The MNCAA Program Grew Significantly in Early Years, but Growth Has Tapered Since
The MNCAA program began accepting applications from Level 1 MNCAAs in March of 2008. Thirty-five organizations submitted applications through the program in its first year. Due in part to strong early recruitment efforts by the MNCAA Resource Center including targeted mailings and staffpresentations in both the metro area and in Greater Minnesota, that number had more than doubled by the end of 2009. This growth in the number of organizations submitting applications began tapering in 2010. As of the writing of this report in mid-20121, it appears that participation in the program in terms of those organizations offering full application assistance is roughly the same as it was in 2009. Over the life of the program (2008-2012), 123 unique organizations have submitted applications.
Figure 4. Number of unique Level 1 MNCAAs submitting applications per year
*Represents number of unique MNCAAs submitting applications for a partial year.
This same basic pattern is evident in MNCAA application and applicant volume over time. Tremendous growth in 2009 in both the number of applications submitted through the MNCAA program and the number of MHCP applicants is followed by more even results in 2010, and then an actual decline in application and applicant volume in 2011. Data for the first five months of 2012 suggests that MNCAA application and applicant volume is roughly on track to mirror 2011 results by the end of 2012.
A combination of factors have likely contributed to the tapered growth and then decline in the number of MNCAAs submitting applications, the number of applications submitted, and the number of applicants over time. First, underlying economic and public health care program enrollment trends have probably had some impact, but the extent of the this impact is unknown. It is important to note that caseloads for MHCP during this time period have been growing, generally speaking. Also, through unallotment and
2008* 2009 2010 2011 2012* Total
subsequent budget bills, the funding for this program was reduced significantly from original levels beginning in FY 2010 (July 2009-June 2010). According to State staff interviewed for this evaluation, by early in calendar year 2010, the Resource Center had stopped adding new Level 1 MNCAAs because there was not enough funding available to provide additional bonus payments. Finally, staffing changes, resource constraints, and travel restrictions within DHS during this same time period likely impacted the strength of MNCAA recruitment efforts, especially in Greater Minnesota.
Figure 5. Level 1 MNCAA application and applicant volume per year
* Represents number of unique MNCAAs submitting applications for a partial year.
A Small Group of MNCAAs Are Responsible For the Vast Majority of Applications
The top MNCAA organizations in terms of application volume have remained fairly consistent since the inception of the program. Portico Healthnet, MedEligible, HCMC’s Whittier and Richfield Clinics, Lake Superior Community Health Clinic, Children’s Hospitals and Clinics (Minneapolis and St. Paul), St. Cloud Area Legal Services, and Southside Medical Clinic have all been consistently among the top MNCAAs in terms of application volume. Organizations now responsible for a significant number of applications but joining the program after 2008 include Cardon Outreach (2010), La Clinica (2009), Cardon Outreach Duluth (2010), Hennepin County Medical Center (2012), and Fond du Lac Human Services Division (2011). Table 2 provides the top 15 MNCAAs by percent of application volume (denoted by red figures) for each year of the program as well as during 2008-2012 overall.
As shown below, the top 15 MNCAA organizations account for almost 75 percent of total applications submitted during 2008-2012 (in other words, over the entire life of the program). In 2008, the top 15 organizations accounted for 96 percent of the total application volume, while in 2012, the top 15 organizations accounted for 70 percent. This demonstrates that although a small number of organizations are responsible for the vast majority of applications, more and more MNCAAs have become contributors to overall application volume over time.
