In April of 2016, Iowa transitioned its entire Medicaid program from a fee-for-service model to a managed care model. Over the past five years, Iowa’s Medicaid program has dealt with more than its fair share of upheaval—from managed care organizations (MCOs) reporting catastrophic losses to a lawsuit claiming that the transition to managed care deprived individuals of necessary services. There has also been considerable turnover in leadership—with three different Medicaid Directors overseeing the program during this time period. In the face of these challenges, it has been difficult for child health advocates to get the state and the MCOs to focus sufficient attention and resources on kids (despite the fact that kids make up over half of Iowa’s Medicaid members). However, the state recently took an important step forward by creating a child health dashboard. The newly created dashboard provides an overview of the nearly 400,000 kids currently receiving care through Iowa’s Medicaid program. The dashboard will be updated on a quarterly basis and includes information on:
- The total number of children enrolled in each MCO (broken down by age group);
- The total number of children receiving well-child visits;
- The total number of children receiving lead, vision, and hearing screenings; and
- The total number of immunizations
Unfortunately, the dashboard does not disaggregate data by race and ethnicity. In order to provide disaggregated data, the state will have to improve the accuracy and completeness of its demographic enrollment data. The race and ethnicity is “unknown” for approximately one-third of Medicaid enrollees.
The state has indicated that they are willing to modify and expand the dashboard over time. For example, next quarter’s dashboard will include information on Covid-19 vaccination rates. Child health advocates plan to encourage the state to include information on the amount of capitation payments for children and more details on the EPSDT services children received. The state also has plans to validate the data that is used for the dashboard. Currently, the state simply uses the data that the MCOs provide them with, but they hope to develop a process to cross-check and validate the data’s accuracy in the future.
Despite the fact that dashboard is in its infancy (the first edition was just published in April), the state Medicaid agency is already finding it useful. The state went back and pulled data for the previous 1.5 years to backfill the child health dashboard. This provides useful context and allows the state to compare the performance using the same quarter, one year apart (which can help control for seasonal fluctuations in care, like back-to-school). The state plans to use the data from the child health dashboard to jumpstart conversations and actions with the MCOs. For example, if an issue is identified (e.g. low number of well-child visits) the state will flag the issue with the MCOs and if unresolved, it could lead to corrective action. The state also plans to use the dashboard to help identify future pay-for-performance measures.
It is too early to tell how the MCOs will respond to this new tool—at this point they haven’t publicly responded or changed any behaviors. However, the state has used a similar tactic with other elements from their quarterly reports. For example, the state noticed that the Medical Loss Ratio (MLR) of one of the MCOs was falling below the required threshold. While the contractual requirement for the MLR is calculated as an average over a 12-month time period, the fact that the state could see that the MCO wasn’t meeting this target on a quarterly basis allowed them to initiate conversations with the MCO and the actuaries early in the process. Sidenote, the MCO still failed to meet the mark and for the first time, the state will be recouping the difference.
The child health dashboard represents a significant step forward for Iowa’s Medicaid program, increasing transparency and accountability by making it easier to see how the MCOs are (or are not) meeting the needs of kids. The dashboard also helps elevate the profile of kids within the Medicaid program. The fact that kids were the first group to receive a dashboard sends the message—kids matter! As the dashboard was released at the end of the state’s legislative session, is has yet to garner much attention from legislators. However, the management and oversight of Iowa’s Medicaid program has been a hot topic over the years. Child health advocates intend to use the tool to help legislators develop a better picture of how managed care is working for Iowa’s kids.
Iowa’s dashboard also represents a significant milestone for child health advocates in other states. Iowa can serve as an example of what is possible. Iowa’s Medicaid program contracts Amerigroup Iowa (Anthem Inc.) and Iowa Total Care (Centene). Both MCOs currently operate in other states (Anthem has subsidiaries in 18 other states and Centene is in 27 states), so if they can do it in Iowa, they can do it in your state too!