Medicaid and SCHIP
States Use Varying Approaches to Monitor Children's Access to Care Gao ID: GAO-03-222 January 14, 2003Over 25 million children have health insurance coverage through Medicaid or the State Children's Health Insurance Program (SCHIP). Coverage alone, however, does not guarantee that services will be available or that children will receive needed care. GAO was asked to evaluate states' efforts to facilitate and monitor access to primary and preventive services for children in these jointly funded federal-state programs. The study surveyed 16 states, covering over 65 percent of the Medicaid and SCHIP population. GAO analyzed requirements relevant to managed care and fee-for-service (FFS) delivery systems, including the number and location of physicians and their availability to see beneficiaries, monitoring of health plan or physician compliance with these requirements, and collection and analysis of beneficiary service utilization data.
Overall, states imposed more access-related requirements on participating providers and more actively monitored children's use of services in their Medicaid managed care programs than in their Medicaid FFS or SCHIP programs. Medicaid managed care: State requirements for managed care plans ranged from very broad provisions that health plans must have "adequate" physician networks for serving their enrolled members to very specific standards, such as the number and geographic proximity of physicians and maximum time frames within which a new beneficiary receives a first appointment. States less often verified data that plans submitted to show compliance with these requirements or independently monitored physicians' availability. In one instance of verification, a state found that a third of a health plan's physician network was not accepting new Medicaid patients, thus limiting access for new beneficiaries. The value of plan-submitted data that states used to monitor children's use of services was often compromised by continuing problems with their completeness and reliability. Furthermore, information derived from beneficiary satisfaction surveys was not necessarily representative of all Medicaid managed care beneficiaries. Medicaid FFS: Most states did not set goals for or analyze the availability of participating primary care physicians even though a majority of Medicaid-eligible children in half of the states reviewed are still served in FFS programs. In most FFS programs, beneficiaries may seek care from any providers participating in the Medicaid program and may change providers at any time if they are dissatisfied. However, when FFS payment rates are lower than those paid by other purchasers--which was the case in most states reviewed--providers can be discouraged from participating in Medicaid and thus restrict beneficiaries' access. States did little to monitor the use of services by Medicaid-eligible children in FFS programs despite having a ready source of data in their claims payment systems. SCHIP: Nine of the 16 states used the same providers, administrative systems, and monitoring approaches for their SCHIP programs as they did for Medicaid. The remaining 7 states, whose SCHIP programs were distinct from Medicaid and used managed care almost exclusively, set few requirements for or monitored providers' availability to SCHIP-eligible children. States with distinct SCHIP programs also reported fewer efforts to monitor children's use of services than in their Medicaid programs. Comments on our report from the Department of Health and Human Services highlighted new federal requirements for state oversight of managed care, and design differences between Medicaid and SCHIP that can affect monitoring approaches. States we reviewed provided clarifying or technical comments regarding their oversight of access, which we incorporated in the report as appropriate.
GAO-03-222, Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's Access to Care
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Report to Congressional Requesters:
United States General Accounting Office:
GAO:
January 2003:
MEDICAID AND SCHIP:
States Use Varying Approaches to Monitor Children‘s Access to Care:
Medicaid and SCHIP Access:
GAO-03-222:
Highlights:
Highlights of GAO-03-222, a report to Representatives Sherrod Brown;
John Conyers, Jr.; Diana DeGette; John D. Dingell; Gene Green; William
J.
Jefferson; Sander M. Levin; and Ted Strickland
MEDICAID AND SCHIP
States Use Varying Approaches to Monitor Children‘s Access to Care
Why GAO Did This Study:
Over 25 million children have health insurance coverage through
Medicaid or
the State Children‘s Health Insurance Program (SCHIP). Coverage
alone, however,
does not guarantee that services will be available or that
children will receive
needed care. GAO was asked to evaluate states‘ efforts to
facilitate and monitor
access to primary and preventive services for children in these
jointly funded
federal-state programs. The study surveyed 16 states, covering
over 65 percent
of the Medicaid and SCHIP population. GAO analyzed requirements
relevant to managed
care and fee-for-service (FFS) delivery systems, including the
number and location
of physicians and their availability to see beneficiaries, monitoring
of health plan
or physician compliance with these requirements, and collection and
analysis of
beneficiary service utilization data.
What GAO Found:
Overall, states imposed more access-related requirements on
participating providers
and more actively monitored children‘s use of services in their
Medicaid managed care
programs than in their Medicaid FFS or SCHIP programs. Medicaid
managed care: State
requirements for managed care plans ranged from very broad
provisions that health
plans must have ’adequate“ physician networks for serving their
enrolled members to
very specific standards, such as the number and geographic
proximity of physicians
and maximum time frames within which a new beneficiary receives
a first appointment.
States less often verified data that plans submitted to show
compliance with these
requirements or independently monitored physicians‘ availability.
In one instance
of verification, a state found that a third of a health plan‘s
physician network was
not accepting new Medicaid patients, thus limiting access for
new beneficiaries. The
value of plan-submitted data that states used to monitor
children‘s use of services
was often compromised by continuing problems with their
completeness and reliability.
Furthermore, information derived from beneficiary satisfaction
surveys was not necessarily
representative of all Medicaid managed care beneficiaries.
Medicaid FFS: Most states
did not set goals for or analyze the availability of
participating primary care physicians
even though a majority of Medicaid-eligible children in half of
the states reviewed are
still served in FFS programs. In most FFS programs,
beneficiaries may seek care from
any providers participating in the Medicaid program and may
change providers at any time
if they are dissatisfied. However, when FFS payment rates
are lower than those paid by
other purchasers”which was the case in most states reviewed”
providers can be discouraged
from participating in Medicaid and thus restrict
beneficiaries‘ access. States did little
to monitor the use of services by Medicaid-eligible children
in FFS programs despite
having a ready source of data in their claims payment systems.
SCHIP: Nine of the 16 states
used the same providers, administrative systems, and
monitoring approaches for their
SCHIP programs as they did for Medicaid. The remaining 7 states,
whose SCHIP programs were
distinct from Medicaid and used managed care almost exclusively,
set few requirements for
or monitored providers‘ availability to SCHIP-eligible children.
States with distinct SCHIP
programs also reported fewer efforts to monitor children‘s use of
services than in their
Medicaid programs.Comments on our report from the Department of
Health and Human Services
highlighted new federal requirements for state oversight of
managed care, and design differences
between Medicaid and SCHIP that can affect monitoring approaches.
States we reviewed provided
clarifying or technical comments regarding their oversight of
access, which we incorporated
in the report as appropriate.
To view the full report, including the scope
and methodology, click on the link above.
For more information, contact Kathryn G. Allen (202) 512-7118
Contents:
Letter:
Results in Brief:
Background:
In Medicaid Managed Care, States Focused More on Setting Plan Network
Requirements than on Monitoring Plans or Analyzing Service Utilization:
For Medicaid FFS, State Requirements for Providers and Monitoring of
Service Utilization Were More Limited:
Distinct SCHIP Programs Had Fewer Network Requirements and Less
Monitoring of Service Utilization:
Agency and State Comments and Our Evaluation:
Appendix I: Medicaid HEDIS Measures Related to Service
Utilization:
Appendix II: Managed Care Plan Withdrawals from Medicaid in
Four States:
Massachusetts:
Ohio:
Tennessee:
Texas:
Appendix III: Analysis of Medicaid FFS Payment Rates in
Selected States:
Methodology for Comparison of FFS Payment Rates:
Appendix IV: Comments from the Department of Health and
Human Services:
Appendix VGAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: SCHIP Design Choices for 16 States, as of March 2002:
Table 2: Share of Children Enrolled in Medicaid and Separate SCHIP
Programs, by Service Delivery Method, for 16 States:
Table 3: Examples of Specific State Standards for Plan Networks and
Appointment Waiting Times:
Table 4: Examples of Medicaid HEDIS Measures Related to Service
Utilization for Children:
Table 5: Estimated Percentage of Medicaid Children Excluded from HEDIS:
Table 6: Examples of Beneficiary Satisfaction Questions for Children
Covered by CAHPS:
Table 7: Estimated Percentage of Medicaid Children Excluded from CAHPS:
Table 8: Length of Medicaid Enrollment Required for Selected HEDIS
Measures for Children‘s and Adolescents‘ Use of Services:
Table 9: Examples of Plan Withdrawal Transition Activities Conducted by
Four State Medicaid Programs:
Table 10: Medicaid FFS Payment Rates, Expressed as a Percentage of
Medicare Payments, in 13 States with Traditional FFS or Primary Care
Case Manager Delivery Systems That Serve Children:
Table 11: CPT 4 Codes Used in Comparing Medicaid and Medicare Fees:
Figures:
Figure 1: Selected Medicaid Managed Care Plan Network Requirements and
Standards in 14 States:
Figure 2: Variation in 14 States‘ Monitoring of Medicaid Managed Care
Plans‘ Provider Information:
Figure 3: Selected Requirements for Medicaid PCCM Providers in Seven
States:
Figure 4: Comparison of Seven States‘ Requirements and Standards for
Providers in Medicaid and SCHIP Managed Care:
Abbreviations:
ACG ambulatory care group:
AHRQ Agency for Healthcare Research and Quality:
CAHPS Consumer Assessment of Health Plans:
CMS Centers for Medicare & Medicaid Services:
CPT 4 Current Procedural Terminology, 4th edition:
EPSDT Early and Periodic Screening, Diagnostic and Treatment:
FFS fee-for-service:
HEDIS Health Plan Employer Data and Information Set:
HHS Department of Health and Human Services:
HRSA Health Resources and Services Administration:
NCQA National Committee on Quality Assurance:
PCCM primary care case manager:
PCP primary care provider:
SCHIP State Children‘s Health Insurance Program:
United States General Accounting Office:
Washington, DC 20548:
January 14, 2003:
The Honorable Sherrod Brown
The Honorable John Conyers, Jr.
The Honorable Diana DeGette
The Honorable John D. Dingell
The Honorable Gene Green
The Honorable William J. Jefferson
The Honorable Sander M. Levin
The Honorable Ted Strickland
House of Representatives:
Over 25 million children have health care coverage through Medicaid or
the State Children‘s Health Insurance Program (SCHIP), joint federal-
state programs that finance health insurance for certain low-income
adults and children. Medicaid and SCHIP provide the financial means for
low-income children to receive primary, preventive, and specialty care,
which are important to ensuring a healthy child and adolescent
population. Having a regular provider, or usual source of care, also
can help reduce the use of services from high-cost sources such as
emergency rooms and inpatient hospital care.[Footnote 1]
While health insurance coverage can provide the financial means to
obtain care, it does not by itself guarantee that health services will
be available and accessible or that beneficiaries will receive needed
care. Access to primary care services is significantly affected by
local factors that vary across and within states, such as physician
supply, location, and willingness to participate in a state‘s Medicaid
and SCHIP programs. While federal law establishes general requirements
to ensure that Medicaid and SCHIP beneficiaries have access to covered
health services, the extent to which children actually receive these
health care services is influenced by how states implement their
programs and monitor access at the state and local levels.
The type of service delivery and financing system that states use in
their Medicaid and SCHIP programs potentially affects beneficiaries‘
ability to locate and obtain services. Managed care, which often
entails states making capitation payments to managed care plans to
provide or arrange for all services for enrolled beneficiaries,
encourages participating plans to offer and coordinate primary and
specialty care for beneficiaries. Managed care also may promote
efficiency by attempting to ensure that only necessary services are
provided in the most appropriate setting. Appropriate safeguards are
important, however, as capitation payments can also create an incentive
to underserve or even deny beneficiaries access to needed care since
plans and, in some cases, providers can profit from not delivering
services for which they have already received payment. In contrast,
beneficiaries in fee-for-service (FFS) systems, including those
receiving care in a primary care case manager (PCCM) system,[Footnote
2] may be at risk for the overprovision of services as providers seek
to increase revenue. However, if FFS payment levels are too low,
physicians may underserve their patients or be unwilling to participate
at all.
Our prior work has shown that access to care in Medicaid has been
problematic for certain services--such as health screening for
children, oral health, and mental health--and for particular
populations, such as children with special needs.[Footnote 3] Recent
reports that some physicians are unwilling to take more Medicaid
patients and that some managed care plans are exiting from the Medicaid
program have raised additional concerns about adequate access for
eligible children. Now that SCHIP is beginning its sixth year of
implementation, a related concern is the experiences of children in
accessing care under SCHIP, where states have greater flexibility to
decide whom to cover, what services to provide, and how to pay for
services, including required beneficiary cost sharing. Accordingly, you
asked us to evaluate states‘ efforts to routinely monitor access to
primary and preventive care services in (1) Medicaid managed care,
including actions selected states took when participating health plans
withdrew from the program, (2) Medicaid FFS-based delivery systems,
including PCCM systems, and (3) SCHIP.
To examine these issues, we analyzed 16 states‘ approaches to
monitoring access to primary and preventive health care services in
their Medicaid and SCHIP programs. These states were Arkansas,
California, Colorado, Florida, Illinois, Louisiana, Maryland,
Massachusetts, Michigan, Nevada, New York, Ohio, Pennsylvania,
Tennessee, Texas, and Washington. We selected these states to obtain
wide representation of geographic regions, managed care and FFS
systems, and SCHIP program designs.[Footnote 4] Over 65 percent of all
Medicaid and SCHIP beneficiaries resided in these 16 states. To
evaluate state approaches to monitoring access to care, we focused our
analysis of states‘ managed care and FFS delivery systems in three key
areas:
* specific requirements for participating managed care plans and
physicians to help ensure sufficient physician capacity and
accessibility for eligible beneficiaries;
* actions to independently verify or otherwise monitor provider
participation; and:
* routine data collection and analysis of information on beneficiaries‘
actual service utilization, including patient satisfaction surveys.
For states‘ Medicaid and SCHIP managed care programs, these service
utilization data included encounter data, which are individual-level
data on service use that plans are required to collect and report to
the state; the Health Plan Employer Data and Information Set (HEDIS),
developed by the National Committee for Quality Assurance (NCQA) to
help purchasers and consumers compare the performance of health plans
in providing selected services; and the Consumer Assessment of Health
Plans (CAHPS), which is a standardized patient satisfaction survey
developed by the federal Agency for Healthcare Research and Quality
(AHRQ). We conducted site visits in four states where managed care plan
withdrawals had been reported--Massachusetts, Ohio, Tennessee, and
Texas--and analyzed information from primary care providers
(PCP);[Footnote 5] representatives of advocacy groups; state insurance
departments; and managed care plans participating in Medicaid, SCHIP,
or both. At the federal level, we interviewed officials at the Centers
for Medicare & Medicaid Services (CMS), which oversees states‘ Medicaid
and SCHIP programs, and the Health Resources and Services
Administration (HRSA), which has responsibility for analyzing issues
related to access to care, as well as joint responsibility for
oversight of SCHIP. We reviewed relevant documents, including federal
laws, federal regulations, state contracts with managed care
organizations, and various federal and state reports related to access.
We conducted our work from June 2001 through December 2002 in
accordance with generally accepted government auditing standards.
Results in Brief:
Each of the states we reviewed with Medicaid managed care programs set
requirements for participating plans‘ provider networks, which include
the physicians and specialists who have agreed to deliver or arrange
for health care services to beneficiaries enrolled in a health plan.
These state requirements ranged from broad provisions that health plans
must have ’adequate“ networks for serving their enrolled members, to
very specific standards that set, for example, a maximum number of
beneficiaries per primary care physician or maximum time frames within
which a provider must see a new beneficiary for a first appointment.
The states less frequently verified data that plans submitted to them
or independently collected or analyzed data to ascertain compliance
with the requirements. States that did routinely monitor plans‘
compliance with network requirements often identified potential access
problems and took steps to address them. For example, a state review of
the physicians listed in a plan‘s network found that many physicians
were not accepting new Medicaid patients, resulting in too few
physicians accessible to such patients. Beyond setting requirements for
or monitoring plans‘ network size and availability, states attempted to
assess the extent to which beneficiaries were actually receiving
services through three key routine data sources: encounter data that
states require plans to submit on individual-level service use,
assessments of managed care plans‘ performance on specified measures,
and periodic beneficiary satisfaction surveys. However, the value of
these data was compromised by continuing problems in most states with
encounter data‘s completeness and reliability; additionally,
standardized data on plan performance and beneficiary satisfaction
surveys were not representative of all Medicaid managed care
beneficiaries. Potential issues of access to care associated with
managed care plans withdrawing from Medicaid in four states we visited
affected significantly different shares of eligible beneficiaries,
ranging from about 1 percent of Medicaid beneficiaries in Texas to
almost 50 percent in Tennessee. While these four states had taken
various steps to help minimize disruption in access to care for
beneficiaries affected by plan withdrawals, it was not clear to what
extent these efforts had been successful in helping beneficiaries
transition smoothly to new health plans and avoid access-to-care
problems.