2008* 2009 2010 2011 2012* Total
Applications 3,135 10,733 11,382 9,801 4,593 39,644
Applicants 4,766 16,001 15,972 14,115 6,693 57,547
Table 2. Percent of total applications submitted by top 15 MNCAA organizations
Figures for top 15 MNCAAs denoted in red 2008 2009 2010 2011 2012 Total
Portico Healthnet 39% 19% 10% 8% 10% 14%
MedEligible 15% 12% 7% 9% 4% 9%
HCMC Whittier Clinic 5% 11% 9% 3% 2% 7%
Cardon Outreach 0% 0% 7% 15% 9% 7%
Lake Superior Community Health Clinic 13% 6% 4% 5% 5% 6%
Children's Hospitals and Clinics of MN (Mpls) 3% 7% 6% 4% 4% 5%
St. Cloud Area Legal Services 10% 4% 3% 3% 1% 4%
HCMC Richfield Clinic 1% 3% 4% 4% 3% 3%
HCMC East Lake Clinic 2% 5% 4% 2% 0% 3%
Children's Hospitals and Clinics of MN (St. Paul) 1% 3% 3% 3% 3% 3%
La Clinica (West Side Community Health Services) 0% 3% 3% 3% 3% 3%
Cardon Outreach – Duluth 0% 0% 4% 4% 5% 3%
Southside Medical Clinic 1% 4% 3% 1% 3% 3%
Park Nicollet Methodist Hospital 0% 0% 7% 1% 0% 2%
Indian Health Board 1% 3% 2% 2% 1% 2%
Vietnamese Social Services of MN 1% 2% 2% 1% 2% 2%
East Side Family Clinic 0% 2% 2% 2% 1% 2%
Southside Community Health Services 1% 1% 2% 3% 0% 2%
HCMC - Hennepin County Medical Center 0% 0% 0% 0% 10% 1%
Cardon Outreach - St. Cloud Hospital 0% 0% 1% 2% 2% 1%
HCMC Brooklyn Park Clinic 0% 0% 0% 3% 2% 1%
Native American Community Clinic 1% 1% 1% 1% 1% 1%
Cardon Outreach - Austin Medical Center 0% 0% 0% 2% 2% 1%
Fond du Lac Human Services Division 0% 0% 0% 2% 4% 1%
Cardon Outreach – Hibbing 0% 0% 2% 1% 0% 1%
HCMC Brooklyn Center Clinic 1% 2% 1% 0% 0% 1%
Olmsted Community Action Program 1% 1% 0% 0% 1% 1%
Face to Face Health and Counseling Service, Inc. 1% 0% 1% 0% 0% 1%
Subtotal 97% 90% 87% 86% 81% 88%
Subtotal, top 15 MNCAAs 96% 86% 77% 73% 70% 74%
Total number of applications 3,135 10,733 11,382 9,801 4,593 39,644
Another way to look at which community partners have been responsible for the most application volume is to look at MNCAA parent organizations. MNCAA parent organizations are typically the
organizations with which DHS contracts, and may have several different locations. For example, DHS contracts with HCMC’s Whittier Clinic as a parent organization, and HCMC and HCMC’s Richfield, East Lake, Brooklyn Park, Brooklyn Center clinics participate as MNCAAs under this umbrella.
Table 3 shows the top 10 MNCAA parent organizations—and 20 affiliated MNCAAs—by percent of total applications each year. Again, one can see that a small number of contracted partners have been responsible for the vast majority of applications over the life of the MNCAA program. During 2008-2012, these top 10 MNCAA parent organizations and 20 affiliated MNCAAs account for 84 percent of the total application volume. This means that the remaining 93 MNCAAs submitting applications during 2008-2012 represent just 16 percent of the total application volume during that time.
