Medicaid and Public Health Partnerships in Iowa: Improving Access to Care for People Living with HIV

April 18, 2023 | Rachel Sheckman

A newly formed government agency in Iowa, the Iowa Department of Health and Human Services (HHS), represents an important step forward in the state’s fight against HIV. Iowa HHS integrates two government programs that are essential to ending the state’s HIV epidemic—the state Medicaid program and the Bureau of HIV, STI, and Hepatitis.

After a two-year merger process, the new Iowa HHS opened its doors in August 2022, combining multiple government programs and services that previously operated within two different agencies: the Iowa Department of Public Health and the Iowa Department of Human Services. This realignment has led to stronger communication and better coordination of services between agencies that once sat in different departments and reported to different leaders, such as the state’s Medicaid program and the Bureau of HIV, STI, and Hepatitis.

A key part of this restructuring is a new data-sharing agreement (DSA) between Medicaid and the HIV Surveillance Program, which facilitates analysis of viral suppression rates for Medicaid enrollees living with HIV. Although Iowa’s HIV/AIDS Program and Medicaid had some limited successes developing a data-sharing relationship, challenges arose around federal provisions, such as certain HIPAA considerations, that generally precluded a more robust DSA. The agency realignment allowed a more comprehensive DSA between the two programs.

To learn more about Iowa’s recent efforts, ASTHO spoke with Sarah Reisetter, chief of compliance and a deputy director at Iowa HHS, and Randy Mayer, chief of the Iowa HHS Bureau of HIV, STI, and Hepatitis. Listen to an abbreviated version of the discussion in the embedded video or read the highlights below.

Iowa recently completed a merger that resulted in the new Iowa HHS structure. Can you describe the process and some successes?

We started talking about the alignment work about two and a half years ago. Iowa HHS Director Kelly Garcia was hired as the director of Iowa’s Department of Human Services and soon after also became the director of the Iowa Department of Public Health. Director Garcia was open about the analysis that she was doing of the work of the two departments and talked about the potential that these departments might come together. In retrospect, this was very smart because she started socializing the concept of bringing the agencies together early on and gave staff a forum to talk about the concerns and opportunities they saw.

When we began planning, we hired an external vendor who helped us with foundation setting and stakeholder engagement to support our goals as we came together as a new, merged department. That culminated in a final change package that articulated the goals that the agencies hoped to achieve through the realignment process.

The goals we set included the development of an integrated organizational structure with the overarching goal of creating a welcoming and efficient front door for Iowans seeking the services and supports that Iowa HHS provides. We also wanted to improve the use and integration of data to make informed decisions and provide seamless service to Iowans.

At the level of the Bureau of HIV, STI, and Hepatitis, we have been involved in contributing to discussions on mission, vision, and values for Iowa HHS. I think the biggest success has been data-sharing. We had been sharing limited enrollment data between Medicaid and the Ryan White HIV/AIDS Part B Program since 2016, but we were unable to sign a more comprehensive DSA until the alignment started.

What does the new DSA allow you to do?

Since 2013, we have had access to the Medicaid claims database and enrollment system, but only on a client-by-client basis. That has evolved now that the DSA allows us to do wholesale data matching.

We are currently concentrating on routinizing our data matching for HIV to ensure we are able to continue reporting HIV viral load suppression numbers to CMS, which we began reporting in December 2022. However, we hope to include other STIs and viral hepatitis in our data matching efforts in the future.

The DSA outlines the types of data and frequency of data transfers (monthly) between Medicaid and the HIV Surveillance Program. The DSA allows us to match Medicaid claims data and surveillance data to (a) calculate viral suppression among Medicaid participants with HIV in aggregate, by managed care organization or disaggregated by demographics or geographic area, and (b) identify Medicaid participants with HIV who are not in care for HIV but are receiving other services from Medicaid. For persons not receiving HIV primary medical care, the HIV program can now directly reengage clients in care more efficiently than it could in the past.

What is your process for sharing data with Medicaid?

HIV surveillance data are being matched with Medicaid claims through a secure mechanism to help identify potential gaps in surveillance data and to calculate viral suppression rates. Each month, the HIV Surveillance Program sends the state Medicaid agency a file of surveillance data. Medicaid then compares that file to its claims data, flagging those with an HIV-related claim not in the surveillance system. Medicaid sends the data back to the HIV Surveillance Program, which investigates to determine whether the flagged claims are true cases of people diagnosed with HIV who need to be reengaged in care. The HIV Surveillance Program then calculates viral suppression in the Medicaid population, which the Medicaid agency uses to report to CMS for its fee-for-service and managed care populations.

How has cross-agency communication between public health and Medicaid changed since the realignment?

We have developed a new cadence for leadership meetings that allows us weekly opportunities for division directors to come together and have these conversations. There's a lot of value in having relationships, seeing people in the same room, and having an opportunity to talk about collective goals and strategies.

We now have a process to meet monthly with Medicaid staff about the DSA, including discussing what we plan to do with the data and how we can use it to improve services. We are building rapport between the two programs.

In 2020, Iowa Department of Public Health reported a three-year sustained reduction in the transmission of HIV. What contributed to this success?

Consistent leadership in our bureau and programs throughout the state. We also strongly pursued supplemental funding through the Ryan White HIV/AIDS Program, which we invested in our system.

Also, because Iowa does not have a single epicenter of HIV, we’ve developed a statewide network of providers by spreading our five Ryan White HIV/AIDS Part C clinics, our case management agencies, and our prevention agencies across the state. The Iowa Department of Public Health invested heavily in our prevention and care services, including expanding our workforce. We have added case managers, disease intervention specialists, and testing. I think it's all of those things finally coming together in the state.

We have always had good viral suppression rates, and right now we have the highest in the nation. We kept predicting that would eventually lead to a decrease in transmission, but it seemed like it never happened until we were able to increase our investment.