States did considerably less in their Medicaid FFS programs--which
still serve the majority of children in half of the states we reviewed-
-to establish requirements for or monitor provider availability or to
assess beneficiaries‘ utilization of services than in their managed
care programs. For traditional FFS programs, beneficiaries may seek
care from any providers participating in the Medicaid program and may
change providers at any time if they are dissatisfied. However,
Medicaid beneficiaries‘ ability to easily change providers depends on
the number, type, and location of providers willing to take new
Medicaid patients, which in turn is strongly influenced by Medicaid
payment rates and associated administrative processes. We found that
FFS payment rates in most states we reviewed were significantly lower
than those paid by other purchasers for comparable services, which can
discourage providers from participating in the program and thus
restrict beneficiaries‘ access to a broad supply of providers.
Officials in several of the states we contacted with Medicaid FFS
programs said that anecdotal information and complaint data suggested
that low payment rates, slow payment, and other administrative issues
deterred physicians in primary care or in some specialties from
participating in the program. Most of the seven states we reviewed with
PCCM programs set certain requirements for participating physicians,
such as limiting the number of beneficiaries that a PCCM could enroll
in an effort to ensure that physicians had the capacity to serve each
beneficiary. However, these states did little to monitor the extent to
which beneficiaries were successful in obtaining appointments as
needed. In regard to routine data collection and analyses, all but one
of these seven states analyzed their FFS claims data and provided PCCMs
with comparative data on service utilization patterns for their own
practices and for other PCCMs. However, these comparative data often
focused on higher-cost services, such as inpatient hospitalization or
emergency room use.
The majority of the states we reviewed--9 of the 16--designed their
SCHIP programs to be an expansion of their Medicaid programs or modeled
them after Medicaid, with the same providers and administrative
systems. Therefore, in these states, the requirements for, and
monitoring of, SCHIP provider participation and beneficiary service
utilization mirrored that of their Medicaid programs. In contrast to
these states, 7 states chose to serve all or most of their SCHIP
beneficiaries through programs that were distinct from Medicaid. These
states did significantly less in their distinct SCHIP programs in terms
of setting requirements for, or monitoring, participating providers or
beneficiary service use than they did for their Medicaid programs.
We received comments on a draft of this report from the Department of
Health and Human Services (HHS), as well as from 13 of the 16 states
that were included in our review. In response to our findings, HHS
highlighted new federal requirements for state oversight of Medicaid
managed care that are to be fully implemented by August 2003. HHS also
pointed out that design differences between Medicaid and SCHIP may
affect states‘ approaches to monitoring access to care. State officials
provided clarifying and technical comments regarding their oversight of
access to care, which we incorporated as appropriate throughout this
report.
Background:
States‘ Medicaid and SCHIP programs are governed by various federal
requirements regarding eligibility, covered services, and access to
care. Under these requirements, states generally have some discretion
in determining the amount, duration, and scope of services their
programs will provide, and the delivery and financing systems through
which beneficiaries will receive care--that is, FFS, managed care, or
both. Federal requirements relating to Medicaid beneficiaries‘ access
to care are established in statute; for managed care service delivery
systems, detailed federal regulations regarding access were recently
issued.[Footnote 6] SCHIP requirements are also set out in statute but
are less specific than those for Medicaid and do not include detailed
managed care requirements or regulations comparable to those for
Medicaid.
Populations Covered and Program Characteristics:
Since 1965, Medicaid has financed health care coverage for certain
categories of low-income individuals--including over 22 million
children in 2000. Federal law requires states to extend Medicaid
eligibility to children aged 5 and under if their family incomes are at
or below 133 percent of the federal poverty level and to children aged
6 through 18 in families with incomes at or below the federal poverty
level. At their discretion, most states have set income eligibility
thresholds for families with children that expand their Medicaid
programs beyond the minimum federal statutory levels.
In 1997, the Congress established SCHIP, which provides health care
coverage to low-income, uninsured children living in families whose
incomes exceed the eligibility limits for Medicaid. SCHIP covered over
4.6 million children in fiscal year 2001, generally targeting children
in families with incomes up to 200 percent of the federal poverty
level.[Footnote 7] Compared with Medicaid, which has specific minimum
federal eligibility and benefit requirements, the SCHIP legislation
provides states more flexibility in how they choose to structure their
programs. States have three options in designing SCHIP: They may expand
their Medicaid programs, develop a separate child health program that
functions independently of Medicaid, or create a combination of the two
approaches. (See table 1 for the program designs of the 16 states in
our sample.) While Medicaid expansion programs under SCHIP must use
Medicaid‘s provider networks and delivery systems, SCHIP separate child
health programs may depart from Medicaid requirements particularly with
regard to covered benefits and the plans, providers, and delivery
systems available to beneficiaries.[Footnote 8]
Table 1: SCHIP Design Choices for 16 States, as of March 2002:
Design: Medicaid expansion; State: Arkansas,[A] Louisiana, Ohio, and
Tennessee.
Design: Separate program; State: Colorado, Nevada, Pennsylvania, and
Washington.
Design: Combination; State: California, Florida, Illinois,
Maryland,[B]; Massachusetts,[B] Michigan, New York, and Texas.
Source: CMS.
[A] In February 2001, Arkansas received approval from CMS to implement
a separate SCHIP program; however, this program had not been
implemented as of February 2002.
[B] The state‘s separate SCHIP portion of its combination program
provides coverage either through
(1) a premium assistance program for families with access to private
insurance coverage or (2) Medicaid providers and services. Premium
assistance programs were not included in our study.
[End of table]
Medicaid and SCHIP differ in terms of the share of their program
expenditures that come from federal funds. No overall federal budget
limit exists for the Medicaid program; it is an open-ended entitlement
whereby state expenditures for services that are provided under a CMS-
approved state Medicaid plan are matched by the federal government
using a formula that results in federal shares that currently range
from 50 to 76 percent of expenditures, depending on a state‘s per
capita income in relationship to the national average. The federal
share of Medicaid expenditures is about 57 percent. In contrast to
Medicaid, federal funding for SCHIP is limited. The Congress
appropriated $40 billion over 10 years (from fiscal years 1998 to
2007), with a specified amount allocated annually to each of the 50
states, the District of Columbia, Puerto Rico, and 4 U.S. territories.
State SCHIP expenditures are matched by federal payments up to the
state‘s annual appropriated allotment.[Footnote 9] The SCHIP statute
provides for an ’enhanced“ federal matching rate, with each state‘s
SCHIP rate exceeding its Medicaid rate. The federal share of each
state‘s SCHIP expenditures ranges from 65 to 83 percent; the federal
share of total SCHIP expenditures is about 72 percent.
Delivery Systems:
States provide Medicaid and SCHIP services through two distinct service
delivery and financing systems--managed care and FFS, with the latter
including PCCM.[Footnote 10] Under a capitated managed care model,
states contract with a managed care organization and prospectively pay
the plans a fixed monthly fee per patient to provide or arrange for
most health services. Plans, in turn, pay providers either
retrospectively for each service delivered on a FFS basis or through
prospective capitation payment arrangements. In contrast, in a
traditional FFS delivery system, the Medicaid program reimburses
providers directly and on a retrospective basis for each service
delivered. The PCCM model is similar to a traditional FFS arrangement
except that PCCMs are paid a monthly, per capita case management fee,
usually around $3, to coordinate care for beneficiaries, in addition to
FFS reimbursement for any health care services they provide. PCCMs,
which are selected by beneficiaries upon enrollment, are responsible
for treating and coordinating the care for those beneficiaries.
Coordination may involve referrals to specialists and other providers.
In some cases, receipt of specialty and other services may require PCCM
approval.
The 16 states we reviewed often structured their Medicaid and SCHIP
service delivery systems differently. As shown in table 2, the
exclusive use of managed care was less prevalent in Medicaid than in
separate SCHIP programs (3 and 6 states, respectively), with 3 states-
-Maryland, Michigan, and Tennessee--using managed care for virtually
all children in both Medicaid and SCHIP. The states were more likely to
use a combination of managed care and FFS approaches for their Medicaid
programs than for SCHIP (11 and 5 states, respectively). Despite the
recent growth in states‘ use of managed care, FFS is still a major
component of many states‘ programs, especially for Medicaid.
Table 2: Share of Children Enrolled in Medicaid and Separate SCHIP
Programs, by Service Delivery Method, for 16 States:
State: Arkansas; Medicaid: FFS-based: Traditional FFS: [B]; Medicaid:
FFS-based: PCCM: 100%; Medicaid: Managed care: --; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: [C]; Separate SCHIP
program[A]: FFS-based: PCCM: [C]; Separate SCHIP program[A]: Managed
care: --.
State: California; Medicaid: FFS-based: Traditional FFS: 29%; Medicaid:
FFS-based: PCCM: [B]; Medicaid: Managed care: 71%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: --; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: 100%.
State: Colorado; Medicaid: FFS-based: Traditional FFS: 28%; Medicaid:
FFS-based: PCCM: 18%; Medicaid: Managed care: 54%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: --; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: 100%.
State: Florida; Medicaid: FFS-based: Traditional FFS: [D]; Medicaid:
FFS-based: PCCM: 53%; Medicaid: Managed care: 47%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: [B]; Separate SCHIP
program[A]: FFS-based: PCCM: 2%[E]; Separate SCHIP program[A]: Managed
care: 98%.
State: Illinois; Medicaid: FFS-based: Traditional FFS: 87%; Medicaid:
FFS-based: PCCM: --; Medicaid: Managed care: 13%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: 99%; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: 1%.
State: Louisiana; Medicaid: FFS-based: Traditional FFS: 88%; Medicaid:
FFS-based: PCCM: 12%; Medicaid: Managed care: --; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: [C]; Separate SCHIP
program[A]: FFS-based: PCCM: [C]; Separate SCHIP program[A]: Managed
care: --.
State: Maryland; Medicaid: FFS-based: Traditional FFS: [D]; Medicaid:
FFS-based: PCCM: --; Medicaid: Managed care: 100%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: --; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: [F].
State: Massachusetts; Medicaid: FFS-based: Traditional FFS: [D];
Medicaid: FFS-based: PCCM: 63%; Medicaid: Managed care: 37%; [Empty];
Separate SCHIP program[A]: FFS-based: Traditional FFS: --; Separate
SCHIP program[A]: FFS-based: PCCM: 65%; Separate SCHIP program[A]:
Managed care: 35%.
State: Michigan; Medicaid: FFS-based: Traditional FFS: [D]; Medicaid:
FFS-based: PCCM: --; Medicaid: Managed care: 100%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: --; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: 100%.
State: Nevada; Medicaid: FFS-based: Traditional FFS: 41%; Medicaid:
FFS-based: PCCM: --; Medicaid: Managed care: 59%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: 13%; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: 87%.
State: New York; Medicaid: FFS-based: Traditional FFS: 61%; Medicaid:
FFS-based: PCCM: --; Medicaid: Managed care: 39%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: [B]; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: 100%.
State: Ohio; Medicaid: FFS-based: Traditional FFS: 67%; Medicaid: FFS-
based: PCCM: --; Medicaid: Managed care: 33%; [Empty]; Separate SCHIP
program[A]: FFS-based: Traditional FFS: [C]; Separate SCHIP program[A]:
FFS-based: PCCM: --; Separate SCHIP program[A]: Managed care: [C].
State: Pennsylvania; Medicaid: FFS-based: Traditional FFS: [D];
Medicaid: FFS-based: PCCM: 24%; Medicaid: Managed care: 76%; [Empty];
Separate SCHIP program[A]: FFS-based: Traditional FFS: --; Separate
SCHIP program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]:
Managed care: 100%.
State: Tennessee; Medicaid: FFS-based: Traditional FFS: --; Medicaid:
FFS-based: PCCM: --; Medicaid: Managed care: 100%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: --; Separate SCHIP
program[A]: FFS-based: PCCM: --; Separate SCHIP program[A]: Managed
care: [C].
State: Texas; Medicaid: FFS-based: Traditional FFS: 42%; Medicaid: FFS-
based: PCCM: 21%; Medicaid: Managed care: 37%; [Empty]; Separate SCHIP
program[A]: FFS-based: Traditional FFS: --; Separate SCHIP program[A]:
FFS-based: PCCM: --; Separate SCHIP program[A]: Managed care: 100%.
State: Washington; Medicaid: FFS-based: Traditional FFS: 34%; Medicaid:
FFS-based: PCCM: [B]; Medicaid: Managed care: 66%; [Empty]; Separate
SCHIP program[A]: FFS-based: Traditional FFS: 57%; Separate SCHIP
program[A]: FFS-based: PCCM: [B]; Separate SCHIP program[A]: Managed
care: 43%.
State: Number of states using system; Medicaid: FFS-based: Traditional
FFS: 9; Medicaid: FFS-based: PCCM: 7; Medicaid: Managed care: 14;
[Empty]; Separate SCHIP program[A]: FFS-based: Traditional FFS: 3;
Separate SCHIP program[A]: FFS-based: PCCM: 2; Separate SCHIP
program[A]: Managed care: 11.
Source: State data, as of December 2001, except for New York data,
which are as of September 2001.
[A] Includes the separate child health programs in states with
combination or separate SCHIP programs.
[B] Although this delivery system exists in the state, it includes less
than 1 percent of children enrolled in Medicaid or SCHIP and thus was
not included in our study.
[C] Not applicable. State‘s SCHIP program is a Medicaid expansion;
thus, delivery systems are the same as those in the state‘s Medicaid
program.
[D] Delivery system exists for children with special needs, which is
outside the scope of this study. Additionally, state enrolls children
in FFS until they transition to a managed care or a PCCM delivery
system. For example, families with eligible children in Florida are
allowed 90 days in which to select a PCP in managed care or a PCCM;
during these 90 days, they are enrolled in Medicaid FFS.
[E] In Florida, delivery systems under SCHIP vary by age. Families with
children under age 5 can select between managed care and a PCCM, while
older children are limited to managed care service delivery.
[F] Not applicable; Maryland‘s separate SCHIP portion of its
combination program was not operational when our study began and thus
was not included in the study.
[End of table]
Federal Requirements for Access to Care:
A state is required by federal statute to ensure that its payment and
delivery systems will afford beneficiaries‘ access to services similar
to that of its general population;[Footnote 11] further, Medical
assistance must be provided with reasonable promptness.[Footnote 12]
While Medicaid traditional FFS delivery systems have no additional
access requirements, managed care and PCCM delivery systems do. States
are required to ensure that beneficiaries‘ access to care in managed
care and PCCM is equal to that available to beneficiaries in
traditional FFS. On June 14, 2002, CMS published final rules to
implement new provisions the Balanced Budget Act of 1997 set out for
states‘ Medicaid managed care programs. These new rules address the
requirements, prohibitions, and procedures for the provision of
different types of Medicaid managed care and PCCM delivery systems.
Under these rules, which became effective August 13, 2002, states have
until August 13, 2003, to bring all aspects of their state managed care
programs into compliance with the new requirements.[Footnote 13]
States that wish to use managed care and PCCMs to deliver Medicaid
services must have CMS approval to do so. CMS approval is in part
intended to ensure that adequate protections are in place to safeguard
the interests of beneficiaries enrolled in managed care who may find
their freedom to seek the care of any participating provider at any
time more restricted than in FFS. In managed care, states may ’lock in“
beneficiaries to one managed care plan and its network of providers for
up to 1 year in order to provide the plan sufficient time and
opportunity to manage the care of its enrollees most efficiently and
appropriately. States request CMS approval for their managed care
programs through one of two methods: (1) as a waiver from certain
statutory requirements or (2) as an amendment to the state‘s Medicaid
plan.[Footnote 14] Fifteen of the 16 states we reviewed received CMS
approval to provide managed care through two types of waivers of
statutory provisions, program and demonstration waivers, while one
state--Nevada--received approval through a state plan amendment.
Of the states we reviewed, 12 had approved ’freedom-of-choice“ program
waivers, under section 1915(b) of the Social Security Act, which
permitted them to direct beneficiaries to enroll in a managed care
system.[Footnote 15] In reviewing and approving program waivers, CMS
requires states that wish to limit beneficiaries‘ enrollment to managed
care to offer a choice of at least two managed care plans or allow
beneficiaries to choose between one managed care plan and a PCCM
system. CMS also requires states to ensure that (1) managed care plans‘
physician networks under the waiver include approximately the same
number or more physicians than were available before the waiver‘s
implementation and (2) services under program waivers are provided
within reasonable time frames and are furnished within reasonable
distances for the beneficiaries to travel. As a condition of waiver
approval, during the period of our review CMS asked states to specify
whether they had established access-related requirements for
participating plans in areas such as provider capacity, or maximum
times frames for beneficiaries to schedule appointments, travel to
physicians‘ offices, or wait in physicians‘ offices to be seen. CMS did
not require states to establish specific requirements in these areas,
but if they did, they were asked to describe in their waiver
applications how they planned to monitor compliance with any
established requirements. Initial approval of a program waiver is for a
2-year period, at which time the waiver can be reviewed and approved
for renewal by CMS. Waiver renewals can result in changes in specific
requirements for states.