Table 3. Percent of total applications submitted by top 10 MNCAA parent organizations and affiliated MNCAAs
*Denotes MNCAA parent organization 2008 2009 2010 2011 2012 Total
HCMC 9% 21% 17% 12% 19% 17%
HCMC Whittier Clinic* 5% 11% 9% 3% 2% 7%
HCMC Richfield Clinic 1% 3% 4% 4% 3% 3%
HCMC East Lake Clinic 2% 5% 4% 2% 0% 3%
HCMC 0% 0% 0% 0% 10% 1%
HCMC Brooklyn Park Clinic 0% 0% 0% 3% 2% 1%
HCMC Brooklyn Center Clinic 1% 2% 1% 0% 0% 1%
HCMC FY 2012 Grant 0% 0% 0% 0% 1% 0%
Portico Healthnet* 39% 19% 10% 8% 10% 14%
Cardon Outreach 0% 0% 17% 27% 19% 14%
Cardon Outreach* 0% 0% 7% 15% 9% 7%
Cardon Outreach – Duluth 0% 0% 4% 4% 5% 3%
Cardon Outreach - St. Cloud Hospital 0% 0% 1% 2% 2% 1%
Cardon Outreach - Austin Medical Center 0% 0% 0% 2% 2% 1%
Cardon Outreach – Hibbing 0% 0% 2% 1% 0% 1%
Cardon Outreach - Albert Lea Medical Center 0% 0% 1% 1% 0% 1%
Cardon Outreach - North Country Health
Services – Bemidji 0% 0% 1% 1% 1% 1%
Cardon Outreach – Rochester 0% 0% 0% 0% 0% 0%
MedEligible* 15% 12% 7% 9% 4% 9%
Children's Hospitals and Clinics of MN 4% 10% 9% 8% 7% 8%
Minneapolis* 3% 7% 6% 4% 4% 5%
St. Paul 1% 3% 3% 3% 3% 3%
Lake Superior Community Health Clinic* 13% 6% 4% 5% 5% 6%
*Denotes MNCAA parent organization 2008 2009 2010 2011 2012 Total
La Clinica and Affiliated Clinics 0% 6% 5% 5% 5% 5%
La Clinica (West Side Community Health Svcs.)* 0% 3% 3% 3% 3% 3%
East Side Family Clinic 0% 2% 2% 2% 1% 2%
McDonough Homes Clinic 0% 0% 0% 0% 0% 0%
Healthcare for the Homeless 0% 0% 0% 0% 0% 0%
Southside Clinics 2% 5% 5% 4% 4% 4%
Southside Medical Clinic* 1% 4% 3% 1% 3% 3%
Southside Community Health Services 1% 1% 2% 3% 0% 2%
Southside Dental Clinic 0% 0% 0% 0% 1% 0%
St. Croix Family Medical Clinic 0% 0% 0% 0% 0% 0%
St. Cloud Area Legal Services* 10% 4% 3% 3% 1% 4%
Park Nicollet 0% 0% 8% 3% 2% 3%
Park Nicollet Methodist Hospital 0% 0% 7% 1% 0% 2%
Park Nicollet Health Services* 0% 0% 1% 1% 2% 1%
Subtotal 92% 83% 86% 84% 77% 84%
Total number of applications 3,135 10,733 11,382 9,801 4,593 39,644
Roughly 70 Percent of Applications Currently Submitted Via the MNCAA Program Come from Health Care Organizations
During the first year of the program, 41 percent of the applications submitted came from human service organizations (e.g., Portico Healthnet), 32 percent came from health care organizations (e.g., Lake Superior Community Health Clinic), 15 percent came from for-profit businesses (e.g., MedEligible), 10 percent came from legal service organizations (e.g., St. Cloud Area Legal Services), and 2 percent came from all other partners.
Since that time, the mix has shifted toward health care organizations, and away from human service organizations, for-profit businesses, and legal service providers. In 2011, for example, the last year of complete data, health care organizations accounted for 70 percent of the applications submitted, human service organizations accounted for 15 percent, for-profit businesses accounted for 9 percent, and legal service organizations accounted for 3 percent.
Much of this shift can be explained by two factors. First, Cardon Outreach, a for-profit eligibility
assistance and revenue recovery company affiliated with various hospitals in the State began participating in the MNCAA program in 2010, submitting 27 percent of all MNCAA applications by 2011. The MNCAA database maintained by the Resource Center classifies Cardon Outreach as a health care organization, which has a notable impact on the distribution by organization type over time. Newer health care MNCAAs like La Clinica, East Side Family Clinic, and Park Nicollet Methodist Hospital and Health Services, and higher MNCAA application volume from Children’s Hospitals and Clinics and Southside Clinics, also contribute to this shift toward health care organizations.
