary care provider ratings, and Iowa s scores were similar to the national NCBD 2003 benchmark. Table Rating of child s personal doctor or nurse Plan N Comparison John Deere 299 2% 15% 33% 51% Average Iowa Health Solutions 282 4% 13% 33% 50% Average Coventry 184 2% 15% 30% 52% Average MediPASS 350 2% 17% 32% 49% Average Total % 15% 32% 50% Average Overall rating of specialist Those respondents whose child had seen a specialist in the previous six months rated that specialist on the 0-10 scale (Table 2-11). These scores were also fairly high, with an average of 8.4. Again, there were no plan differences and Iowa s scores were not statistically different from the national NCBD 2003 benchmark. Table Rating of specialist seen most often Plan N Comparison John Deere 74 5% 19% 46% 30% Average Iowa Health Solutions 58 5% 19% 36% 40% Average Coventry 38 3% 18% 32% 47% Average MediPASS 80 6% 10% 41% 43% Average Total 250 5% 16% 40% 39% Average 21

29 Communication with child s primary care provider Two thirds of respondents reported that their child s health care providers always communicated well with them and treated them with respect (Table 2-12). There were no differences between plans, and Iowa scores were similar to the NCBD 2003 benchmark. Table Doctor communication (CAHPS 3.0) Plan N Never/ Sometimes Usually Always Average score Comparison John Deere 305 9% 24% 67% 3.56 Average Iowa Health Solutions 274 9% 23% 68% 3.56 Average Coventry % 21% 69% 3.56 Average MediPASS % 23% 67% 3.55 Average Total % 23% 67% 3.56 Average Getting information from doctors about child s health Over half of respondents (58%) reported that they always felt comfortable talking with their child s doctor, always got their questions answered, and got the information they needed about their child s health (Table 2-13). Another 29% said they usually did. There were no plan differences. Table Information sharing (CAHPS 3.0) Plan N Never/ Sometimes Usually Always Average score Comparison John Deere % 26% 64% 3.51 Average Iowa Health Solutions % 28% 61% 3.45 Average Coventry 68 16% 27% 57% 3.41 Average MediPASS % 35% 52% 3.38 Average Total % 29% 58% 3.44 Average Office staff Seventy-two percent of respondents reported that staff members in health care providers offices were always helpful and courteous when they brought their children for care (Table 2-13). Twenty percent said they were usually treated well, while 7% said they never or only sometimes were. There were no differences between the four Iowa plans, and Iowa s scores were consistent with the national benchmark. 22

30 Table Office staff helpful and courteous (CAHPS 3.0) Plan N Never/ Sometimes Usually Always Average score Comparison John Deere 305 7% 20% 74% 3.66 Average Iowa Health Solutions 274 7% 24% 70% 3.62 Average Coventry 181 9% 14% 77% 3.67 Average MediPASS 346 7% 21% 72% 3.64 Average Total 1,106 7% 20% 72% 3.65 Average Consumer Perceptions of the Health Plan Overall rating of health plan Although the mean rating of 8.4 out of 10 for overall health plan was fairly high (Table 2-14), ratings for Iowa Medicaid as a whole, and for Coventry as an individual plan, were statistically significantly lower than the NCBD 2003 benchmark. There were no differences between plans within the Iowa Medicaid program. Table Health plan rating (CAHPS 3.0) Plan N Comparison John Deere 349 2% 23% 42% 33% Average Iowa Health Solutions 329 3% 22% 36% 39% Average Coventry 231 5% 23% 36% 37% Average MediPASS 400 3% 18% 41% 38% Average Total 1,309 3% 21% 39% 37% Average Customer service, paperwork and information About 30 percent of respondents had a problem with health plan customer service, information and/or paperwork in the previous six months (Table 2-15). There were no plan differences within Iowa Medicaid. However, scores for Iowa Medicaid as a whole and for John Deere as an individual plan were lower than the national NCBD 2003 benchmark scores. Table Customer service, information and paperwork (CAHPS 3.0) Plan N Big problem Small problem No problem Average Score Comparison John Deere 127 8% 28% 64% 2.57 Average Iowa Health Solutions 122 5% 20% 76% 2.70 Average Coventry 91 8% 19% 73% 2.66 Average MediPASS % 19% 71% 2.59 Average Total 498 8% 21% 71% 2.63 Average 23