Six of the states we reviewed--Arkansas, California, Maryland,
Massachusetts, New York, and Tennessee--had approved comprehensive
research and demonstration waivers, authorized by section 1115 of the
Social Security Act, to test concepts likely to further program
objectives.[Footnote 16] A demonstration waiver provides a state with
greater flexibility to design its Medicaid programs in areas such as
eligibility standards, covered benefits, and reimbursement rules. In
reviewing and approving demonstration waivers, CMS often establishes
terms and conditions with which states must comply that are more
prescriptive than requirements for program waivers. For example, in
approving demonstration waivers, CMS has required states to (1) specify
ratios that set the maximum number of enrolled beneficiaries per
participating PCP, (2) establish the maximum time or distance for
beneficiaries to travel to a physician‘s office, and
(3) limit beneficiaries‘ waiting times when scheduling appointments for
urgent, routine, or specialty care. Initial approval of a demonstration
waiver is for a 5-year period, at which time the waiver can be reviewed
and approved for renewal by CMS.
In contrast to Medicaid, in their SCHIP programs states may require
mandatory beneficiary enrollment in managed care without offering a
choice among health plans. Federal SCHIP access-related requirements
are also less extensive than those for Medicaid. The SCHIP statute
requires that states have methods in place to ensure access to covered
services, including emergency services, but does not specify precise
requirements.[Footnote 17] States must describe their methods to ensure
access to covered services, including any monitoring procedures, in
their SCHIP state plans. In addition, the SCHIP statute required each
state to submit to the Secretary of HHS a one-time program evaluation
in March 2000.[Footnote 18] States must also submit to the Secretary
annual reports that show their progress toward reaching their strategic
objectives and performance goals, some of which may relate to access to
care.
In Medicaid Managed Care, States Focused More on Setting Plan Network
Requirements than on Monitoring Plans or Analyzing Service Utilization:
In attempting to ensure access to care in Medicaid managed care, states
focused more on setting requirements for managed care plans than on
monitoring compliance with these requirements or on analyzing
beneficiaries‘ use of services. The 14 states we reviewed with Medicaid
managed care programs reported varying levels of effort (1) to
establish certain requirements and standards for participating plans‘
physician networks and to monitor their implementation and (2) to
collect and analyze data on service utilization, such as encounter data
from participating plans and beneficiary satisfaction surveys. State
requirements for plans‘ physician networks varied widely in their
specificity, from broad statements that health plans must have
’adequate“ physician networks serving their enrolled members to very
specific standards that set, for example, a maximum average number of
beneficiaries per PCP or a maximum time frame for scheduling a first
appointment. All but 1 of the 14 states required managed care plans to
routinely submit lists of physicians participating in their networks,
ranging from weekly to quarterly reporting. However, fewer states
independently verified or routinely monitored aspects of the submitted
data on managed care plans‘ provider networks. For example, 8 of the 13
states receiving plans‘ routine lists of participating physicians
periodically verified the number of physicians accepting new Medicaid
patients, but only 5 states analyzed the number of physicians to
identify those participating in multiple plans, which could overstate
overall physician capacity. Moreover, only 5 states routinely or
independently assessed plans‘ compliance with maximum waiting times for
beneficiaries‘ scheduling appointments. In some cases, states left it
to plans to establish time frames for scheduling appointments, rather
than setting statewide standards for all plans.
Beyond network-related requirements and any associated monitoring,
states attempted to assess beneficiaries‘ actual use of services
through various routine data sources and occasional special studies.
Routine data sources included encounter data, where states require
health plans to submit data for each service provided to each enrollee,
periodic assessments of plans‘ performance against standardized
measures, and beneficiary satisfaction surveys. But continuing problems
with the reliability of encounter data--and the fact that standardized
data on plan performance and beneficiary satisfaction surveys were not
representative of all Medicaid managed care enrollees--tended to
undermine the utility of these data sources in describing the
experiences of beneficiaries and their service utilization. The four
states we visited that had experienced the withdrawal of managed care
plans from their Medicaid programs had taken various steps to help
minimize disruption in care for affected beneficiaries. However, it is
not clear to what extent these states monitored service utilization for
beneficiaries affected by such changes and their experiences in
transitioning to new plans and physicians.
Most States Set Plan Network Requirements but Less Frequently Monitored
Plans‘ Compliance:
To oversee access to care in their Medicaid managed care programs, the
states we reviewed established requirements for participating plans
that most often focused on the size and structure of their physician
networks, such as the number and geographic location of PCPs and
specialists, and beneficiaries‘ ability to schedule appointments. Some
states, such as Colorado, Texas, and Washington, had broad requirements
that physician networks must be adequate to serve beneficiaries, as
shown in figure 1. Among the 14 states that used managed care in their
Medicaid programs, broad network requirements were more prevalent for
specialists than for PCPs. In contrast, 11 of 14 states set specific
standards or ratios relating to the number of enrolled beneficiaries
per PCP, and 13 set standards for providers‘ geographic proximity to
beneficiaries, such as the maximum distance or travel time for a
beneficiary to reach a provider‘s office. More variation was evident in
states‘ requirements for plans in terms of appointment scheduling for
beneficiaries. All 14 states set maximum time frames to schedule
routine and urgent appointments, while 6 states also set maximum time
frames for a newly enrolled beneficiary‘s first appointment and 8
states set maximum in-office waiting times.
Figure 1: Selected Medicaid Managed Care Plan Network Requirements and
Standards in 14 States:
[See PDF for image]
[End of figure]
AState does not have a specific standard but does require plans to
monitor this measure.
[B] State only has a standard for selected populations, such as
children with special needs.
States took varying approaches in setting their requirements for plan
networks and appointment waiting times, as shown in table 3. For
example, Florida required physicians to certify that their overall
practice did not exceed 3,000 patients, whereas other states
established specific Medicaid beneficiary-to-PCP ratios ranging from
1,000 to 1 in Pennsylvania to 2,500 to 1 in Tennessee. With regard to
appointment waiting times, some states required plans to set their own
standards rather than establishing a consistent statewide standard.
Table 3: Examples of Specific State Standards for Plan Networks and
Appointment Waiting Times:
Availability measure: Plan network: PCPs; Examples of standards used:
Plan network: * Florida requires physicians to certify that their
overall practice does not exceed 3,000 patients.; * Maryland requires
each health plan to have enrolled beneficiaries-to-PCP ratios that do
not exceed 2,000:1 for adults and PCPs should have no more than 1,500
beneficiaries under age 21. Tennessee uses a maximum 2,500:1
beneficiaries-to-PCP ratio.; * Ohio‘s contracts with health plans
specify a required number of PCPs based on the number of beneficiaries
and plans in a county..
Availability measure: Plan network: Specialists; Examples of standards
used: Plan network: * New York requires each participating plan to have
30 specialties: 14 with specific ratios of enrolled beneficiaries to
specialists and 16 specialties for which health plans must have at
least two providers.; * Ohio requires health plans to have a specified
number of 6 types of specialists, including dentists, allergists, and
general surgeons, per county or service area.; * Pennsylvania requires
health plans to provide beneficiaries with a choice of at least 2
appropriate specialists within a reasonable geographic distance..
Availability measure: Plan network: Geographic distribution; Examples
of standards used: Plan network: * Ohio requires health plans to ensure
that 40 percent of beneficiaries reside within 10 miles of a PCP.; *
Texas requires health plans to have a PCP within 30 miles of a
beneficiary‘s residence and specialty care within 75 miles.; *
Washington requires health plans in urban areas to have two PCPs within
10 miles of 90 percent of beneficiaries; plans in rural areas must have
one PCP within 25 miles of most beneficiaries..
Availability measure: Plan network: Appointment waiting times.
Availability measure: Plan network: First visit; Examples of standards
used: Plan network: * California requires that the first visit of newly
enrolled beneficiaries be within 120 days.; * Michigan requires health
plans to set a standard for when new beneficiaries should first visit a
PCP.; * Pennsylvania requires that health assessments, general physical
examinations, or first examinations be scheduled within 3 weeks of
enrollment..
Availability measure: Plan network: Appointment scheduling; Examples of
standards used: Plan network: * California requires health plans to
provide urgent care within 24 hours and to set a standard for routine
appointments.; * Nevada requires appointments for urgent care within 2
days, and that routine care be scheduled within 2 weeks of request.; *
New York requires that appointments be scheduled within 24 hours for
urgent care, 4 weeks for routine and preventive care, and 4 to 6 weeks
for specialist care..
Availability measure: Plan network: In-office waiting time; Examples of
standards used: Plan network: * Florida requires that explanations be
given to beneficiaries if they must wait more than 30 minutes; if the
wait will exceed an hour, the provider is to reschedule the
appointment.; * Michigan requires health plans to set an in-office
waiting time standard.; * Pennsylvania requires that beneficiaries wait
no more than 20 minutes on average or 1 hour maximum past their
scheduled appointment times..
Source: GAO analysis of states‘ data, as of December 2001.
[End of table]
Routinely monitoring plan performance, especially with established
network requirements and standards, is critical because providers can-
-and do--change their participation in Medicaid managed care, which in
turn can affect beneficiaries‘ access to care. In some cases, a state
may not have set a specific network requirement but nonetheless
independently monitors plan performance. States that monitor the extent
to which participating plans‘ network providers are actually available
to beneficiaries are better able to systematically identify and respond
to access problems. For example, see the following.
* In 1999, Tennessee reviewed each managed care plan‘s contracts with
its providers and contacted providers directly to independently verify
their participation with the plan and whether they were open to new
Medicaid patients. The state found that, for one health plan, only 44
percent of the participating PCPs accepted new Medicaid patients; of
the remaining 56 percent of PCPs, 33 percent had Medicaid patients but
would not accept any new ones, and 23 percent either did not accept any
Medicaid patients or could not be reached by telephone. Determining
that the plan did not comply with requirements for PCP availability,
the state required the plan to add providers who would accept new
Medicaid beneficiaries before assigning any additional beneficiaries to
the plan. State officials also reported that they now conduct a regular
telephone survey of providers to verify the provider data that
participating plans submit.
* Washington has a broad requirement that physician networks be
adequate to serve enrolled beneficiaries but does not set as many
additional specific standards as do some other states. The state does,
however, require participating plans to routinely report which
physicians are participating in their Medicaid networks and
independently verifies plan reports by periodically placing test calls
to physicians. Washington also compiles the physician-level information
into a centralized database to review physician participation across
health plans in order to better ensure that capacity is not overstated.
To monitor plan performance in terms of provider availability to
beneficiaries, 13 of the 14 states we reviewed routinely obtained
periodic data from participating plans on the number of physicians in
their networks, ranging from weekly reports in Maryland to quarterly
reports in California, Massachusetts, and New York. As a part of this
routine data collection, 12 states also reviewed the geographic
distribution of physicians in their networks. Fewer states, however,
took additional steps to determine, on an ongoing basis, whether the
plan-submitted data adequately reflected network capacity to serve
Medicaid beneficiaries. For example, in 9 states the plans‘ provider
lists identified those physicians who were accepting new Medicaid
patients, which would help indicate the extent to which plan networks
were open to new public beneficiaries, and 7 states independently
verified the accuracy of the submitted provider lists. Five states
analyzed information across the plans‘ provider lists to help identify
the unduplicated number of PCPs available to the Medicaid managed care
population and to help avoid overstating overall physician
availability. (See fig. 2.):
Figure 2: Variation in 14 States‘ Monitoring of Medicaid Managed Care
Plans‘ Provider Information:
[See PDF for image]
[End of figure]
AIn some counties in California, plans are required to update their
provider lists semiannually.
[B] The state imposed specific standards regarding the number of PCPs
in a health plan‘s network (such as beneficiaries-to-PCP ratios) but
did not account for providers that may be enrolled in multiple plans.
[C] The state plans to reinstitute requirements for health plans to
submit provider information quarterly in the next contract period.
[D] The state requires health plans to limit the total number of
patients a physician may have across all lines of business (for
example, private pay, Medicaid, and other types of insurance coverage),
but the state does not monitor compliance with this limit.
[E] The state does not obtain lists from health plans that indicate the
number of providers accepting new patients. Instead, it tracks the
number of patients each provider is willing to accept through a health
plan and compares this information to the number of beneficiaries
enrolled with a particular physician. Based on this comparison, the
state identifies which physicians should be accepting new patients.
Compared to state monitoring of provider network information, even
fewer states monitored compliance with their requirements for
appointment waiting times. Five of the 14 states with Medicaid managed
care--California, Massachusetts, New York, Tennessee, and Washington--
routinely collected data or otherwise independently verified health
plans‘ compliance with specific appointment-related standards such as
maximum time frames to schedule an initial health assessment (first
visit) or routine-care appointment and in-office waiting times. To
determine whether beneficiaries newly enrolled in a plan received
initial health assessments within 120 days of enrollment, California
regularly reviews health plan reports and physician office medical
records for a sample of new beneficiaries in each plan. To verify
physician compliance with appointment scheduling standards, New York
makes random calls to physicians (200 offices per plan service area per
year), requesting information on the next available appointment for a
specified need, such as routine care, urgent care, or after-hours care.
In contrast, Massachusetts directs plans to develop and monitor
compliance with their own appointment scheduling requirements, and the
state annually reviews and critiques the methodology and results
reported by each plan.
Absent routine verification or monitoring of plans‘ compliance with
network and availability requirements, states do not have an adequate
assurance that such requirements are having their intended effect on
beneficiaries‘ access to managed care providers. Officials in one state
that did not verify requirements indicated that the standards served as
a basis for legal recourse in the event that beneficiaries raised
complaints regarding appointment availability. Undertaking additional
measures to verify plan compliance, as Tennessee did, can identify more
comprehensive network problems that limit access to care for Medicaid
beneficiaries and that might otherwise go undetected.
New Regulations May Alter States‘ Approaches to Monitoring Managed
Care:
The new Medicaid managed care regulations, effective August 13, 2002,
and to be fully implemented by August 13, 2003, will likely require
some states to alter their approaches to requirements for their
participating plans and provider networks. In general, the regulations
require that states ensure--through their contracts with managed care
plans--that participating plans demonstrate their capacity to serve the
needs of their enrollees for any specific standards that states set for
access to care. Among other things, the regulations require states to
ensure that participating plans:
* maintain and monitor their networks of providers to provide adequate
and timely access to all services covered under their contracts with
the states, including monitoring the numbers of network providers who
are not accepting new Medicaid patients;
* ensure that network providers offer hours of operation that are no
less than the hours offered to commercial enrollees or comparable to
those of Medicaid FFS;
* make services included in the contract available 24 hours a day, 7
days a week, when medically necessary; and:
* establish mechanisms to ensure compliance by providers with state
standards for access to care.
The regulations require states to certify to CMS--at the time the state
enters into a contract with a plan or when there are significant
changes that would affect the ability of plans to provide adequate
capacity or services--that plans have complied with state requirements
for the availability of services covered by managed care contracts. To
the extent that states have not made specifications regarding health
plan physician network capacity or assurances of access to care, states
may need to revise their contracts with plans to comply with this new
requirement. States that verify or monitor participating plans‘ actual
compliance with the terms of their contracts will likely have greater
direct and routine information on whether the access-related
requirements they have set out for participating plans are achieving
their intended benefit for covered beneficiaries.
Routine Monitoring of Service Utilization Often Handicapped by Poor
Data:
Determining the extent to which Medicaid beneficiaries are utilizing--
and are satisfied with--covered program services is an important test
of the effectiveness of any state requirements for managed care plans‘
network capacity and accessibility. To assess beneficiaries‘ service
utilization and satisfaction, the states we reviewed generally required
participating plans to routinely provide data from two key sources:
encounter data, which are individual-level data on service use, and
HEDIS, which provides comparative information across participating
plans for designated service measures. Most states also administered
CAHPS, which is a standardized beneficiary satisfaction survey.
However, for the majority of states we reviewed, the utility of these
data for routine monitoring was often handicapped because of the
frequent failure of plans to submit reliable encounter data and the
exclusion of significant shares of beneficiaries from the HEDIS and
CAHPS data. CAHPS survey results were further limited by poor response
rates in most states. A few states reported making sufficient progress
in their efforts to improve the quality of their encounter data that
they could use them to routinely analyze service utilization in their
Medicaid managed care programs. In addition to these routine data
sources, a few states reported conducting occasional special studies
that enabled them to identify and focus on access issues pertaining to
beneficiaries‘ use of services or satisfaction with services received.
Encounter Data:
Encounter data are intended to capture information on beneficiaries‘
use of primary and preventive care as well as other services, such as
emergency room visits. These data can help states identify patterns of
care along several dimensions, such as by type of visit or patient
(such as well-child visits by age), by health condition or disorder
(such as asthma or diabetes), and by plan. As a condition of their
approved federal managed care waivers, states must require Medicaid
managed care plans to submit encounter data. But obtaining reliable and
useful encounter data has proven to be a difficult undertaking, as we
have earlier reported.[Footnote 19] According to CMS and several of the
states we reviewed, many states continue to struggle with obtaining
reliable and complete encounter data. One state we contacted found that
the lack of standardized provider coding and formatting procedures
resulted in missing and incomplete data. As a result, only 16 percent
of the provider identifiers in the submitted encounter data could be
matched to the state‘s Medicaid provider master file. Another state
noted that its encounter data were of limited use because many health
plans were unable to obtain complete data from their providers. Two of
the 14 states we reviewed reported that obtaining complete encounter
data was more problematic for health plans that paid their physicians a
monthly capitated payment that is not linked to the delivery of
specific services.
