Medicaid Managed Care for Children in Iowa: Not So Transparent

Is transparency an advantage for Medicaid managed care?  Craig Kennedy, who heads Medicaid Health Plans of America, thinks so. (MHPA is a trade association for Medicaid managed care organizations (MCOs)).   In a recent op-ed in the Des Moines Register,  Kennedy wrote: “… managed care provides more predictability and transparency than a fee-for-service system, in which payments are based on the quantity rather than the quality of services. With managed care, states pay a fixed, per-member, per-month rate, which allows them to budget with transparency.”

Mr. Kennedy  was responding to an editorial that highlighted the frustrations of providers (reported in a recent State Auditor’s survey)  and called for the state  to end its Medicaid managed care program and return to a fee-for-service system. We don’t know whether fee-for-service or managed care is the best model for Medicaid beneficiaries in Iowa.  But we do know that transparency is essential to understanding how  Medicaid MCOs are performing for children and families.   So we decided to take a look at how transparent Medicaid managed care in Iowa is when it comes to access and quality for kids.

Iowa’s Medicaid program contracts with two for-profit MCOs—Amerigroup Iowa and Iowa Total Care.  Amerigroup Iowa is a subsidiary of Anthem Inc., and as of last month had over 364,000 enrollees.   Iowa Total Care is a subsidiary of Centene, and had 264,000 enrollees as of last month.   Both Anthem and Centene are major players in the Medicaid managed care market nationally.  Anthem has a Medicaid presence in 23 states and the District of Columbia; Centene has subsidiaries in 24 states.  For the quarter ending June 30, 2020, Anthem reported $17.2 billion in revenues on its government business, which includes Medicare as well as Medicaid, while Centene reported $18.1 billion in Medicaid revenues alone.

Federal regulations require that state Medicaid programs operate a website that provides certain information about Medicaid MCOs, including the names of participating companies, the contracts between the state Medicaid agency and the companies,  enrollee handbooks, provider directories, and prescription drug formularies. The state agency can either post the information on its website or post a link to the websites of the contracting MCOs.  So we searched both the Iowa Medicaid agency’s website and those of Amerigroup Iowa and Iowa Total Care for information on the performance of these two MCOs vis-à-vis children.  For extra credit, we also looked for this information on the CMS, MACPAC, and Kaiser Family Foundation websites as well as the websites of the parent companies.

Here’s what we found.  As required,  the Iowa Medicaid agency posted the most recent (Calendar Year 2019) Annual Technical Report prepared by its  External Quality Review Organization contractor (Health Services Advisory Group).  This report presents the results for Amerigroup Iowa on 22 child-specific 2019 HEDIS measures across four different domains of care (Access to Preventive Care, Behavioral Health, Keeping Kids Healthy, and Medication Management); the data reflect the MCO’s performance in Calendar Year 2018. (The report does not present results for Iowa Total Care, which did not begin participating in the Iowa Medicaid program until July 1, 2019).

While the report does not compare the performance of the two MCOs head-to-head, it does compare  the Amerigroup Iowa results with the national Medicaid HMO percentiles for HEDIS 2019 calculated by the National Committee on Quality Assurance.  Amerigroup performed at or above the 75th percentile on six child health measures:  Access to Primary Care Practitioners (25 months to 6 years and 12 to 19 years); Childhood Immunization Status (Combinations 1 and 10); Immunizations for Adolescents (Combination 1); and Lead Screening.  Amerigroup performed below the 25th percentile on four child health measures:  Metabolic Monitoring for Children and Adolescents on Antipsychotics (Total); Appropriate Treatment for Children with Upper Respiratory Infection; Follow-Up Care for Children Prescribed ADHD Medication (Initiative Phase and Continuation and Maintenance Phase); and Use of Multiple Concurrent Antipsychotics in Children and Adolescents (Total).

Here’s what we didn’t find:

  • The total number of children enrolled in each MCO.
  • The total number of children enrolled in each MCO broken down by age (e.g., 0-1, 1-5, etc.).
  • The total number of children enrolled in each MCO broken down by race and ethnicity.
  • The total amount the state paid each MCO to manage the care of the children enrolled during the most recent contract year.
  • The share of children in each MCO who received the general health screenings, referrals for corrective treatment, screening blood lead tests, and dental preventive and treatment to which they are entitled under the Medicaid EPSDT child health benefit.

The absence of EPSDT performance data is particularly disappointing given the child health advocates’ extensive work in 2017  to protect and strengthen the EPSDT benefit when the state converted from fee-for-service to managed care.

State Medicaid programs should be transparent about the results they are producing for children and families.  That is true whether they use fee-for-service or managed care to deliver needed health care services to beneficiaries.  The same goes for MCOs.  If MCOs believe they have a transparency advantage over fee-for-service, they should demonstrate it.  As to their performance for Medicaid kids in Iowa, they haven’t done so.

The child health performance information we were looking for but did not find is not esoteric.  The MCOs have it—they are, after all, being paid to manage care.  The state Medicaid agency and its EQRO contractor have this information (or should have it).  Only the public does not have it.  And although federal regulations do not require that this information be posted, they do not prohibit states or MCOs from doing so. Posting the information cannot be that difficult.  What is extremely difficult, however, is for the public to judge how well individual MCOs are performing for kids without this information.

Medicaid MCOs and their parent companies should practice the transparency they preach.  They and the children they enroll would be better off for it.