Second, one MNCAA partner classified as a human service organization that was responsible for a significant portion of applications in 2008–Portico Healthnet, a non-profit health care application and coverage assistance organization—began receiving federal Children’s Health Insurance Program Reauthorization Act (CHIPRA) outreach grants beginning in 2010. Funding could not be claimed from both the State and federal governments for the same activities, so while overall outreach activities for Portico Healthnet increased, applications directed specifically toward the MNCAA program tapered during the same time.
Figure 6. Percent of total applications by MNCAA organization type
2008 2009 2010 2011 2012 Total
Total number of applications 3,135 10,733 11,382 9,801 4,593 39,644
The Vast Majority of Applications from Health Care Organizations Come from MNCAAs Operating Under Data Share Agreements
As mentioned earlier in this report, through unallotment and subsequent budget bills, the funding for the MNCAA program was reduced significantly from original levels beginning in FY 2010. By early in
calendar year 2010, the Resource Center had stopped adding new Level 1 MNCAAs because there was not enough funding available to provide additional bonus payments. At the same time, there continued to be significant interest from Level 2 and 3 partners on how to participate as Level 1 MNCAAs, begin offering application assistance to community members, and receive bonus payments for successful enrollments.
Faced with resource constraints, the MNCAA Resource Center began exploring alternate strategies.
Certain Level 1 MNCAAs—most notably health care providers that have a strong financial interest in securing public health care coverage for individuals—were willing to forgo the $25 bonus payments if they were able to retain access to the data provided by the Resource Center (most importantly, case status updates). This would free up resources so other community partners could join as Level 1
64%
Health Care Human Service For-Profit Business Legal Service Other
MNCAAs and receive bonus payments. By December of 2010, the Resource Center had entered into Data Sharing Agreements with 22 Level 1 MNCAA organizations. A list of the 37 current Data Share Organizations is provided below.
Table 4. MNCAA Level 1 Data Share Organizations as of June 5, 2012 Allina Health System – Unity Hospital HCMC – Whittier Clinic
Altegra Health HCMC – FY12 Grant
Bois Forte Reservation Health Services LakeWood Health Center
Cardon Outreach MedEligible
Cardon Outreach – Albert Lea Medical Center Park Nicollet Health Services Cardon Outreach – Austin Medical Center Park Nicollet Methodist Hospital
Cardon Outreach – Duluth PrimeWest Health
Cardon Outreach – Hibbing Rainy Lake Medical Center Cardon Outreach – North Country Health
Services Bemidji
Red Lake IHS Hospital Cardon Outreach – Rochester Regina Medical Center
Cardon Outreach – St. Cloud Hospital Riverwood Healthcare Center Children’s Hospitals and Clinics of MN (Mpls) St. Joseph’s Area Health Services Children’s Hospitals and Clinics of MN (St. Paul) U of M Physicians – PFS
Fond du Lac Human Services Division UMP – Bethesda Clinic
HCMC – Hennepin County Medical Center UMP – Broadway Family Medicine HCMC – Brooklyn Center Clinic UMP – Phalen Village Clinic HCMC – Brooklyn Park Clinic UMP – Smiley’s Clinic
HCMC – East Lake Clinic University of Minnesota Physicians – Family Medicine Clinic
HCMC – Richfield Clinic
Interestingly, Figure 7 shows that the vast majority of applications (73-74 percent) submitted through the MNCAA program by health care organizations and all of the applications from for-profit businesses were submitted under Data Share Agreements in 2011 and 2012.