For states providing Medicaid services through managed care, encounter
data often are the basis for states‘ responses to federal reporting
requirements under Medicaid‘s Early and Periodic Screening, Diagnostic
and Treatment (EPSDT) services. EPSDT is designed to provide children
and adolescents with access to comprehensive, periodic evaluations of
health, developmental, and nutritional status, as well as hearing,
vision, and dental services.[Footnote 20] The EPSDT annual reports that
states must submit to CMS are designed to capture, by age group,
information such as the number of children who (1) received EPSDT
health screenings,[Footnote 21] (2) were referred for corrective
treatment, (3) received dental treatment or preventive services, and
(4) were enrolled in managed care plans. However, we have previously
reported that managed care plans, particularly those that pay their
participating physicians on a capitated basis, often had difficulty
collecting and reporting complete and accurate EPSDT data.[Footnote 22]
Thus, EPSDT reports that are based on encounter data are often
incomplete or inaccurate, compromising the reliability of states‘ data
on use of these services.
Despite these widespread problems with encounter data, a few states we
reviewed noted that the reliability and usefulness of their encounter
data have improved over time. Maryland, New York, and Michigan, for
example, reported sufficient progress with improving the quality of
their encounter data that they are now able to use them to analyze
service utilization in their Medicaid managed care programs, as
indicated below.
* Maryland officials noted that after spending several years developing
and refining its system for obtaining encounter data, the state is now
able to use them as the basis to make risk-adjusted payments to plans
and to routinely assess Medicaid managed care beneficiaries‘
utilization of well-child, ambulatory, and emergency room visits. The
state publicly reports performance information by health plan, creating
a strong incentive for health plans to ensure that all encounters are
reported. To ensure that the reported encounter data accurately portray
services delivered, the state conducts validation studies on the data
submitted by health plans. The state also reviews the distribution and
frequency of diagnoses reported through the encounter data over time to
monitor whether the mix of diagnoses across the population changes.
* New York established a data warehouse for Medicaid managed care in
1997. The warehouse includes encounter data submitted by health plans
as well as data from other providers‘ FFS claims for reimbursement for
services provided to managed care beneficiaries outside of their health
plan. A variety of reports on utilization and access data are generated
and shared with plans on a restricted access web site.
* Michigan is developing a data warehouse that will combine managed
care encounter data with FFS claims and public health data, such as
vital statistics and immunization records, into a single information
system that it will use to analyze beneficiaries‘ service utilization.
The data warehouse will also be able to create utilization profiles by
managed care plan. The state has begun testing the data warehouse that
is expected to be operational within the next year.
HEDIS:
HEDIS is a set of standardized performance measures that helps
purchasers and consumers compare the performance of managed health care
plans.[Footnote 23] HEDIS performance measures are organized into eight
categories, four of which include measures directly related to
beneficiary service utilization.[Footnote 24] The Medicaid version of
HEDIS includes various access-related measures that attempt to capture
beneficiaries‘ use, often by age, of various preventive and other
services from specified providers, as illustrated in table 4. (See app.
I for a more detailed list of Medicaid HEDIS measures related to
service utilization.):
Table 4: Examples of Medicaid HEDIS Measures Related to Service
Utilization for Children:
General HEDIS category: Effectiveness of care; Specific HEDIS measure:
Childhood immunization status; Description: The percentage of enrolled
children who turned 2 years old during the measurement year, who were
continuously enrolled for 12 months preceding their second birthdays
and who were identified as having the recommended number of specific
immunizations by their second birthdays.
Specific HEDIS measure: Adolescent immunization status; Description:
The percentage of enrolled adolescents who turned 13 during the
measurement year, who were continuously enrolled for 12 months
immediately preceding their 13th birthdays and who were identified as
having had the recommended number of specific immunizations by their
13th birthdays.
Specific HEDIS measure: Use of appropriate medications for people with
asthma; Description: Whether members with persistent asthma are being
prescribed medications acceptable as primary therapy for long-term
control of asthma.
General HEDIS category: Access/ availability of care; Specific HEDIS
measure: Children‘s access to PCPs; Description: The percentage of
enrolled members age 12 months through 24 months, 25 months through 6
years, and 7 years through 11 years who had a visit with a network
PCP.
Specific HEDIS measure: Annual dental visit; Description: The
percentage of enrolled members age 4 through 21 who were continuously
enrolled during the measurement year and who had at least one dental
visit during the measurement year (when dental services are a covered
benefit under Medicaid).
General HEDIS category: Use of services; Specific HEDIS measure: Well-
child visits in years 3, 4, 5, and 6 of life; Description: The
percentage of members who were 3, 4, 5, or 6 years old during the
measurement year, who were continuously enrolled during the measurement
year, and who received one or more well-child visits with a primary
care practitioner during the measurement year.
Specific HEDIS measure: Adolescent well-care visits; Description: The
percentage of enrolled members who were age 12 through 21 years during
the measurement year, who were continuously enrolled during the
measurement year, and who had at least one comprehensive well-care
visit with a PCP or an obstetrician/gynecologist practitioner during
the measurement year.
Source: NCQA, HEDIS 2000: Technical Specifications (Washington, D.C.:
1999).
[End of table]
Twelve of the 14 states we reviewed used HEDIS measures to help assess
Medicaid beneficiaries‘ utilization of services. Eleven states required
participating plans to submit HEDIS performance results, while 1 state-
-Ohio--conducted its own HEDIS analysis using encounter data submitted
by plans.[Footnote 25] Some states used the full set of HEDIS measures,
while others used selected measures corresponding to areas of interest.
Despite the potential of HEDIS to provide valuable information
regarding beneficiaries‘ use of managed care services, its narrow focus
in identifying beneficiaries to be included in the assessments often
limits the ability to generalize results to all beneficiaries within a
plan or within a state. Many HEDIS measures require beneficiaries to
have 12 months of continuous enrollment in a single managed care plan
in the assessment year in order to be included in the
measures.[Footnote 26] As a measurement criterion, the continuous
enrollment requirement is intended to ensure that comparisons of
performance across health plans are made on the basis of sample
populations that have been enrolled for similar periods of time.
However, because beneficiaries‘ average length of time in the Medicaid
program can be less than 12 months--ranging from 6 to 9 months in three
states--this 12-month enrollment requirement excluded at least one
quarter of Medicaid beneficiaries from most of the states we reviewed
and more than half in four states, as shown in table 5.[Footnote 27]
Consequently, HEDIS measures may not provide a representative measure
of service utilization for a significant share of children covered by
Medicaid managed care. Another limitation of the HEDIS measures is that
they are often based on encounter data and are thus subject to the
reliability concerns previously raised.
Table 5: Estimated Percentage of Medicaid Children Excluded from HEDIS:
State[A]: Colorado; Percentage excluded from HEDIS[B]: 79.
State[A]: Ohio; Percentage excluded from HEDIS[B]: 75.
State[A]: Washington; Percentage excluded from HEDIS[B]: 52.
State[A]: Florida; Percentage excluded from HEDIS[B]: 51.
State[A]: New York; Percentage excluded from HEDIS[B]: 40.
State[A]: Michigan; Percentage excluded from HEDIS[B]: 33.
State[A]: Maryland; Percentage excluded from HEDIS[B]: 32.
State[A]: Pennsylvania; Percentage excluded from HEDIS[B]: 31.
State[A]: Massachusetts; Percentage excluded from HEDIS[B]: 29.
State[A]: California; Percentage excluded from HEDIS[B]: 26.
State[A]: Illinois; Percentage excluded from HEDIS[B]: 24.
State[A]: Nevada; Percentage excluded from HEDIS[B]: [C].
State[A]: Tennessee; Percentage excluded from HEDIS[B]: [D].
State[A]: Texas; Percentage excluded from HEDIS[B]: [D].
Source: GAO analysis of states‘ data, as of December 2001.
[A] States were asked for enrollment information for the most recent
year for which data were available, which was generally 2001.
[B] Percentages represent the portion of the population excluded from
the required sample for some of the HEDIS measures because they were
enrolled for less than 12 months.
[C] State could not provide exclusion data.
[D] State does not use HEDIS data.
[End of table]
Several states we reviewed provided examples of how they used the HEDIS
data they received from participating plans. These included using the
information to compare each plan‘s performance against national
Medicaid averages for selected measures and developing report cards to
compare results across plans. Given issues we identified with the
completeness of the data, however, such uses and comparisons may not be
reliable indicators of beneficiaries‘ use of services and may render a
false impression of beneficiaries‘ actual experience in service
utilization.
CAHPS:
State Medicaid managed care programs are required to have an internal
quality assurance system, which can involve administering beneficiary
satisfaction surveys.[Footnote 28] Thirteen of the 14 states we
reviewed reported using CAHPS to assess beneficiaries‘ experiences with
their Medicaid managed care plans.[Footnote 29] CAHPS is a standardized
survey designed to compare the performance of managed care plans on the
basis of beneficiaries‘ perceptions regarding the care they received
through their plans.[Footnote 30] The CAHPS survey covers a range of
topics related to service utilization, including appointment
scheduling, waiting time in a physician‘s office, and the use of
specialty services, as shown in table 6.
Table 6: Examples of Beneficiary Satisfaction Questions for Children
Covered by CAHPS:
Measure: First visit; Question: * Did you get an appointment for your
child‘s first visit to a doctor or other health care provider for a
checkup, or for shots or drops, as soon as you wanted?.
Measure: Appointment scheduling; Question: * In the last 6 months, how
often did your child get an appointment for regular or routine health
care as soon as you wanted?; * In the last 6 months, when your child
needed care right away for an illness or injury, how often did your
child get care as soon as you wanted?.
Measure: Ambulatory care; Question: * In the last 6 months (not
counting times your child went to an emergency room), how many times
did your child go to a doctor‘s office or clinic?.
Measure: In-office waiting time; Question: * In the last 6 months, how
often did your child wait in the doctor‘s office or clinic more than 15
minutes past the appointment time to see the person your child went to
see?.
Measure: Referral to specialist; Question: * In the last 6 months, how
much of a problem, if any, was it to get a referral to a specialist
that your child needed to see?.
Source: CAHPS 2.0, Child Medicaid Managed Care Questionnaire and Child
Supplemental Questions, (Rockville, Md.: AHRQ, 1998).
[End of table]
Like HEDIS, however, information from CAHPS is only gathered from a
subset of beneficiaries. CAHPS has a 6-month continuous enrollment
requirement for Medicaid beneficiaries to be included in the survey
sample. While this is a shorter minimum enrollment period than for
HEDIS, it still resulted in excluding about one quarter or more of
covered beneficiaries in five states we reviewed, and nearly half or
more in two states, as shown in table 7. Moreover, several states using
CAHPS reported that they had low response rates from the sampled
population; in some cases, surveys targeted only those beneficiaries
with telephones, a practice that has the potential to bias the results
for beneficiaries who could not be reached by that method.[Footnote 31]
Table 7: Estimated Percentage of Medicaid Children Excluded from CAHPS:
State[A]: Colorado; Percentage excluded from CAHPS[B]: 61.
State[A]: Ohio; Percentage excluded from CAHPS[B]: 49.
State[A]: Texas; Percentage excluded from CAHPS[B]: 31.
State[A]: Florida; Percentage excluded from CAHPS[B]: 30.
State[A]: Washington; Percentage excluded from CAHPS[B]: 24.
State[A]: Michigan; Percentage excluded from CAHPS[B]: 17.
State[A]: Maryland; Percentage excluded from CAHPS[B]: 16.
State[A]: Massachusetts; Percentage excluded from CAHPS[B]: 15.
State[A]: New York; Percentage excluded from CAHPS[B]: 15.
State[A]: Pennsylvania; Percentage excluded from CAHPS[B]: 13.
State[A]: California; Percentage excluded from CAHPS[B]: 11.
State[A]: Illinois; Percentage excluded from CAHPS[B]: 10.
State[A]: Nevada; Percentage excluded from CAHPS[B]: [C].
State[A]: Tennessee; Percentage excluded from CAHPS[B]: [D].
Source: GAO analysis of states‘ data, as of December 2001.
[A] States were asked for enrollment information for the most recent
year for which data were available, which was generally 2001.
[B] Percentages represent the portion of the population excluded from
CAHPS because this group was enrolled for less than 6 months.
[C] State could not provide data.
[D] Tennessee does not use CAHPS, although it does conduct a state-
designed survey of a sample of all state residents about insurance
coverage and satisfaction with services, including access to care.
[End of table]
Gauging beneficiary satisfaction with services solely through a
satisfaction survey is an inherently difficult process, especially when
a sample is not representative or response rates are low. To augment
information on beneficiary satisfaction, states also had available the
results of their complaints and grievances processes, which they are
required to have as a condition of their managed care programs. Nearly
all of the states we reviewed with Medicaid managed care operated a
central hotline or complaint number, where beneficiaries could obtain
program information or request assistance locating providers in
addition to filing complaints. The states we reviewed generally focused
on ensuring that complaints and questions raised by beneficiaries‘
calls were addressed. For example, five states--Ohio, Maryland,
Michigan, New York and Washington--had information databases that
tracked complaints from their inception to their resolution. New York,
Ohio, and Washington complaint reports were also analyzed by managed
care plan, which allowed officials to identify any trends in
beneficiary complaints.
As a tool to assess overall problems with access to care, records of
complaints and grievances had several limitations. In some cases,
states‘ hotline or complaint data did not distinguish between requests
for assistance and complaints about provider services, thus making it
difficult to assess the extent of any systemic access problems. In
addition, a small number of complaints could be difficult to interpret
at face value; while few complaints or grievances could indicate
overall satisfaction with care, it could also indicate a general lack
of knowledge about or ability to file a formal complaint or grievance.
A small number of complaints also could limit the state‘s ability to
identify any specific trends of systemic problems with access to care
with a specific plan or within a state‘s Medicaid managed care program
as a whole.
Special Studies:
A few states we contacted reported that they occasionally conducted
special studies, in addition to any routine monitoring they did, to
assess service utilization issues for their Medicaid beneficiaries. For
example, Maryland‘s 4-year evaluation of its Medicaid managed care
program, published in January 2002, concluded that providers and
consumers felt that PCP networks were ’under stress“ in certain areas
of the state, with a notable lack of physicians in rural areas of the
state.[Footnote 32] The evaluation also identified significant
inaccuracies with plan-submitted data on physician providers, including
duplicate provider entries, incorrect provider affiliation status with
participating plans, and missing information. As a result, the state
took steps to develop and implement more rigorous methods of monitoring
plan-submitted data. In particular, the state now monitors plans‘ PCP
networks, including verification calls to samples of physicians, so
that PCP shortage areas can be identified and addressed. In the future,
the state also plans to develop more specific standards for commonly
used specialists and monitor plans‘ compliance with these standards.
In 2001, Washington conducted a survey of new Medicaid managed care
beneficiaries in 14 counties as a result of concerns raised by
beneficiary advocates in light of managed care plans‘ withdrawal from
program participation. The study examined these beneficiaries‘
experiences with accessing medical care, including emergency room use.
The study found that 90 percent of new beneficiaries reported having a
PCP after enrollment in Medicaid, compared to 62 percent having a PCP
before enrollment in Medicaid managed care. Additionally, there were no
significant differences between the experiences of managed care and FFS
beneficiaries who had obtained medical, specialist, or emergency room
care. However, the study did find that the majority of beneficiaries
were unfamiliar with several key processes concerning their managed
care plans, such as how to change PCPs within a health plan, contact
their health plans when questions or problems arose, and make
complaints. Based on these findings, the state plans to work with
managed care plans to improve beneficiaries‘ awareness regarding PCP
selection and communication with their health plans.
States Attempted to Minimize Impact of Managed Care Plan Withdrawals on
Access to Care, but Effect on Beneficiaries Is Uncertain:
The managed care industry--in the commercial as well as public sectors-
-has experienced considerable changes in recent years following periods
of rapid entry of multiple managed care plans in certain markets and
subsequent retrenchment based on plans‘ willingness or ability to
compete in those markets. Many communities and states have experienced
changes in the number of managed care plans as a result of numerous
health plan mergers, acquisitions, and closures as the managed care
industry has evolved and matured. State Medicaid programs have often
been affected by the withdrawal of some managed care plans from their
programs; in some cases, states have intentionally acted to reduce the
number of participating plans. The four states we visited--
Massachusetts, Ohio, Tennessee, and Texas--had experienced such changes
to varying degrees. These states had taken various measures to help
minimize any adverse effects on beneficiaries‘ access to care due to
participating plans leaving the Medicaid program. It is not clear,
however, to what extent these states‘ efforts had been successful in
helping beneficiaries transition smoothly to new health plans and
physicians and thus avoid problems with access to care.
