Medicaid and CHIP
Reports for Monitoring Children's Health Care Services Need Improvement Gao ID: GAO-11-293R April 5, 2011Medicaid and the Children's Health Insurance Program (CHIP)--two joint federal-state health care programs for low-income families and children--play a critical role in addressing the health care needs of children. In 2008, more than 36 million children in the United States received health care coverage through Medicaid or CHIP. Like all children, children covered by Medicaid and CHIP may have health care conditions that could warrant care from primary care or specialist providers. At the same time, a significant number of children in Medicaid and CHIP may not be receiving basic preventive care, which these programs generally cover. For example, we reported in 2009 that, on the basis of parents' reports in national surveys, about 40 percent of children in Medicaid and CHIP had not had a well-child checkup over a 2-year period. Many state Medicaid and CHIP programs and other health care purchasers have started initiatives to improve care coordination for children and provide children with access to networks of care. For the purposes of this report, care coordination is broadly defined as a process in which an individual or group helps to arrange a patient's primary and specialty health care services. Care coordination can be provided by primary care providers or through other individuals such as social workers or case managers. Care coordination activities can include communication--sharing information among participants in a patient's care--and linking patients to community resources. Care coordination can help children gain access to a network of care, that is, a set of providers who are available to help address the primary and specialty health care needs of a patient. The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), oversees state Medicaid and CHIP programs at the federal level and collects annual reports. States are required, under federal law, to annually report to CMS on the provision of a range of preventive, diagnostic, and treatment services for eligible children, known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. States generally provide Medicaid and CHIP services through two service delivery and financing models--fee-for-service and managed care. Under a fee-for-service model, states pay providers for each covered service for which the providers bill the state. Under a managed care model, states contract with managed care plans, such as health maintenance organizations, to provide or arrange for medical services, and prospectively pay the plans a fixed monthly fee per enrollee. Concerns have been raised about delivery model incentives and health care service utilization. In contrast, because providers are paid for each covered service provided in fee-for-service models, there may be an incentive to provide more services to beneficiaries than necessary. As a result, interest in understanding access to, and use of, services by delivery model in Medicaid and CHIP has been long-standing. In the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Congress required that we study Medicaid and CHIP children's access to primary and specialty care, including the extent to which care coordination is provided for children's care in Medicaid and CHIP and information on children's access to networks of care. In addition, Congress required that we study, as appropriate, information on the degree of availability of services for children in Medicaid and CHIP. This report examines 1) the extent to which children in Medicaid and CHIP receive care coordination and have access to networks of care, 2) how selected states are coordinating care for children in Medicaid and CHIP, and 3) the extent to which required state reports collected by CMS provide information on the provision of services to children in Medicaid and CHIP.
Two nationally representative surveys from 2007 suggest that many children in Medicaid and CHIP needing care coordination did not receive it, and many needing access to networks of care had a problem with accessing the needed services, as the following specifics illustrate. 1) Care coordination: NSCH survey data from 2007 reveal that 45 percent of children in Medicaid and CHIP needed care coordination services, and of this group, 37 percent did not receive it. 2) Access to networks of care: The 2007 MEPS data reveal that 34 percent of children in Medicaid and CHIP needed care, tests, or treatments, and of this group, 12 percent of the children's families had problems accessing the needed services. In addition, based on the MEPS data, 15 percent of children in Medicaid and CHIP needed to see specialists, and of these children, 24 percent had problems seeing the specialists they needed to see. MEPS data from 2007 also suggest that a greater proportion of children in Medicaid and CHIP and uninsured children experienced a problem accessing needed care and needed specialists than privately insured children. The five states we examined had initiatives designed to improve care coordination for children in Medicaid and CHIP by having a process in place for beneficiaries to choose or be assigned to a medical home--typically a primary care provider--and by providing enhanced payments to providers of care coordination services. Four of the five states provided monthly payments--per member per month--to providers for each patient covered by the initiative who was enrolled with the provider. States had various methods for monitoring participating providers. State officials reported challenges to improving care coordination for children in Medicaid and CHIP. Other challenges identified by states included ensuring timely payments to providers and adequate reimbursement for specialists. As of December 2010, only one state--North Carolina--had formally evaluated its initiative. The two required summary reports that states provide annually to CMS are of limited use for monitoring the provision of services to children in Medicaid and CHIP due to reporting errors, missing information, and lack of detail. Our review of fiscal year 2008 CMS 416 reports found that 12 states made reporting errors on their reports, and in 10 of these states errors were large enough to result in overstatement of the extent to which children received well-child checkups. For both the CMS 416 and the CHIP annual reports, we found missing information, such as states not reporting required information on the number of children in Medicaid referred for additional services, which resulted in gaps in information on children's access. Both annual reports lack the detail necessary to assess children's access to care by delivery model, that is, the information needed to monitor services provided to children in managed care versus services provided in fee-for-service systems. In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, we recommend that the Administrator of CMS establish a plan, with goals and time frames, to review the accuracy and completeness of information reported on the CMS 416 and CHIP annual reports and ensure that identified problems are corrected, and work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Katherine M. Iritani Team: Government Accountability Office: Health Care Phone: (206) 287-4820GAO-11-293R, Medicaid and CHIP: Reports for Monitoring Children's Health Care Services Need Improvement
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GAO-11-293R:
United States Government Accountability Office:
Washington, DC 20548:
April 5, 2011:
The Honorable Max Baucus:
Chairman:
The Honorable Orrin Hatch:
Ranking Member:
Committee on Finance:
United States Senate:
The Honorable Fred Upton:
Chairman:
The Honorable Henry A. Waxman:
Ranking Member:
Committee on Energy and Commerce:
House of Representatives:
Subject: Medicaid and CHIP: Reports for Monitoring Children's Health
Care Services Need Improvement:
Medicaid and the Children's Health Insurance Program (CHIP)--two joint
federal-state health care programs for low-income families and
children--play a critical role in addressing the health care needs of
children.[Footnote 1] In 2008, more than 36 million children in the
United States received health care coverage through Medicaid or CHIP.
