Health

Medicaid report raises concern on critical incidents, care coordination in Iowa

A photo illustration shows a stethoscope and  blood-pressure machine.   REUTERS/Regis Duvignau
A photo illustration shows a stethoscope and blood-pressure machine. REUTERS/Regis Duvignau

Discussion of the latest quarterly report from the insurers that administer Iowans’ Medicaid coverage prompted a concern that not all enrollees were receiving the care coordination they should.

The fourth-quarter report that was discussed during a Council on Human Services meeting in Des Moines Wednesday showed that more than 617,000 Iowans are enrolled in Medicaid managed care.

The report, which looked at the months April through June of state fiscal year 2019, found the majority of those members — 427,402 individuals, or about 69 percent — are enrolled in UnitedHealthcare. The remaining 31 percent, or 190,205 individuals, are enrolled in Amerigroup.

Among other aspects of the report, the Iowa Department of Human Services officials and council members discussed the number of critical incidents reported to the managed-care organizations this past quarter.

Theses incidents, which all involve a population of long-term support members under a certain waiver, are “higher than what anyone would want,” said Liz Matney, Iowa Medicaid managed care bureau chief, in Wednesday’s meeting.

The Home and Community Based Services Waiver is provided to older members or those with disabilities who need services to allow them to stay in their homes. Providers and health care coordinators are required to report critical incidents to the managed-care organizations to which those individuals are enrolled.

Incidents can include physical injury, emergency mental health treatment or death.

As of June, UnitedHealthcare stated it received 1,945 critical incidents from its total 18,145 waiver members. 875 of these critical incidents involved members who are intellectually disabled.

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Amerigroup reported 558 critical incidents among its 5,655 members. The managed-care organization saw the most reports from the Habilitation waiver, allocated to members with functional impairments associated with chronic mental health conditions, at 232 reports.

Matney said there are certain member populations — including those under the Home and Community Based Services waiver — who historically have a higher number of incidents.

“Sometimes, this isn’t a reflection of anything bad happening in the system when you look at data over time,” Matney said. “(Since) we started tracking these incidents, it’s pretty consistent across the past several years, especially population by population.”

Matney added that, “We work with providers on education and remediation to prevent future incidents from happening both at an individual level and systemic level.”

In the previous report, covering the fiscal year third quarter, UnitedHealthcare reported 1,1916 critical incidents for its 18,089 members and Amerigroup reported 184 among its 5,535 members.

Iowa’s Medicaid officials also discussed a downward trend in the total members enrolled in a chronic care coordination services following the exit of AmeriHealth Caritas in December.

The report showed more than 2,400 members were enrolled in care coordination — called a Chronic Condition Health home, or a medical office that provides care coordination services on behalf of the insurer.

However, in the second quarter of this state fiscal year, nearly 5,900 members were enrolled in the service.

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Matney said despite the drop in membership in the Chronic Condition Health program, individuals enrolled in Medicaid still are receiving the care coordination, but through a different delivery model.

After UnitedHealthcare absorbed the majority of membership from AmeriHealth, Matney said Medicaid officials found care coordination services were being duplicated across a Chronic Condition Health Home and a separate provider organization.

However, Council on Human Services Member Kimberly Spading raised a concern as to whether officials could ensure members receive care coordination through this model, adding she’s “not 100 percent convinced those services are happening.”

But Matney reassured the council that oversights were in place to make sure payments going to the managed care organizations “are demonstrated through results” with the member.

The quarterly report found that there was an increase in the number of grievances received in the past quarter, a trend that has continued through the past state fiscal year.

Amerigroup reported 297 complaints this past quarter, a slight increase from the previous quarter, which saw 276 grievances.

UnitedHealthcare received 745 grievances for the fourth quarter, 274 more complaints from the previous quarter. According to the report, the majority of complaints were because a request to enroll in or change a benefit plan did not occur during an open enrollment period.

Nearly all grievances were resolved within 30 calendar days, the report stated.

l Comments: (319) 368-8536; michaela.ramm@thegazette.com

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