Figure 7. Percent of total applications submitted under DHS Data Share Agreements by MNCAA organization type
Total Number of Applications
Health Care Human Service For-Profit Business All Other
2011 6,855 1,434 873 639
2012 3,155 970 237 231
MNCAAs that Have Data Share Agreements with DHS Now Account for the Majority of Applications Submitted Through the Program
Given that most of the applications submitted by MNCAAs come from health care organizations, and that the vast majority of these organizations now operate under Data Share Agreements and do not receive $25 bonus payments, it is not surprising that most MNCAA program activity now occurs under Data Share Agreements versus pay-for-performance contracts.
As illustrated in Figure 8 below, during 2011 and roughly the first half of 2012, around 60 percent of the applications submitted through the MNCAA program came from MNCAAs that had Data Share
Agreements with DHS; roughly 40 percent came from MNCAAs that were receiving $25 bonuses for successfully enrolling individuals in MHCP.
73% 74%
17% 22%
100% 100%
0% 0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2011 2012 2011 2012 2011 2012 2011 2012
Health Care Human Service For-Profit Business All Other
Figure 8. Percent of total applications from MNCAAs with Data Share Agreements and those receiving $25 bonus payments
2011 2012
Total number of applications 9,801 4,593
Regional MNCAAs Now Account for Almost All of the Applications Submitted Through the Program
As of June 2012, 56 percent of Level 1 MNCAA organizations were classified as central organizations, meaning they submit applications to the MNCAA Resource Center for screening before they are forwarded to the county or to MinnesotaCare. Thus, 44 percent Level 1 MNCAAs had graduated to regional organization status and submit MHCP applications to the county or MinnesotaCare directly.
While the MNCAA outreach database does not include information on when MNCAAs graduated from central to regional status, looking at application volume in 2011 and 2012 should provide a fairly
accurate picture of the current proportion of applications being submitted to the MNCAA Resource Center first, and the proportion being submitted to the county or MinnesotaCare directly.
The majority of MNCAAs submitting applications in 2011 (70 percent) and in 2012 (61 percent) are regional organizations going directly to counties or to MinnesotaCare for eligibility decisions. Figure 5 illustrates that the percent of applications being submitted directly to counties or MinnesotaCare is now extremely high: roughly 98 percent in 2011, and 92 percent in 2012.
62% 60%
38% 40%
0%
10%
20%
30%
40%
50%
60%
70%
2011 2012
MnCAAs with Data Share Agreements MnCAAs receiving $25 bonuses
Table 5. Number and percent of total applications by central and regional MNCAAs Number of
Applications
Percent of Total Applications 2011
Central 224 2%
Regional 9,577 98%
2012
Central 348 8%
Regional 4,245 92%
The MNCAA Program Has Targeted Population Groups Known to Face Health Care Disparities
Of all applicants to MHCP assisted by the MNCAA program identifying their race or ethnicity between 2008 and 2012, 43 percent identified themselves as Black, American Indian, or Hispanic, while 31 percent identified themselves as White. This result has been very consistent except for in the first year of the program, 2008, when the proportion of clients identifying themselves as Black, American Indian, or Hispanic was somewhat lower (34 percent). All in all, the demographic information provided below suggests that the MNCAA program has been successful in targeting population groups that are known to face disparities in accessing public health care programs.
Figure 9. Percent of total applicants submitting applications through the MNCAA program reporting race and ethnicity
2008 2009 2010 2011 2012 Total
Total number of applicants 4,766 16,001 15,972 14,115 6,693 57,547
28%
In addition to race and ethnicity, understanding the age of applicants submitting applications through the program can provide insights about whether at-risk populations like children have been served by MNCAA organizations. The distribution of applicants served by age cohort has been very consistent across the years, with children under the age of 18 representing the largest percentage of individuals served by the MNCAA program (43 percent across 2008-2012). Adults 19-26, 27-40, and 41-64 are also a significant portion of the population served (16 percent, 20 percent, and 19 percent, respectively).
A very small proportion of elderly individuals (over 65) applied to MHCP through the MNCAA program over the life of the program.