The potential amount of disruption that occurs when a health plan
withdraws from a state or community can vary considerably, depending on
a number of circumstances. Health plan mergers can result in minimal
changes for beneficiaries if they are able to maintain established
relationships with their providers and can even strengthen the network
of available providers within a plan. In Massachusetts, for example, a
merger between two health plans in the early 1990s was considered by
state officials to have increased physician availability for Medicaid
beneficiaries enrolled in managed care. Officials in Massachusetts also
noted that reductions in the number of health plans ensured that
participating plans have enough enrolled beneficiaries to spread the
costs and risks associated with capitation payments. In other cases,
however, the extent of disruption may be more severe, particularly when
large numbers of beneficiaries are affected and a significant number of
plans struggle to remain financially viable.
Each of the four states we visited experienced varying levels of health
plan withdrawals from their Medicaid managed care programs. Plan
withdrawals over several years have affected almost 50 percent of
beneficiaries in Tennessee and over 15 percent in Ohio, raising
concerns about the accessibility of care to beneficiaries in these
states. The magnitude of health plan withdrawals in Tennessee
necessitated state efforts to recruit additional plans, at least one of
which was later found by the state to have deficiencies related to
failure to pay physicians accurately and promptly. In Ohio, at least
one health plan that withdrew from the state program also failed to pay
some of its network providers for services already rendered. In such
cases, delayed reimbursement by managed care plans can seriously
jeopardize providers‘ willingness to continue participating in the
Medicaid program and provide services to eligible beneficiaries. In
contrast to Tennessee and Ohio, plan withdrawals in Massachusetts and
Texas have affected a smaller share of beneficiaries. Massachusetts
estimated that about 4 percent of its beneficiaries were affected by an
early period of plan fluctuation as the state was implementing its
mandatory managed care program; since 2000, however, the program has
been stable with the same four managed care plans participating. In
Texas, approximately 1 percent of beneficiaries have been affected by
withdrawals of participating plans since the state implemented managed
care in 1996.
To avoid disruptions in care for beneficiaries when plans ceased their
participation in the Medicaid program, these states had implemented
various procedures to help smooth beneficiaries‘ transition to other
plans or providers. For example, in cases where a withdrawing health
plan intended to sell its membership to another plan, Ohio first
compares the provider network of the withdrawing plan with the health
plan that is purchasing the membership. The state does not approve the
sale of membership unless most of the providers participating in the
withdrawing plan also participate in the purchasing plan. In other
cases, a state‘s contract with its managed care plans required certain
actions. Ohio‘s contract, for example, requires a minimum of 75 days
advance notice of a plan‘s intention to terminate its participation in
the program and includes provisions to collect a monetary assurance
from the withdrawing plan or to withhold payments until all contractual
requirements are completed, including required payments to network
providers. Ohio and Texas provided examples of efforts to inform
beneficiaries directly affected by a plan‘s withdrawal about options
available to them to continue care, such as information on other
participating plans and how to choose another plan. These four states
indicated that they believed their efforts to respond to changes in
managed care participation were sufficient to minimize disruption to
care for Medicaid-eligible beneficiaries. However, the extent to which
the states‘ efforts adequately ensured beneficiaries‘ access to
continuous care was uncertain. Appendix II provides more detail on
managed care plan withdrawals in these four states.
For Medicaid FFS, State Requirements for Providers and Monitoring of
Service Utilization Were More Limited:
For states‘ FFS-based Medicaid delivery systems, which continue to
serve the majority of children in half of the states we reviewed,
requirements for participating providers and monitoring of provider
availability were significantly more limited than for managed care.
State analysis of service utilization data to assess the frequency and
patterns of care that beneficiaries received was also more limited,
despite the ready availability of such data through states‘ claims
payment systems. For traditional FFS programs, beneficiaries may seek
care from any providers participating in the Medicaid program and may
change providers at any time if they are dissatisfied. However,
Medicaid beneficiaries‘ ability to easily change providers is dependent
on the number, type, and location of providers willing to take new
Medicaid patients, which in turn is strongly influenced by Medicaid
payment rates and associated administrative processes. We found that
Medicaid FFS payment rates were significantly lower than rates for
comparable Medicare services in the majority of states we reviewed,
which can discourage provider participation and thus restrict
beneficiaries‘ access to a broad supply of providers. States that used
PCCM programs as part of their FFS service delivery systems were
somewhat more prone to set certain requirements for participating
PCCMs, such as a maximum number of assigned beneficiaries and their
geographic proximity to beneficiaries, than were states with
traditional FFS systems. States with FFS programs generally did not set
requirements for specialists or for physicians‘ appointments, such as
maximum waiting times to schedule an appointment, as they did for their
managed care plans. States were more likely to conduct beneficiary
satisfaction surveys for their PCCM programs than for their traditional
FFS systems; the survey results, however, had the same constraints as
previously discussed for managed care due to the limited share of
beneficiaries participating in the surveys and low response rates.
Low FFS Payment Rates Can Reduce Provider Participation and Restrict
Access to Care:
States are required to ensure that their Medicaid service delivery and
payment systems will afford beneficiaries access to services similar to
those provided to the state‘s general population. To do this, states
determine which providers may enroll in the Medicaid program to provide
services, set payment rates for covered services, and pay claims that
providers submit for the services they provide. In several of the
states we reviewed with Medicaid FFS programs, program officials said
that provider survey information and beneficiary complaint data
suggested that low payment rates, slow payment, and other
administrative issues deterred physicians in primary care or in some
specialties from participating in the program. As we reported earlier,
if payment rates decline to the point that they cause physicians to
leave Medicaid or to reduce the number of beneficiaries they serve,
then beneficiary access may be restricted.[Footnote 33]
Our analysis of payment rates indicated that Medicaid FFS payments to
physicians for primary and preventive services for children were often
significantly lower than what Medicare paid for comparable services in
many of the states we reviewed. For the 13 states that paid physicians
on a FFS basis for Medicaid-eligible children, payment rates ranged
from 32 percent to 89 percent of Medicare rates. Nine of these states‘
Medicaid rates were two-thirds or less of Medicare rates for comparable
services. (See app. III for more detail.) Officials in many of these
states said that Medicaid rates were also below those of commercial
payers, although they generally had not conducted systematic studies to
document these differences.
Most Traditional FFS Programs Set Few Goals Regarding the Number of
Providers, and Conducted Minimal Monitoring of Service Utilization:
Despite the potential for low FFS rates to limit the number of
providers willing to participate in the program, the nine states we
reviewed with traditional FFS programs did not set specific goals for
the number of physicians participating in their Medicaid programs and
did not actively monitor the number and location of providers.[Footnote
34] While states had lists of physicians who were enrolled as Medicaid
providers and who submitted claims for services provided, in most cases
these lists were not frequently or comprehensively updated and thus did
not provide an accurate count of actively participating physicians.
Some states‘ Medicaid physician databases included physicians who had
not provided services to Medicaid patients for years. In one state, the
database doublecounted providers who had more than one service location
or billing identifier. In addition, although states have claims data
that serve as the basis for paying providers for services rendered,
only some analyzed this information to identify PCPs, specialists, or
other providers who were actively treating Medicaid beneficiaries. Even
when they did, states often defined ’active“ providers to include those
who submitted a single claim during the past year. With respect to
appointments, such as maximum waiting times to schedule a routine or
urgent appointment, none of the states we reviewed with traditional FFS
programs had specific standards comparable to those we saw for managed
care programs.
States also did little to monitor service utilization by Medicaid
beneficiaries participating in traditional FFS care despite having a
ready source of data in their claims payment systems. Claims data
contain the type and frequency of services Medicaid beneficiaries have
received and the type of provider delivering the care, which can be
used to analyze service utilization. States did report using claims
data to develop utilization statistics to meet federal requirements for
annual reporting on EPSDT services for children. However, we have
reported earlier that state EPSDT reports are often incomplete and
unreliable, thus compromising their utility in assessing whether
children are receiving required services.[Footnote 35] Beyond EPSDT,
only one state with a Medicaid traditional FFS system reported
analyzing claims data to evaluate access to care on primary and
preventive services, such as annual well-child and dental
visits.[Footnote 36] Rather than evaluate access to primary care, at
least three states used claims data to assess inappropriate utilization
of higher-cost services, such as emergency room care. For example,
Texas collects and analyzes information on beneficiaries who
potentially overuse care--defined as those at or above the 90th
percentile of use for particular services, including physician,
emergency room, and pharmacy services. Patients suspected of misusing
services may be restricted to using a specific physician or pharmacy,
with the goal of reducing their use of services to a more appropriate
level.
Four of the nine states with traditional FFS systems reported
periodically using beneficiary satisfaction surveys, such as CAHPS, to
help assess issues regarding access to care. These states were
Colorado, Illinois, Ohio, and Washington. As with Medicaid managed
care, however, the utility of these surveys is diminished when there
are low response rates and a lack of beneficiary representation in the
sample selection. In one state, the survey sample was limited to
individuals who had received at least one service in the prior 6
months, thus excluding individuals who may have tried but failed to
obtain services. Another state reporting a low beneficiary response
rate found that while the cooperation rate was high among those who
were reached, many potential respondents in the survey sample could not
be contacted because of address or telephone number changes.
PCCM Programs Had Some Requirements for Providers, but Monitoring of
Service Utilization Was Limited:
States‘ PCCM programs are a hybrid of FFS and managed care service
delivery approaches. They emulate FFS programs in the sense that the
state has a direct relationship with providers who are enrolled to
participate in the program and paid retrospectively for services
actually delivered. PCCM programs share characteristics of managed care
in the sense that beneficiaries are assigned to a PCCM--a physician, or
a practice or other entity--that is responsible for coordinating their
care as a case manager. The seven states we reviewed with PCCM programs
had more requirements for participating PCCMs than they did for
providers in traditional FFS programs, but fewer than PCPs in managed
care programs.[Footnote 37] Similar trends were evident in terms of
states‘ routine monitoring of PCCM availability and beneficiaries‘
service utilization: more than FFS, less than managed care.
The states we reviewed with Medicaid PCCM programs most often set
requirements for the maximum number of beneficiaries that a PCCM could
serve and the geographic proximity of PCCMs to their enrolled
beneficiaries. None set limits on the number of beneficiaries a
specialist could serve, and few set specific standards for appointment
waiting times with their PCCMs; overall, PCCM programs had fewer
standards than those imposed under managed care, as shown in figure 3.
Figure 3: Selected Requirements for Medicaid PCCM Providers in Seven
States:
[See PDF for image]
[End of figure]
AThis type of standard exists in this state‘s managed care program but
not its PCCM program.
[B] This type of standard exists in the state‘s PCCM program, but not
its managed care program.
States‘ PCCM capacity requirements were most often based on setting a
maximum number of beneficiaries that a PCCM or practice could serve,
ranging from 1,000 beneficiaries per PCCM in Arkansas and Pennsylvania
to 1,500 in Florida and Massachusetts. Louisiana set a limit of 1,200
beneficiaries per PCCM, or 4,800 for a group practice, and allowed an
additional 300 beneficiaries to be enrolled for each nurse
practitioner. With regard to geographic requirements, all five of the
PCCM programs that had requirements for this standard specified a basic
maximum of 30 minutes or 30 miles for beneficiaries to reach their
PCCMs. Four of these states set a higher maximum for rural areas--such
as 50 miles in Colorado or 60 minutes in Pennsylvania--or allowed
general exceptions to the 30-minute standard for beneficiaries living
in some rural areas.
States typically monitored provider participation in their PCCM
programs by compiling weekly or monthly lists of participating PCCMs
and the number of beneficiaries each PCCM was assigned, which could
serve as the basis for paying the monthly PCCM fee. Monitoring these
relative numbers also allowed states to ascertain whether PCCMs could
be assigned additional beneficiaries. States therefore had current
information on those providers actively participating as PCCMs and the
numbers of assigned beneficiaries. This information alone, however,
would not yield insights into how easily beneficiaries could see their
PCCMs.
When states had both managed care and PCCM delivery systems, they less
frequently set requirements for PCCM appointment waiting times than
they did for managed care.[Footnote 38] Three states that operated both
PCCM and managed care programs--Colorado, Florida, and Pennsylvania--
did not set any appointment waiting time standards for PCCMs as they
did for managed care. In contrast, Massachusetts required its PCCMs to
see new patients within a specific time frame in its PCCM program, but
not in managed care. Of the four states that did set specific
requirements for appointment waiting times, only Texas reported
conducting routine monitoring to assess PCCM compliance with those
requirements. Texas officials reported conducting audits of a random
sample of 20 PCCMs per quarter per service area to evaluate compliance
with respect to appointment scheduling and in-office waiting time.
To monitor service utilization within their PCCM programs, states most
often relied on analyses of their FFS claims data. Six of the seven
states with PCCM programs provided PCCMs that had a certain minimum
number of assigned beneficiaries with periodic data profiles that
compare service utilization patterns in their Medicaid practices with
those of the overall program or other PCCMs.[Footnote 39] These data
profiles often focused on high-cost services or those at risk of
overutilization, such as inpatient hospitalization or emergency room
use. Three states also included information related to primary and
preventive services use. For example, see the following.
* Massachusetts provided PCCM practices that had 200 or more enrolled
beneficiaries with practice-specific and comparative information about
the percentage of children who received a recommended number of well-
child visits, by age group. The state further identified, for each
practice, individual patients who had not received the recommended
number of well-child visits. State program staff members met with each
provider twice annually to discuss approaches to address problems
identified in these data that may indicate limited access.
* Texas provided participating PCCMs with comparative information on
selected services per beneficiary, including EPSDT visits, family
planning, and immunizations.
In contrast, states typically did not monitor the utilization of
services provided by specialists, although several state PCCM programs
required documentation of PCCM referrals to specialists. Officials in
several states were aware of problems with access to some types of
providers and specialists in their PCCM programs, including dentists,
dermatologists, and pediatric neurosurgeons. In an attempt to address
such problems, Arkansas conducted a survey of dentists and Florida
conducted a survey of physicians to identify obstacles to their
willingness to accept Medicaid patients. While such one-time surveys
can provide insightful information about problems and potential
solutions in a specific period, they do not take the place of routine
or targeted monitoring that can more systematically pinpoint problems
for particular specialties, geographic areas, or beneficiaries.
Each of the states we reviewed with PCCM programs conducted beneficiary
satisfaction surveys. In addition, Colorado administers its CAHPS
survey to individuals participating in all three of the states‘
Medicaid service delivery systems--managed care, traditional FFS, and
PCCM--in order to help assess experiences of program beneficiaries
relative to one another. However, given the shortcomings identified
earlier--low response rates and exclusions of certain beneficiaries
from sample selection--states could not with confidence generalize the
results of these beneficiary surveys to the larger population.
Distinct SCHIP Programs Had Fewer Network Requirements and Less
Monitoring of Service Utilization:
States have used the flexibility provided by SCHIP to take varying
approaches for their service delivery systems for eligible children. Of
the 16 states we reviewed, 9 states chose to serve their SCHIP
beneficiaries through programs that were primarily designed as
expansions of Medicaid or modeled on their Medicaid programs in terms
of benefits and provider networks.[Footnote 40] These 9 states used the
same health plan contracts for Medicaid and SCHIP managed care, and the
same provider lists for both programs‘ FFS-based delivery systems. In
these cases, the extent of SCHIP monitoring would mirror that of the
states‘ Medicaid programs. On the other hand, 7 states designed at
least part of their SCHIP programs to be distinct from Medicaid. These
programs relied almost exclusively on managed care to deliver services.
Although most of these states also had significant shares of their
Medicaid beneficiaries in managed care, they set significantly fewer
provider network requirements for their distinct SCHIP programs than
for Medicaid and did less monitoring of providers enrolled in their
SCHIP programs and of children‘s use of services in SCHIP. In general,
few states with distinct SCHIP programs routinely collected and
analyzed data to ensure that SCHIP-eligible children were receiving
covered services.
States with SCHIP Programs Distinct from Medicaid Set Few Provider
Requirements:
The seven states that chose to serve all or most of their SCHIP
beneficiaries through programs that were distinct from Medicaid used
managed care delivery systems almost exclusively.[Footnote 41] These
states were not bound by access-related requirements comparable to
those for Medicaid PCCM or managed care programs. As such, they set
provider network requirements and monitored service utilization less
often in their distinct SCHIP managed care programs than they did in
their Medicaid managed care programs. As shown in figure 4, only two of
these seven states set specific beneficiary-to-PCP ratios for SCHIP,
compared to five states for Medicaid, and no state set specific
requirements for specialists, compared to three states for Medicaid.
Similarly, only one of the seven states with distinct SCHIP programs
set a maximum waiting time for a first appointment with a PCP and none
had a requirement for in-office waiting times; in contrast six of these
states‘ Medicaid managed care programs set specific requirements for
one or both of these access measures. Only four of the distinct SCHIP
programs in these states set any specific standards for appointment
scheduling, compared to all seven of the states‘ Medicaid managed care
programs.
