March 20, 2015
Carrie Lindgren
Iowa Department of Human Services
Hoover State Office Building
1305 East Walnut Street
Des Moines, IA 50319
RE: Iowa High Quality Healthcare Initiative (Bid Number: MED-16-009)
Dear Ms. Lindgren:
On behalf of the 6,400 physician and student members of the Iowa Medical Society
(IMS), thank you for this opportunity to submit additional comments on the Iowa
High Quality Healthcare Initiative (Bid Number: MED-16-009), which seeks
proposals to transition Iowa’s Medicaid program to a managed care system of
payment and delivery. The core purpose of the Iowa Medical Society is to assure the
highest quality health care in Iowa through our role as physician and patient
advocate. With this purpose in mind, IMS urges the Department of Human Services
(DHS) to consider the following recommendations.
Procedural Transparency
Transitioning nearly all of Iowa’s Medicaid populations to a system of healthcare
payment and delivery that has a limited history in Iowa’s healthcare arena will
necessitate clear communication with Iowa’s healthcare providers and other
stakeholders in order to avoid sacrificing patient care due to confusion or
misinformation. IMS supports DHS’s mechanism of issuing an updated FAQ
document on a weekly basis. This FAQ document, and all other communications
regarding the transition to managed care, must offer reliable information consistent
with the details outlined in the program’s RFP. Because efforts to successfully
transition Iowa’s Medicaid beneficiaries to the new system will be ongoing well past
the program’s January 1, 2016 start date, DHS should continue to issue updated
responses to stakeholder and public comments and questions even after that
implementation date passes.
MCO Alignment
Among the core purposes of transitioning Iowa Medicaid to a managed care system
is the need to minimize procedural and care fragmentation and establish greater
efficiency in the program as a whole. Potentially contrary to that core purpose, the
program will be administered by up to four distinct managed care organizations
(MCOs), each with entirely distinct policies, payment arrangements, patient and
Carrie Lindgren
March 20, 2015
Page 2
provider incentive programs, and provider credentialing processes. A lack of
uniformity among the MCOs could further splinter these key components of the
healthcare system, counteracting the mission of managed care, creating additional
administrative burdens for providers, and placing vulnerable Medicaid populations in
danger of diminished access to high quality care. Consistent patient and provider
performance and healthy behavior incentives; uniform cost and quality reporting;
uniform prior authorization procedures; consistent electronic billing requirements;
and a single uniform provider credentialing entity, process, and form will ease the
administrative burden on providers and help patients navigate this new healthcare
system. IMS recommends that, wherever possible, the state enforce procedural
uniformity among the MCOs.
Provider Credentialing
Provider credentialing standards among MCOs is an area of particular need for
uniformity. Requiring providers to navigate up to four distinct credentialing
processes in order to contract with each of the MCOs places an unsustainable burden
on providers and practices. IMS recommends that the state administratively
credential providers currently credentialed under Medicaid with all MCOs contracted
with the state. Any credentialing of new providers must utilize a single, standardized
form and a single centralized credentialing body, ensuring uniformity across all
MCOs.
Telehealth Services
Given Iowa’s large rural population, the use of emerging technologies, including
telehealth, in healthcare delivery can play a vital role in expanding patient access and
enhancing the patient experience of care. The transition to managed care offers an
opportunity to drive further innovation in this area. IMS recommends that the state
require MCOs to allow utilization of these technologies in a medically appropriate
manner in order to expand access to services and extend the reach of provider
networks, particularly into rural areas of the state. As part of facilitating these
emerging technologies, the state must ensure MCOs provide coverage for services
provided via telehealth at the same rates as in-person services.
Capitation Rate Data Book
The capitation rate data book narrative provides crucial information on the factors of
each population’s history that will be taken into account when developing provider
rates for the managed care system. Attachments with further information that will be
used in the development of these rates have so far only been released to MCOs who
submitted a Letter of Intent to Bid. In order to preserve procedural transparency and
help Iowa’s provider community prepare for this significant transition, IMS
recommends DHS release that information to the public and Medicaid providers as
well.
Carrie Lindgren
March 20, 2015
Page 3
Utilization Management
The RFP as written encourages MCOs to exercise a high degree of creativity in the
development of utilization management procedures. The lack of clear guidelines
governing the use of prior authorization or other utilization review mechanisms by
all MCOs will naturally lead to added complexity for providers who contract with
multiple MCOs. Further, the open-endedness of the RFP’s guidelines grants the
MCOs too much freedom to develop policies that may not be in the best interest of
patients or providers and are not sufficiently subject to oversight by the state. There
is currently no mechanism to avoid incentivizing rationing care absent medical
necessity simply for the sake of saving costs. IMS recommends the state establish
clear, enforceable, and uniform criteria for prior authorization and utilization review
procedures among all MCOs. Such criteria must be evidence-based and consider the
medical necessity of treatment, and not be based solely upon arbitrary financial
triggers. In support of those clear, uniform criteria, IMS recommends the state also
establish an enforcement mechanism to address MCOs that fail to comply with their
contractual obligations, including the development of a consistent, accessible
provider appeals process.
Program Savings
In addition to improving patient outcomes, one of the stated goals of the managed
care program is to decrease the cost of care through improved care coordination,
which itself should contribute to improved quality outcomes. IMS supports these
reciprocal goals of improved outcomes and increased coordination. As a means of
extending those goals to improve the health of all Iowans, IMS recommends that a
portion of any savings achieved through improved care coordination of the Medicaid
program be shared with providers for the purpose of reinvesting in Iowa’s statewide
healthcare workforce and infrastructure. However, again, IMS urges close state
oversight to ensure MCOs are not arbitrarily denying coverage for medically
necessary services strictly for financial reasons.
Patient Access
The Medicaid program serves many of Iowa’s most vulnerable populations. Ensuring
that all patients have ready access to high quality care under the new managed care
system will be of utmost importance to keeping these Iowans healthy and well. It is
imperative that the state vigorously monitor and enforce the time and distance
network adequacy standards detailed in the RFP to ensure that enrollees are able to
access appropriate care as close to their own homes as possible. IMS recommends
that DHS review MCO network adequacy compliance at least quarterly, and require
that MCOs disseminate easily accessible provider panel directories to ensure that all
patients are able to find and access the provider most suited to their medical needs. If
DHS finds that an MCO’s provider network is no longer in compliance, there must
be a mechanism for swift, defined corrective action, and the results of that correction
must be clearly communicated with the plans’ enrollees and provider network.
Carrie Lindgren
March 20, 2015
Page 4
Provider Rates
Provider rates are another critical component of ensuring adequate patient access to
care. Medicaid providers have struggled for many years with unsustainably low rates
that often fail to cover the actual costs of providing care. These inadequate rates lead
to diminished patient access as providers must reduce the portion of their patient
panel open to Medicaid patients. As the state pursues savings through the new
managed care system, IMS reminds the state to be mindful that those savings not
come at the expense of cutting already inadequate provider rates, which could further
restrict patients’ access to care. IMS supports the vital payment floor criteria already
outlined in the RFP to prevent MCOs from paying providers less than the current
fee-for-service rates. However, those payment floors are inconsistently applied and
time-limited. IMS recommends that the state institute a fee-for-service physician
payment floor that extends for the duration of the MCO-provider contract.
IMS again thanks the department for the opportunity to submit these comments on
the transition to Medicaid managed care. We look forward to ongoing engagement
and discussion throughout this process.
Sincerely,
Clare M. Kelly
Executive Vice President