Interim Report Iowa Health and Wellness Plan Evaluation

Natoshia M Askelson; Juan Bao; Aislinn R Conrad; Joanne Constantin; Peter C Damiano; David E Frisvold; Tessa Heeren; Kandyce Larson; Fadi Martinos; Brooke McInroy; Susan C McKernan; Elizabeth T Momany; Nguyen Phuong; Pamela C Nwachukwu; Julie C Reynolds; Dan M Shane; Alex Sukalski

doi:10.17077/rep.006706

Executive Summary The University of Iowa serves as the independent evaluator for Iowa's 1115 Waiver: Iowa Health and Wellness Plan. The demonstration originally began on January 1, 2014. It is in the second 5-year extension which will end on December 31, 2024. IHAWP continues to change and evolve, as does the evaluation plan. There are currently seven key areas of investigation within the evaluation: Health Behaviors Incentive (HBI) program, Dental Wellness Plan (DWP), waiver of retroactive eligibility (WRE), cost sharing, cost and sustainability, waiver of non-emergency medical transportation (NEMT), and member experiences. Healthy Behaviors Incentive Survey data indicated that those who were enrolled since 2015 have the highest level of awareness at 47%. Those enrolled before the pandemic began (March 2020) report awareness of the HBI program at 35%, while 27% of those who were only enrolled during the pandemic (when the program was on pause due to the public health emergency) were aware of the program. Additionally, adjusted results show higher awareness of the HBI program for White (37%) as compared to Black (26%) and Hispanic members (24%) and for those with a 4-year degree (44%) as compared to those with less education. Females also had higher adjusted rates than males. As members spend more time in the IHAWP program, the likelihood of having a well-visit during the year increases. For example, 40% of members with eight years of enrollment reported having a well-visit compared to 31% for members with only one year of enrollment. Health risk assessment completion remains low and is not as closely associated with time in the program; reported completion rates are between 10% and 15% for members regardless of the total number of years in the program. Of members enrolled for at least eleven months during the year, 41% reported having a well-visit while only 11% of members reported having a well-visit if they were enrolled six months or fewer. IHAWP members with higher incomes are more likely to report having well-visits during the year compared to members with lower incomes. Analyses of claims and enrollment data, indicate there is an overall increase in the percentage of members completing a well visit over years of enrollment, with the greatest percentage (39%) being in the 8th year of enrollment. Additionally, a number of factors are related HBI completion rate: <ul><li>A greater proportion of members belonging to the highest income group (>100% FPL) complete a well-visit, HRA or both, followed by members belonging to the middle-income group (51–100% FPL), and then by members with the lowest income level (≤50%).</li> <li>A greater proportion of members residing in small towns/rural areas tend to complete both required activities over time compared to those residing in metropolitan or micropolitan areas.</li> <li>The Black population has the smallest percentage of members completing both required activities over time compared to other races/ethnicities. People with “unknown race” have the highest percentages of members completing both activities over time.</li></ul> Overall, most of the race/ethnicity groups follow a broadly similar pattern over time, with the highest percentage of members completing both required activities being in the 6th year. There is no regular pattern of change over time in the percentages of members completing both required activities by MCO membership status (i.e., MCO versus non-MCO beneficiary), or by MCO type (i.e., AmeriGroup, AmeriHealth, UHC, or ITC beneficiary). Dental Wellness Plan A plan to evaluate the dental portions of Iowa Medicaid’s 1115 waiver (also known as the Dental Wellness Plan-DWP) was originally approved by CMS in 2020 as part of the comprehensive IHAWP evaluation plan. In December 2021, however, Iowa Medicaid made significant programmatic changes to the DWP that necessitated a new evaluation plan, such as eliminating the healthy behavior requirements as described in the Iowa Wellness Plan Section 1115 Demonstration Waiver, This new DWP evaluation plan was submitted and approved by CMS in early 2023 with new hypotheses and research questions appropriate to the new design of the program. The new evaluation plan focuses on access to care, particularly on member knowledge of the program changes and access to a dental wellness exam, in addition to the use of Hospital Emergency Department for non-emergent dental care. The primary analytic results thus far have been from a mail survey called the 2021 Survey of Iowa Private Practice general dentists, which evaluated the level of dentist Medicaid participation and attitudes toward the program, as one perspective on access to care. About two-thirds of dentists had an adult Medicaid patient in their practice, with participation varying significantly between the two dental carriers contracted with the program. Less than one in three Iowa dentists were accepting new adult Medicaid patients (most with some limits such as the number of Medicaid patients or the type of patients such as only family members of current patients in the practice). Waiver of retroactive eligibility Preliminary analyses indicate that there are no increases in charity care or bad debt for Iowa hospitals following implementation of the WRE. Information provided through the process evaluation indicates that providers have increased their role in initiating Medicaid applications. Cost SharingNo results to date. Cost and sustainabilityNo results to date. Waiver of non-emergency medical transportation A survey was conducted with IHAWP members to evaluate the impact of the waiver of non-emergency medical transportation (NEMT) services for most IHAWP members. Results were compared for IHAWP members who do not have the NEMT benefit with a traditional group of Medicaid-enrolled adults who retained their NEMT benefit. Transportation was an important issue for all Medicaid members, regardless of NEMT waiver status. One in nine traditional Medicaid members had a missed health appointment in the last 6 months due to transportation problems and one in 15 IHAWP members without the NEMT benefit had a missed health appointment. Around one in three Medicaid members overall indicated a concern for the cost of transportation to health care. Overall, transportation-related access to health care for IHAWP members without NEMT was similar or better than for other Iowa Medicaid-enrolled adults with the NEMT benefit, as underlying risk factors were more important than the benefit itself. The NEMT benefit was also not well understood by IHAWP or traditional Medicaid members. About one in five Medicaid members with the NEMT benefit knew that they had transportation coverage and about one in 14 IHAWP members without NEMT “thought” they had NEMT coverage. Member experiences A 2022 mail survey of IHAWP enrolled adults was used to assess member experience, access to care, health status and quality of the care. Results were compared to either primary data collected in 2022 from a mail survey of traditional Iowa Medicaid adult members and/or national data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey where appropriate. Even though the IHAWP members were generally older and more likely to have a condition that affected their activities of daily living, their overall health status was rated similarly to traditional Medicaid adults. There were more similarities than differences regarding a number of utilization measures including the proportion with a personal doctor (about three-quarters), receipt of preventive care in the last 6 months (about half), use of routine care (about three-fifths), use a specialist (about one-third), need for urgent care (about one in four), and hospitalizations in the previous 6 months (about one in 11). Regarding access, there were again more similarities than differences between IHAWP and adult Medicaid members with about one in 10 having reported an unmet need for preventive care, one in 12 reporting an unmet need for routine care, one in four an unmet need for a specialist and one in five reporting an unmet need for urgent care. IHAWP members did report lower rates of need, use and unmet need for mental health care and were more likely to report having received a seasonal flu vaccine and at least one COVID-19 vaccine. A smaller proportion of IHAWP members used the emergency department in the past 6 months than Medicaid members and among those who used the ED, significantly more Medicaid members than IHAWP members reported that the care they received in the ED could have been provided in a doctor’s office.

Interim Report Iowa Health and Wellness Plan Evaluation

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