Figure 4: Comparison of Seven States‘ Requirements and Standards for
Providers in Medicaid and SCHIP Managed Care:
[See PDF for image]
[End of figure]
Note: Table does not include Medicaid and SCHIP programs that have only
a general requirement that health plans‘ networks be adequate to serve
their members.
[A] Although the state did not have a specific standard, it did require
plans to monitor this measure.
[B] Florida‘s separate SCHIP programs vary by beneficiary age category.
The SCHIP column in this table refers to the program for older
children, as the program for children under age 5 is modeled after
Medicaid and thus has the same standards as the Medicaid program.
[C] Michigan‘s data reflect its arrangement with all participating
health plans except for one plan, which operates under different
requirements.
The seven states with distinct SCHIP programs also monitored the
availability of PCPs in plan provider networks less frequently than in
Medicaid. In contrast to Medicaid managed care where nearly all states
monitored providers at least quarterly, just three states required
plans to submit provider lists periodically throughout the year--
Colorado, New York, and Texas. To confirm provider information
submitted by plans participating in SCHIP, only New York systematically
contacted physicians to verify information about whether network PCPs
were accepting new SCHIP patients.[Footnote 42] Four states required
SCHIP plans to submit physician data annually or every several years
during state licensure reviews or for the contract renewal process.
Among these, California‘s SCHIP program required plans to indicate the
number and percentage of PCPs and specialists accepting new patients
and also to notify the state when there was a change in the provider
network that resulted in disruption of 25 or more beneficiaries.
The extent of states‘ monitoring of participating plans‘ SCHIP provider
networks did not appear to be related to whether SCHIP-eligible
beneficiaries had access to commercial or noncommercial networks within
the plans. Some states--such as New York and Texas--did not know
whether SCHIP-eligible beneficiaries had access to the same providers
as were participating in plans‘ commercial networks. Other states--such
as Florida, Michigan, and Pennsylvania--stated that most if not all of
their SCHIP populations did have access to the same providers as in the
plans‘ commercial networks. However, without direct monitoring of PCPs
enrolled in SCHIP plan networks, states had little or no direct
knowledge of the extent to which PCPs would see SCHIP beneficiaries,
including whether enrolled PCPs would accept new SCHIP patients at all
or limited their practice to only a small number.
Distinct SCHIP Programs Monitored Service Utilization Less than
Medicaid:
States with SCHIP programs distinct from Medicaid reported fewer
efforts to monitor children‘s utilization of services than in their
Medicaid managed care programs. This held true for their use of
encounter data as well as for HEDIS measures and CAHPS beneficiary
satisfaction survey data.
CMS does not require states to collect encounter data from managed care
plans participating in SCHIP, as it does in Medicaid managed care. Of
the states we reviewed with distinct SCHIP programs, we found that two
states--Florida and Texas--were attempting to collect as well as
analyze encounter data for SCHIP-eligible children in order to assess
the type and frequency of services they received. Florida‘s distinct
SCHIP program uses encounter data to compare the number of ambulatory
visits made by SCHIP beneficiaries to the number of visits that would
be expected for those children based on their diagnoses.[Footnote 43]
Texas‘ distinct SCHIP program, which was initiated in 2000, has used
encounter data to compare immunization rates by plan with rates in
commercial plans.
Four of the seven states--California, Michigan, New York, and
Pennsylvania--required plans to submit HEDIS data so that the states
could assess plans‘ performance with respect to access to various
preventive and other services.[Footnote 44] Compared to Medicaid, these
HEDIS data may be more complete in three of these states--California,
Michigan, and Pennsylvania--because they had opted to provide SCHIP-
eligible children with continuous eligibility for a 12-month period,
thus increasing the likelihood that a more representative share of
eligible children and their families would be included in the
assessments.
Five of the seven states--California, Florida, Michigan, Pennsylvania,
and Texas--used CAHPS to assess beneficiaries‘ satisfaction with care.
Compared to Medicaid, the CAHPS data for four of these states‘ SCHIP
programs may be more complete than for their Medicaid programs because
these states provide continuous eligibility for a 12-month period.
Agency and State Comments and Our Evaluation:
We provided a draft of our report for comment to HHS, as well as to
Medicaid and SCHIP officials in the 16 states included in our analysis.
We received comments from HHS and from 13 states. Three states did not
respond with comments.
HHS Comments:
With regard to states‘ Medicaid managed care programs, HHS highlighted
new requirements included in CMS‘s June 2002 regulation implementing
Medicaid managed care provisions of the Balanced Budget Act of 1997.
HHS commented that, among other things, the regulation requires states
to develop a quality strategy setting access standards for network
adequacy and timeliness of access to care. HHS described this new
regulation as also making clear the states‘ responsibility to
continually monitor plans‘ compliance with these standards. While many
states, including 13 of the 14 states we reviewed with Medicaid managed
care delivery systems, were already subject to certain access
requirements as a condition of receiving waivers of federal Medicaid
requirements to operate their managed care programs, these requirements
were not consistent from state to state. This new regulation, which
must be fully implemented by August 13, 2003, has the potential to
bring a more systematic approach to access requirements. More
importantly, its emphasis on state monitoring could better ensure that
such requirements are achieving their intended purposes.
For states‘ Medicaid FFS delivery systems, HHS acknowledged the
relationship between reimbursement rates and provider participation,
noting that states can increase payment rates in geographic areas and
specialties where access has been demonstrated to be a problem. Beyond
reimbursement rates, HHS commented that our draft report pointed out a
lack of data to quantify whether there is an access problem in Medicaid
FFS. To the contrary, our report indicates that despite a ready source
of information--claims data--for evaluating access to care in a FFS
environment, states generally did not do so.
HHS agreed that our placement of PCCM programs in the FFS category was
accurate from a reimbursement standpoint, but stated that PCCM should
be considered a managed care delivery system because PCPs are expected
to coordinate care. We continue to believe that a PCCM program is
better described as an FFS-based delivery system because the
differences between PCCM and managed care reimbursement approaches can
differentially affect provider incentives in providing covered
services. Our report does distinguish, however, the degree to which
managed care, traditional FFS, and PCCM programs employ access
standards and monitoring. Overall, states with PCCM programs tended to
establish more standards and conduct somewhat more monitoring than for
their traditional FFS programs, but less than for their managed care
programs.
With regard to our finding that states with distinct SCHIP programs did
significantly less to monitor access to care than for their Medicaid
managed care programs, HHS stated there was a key difference in design
and intent by the Congress between SCHIP and Medicaid. HHS commented
that SCHIP allows states to have the flexibility to design programs
that mirror private insurance and rely on private insurance mechanisms
to ensure access to and quality of care, rather than laying out
specific requirements. Acknowledging that states may not have
comparable requirements for SCHIP and Medicaid monitoring provider
participation and beneficiary service utilization, HHS said that states
are monitoring enrollment, health access, and outcomes in their SCHIP
programs. However, with regard to access, we found that few states with
distinct SCHIP programs monitored provider network participation or
routinely collected and analyzed data to ensure that SCHIP-eligible
children were receiving covered services. We did not intend to suggest
that states should use the same processes for their SCHIP and Medicaid
programs, but rather simply to contrast states‘ monitoring of access to
care for low-income children eligible for these two programs.
HHS‘s comments are reprinted in appendix IV. Additionally, HHS provided
technical comments, which we incorporated as appropriate.
State Comments:
Several states provided clarifying comments regarding their oversight
of access to care in Medicaid and SCHIP. These comments generally
pertained to additional factors affecting access to care, the
relationship between monitoring and access, and the extent of
monitoring in traditional FFS and distinct SCHIP programs.
Two states identified factors that affect access to care within their
Medicaid and SCHIP programs but are not easily controlled by the
states. One state noted that the supply of physicians is severely
limited in some states and in some regions of states, affecting all
payers, including commercial payers as well as Medicaid and SCHIP.
Another state raised the point that the extent to which children
receive health care services is influenced by how well their parents or
guardians understand and comply with recommended levels of health care
set by providers or by the Medicaid program. We agree that provider
supply and parental decision making are important determinants in
children‘s access to care and can be difficult factors for state
programs to address. However, the type of monitoring activities
addressed in this report can help to identify such factors and areas or
locations where problems may be more pronounced, thus leading to more
targeted solutions.
Four states identified certain activities that they believed
facilitated access to care, but were not addressed in the report. One
state, for example, noted that its Medicaid program helped
beneficiaries locate a source of medical care, and another state
described an initiative to send letters to parents of beneficiaries
reminding them to schedule medical appointments. Although we recognize
that these activities may help promote access to care for the Medicaid
and SCHIP populations, this report did not address activities that
primarily facilitated access, such as providing outreach to
beneficiaries or offering provider payment incentives. Instead, we
focused on states‘ efforts to (1) establish and monitor requirements
for provider availability and (2) gather and analyze data on receipt of
care. In this regard, one state commented that the report had a ’narrow
perspective“ on what constitutes monitoring in managed care and cited a
range of indicators that it used, including beneficiary complaints,
grievance reports, state fair-hearing requests, utilization data, and
immunization rates. While such sources of data and activities hold
strong potential for providing information concerning access to care,
this report identified certain shortcomings of some of these indicators
as programwide measures of access. For example, complaint and grievance
system data can yield important information about problematic providers
or services, but are not reliable measures of programwide access.
Four states cautioned against what they saw as a correlation made in
the report between the amount of monitoring that a state does and the
degree of access to care for program beneficiaries. For example, one
state said that the report suggested that if monitoring is limited,
access is also limited, and disagreed that this is necessarily the
case. We did not intend to present such a direct correlation. However,
if a state does not monitor data related to its access standards and to
utilization of services, it may not know the extent to which
beneficiaries encounter problems locating and obtaining services.
During the course of our work, we identified instances where state data
collection and monitoring revealed access problems that were then
addressed to improve beneficiary access.
A few states emphasized that they considered HEDIS and CAHPS important
tools that had helped them monitor health plan performance or achieve
improvements in quality of care for Medicaid and/or SCHIP
beneficiaries. One state noted that HEDIS was important in identifying
and helping to reduce gaps between commercial and Medicaid plan
performance. Another state questioned whether the continuous enrollment
requirements for HEDIS (12 months) and CAHPS (6 months) would in fact
bias the results of any analysis of beneficiaries‘ access to care
because it excludes some beneficiaries. In particular, this state
believed that the benefits of improvements made by health plans are not
limited to individuals enrolled for the full 6-or 12-month period. We
agree that HEDIS and CAHPS are important tools in monitoring and
comparing performance across plans, which necessitates that the sample
population be defined by a comparable enrollment period. However, we do
not believe that states can assume that all beneficiaries have access
to care on the basis of HEDIS and CAHPS results that exclude a
significant portion of the program population from their samples.
Two states discussed the extent to which they monitored access in
Medicaid traditional FFS compared with Medicaid managed care delivery
systems. One state said it analyzes data on key health outcomes for
children, such as ambulatory-sensitive hospital admissions and trends
in health care utilization. Both states specifically noted their
efforts to comply with federally required reporting of EPSDT
utilization for their FFS programs. Nevertheless, most of the states in
our sample had few or no goals regarding the number of providers
available to FFS beneficiaries and, with the exception of federally
required EPDST reporting, few analyzed data related to access to
primary care.
Similar to HHS‘s view, one state noted that the report did not account
for the fact that distinct SCHIP programs may choose approaches to
program design and monitoring that differ from Medicaid, including
approaches used in monitoring states‘ commercial managed care plans.
For example, this state and others reported relying on state insurance
department licensure of health plans as the means of monitoring
provider network adequacy, rather than imposing additional SCHIP-
specific requirements. We acknowledge in our report that states‘ SCHIP
programs may rely on different design and monitoring options than
Medicaid. Overall, however, states with distinct SCHIP programs
reported fewer efforts to monitor children‘s access and use of services
than in their Medicaid managed care programs.
Several states also provided technical comments, which we incorporated
as appropriate.
As arranged with your offices, unless you release its contents earlier,
we plan no further distribution of this report until 30 days after the
issue date. At that time, we will send copies of this report to the
Administrator of the Centers for Medicare & Medicaid Services and the
Administrator of the Health Resources and Services Administration. We
also will make copies available to others upon request. In addition,
the report will be available at no charge on the GAO Web site at http:/
/www.gao.gov.
If you or members of your staffs have any questions regarding this
report, please contact me on (202) 512-7118. Other contributors to this
report are listed in appendix V.
Kathryn G. Allen
Director, Health Care--Medicaid
and Private Health Insurance Issues:
[End of section]
Appendix I: Medicaid HEDIS Measures Related to Service Utilization:
Four of the eight general categories of the Health Plan Employer Data
and Information Set (HEDIS) measures for Medicaid managed care plan
performance relate directly to beneficiary service utilization. These
four categories include effectiveness of care, access/availability of
care, use of services, and satisfaction with the experience of
care.[Footnote 45] Many of the measures in these categories require
beneficiaries to be continuously enrolled for some period, often 12
months, in order to be assessed. Table 8 details selected HEDIS
measures that pertain to service utilization for children and
adolescents enrolled in Medicaid managed care programs and the length
of continuous enrollment required.
Table 8: Length of Medicaid Enrollment Required for Selected HEDIS
Measures for Children‘s and Adolescents‘ Use of Services:
Category: Effectiveness of care; Measure name: Childhood immunization
status; Length of continuous enrollment[A]: 12 months.
Measure name: Adolescent immunization status; Length of continuous
enrollment[A]: 12 months.
Measure name: Cervical cancer screening; Length of continuous
enrollment[A]: 12 months.
Measure name: Chlamydia screening; Length of continuous enrollment[A]:
12 months.
Measure name: Prenatal care in first trimester; Length of continuous
enrollment[A]: About 9 months prior to delivery.
Measure name: Checkups after delivery; Length of continuous
enrollment[A]: About 2 months after delivery.
Measure name: Comprehensive diabetes care; Length of continuous
enrollment[A]: 12 months.
Measure name: Use of appropriate medications for people with asthma;
Length of continuous enrollment[A]: 24 months.
Measure name: Follow-up after mental illness hospitalization; Length of
continuous enrollment[A]: 1 month after discharge.
Measure name: Antidepressant medication management; Length of
continuous enrollment[A]: 12 months.
Measure name: Advising smokers to quit; Length of continuous
enrollment[A]: 6 months.
Category: Access/availability of care; Measure name: Children‘s access
to primary care providers; Length of continuous enrollment[A]: 12
months[B].
Measure name: Initiation of prenatal care; Length of continuous
enrollment[A]: From 1 to 9 months prior to delivery[C].
Measure name: Annual dental visit; Length of continuous enrollment[A]:
12 months.
Measure name: Availability of language interpretation services; Length
of continuous enrollment[A]: None.
Category: Use of services; Measure name: Frequency of ongoing prenatal
care; Length of continuous enrollment[A]: None.
Measure name: Well-child visits in the first 15 months of life; Length
of continuous enrollment[A]: From 1 to 15 months of age[D].
Measure name: Well-child visits in the third, fourth, fifth and sixth
year of life; Length of continuous enrollment[A]: 12 months.
Measure name: Adolescent well-care visits; Length of continuous
enrollment[A]: 12 months.
Measure name: Inpatient utilization--general hospital/acute care;
Length of continuous enrollment[A]: None.
Measure name: Ambulatory care; Length of continuous enrollment[A]:
None.
Measure name: Inpatient utilization--nonacute care; Length of
continuous enrollment[A]: None.
Measure name: Discharges and average length of stay--maternity care;
Length of continuous enrollment[A]: None.
Measure name: Cesarean section rate; Length of continuous
enrollment[A]: None.
Measure name: Vaginal birth after cesarean section rate; Length of
continuous enrollment[A]: None.
Measure name: Births and average length of stay, newborns; Length of
continuous enrollment[A]: None.
Measure name: Mental health utilization--inpatient discharges and
average length of stay; Length of continuous enrollment[A]: None.
Measure name: Mental health utilization--percentage of members
receiving inpatient, day/night care, and ambulatory services; Length of
continuous enrollment[A]: None.
Measure name: Chemical dependency utilization--percentage of members
receiving inpatient, day/night care, and ambulatory services; Length of
continuous enrollment[A]: None.
Measure name: Outpatient drug utilization; Length of continuous
enrollment[A]: None.
Category: Satisfaction with the experience of care; Measure name:
Consumer Assessment of Health Plans (adults and children); Length of
continuous enrollment[A]: 6 months.
Source: National Committee for Quality Assurance, HEDIS 2000: Technical
Specifications (Washington, D.C.: 1999).
[A] For measures listed with a continuous enrollment requirement, HEDIS
guidelines indicate that the managed care entity must assess on a
measure-by-measure basis whether the measure may be reported in the
current measurement year. Partial year reporting for the measures in
this table was considered acceptable or possible by the HEDIS
guidelines.
[B] Older age groups (7 to 11 years) require 24 months enrollment.
[C] Measure requires continuous enrollment of at least 43 days prior to
delivery but no more than 279 days.
[D] Measure requires that child is enrolled from 31 days through 15
months of age.