Figure 10. Percent of total applicants submitting applications through the MNCAA program by age cohort
2008 2009 2010 2011 2012 Total
Total number of applicants 4,766 16,001 15,972 14,115 6,693 57,547
2%
The Vast Majority of Applicants Submitting Applications through the MNCAA Program Reside in the Twin Cities Metro Area, Suggesting an Underrepresentation of MNCAAs Serving Greater Minnesota
Over three-fourths of the applicants to MHCP via the MNCAA program between 2008 and 2012 live in the Twin Cities metro area. Yet just over half of the State’s uninsured population in 2011 lives in the Twin Cities. While certainly not conclusive, this supports the notion that to date, the MNCAA program has been a more successful outreach strategy in the Twin Cities than it has been in Greater Minnesota, generally speaking. The Arrowhead and Central regions of the State stand out as exceptions to this rule.
Figure 11. Distribution of total applicants submitting applications through the MNCAA program versus distribution of Minnesota’s uninsured by economic development region
Source for percent of Minnesota’s uninsured by region, 2011: MDH Health Economics Program and University of Minnesota School of Public Health, Minnesota Health Access Surveys. Last updated 01/12/2011. See separate map with regional definitions at
http://www.health.state.mn.us/divs/hpsc/hasurvey/regions.pdf.
Thirteen Percent of Applicants Assisted by MNCAA Organizations Are New to Minnesota Health Care Programs
One helpful feature of the MNCAA database is that through periodic data reconciliation with DHS’
health care payment system, MMIS, the Resource Center is able to track whether or not individuals assisted by the MNCAA program were new to MHCP. This measure is a meaningful indicator of how the MNCAA program is doing in terms of outreach to underserved populations that have difficulties accessing public health care programs.
As shown below, only 13 percent of applicants assisted by MNCAA organizations over the life of the program have been new to MHCP. This measure has ranged from a low of 11 percent to a high of 17 percent from 2008 to 2012. It is also important to note that this measure actually overstates the outreach effort to individuals new to MHCP through December 2010 because it includes a population of enrollees called “auto-newborns”. Auto-newborns are automatically enrolled in MHCP when their mothers are enrolled and up until this point, the MNCAA program paid bonuses for these newborns and tracked them as new to MHCP. Technically speaking, auto-newborns are new to MHCP, but they probably should not be included in a measure intending to isolate the outreach effort.
Figure 12. Percent of total applicants submitting applications through the MNCAA program who were new to MHCP
2008 2009 2010 2011 2012 Total
Total number of applicants 4,766 16,001 15,972 14,115 6,693 57,547
Among the top 15 MNCAAs in terms of total application volume over 2008-2012, there is wide
variability in the percent of applicants new to MHCP. Children’s Hospitals and Clinics, both Minneapolis and St. Paul locations, have the highest percentage of applicants submitting applications through the MNCAA program during 2008-2012 who are new to MHCP, at 26 and 23 percent respectively. La Clinica and Park Nicollet Methodist Hospital are also above average when it comes to targeting
11% 17% 11% 12% 11% 13%
2008 2009 2010 2011 2012 Total
New to MHCP Not New to MHCP
individuals who have not had attachments to the public health care system in the recent past. Within this group, Cardon Outreach, Cardon Outreach Duluth, and St. Cloud Area Legal Services appear to have the lowest percentage of applicants who are new to MHCP.
Figure 13. Percent of applicants new to MHCP for top 15 MNCAAs (in terms of application volume), 2008-2012
MNCAAs Initially Submit Complete Applications over Half the Time
One of the main goals of the MNCAA program was for trained community partners to submit
applications to the MNCAA Resource Center, counties, or MinnesotaCare with all questions answered and commonly required verifications attached (e.g., income, assets, citizenship, identity, pregnancy, information release). When applications are submitted with all verifications, applicants are more likely to be successfully enrolled in MHCP.
For the purposes of the MNCAA program, an application is considered “complete on arrival” if all
For the purposes of the MNCAA program, an application is considered “complete on arrival” if all