[End of table]
[End of section]
Appendix II: Managed Care Plan Withdrawals from Medicaid in Four
States:
Four states we visited--Massachusetts, Ohio, Tennessee, and Texas--had
varying experiences in terms of the number and impact of managed care
plan withdrawals from their Medicaid managed care programs. In some
cases, as in Massachusetts, the changes occurred early in the states‘
implementation of their programs and the number of plans has been
stable in recent years; in other cases, as in Ohio and Tennessee, the
changes in participating plans continued over time and presented
ongoing challenges to the states in managing their programs and
ensuring appropriate access to care for their beneficiaries. The
proportion of Medicaid beneficiaries affected by withdrawals of
participating managed care plans ranged from about 1 percent in Texas
to almost 50 percent in Tennessee. Following is a brief description of
managed care plan withdrawals in each of the four states and examples
of some of the measures states took to minimize disruption to
beneficiaries‘ care as a result of the changes.
Massachusetts:
Health plan participation in Massachusetts‘ Medicaid managed care
program has slowly stabilized, with four plans participating in the
program since 2000. Earlier fluctuations occurred, however, as the
state shaped its program to limit the number of participating plans and
as some health plans decided to consolidate or leave the market. These
early changes in participating plans affected about 4 percent of the
state‘s Medicaid population.
Massachusetts began its current Medicaid managed care program in July
1997 with nine participating health plans.[Footnote 46] Two of the
health plans, created by hospital systems that had traditionally
provided services to lower income individuals, were formed specifically
for this program. Of the remaining seven plans participating in the
state‘s Medicaid program, many were commercially available. Within the
first 2 years of the program, however, the number of participating
health plans declined to five. This reduction was partially a result of
the state‘s decision to contract with fewer health plans and to provide
each health plan with a greater volume of beneficiaries. As a result of
this decision, contracts were not renewed with two health plans and
approximately 42,000 beneficiaries (about 4 percent of the state‘s
Medicaid population) had to select other plans. In addition, during
this period several health plans merged and at least one plan left the
Massachusetts health care market altogether. State officials reported
that some plans lost interest in participating because of Medicaid‘s
administrative and reporting requirements. Additionally, commercial
plans found that the Medicaid benefit package included certain
services--such as behavioral health services--that the health plans did
not provide their other members. This meant that health plans had to
establish networks specifically for Medicaid beneficiaries; without a
’critical mass“ of Medicaid beneficiaries, however, health plans had
difficulty remaining financially viable in the program. When
participating plans withdrew from the state‘s Medicaid program, state
officials said that beneficiaries enrolled in the affected plans were
informed that the plans would no longer be participating in the program
and were provided an opportunity to choose other plans or enroll in the
state‘s primary care case manager program.
Ohio:
Since the inception of its mandatory managed care program in 1996, Ohio
has faced a large number of health plan withdrawals. As of January
2002, 10 plans had completely withdrawn from program participation,
while 3 additional plans had withdrawn from specific counties in the
state. Over 224,000 Medicaid beneficiaries--over 15 percent of the
state‘s Medicaid population--were affected by plan withdrawals. As a
result of these withdrawals and providers‘ growing reluctance to
participate in managed care, Ohio changed from mandatory to voluntary
managed care enrollment in some counties and fee-for-service (FFS) in
others. As of April 2002, Ohio had 7 managed care plans serving
Medicaid beneficiaries in 15 counties, with mandatory enrollment in
only 4 of the counties.
Ohio Medicaid officials expected to see some fluctuations in plan
participation in the early years of its program. They anticipated that
some plans would withdraw due to the state‘s requirement that plans
that did not have significant enrollment--from 10 to 15 percent of the
eligible population--within 2 years of the program‘s inception would be
required to leave the program. Several reasons were provided for the
number of plans that eventually withdrew from the program, including
voluntary withdrawal and court-ordered liquidations. In many cases,
health plans sold their Medicaid membership to other plans. State
officials acknowledged that the relatively large number of plan
withdrawals affected individuals‘ perception of the program and led to
changes in the state‘s managed care enrollment policy, with some
counties switching from mandatory to voluntary managed care enrollment.
Concerns about the program‘s viability and stability were increased
when the state insurance department liquidated one Medicaid health plan
in 1998 and some of its network providers did not receive compensation
from the plan.
State officials did not believe that beneficiaries‘ access to care was
affected by these plan withdrawals. In cases where a health plan‘s
membership was sold to another plan, the state attempted to ensure
continuity of care by requiring that at least 90 percent of the current
plan‘s primary care providers (PCP) were included in the provider
network of the purchasing plan.[Footnote 47] In other cases, we were
told, beneficiaries were notified of their health plan‘s impending
withdrawal and provided an opportunity to select another plan if
available. If a beneficiary did not select a health plan, or there was
no alternative plan available, then the beneficiary returned to the
state‘s FFS program. In areas with mandatory managed care enrollment,
however, beneficiaries were not allowed to remain in FFS indefinitely;
they were required to select another plan or be automatically assigned
to one.
Tennessee:
In establishing its mandatory managed care program in January 1994,
Tennessee expanded Medicaid eligibility to hundreds of thousands of
previously uninsured individuals and enrolled them into 1 of 12
capitated managed care plans. Four plans left the program or were sold
from 1994 through 1999.[Footnote 48] Since 2001, plan withdrawals have
increasingly been an area of concern, with large numbers of Medicaid
beneficiaries affected by changes to the state‘s 2 largest health
plans. For example, in 2001, almost 580,000 beneficiaries, or 41
percent of the state‘s Medicaid population, were affected when 1 plan
withdrew from the western and central portions of the state and a
second plan‘s contract was terminated due to solvency issues. In
response to the first of these two withdrawals, the state took two
actions: (1) it recruited two new health plans to join the market and
(2) it created a self-insured plan to serve as a backup in areas of the
state where beneficiaries could not be adequately served by other
health plans.
As of April 2002, 10 health plans were participating in Tennessee‘s
Medicaid managed care program although 2 plans, covering 21 percent of
the state‘s Medicaid beneficiaries, were considered to be at financial
risk. The state announced its intention in March 2002 to terminate its
contract with 1 health plan, which would necessitate the transfer of
approximately 135,000 beneficiaries to other health plans.[Footnote 49]
A second plan, with over 160,000 beneficiaries, was under
rehabilitation by the state‘s insurance department.
In view of the instability of the program and participating plans,
Tennessee has taken several steps to help ensure continuous access to
care for Medicaid beneficiaries. In order to provide time to plan ahead
in the event of plan withdrawals, the state‘s contract with
participating plans requires 6 months of advance notice of an intended
withdrawal and a transition plan to assure uninterrupted care to
beneficiaries. When plans stopped participating in the program,
beneficiaries were either provided the option to select new health
plans or were assigned to health plans.
Texas:
Texas began its capitated Medicaid managed care program in1996 in four
areas of the state. Since 1996, managed care was expanded to three
additional service areas and now exists in 46 of the state‘s 254
counties. Since the rollout of managed care began, only three plans
have withdrawn from participation in Texas‘ Medicaid managed care
program, affecting less than 20,000 beneficiaries, or approximately 1
percent of the state‘s Medicaid population.[Footnote 50] Two of these
withdrawals were from the same service delivery area, leaving three
plans participating in that area.[Footnote 51] However, the state
contends that prior to the withdrawals there was a saturation of health
plans in that service delivery area. As of July 2002, 11 plans were
participating in the Medicaid managed care program.
In one instance, a participating plan gave the state less than 3 weeks‘
notice of its intent to leave the program. Because of the limited
notice, beneficiaries were automatically assigned to other plans in
order to minimize disruption in their access to care. Although these
assignments were initially made without direct input from the affected
beneficiaries, their prior PCP and specialist utilization patterns were
taken into account during this assignment process and beneficiaries
were later given an opportunity to change plans. The state paid
particular attention to the number of complaints during these
transition periods and did not see a dramatic change. As such, state
officials believe that the transitions went smoothly. Texas has a
number of other measures in place to facilitate beneficiaries‘
enrollment in alternative plans when their plans leave the program, as
illustrated in table 9 along with additional examples from other states
we visited.
Table 9: Examples of Plan Withdrawal Transition Activities Conducted by
Four State Medicaid Programs:
Type of action: Contractual requirements of managed care plans;
Examples of action: * Massachusetts takes responsibility for notifying
beneficiaries of the health plan‘s withdrawal from the program and the
process beneficiaries must undergo to continue to receive services;
however, health plans must continue to provide services until the
beneficiary is disenrolled and participating in another plan.; * Ohio‘s
contract requires the collection of monetary assurance or the
withholding of payments from withdrawing health plans until all
contract requirements are completed.; * Texas requires health plans to
provide the state 90 days notice of their intention to terminate
participation, Ohio requires 75 days notice, and Tennessee requires 6
months advanced notice.; * Tennessee‘s contract requires withdrawing
health plans to submit transition plans to ensure uninterrupted care to
beneficiaries..
Type of action: Notification of beneficiaries and other stakeholders;
Examples of action: * Ohio, Tennessee and Texas send letters to
beneficiaries informing them of the health plan‘s withdrawal. The
letters may include a list of the other health plans, important
telephone numbers, and actions beneficiaries must take.; * Texas
notifies stakeholders, including the enrollment broker and other health
plans, of the impending withdrawal. Remaining health plans in the area
are provided with a list of PCPs that are only participating with the
exiting plan. Additionally, the state or health plan notifies providers
of the plan‘s intention to withdraw from the program..
Type of action: Coordination between plans; Examples of action: * In
Texas, the withdrawing plan identifies individuals with special needs
and a dialogue between the current and future case managers begins. In
addition, the withdrawing health plan provides instructions for
providers on seeking authorization for continued services from new
health plan..
Source: GAO analysis of states‘ data, December 2001.
[End of table]
[End of section]
Appendix III: Analysis of Medicaid FFS Payment Rates in Selected
States:
Nationally, low Medicaid physician fees have been a long-standing area
of concern because they can affect the degree to which physicians
participate in Medicaid, and thereby affect beneficiaries‘ access to
care. The relative fees paid by different insurers--Medicare, Medicaid,
and SCHIP--can also affect providers‘ willingness to participate in
these programs. Since many children in Medicaid remain in fee-for-
service (FFS)-based programs, we compared Medicaid fees for selected
office visit and pediatric preventive medical care services to the
corresponding Medicare fees. While Medicare is a federal health
insurance program primarily for the elderly and persons with
disabilities, some children do receive Medicare benefits and thus its
fee schedule includes fees for pediatric medical services. Among the 13
states we reviewed that used FFS-based delivery systems as a key care
delivery system for Medicaid children,[Footnote 52] Medicaid fees for
primary and preventive care ranged from 32 percent to 89 percent of
what Medicare would pay for similar services. (See table 10.) Concerns
with the adequacy of Medicaid physician payment levels were also
identified in studies of Medicaid physician payment in California,
Washington, and Maryland.[Footnote 53]
Table 10: Medicaid FFS Payment Rates, Expressed as a Percentage of
Medicare Payments, in 13 States with Traditional FFS or Primary Care
Case Manager Delivery Systems That Serve Children:
State[A]: Massachusetts[B]; Medicaid FFS payments as a percentage of
Medicare FFS payments (weighted): 89.
State[A]: Arkansas; Medicaid FFS payments as a percentage of Medicare
FFS payments (weighted): 71.
State[A]: Florida; Medicaid FFS payments as a percentage of Medicare
FFS payments (weighted): 71.
State[A]: Texas; Medicaid FFS payments as a percentage of Medicare FFS
payments (weighted): 71.
State[A]: Nevada; Medicaid FFS payments as a percentage of Medicare FFS
payments (weighted): 66.
State[A]: Ohio; Medicaid FFS payments as a percentage of Medicare FFS
payments (weighted): 64.
State[A]: Illinois[B]; Medicaid FFS payments as a percentage of
Medicare FFS payments (weighted): 61.
State[A]: Washington; Medicaid FFS payments as a percentage of Medicare
FFS payments (weighted): 60.
State[A]: Colorado; Medicaid FFS payments as a percentage of Medicare
FFS payments (weighted): 57.
State[A]: Louisiana; Medicaid FFS payments as a percentage of Medicare
FFS payments (weighted): 57.
State[A]: New York[B]; Medicaid FFS payments as a percentage of
Medicare FFS payments (weighted): 54.
State[A]: California; Medicaid FFS payments as a percentage of Medicare
FFS payments (weighted): 48.
State[A]: Pennsylvania; Medicaid FFS payments as a percentage of
Medicare FFS payments (weighted): 32.
Source: GAO analysis of Medicare data and states‘ data, as of December
2001.
[A] Other study states not shown on this table include the following:
Tennessee enrolls nearly all beneficiaries in capitated managed care,
and therefore, we did not collect a Medicaid FFS payment schedule that
can be compared to Medicare rates. Maryland uses a FFS-based delivery
system for less than 5 percent of children and includes only those
children requiring case management for rare and expensive conditions,
or who are technology dependent. Michigan uses FFS-based care only for
children in an eligibility category for special needs.
[B] Illinois, Massachusetts, and New York provide payment enhancements
for some services, in addition to the regular fee for the service;
where appropriate, these enhancements were included in the analysis.
[End of table]
Methodology for Comparison of FFS Payment Rates:
For our comparative analysis of Medicaid and Medicare FFS payments, we
obtained fee schedules from 13 of the 16 states we reviewed, compiling
fees for 12 medical services using selected codes from a commonly used
procedural coding system--the standard Physicians Current Procedural
Terminology, 4th edition (CPT 4). (See table 11.) For each state, we
weighted the Medicaid and corresponding lowest Medicare fees[Footnote
54] for that state by the relative utilization of the service among
pediatricians, identified from a 1999 American Academy of Pediatrics
survey.[Footnote 55] The sum of the weighted Medicaid fees was then
expressed as a percentage of the sum of the Medicare payments in order
to develop a single, weighted payment rate.
Table 11: CPT 4 Codes Used in Comparing Medicaid and Medicare Fees:
CPT 4 code: Office or other outpatient visit.
CPT 4 code: 99201; Description: Office or other outpatient visit: New
patient, 10 minute visit.
CPT 4 code: 99202; Description: Office or other outpatient visit: New
patient, 20 minute visit.
CPT 4 code: 99203; Description: Office or other outpatient visit: New
patient, 30 minute visit.
CPT 4 code: 99213; Description: Office or other outpatient visit:
Established patient, 15 minute visit.
CPT 4 code: 99214; Description: Office or other outpatient visit:
Established patient, 25 minute visit.
CPT 4 code: Preventive medical services.
CPT 4 code: 99381; Description: Office or other outpatient visit: New
patient, under 1 year.
CPT 4 code: 99382; Description: Office or other outpatient visit: New
patient, 1 to 4 years.
CPT 4 code: 99383; Description: Office or other outpatient visit: New
patient, 5 to 11 years.
CPT 4 code: 99391; Description: Office or other outpatient visit:
Established patient, under 1 year.
CPT 4 code: 99392; Description: Office or other outpatient visit:
Established patient, 1 to 4 years.
CPT 4 code: 99393; Description: Office or other outpatient visit:
Established patient, 5 to 11 years.
CPT 4 code: 99394; Description: Office or other outpatient visit:
Established patient, 12 to 17 years.
Source: CPT 4.
[End of table]
[End of section]
Appendix IV: Comments from the Department of Health and Human Services:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Inspector General:
Washington, D.C. 20201:
DEC 10 2002:
Ms. Kathryn G. Allen:
Director, Health Care - Medicaid and Private Health Insurance Issues
United States General:
Accounting Office Washington, D.C. 20548:
Dear Ms. Allen:
Enclosed are the department‘s comments on your draft report entitled,
’Medicaid and SCHIP: States Use Varying Approaches to Monitor
Children‘s Access to Care.“ The comments represent the tentative
position of the department and are subject to reevaluation when the
final version of this report is received.
The department also provided several technical comments directly to
your staff.
The department appreciates the opportunity to comment on this draft
report before its publication.
Sincerely,
Janet Rehnquist:
Inspector General:
Signed by Janet Rehnquist:
Enclosure:
The Office of Inspector General (OIG) is transmitting the department‘s
response to this draft report in our capacity as the department‘s
designated focal point and coordinator for General Accounting Office
reports. The OIG has not conducted an independent assessment of these
comments and therefore expresses no opinion on them.
Comments of the Department of Health and Human Services on the General
Accounting Office‘s Draft Report, ’Medicaid and SCHIP: States Use
Varying Approaches to Monitor Children‘s Access to Care“ (GAO-03-222):
The Department of Health and Human Services (department) appreciates
the opportunity to comment on this draft report.
Medicaid Managed Care:
The department would like to note that on June 14, 2002, the Centers
for Medicare and Medicaid Services (CMS) published a final rule
implementing the Medicaid managed care provisions of the Balanced
Budget Act of 1997. The regulation provides clear guidance for states
on access standards and monitoring. Prior to this new regulation, there
were no specific access standards for managed care. With the new
regulation, states will have to develop a quality strategy that
includes establishing access standards for network adequacy and
timeliness of access to care. For network adequacy, the standards must
take into account anticipated enrollment; expected utilization of
services; numbers and types of providers needed; number of providers
not accepting new patients; geographic availability; and physical
access for enrollees with disabilities. The regulation also creates new
standards for direct beneficiary access to women‘s health specialists
and second opinions, as well as timeliness of access to services. The
regulation also directs states to develop and enforce standards for
coordination and continuity of care for primary care and for enrollees
with special health care needs. Also, states must set standards for
coverage and authorization of services, including timeframes for
authorization decisions.
In addition to establishing explicit access standards, the new
regulation makes clear the responsibility of the state to monitor, on
an ongoing basis, plans‘ compliance with these standards. There will
also be increased expectations on state monitoring, and clear guidance
on the requirements for an External Quality Review (EQR) of plans are
expected to be published in the near future. As with access standards,
current requirements for EQR are minimal. Section 4705 of the Balanced
Budget Act of 1997 (BBA) directed CMS to develop standards for an
’external independent review ... of the quality outcomes and timeliness
of, and access to, the items and services for which the organization is
responsible under the contract.“ The CMS has already published detailed
protocols for these reviews:
(see < http://www.ems.hhs.gov/medicaid/managedeare/mcegrhmp.asp>).
Medicaid Fee-for-Service (FFS):
The report indicates that low physician reimbursement rates under
Medicaid FFS have the potential to reduce provider participation in the
program, which can then negatively impact beneficiary access to
providers. The report further indicates that states are doing little to
monitor service utilization. However, as the report also notes, states
have the responsibility to ensure sufficient access to services.
Because states have the discretion to set reimbursement levels in
response to particular program goals and within budgetary:
constraints, this has permitted states to increase payment rates in
those geographic areas and for those particular specialties where
access has been demonstrated to be a problem.
As the report points out, there is a lack of data to quantify whether
there is or is not an access problem in Medicaid FFS. We note, however,
that enrollment in Medicaid managed care continues to increase so more
children are being covered under managed care arrangements where
assurances of adequate access to care is required through appropriate
documentation.
State Children‘s Health Insurance Proaram (SCRIP):
The report concludes that separate SCRIP programs ’did significantly
less in their distinct SCRIP programs in terms of setting requirements
for, or monitoring, participating providers or beneficiary service use
than they did for their Medicaid programs.“ In part, GAO seems to miss
the key difference in design and intent by Congress between SCRIP and
Medicaid. The SCRIP allows states to have the flexibility to design
programs that mirror private insurance and rely on private insurance
mechanisms to assure access and quality of care. Rather than laying out
specific requirements, title XXI is built on accountability by states
by requiring that each state describe their strategic objectives,
performance goals and performance measures. The strategic objectives,
by law, must relate to increasing the extent of creditable health
coverage among targeted low-income children and other low-income
children. As a result, states may not have comparable requirements
between SCRIP and Medicaid for monitoring of provider participation and
beneficiary service utilization. Rather, states are monitoring
enrollment into the program and health access and outcomes. Every state
has established a set of performance goals and measures, which are
generally related to enrollment, access and outcome.
Many states have set performance goals related to quality and
satisfaction of care. Information from state plans and annual reports
in July 2001 indicated that only 5 states do not use any Health Plan
Employer Data Information Sets (HEDIS) measures. All other states use
all or part of the HEDIS set of measures. Most states collect data on
immunizations and well child visits. In addition, CMS is working with
states to establish the Performance Measurement Partnership Project,
which will create a uniform set of indicators across Medicaid and SCRIP
to improve performance monitoring across all states. The SCRIP focuses
on outcomes, as opposed to process, and the core set of performance
measures will allow us to measure and compare access and outcomes
across states.
Specific Comments:
The department notes that the draft report places Primary Care Case
Managers (PCCMs) in the fee-for-service category, which is accurate
from a reimbursement standpoint. However, we believe that it is more
appropriate to categorize PCCMs as a managed care delivery system, as
participating primary care physicians are expected to coordinate needed
care and services as well as act as a gatekeeper/referral mechanism for
specialty:
care. Accordingly, states are increasing their oversight of and
expectations for PCCM programs. Two examples are Massachusetts and
Florida.
Additionally, the final rule implementing the Medicaid managed care
provisions of the BBA does include at section 438.6(k) specific
contract requirements for PCCMs that includes adequate hours of
operation, restricting enrollment to recipients who reside sufficiently
near one of the manager‘s delivery sites and providing for arrangements
with a sufficient number of physicians and other practitioners to
ensure that services are furnished promptly and without compromise to
quality of care.
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Carolyn L. Yocom, (202) 512-4931:
Acknowledgments:
Catina Bradley, Karen Doran, Laura Sutton Elsberg, Mary Giffin,
Michelle Rosenberg, and Ann Tynan made key contributions to this
report.
[End of section]
Related GAO Products:
Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown. GAO-
02-813. Washington, D.C.: August 22, 2002.
Children‘s Health Insurance: Inspector General Reviews Should Be
Expanded to Further Inform the Congress. GAO-02-512. Washington, D.C.:
March 29, 2002.
Medicaid and SCHIP: States‘ Enrollment and Payment Policies Can Affect
Children‘s Access to Care. GAO-01-883. Washington, D.C.: September 10,
2001.
Medicaid: Stronger Efforts Needed to Ensure Children‘s Access to Health
Screening Services. GAO-01-749. Washington, D.C.: July 13, 2001.
Medicaid Managed Care: States‘ Safeguards for Children With Special
Needs Vary Significantly. GAO/HEHS-00-169. Washington, D.C.: September
29, 2000.
Oral Health: Factors Contributing to Low Use of Dental Services by Low-
Income Populations. GAO/HEHS-00-149. Washington, D.C.:
September 11, 2000.
Medicaid and SCHIP: Comparisons of Outreach, Enrollment Practices, and
Benefits. GAO/HEHS-00-86. Washington, D.C.: April 14, 2000.
Oral Health: Dental Disease Is a Chronic Problem Among Low-Income
Populations. GAO/HEHS-00-72. Washington, D.C.: April 12, 2000.
Children‘s Health Insurance Program: State Implementation Approaches
Are Evolving. GAO/HEHS-99-65. Washington, D.C.: May 14, 1999.
Medicaid Managed Care: Challenge of Holding Plans Accountable Requires
Greater State Effort. GAO/HEHS-97-86. Washington, D.C.:
May 16, 1997.
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FOOTNOTES
[1] A provider may be a physician, a group of physicians practicing
together, or an outpatient clinic with physician services.
[2] FFS systems include traditional FFS, in which a provider bills the
program for services provided to an eligible beneficiary, and PCCM
systems, in which a physician, physician group practice, or similar
entity contracts with the state to locate, coordinate, and monitor
primary health services for Medicaid beneficiaries for a nominal
monthly, per capita case management fee (usually around $3).
[3] See related GAO products listed at the end of this report.
[4] States can take three approaches in designing their SCHIP programs:
(1) expand Medicaid, (2) construct separate child health programs
distinct from Medicaid, or (3) use a combination of both approaches.
[5] For purposes of this report, PCPs are usually physicians trained in
internal medicine, pediatrics, family medicine, or obstetrics and
gynecology who participate in PCCM or managed care programs in Medicaid
or SCHIP.
[6] 67 Fed. Reg. 40989 (2002).
[7] The SCHIP statute allows a state to expand eligibility to 200
percent of the poverty level or up to 50 percentage points above its
Medicaid eligibility standard as of March 31, 1997. As of January 2002,
states‘ upper income eligibility thresholds for SCHIP ranged from 133
to 350 percent of the federal poverty level.
[8] Throughout this report, SCHIP beneficiaries enrolled in Medicaid
expansion programs are included in the discussion of Medicaid.
[9] Annual allotments are made to states for use over a 3-year period.
For SCHIP annual allotments that remain unspent after 3 years, the
Secretary of HHS is required to determine an appropriate procedure for
redistributing any unused SCHIP funds to states that have exhausted
their allotments.
[10] We included PCCMs as FFS-based arrangements because participating
providers are predominately paid on a FFS basis. Thus, throughout this
report, the term managed care only refers to capitated managed care
arrangements.
[11] See 42 U.S.C. § 1396a(a)(30); 42 C.F.R § 438.2.
[12] See 42 U.S.C. §1396a(a)(8).
[13] The new Medicaid managed care rules have more detailed
requirements for states than in the past, such as requiring assurances
from participating plans concerning the availability of services,
adequate capacity and services, coordination and continuity of care,
and coverage and authorization of services.
[14] Implementing managed care service delivery by amending a state‘s
Medicaid plan has been an option for states since passage of the
Balanced Budget Act of 1997.
[15] The freedom of choice waiver is established by section 1915(b) of
the Social Security Act and is set forth at 42 U.S.C. §1396n(b). The 12
states that we reviewed with program waivers were Arkansas, California,
Colorado, Florida, Louisiana, Michigan, New York, Ohio, Pennsylvania,
Tennessee, Texas, and Washington.
[16] The demonstration waiver is set forth at 42 U.S.C. § 1315(a). In
addition to comprehensive waivers, states can also use section 1115
waivers for specific populations or services, such as pharmacy or
extending coverage to parents. Four of the 15 states--California,
Colorado, Florida, and Illinois--have noncomprehensive section 1115
waivers.
[17] See 42 U.S.C. § 1397bb.
[18] A state‘s SCHIP evaluation was required to address several areas,
including (1) the quality of health coverage provided, (2) choices of
heath benefits coverage, (3) activities to coordinate SCHIP with other
public and private programs, (4) changes in trends in the states that
affect the provision of health insurance, and (5) recommendations for
improving SCHIP.
[19] See U.S. General Accounting Office, Medicaid Managed Care:
Challenge of Holding Plans Accountable Requires Greater State Effort,
GAO/HEHS-97-86 (Washington, D.C.: May 16, 1997).
[20] Federal law requires that EPSDT include services that are
necessary to correct or ameliorate defects and physical and mental
illnesses and conditions discovered through screening, regardless of
whether those services are covered by the state‘s Medicaid plan.
[21] The components of an EPSDT health screening include a
comprehensive health and developmental history, a comprehensive
unclothed physical exam, appropriate immunizations, laboratory tests
(including a blood lead-level assessment), and health education.
[22] See U.S. General Accounting Office, Medicaid: Stronger Efforts
Needed to Ensure Children‘s Access to Health Screening Services,
GAO-01-749 (Washington, D.C.: July 13, 2001).
[23] NCQA, an independent foundation, has managed HEDIS since 1992.
Originally designed for private employers as purchasers of health care,
it has been adapted for public purchasers, regulators, and consumers,
including Medicaid.
[24] The four general HEDIS categories that directly relate to service
utilization are effectiveness of care, access/availability of care, use
of services, and satisfaction with the experience of care. The
remaining four general categories are health plan stability, cost of
care, informed health care choices, and health plan descriptive
information.
[25] Tennessee and Texas did not use HEDIS to assess plan performance.
[26] Although some HEDIS measures have a 12-month continuous enrollment
requirement, individuals with one gap in enrollment of up to 45 days or
less can be included in the sample. However, to be included,
individuals must remain with the same health plan after a break in
enrollment.
[27] According to one report, at least one state--Iowa--analyzed HEDIS
measures for individuals that were continuously enrolled in Medicaid
for less than 12 months. See NCQA, Medicaid HMO and Fee-For-Service
Comparison Strategy: Methodological Issues (Washington, D.C.: NCQA,
n.d.). http://www.ncqa.org/Programs/qsg/medicaidcomparison.html
(downloaded July 8, 2002).
[28] 42 C.F.R. § 434.34.
[29] Tennessee opted to use a state-designed beneficiary satisfaction
survey rather than CAHPS. In most cases, the states we reviewed
administered CAHPS directly or through the use of an independent
contractor. Three states--Colorado, Illinois, and Pennsylvania--
required participating plans to administer CAHPS.
[30] CAHPS was developed in 1995 by the federal AHRQ to provide
information to help beneficiaries compare health plans.
[31] Among the nine states in our sample that reported their response
rates, the response rates for the CAHPS survey of families with
children ranged from 27 percent in Nevada to 85 percent in Illinois.
[32] Maryland Department of Health and Mental Hygiene, HealthChoice
Evaluation, Final Report and Recommendations (Washington, D.C.: Jan.
15, 2002).
[33] See U.S. General Accounting Office, Medicaid and SCHIP: States‘
Enrollment and Payment Policies Can Affect Children‘s Access to Care,
GAO-01-883 (Washington, D.C.: Sept. 10, 2001).
[34] These nine states were California, Colorado, Illinois, Louisiana,
Nevada, New York, Ohio, Texas, and Washington. The share of Medicaid-
eligible children participating in these states‘ traditional FFS
programs ranged from a low of about 30 percent in California and
Colorado to about 90 percent in Illinois and Louisiana. (See table 2
for more detail by state.)
[35] GAO-01-749.
[36] Since 1995, Ohio has used HEDIS primary care access measures for
beneficiaries in its traditional FFS program.
[37] The seven states we reviewed with PCCM programs were Arkansas,
Colorado, Florida, Louisiana, Massachusetts, Pennsylvania, and Texas.
Arkansas and Louisiana do not have Medicaid managed care programs other
than PCCM, whereas the other five states do. The share of Medicaid-
eligible children participating in the seven states‘ PCCM programs
ranged from a low of 12 percent in Louisiana to a high of 100 percent
in Arkansas. (See table 2 for more detail.)
[38] Some states‘ contracts with PCCMs may include a general
requirement that PCCMs provide care on a ’timely basis.“
[39] Targeting such profiles and analyses to PCPs with a certain
minimum volume of beneficiaries allows more meaningful data comparisons
with the program and other PCPs than would be possible for PCPs with
only a few beneficiaries.
[40] These states were Arkansas, Illinois, Louisiana, Maryland,
Massachusetts, Nevada, Ohio, Tennessee, and Washington.
[41] These states were California, Colorado, Florida, Michigan, New
York, Pennsylvania, and Texas. With the exception of Florida, all of
the states used managed care delivery systems for all of their SCHIP
programs; Florida enrolled a small number of SCHIP children into a PCCM
program.
[42] To achieve this purpose, the state contacted a sample of 50 to 200
providers for each plan participating in Medicaid and SCHIP, twice a
year.
[43] Florida‘s distinct SCHIP program uses the Ambulatory Care Groups
(ACG) Case-Mix Adjustment System to assign beneficiaries to 1 of 53 ACG
categories for the purpose of this analysis.
[44] Although these four states used HEDIS in both their separate SCHIP
and Medicaid programs, only New York reported comparing the results
across the two programs.
[45] The remaining four general categories are health plan stability,
cost of care, informed health care choices, and health plan descriptive
information.
[46] Prior to 1997, Massachusetts had a managed care program with
voluntary enrollment for most Medicaid beneficiaries. As many as 13
health plans participated in the state‘s Medicaid managed care program
during the early 1990s. However, since enrollment was not mandatory,
only a small number of Medicaid beneficiaries joined health plans.
These low enrollment figures, coupled with health plan consolidations,
resulted in some plans leaving the Medicaid program.
[47] Of the beneficiaries affected by plan withdrawals in Ohio from
1996 to January 2002, nearly half were involved in withdrawals that
were the result of a plan selling its membership to another plan.
[48] Plan withdrawals during this period affected approximately 105,000
beneficiaries, about 7 percent of the state‘s Medicaid population.
[49] According to the state, the decision to terminate the contract was
based on problems including the plan‘s financial solvency and failure
to pay accurate and timely claims. As of May 1, 2002, the state was
working with the health plan in an attempt to resolve these problems.
[50] Over 50,000 additional beneficiaries were affected when their
health plan was acquired by another participating health plan.
[51] There are seven service areas, each consisting of multiple
counties, in Texas‘ Medicaid capitated managed care program. Health
plans are contracted by service area, with some health plans having
contracts in multiple service areas.
[52] Tennessee enrolls nearly all beneficiaries in managed care;
therefore, we did not collect a Medicaid FFS payment schedule that can
be compared to Medicare rates.
[53] See PriceWaterhouseCoopers, Comparing CPT Code Payments for Medi-
Cal and Other California Payers (Oakland, Calif.: June 2001) and
University of Washington, State Primary Care Provider Study, Health
Policy Analysis Program (Seattle, Wash.: February 2001). A study was
also conducted in Maryland because, even though most beneficiaries are
served through managed care, the state Medicaid program‘s FFS payment
rates for some groups of beneficiaries are considered to affect what
managed care plans pay physicians. See State of Maryland Department of
Health and Mental Hygiene, Report on the Maryland Medical Assistance
Program and Maryland Children‘s Health Program - Reimbursement Rates
Fairness Act (Baltimore, Md.: September 2001).
[54] States can have more than one Medicare payment rate for a service,
varying by locality.
[55] Monique Morris and Suk-fong Tang, Pediatric Service Utilization,
Fees and Managed Care Arrangements: 2001 Report Based on 1999 Data (Elk
Grove Village, Ill.: American Academy of Pediatrics, 2001).
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analyses, recommendations, and other assistance to help Congress make
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