Like all children, children covered by Medicaid and CHIP may have
health care conditions that could warrant care from primary care or
specialist providers. At the same time, a significant number of
children in Medicaid and CHIP may not be receiving basic preventive
care, which these programs generally cover. For example, we reported
in 2009 that, on the basis of parents' reports in national surveys,
about 40 percent of children in Medicaid and CHIP had not had a well-
child checkup over a 2-year period.[Footnote 2]
Many state Medicaid and CHIP programs and other health care purchasers
have started initiatives to improve care coordination for children and
provide children with access to networks of care. For the purposes of
this report, care coordination is broadly defined as a process in
which an individual or group helps to arrange a patient's primary and
specialty health care services.[Footnote 3] Care coordination can be
provided by primary care providers or through other individuals such
as social workers or case managers. Care coordination activities can
include communication--sharing information among participants in a
patient's care--and linking patients to community resources. Care
coordination can help children gain access to a network of care, that
is, a set of providers who are available to help address the primary
and specialty health care needs of a patient.
The Centers for Medicare & Medicaid Services (CMS), an agency within
the Department of Health and Human Services (HHS), oversees state
Medicaid and CHIP programs at the federal level and collects annual
reports. States are required, under federal law, to annually report to
CMS on the provision of a range of preventive, diagnostic, and
treatment services for eligible children, known as Early and Periodic
Screening, Diagnostic and Treatment (EPSDT) services.[Footnote 4]
Under federal law, the EPSDT benefit generally entitles children in
Medicaid to receive coverage of periodic screening services--often
termed well-child checkups--that include a comprehensive health and
developmental history, a comprehensive physical exam, appropriate
immunizations, laboratory tests, and health education.[Footnote 5]
Under federal law, states are also required to annually assess the
operations of their CHIP programs and report to CMS on the results of
those assessments.[Footnote 6] These reports are important in part
because they are designed to collect a standard set of information
about children's health in Medicaid and CHIP from all states, and thus
serve as a resource for CMS and other stakeholders to monitor
children's utilization of health care services.[Footnote 7] For
Medicaid, CMS requires states to submit EPSDT reports (also known as
CMS 416 reports), which include information on the number of children
receiving well-child checkups and the number of children referred for
treatment services for conditions discovered through well-child
checkups. The CMS 416 reports are used by CMS to monitor states'
progress in meeting the agency's annual goal that states provide a
well-child checkup to at least 80 percent of the children eligible to
receive one.[Footnote 8] CMS, for example, has used CMS 416 reports to
identify states with low reported rates of service provision for
purposes of conducting reviews of state EPSDT programs to identify
needed improvements. For CHIP, CMS requires states to submit a CHIP
annual report. This report provides a wide range of information about
state CHIP programs, including states' performance in four areas
related to services provided to children: receipt of well-child visits
during the first 15 months of life; receipt of well-child visits in
the third, fourth, fifth, and sixth years of life; use of appropriate
medications for children with asthma; and access to primary care
providers.
States generally provide Medicaid and CHIP services through two
service delivery and financing models--fee-for-service and managed
care. Under a fee-for-service model, states pay providers for each
covered service for which the providers bill the state. Under a
managed care model, states contract with managed care plans, such as
health maintenance organizations, to provide or arrange for medical
services, and prospectively pay the plans a fixed monthly fee per
enrollee.[Footnote 9] Concerns have been raised about delivery model
incentives and health care service utilization; for example, one
concern is that the fixed payment in managed care models may create an
incentive to underserve or deny access to needed care. In contrast,
because providers are paid for each covered service provided in fee-
for-service models, there may be an incentive to provide more services
to beneficiaries than necessary. As a result, interest in
understanding access to, and use of, services by delivery model in
Medicaid and CHIP has been long-standing.
In the Children's Health Insurance Program Reauthorization Act of 2009
(CHIPRA), Congress required that we study Medicaid and CHIP children's
access to primary and specialty care, including the extent to which
care coordination is provided for children's care in Medicaid and CHIP
and information on children's access to networks of care. In addition,
Congress required that we study, as appropriate, information on the
degree of availability of services for children in Medicaid and CHIP.
[Footnote 10] This report examines:
1. the extent to which children in Medicaid and CHIP receive care
coordination and have access to networks of care,
2. how selected states are coordinating care for children in Medicaid
and CHIP, and:
3. the extent to which required state reports collected by CMS provide
information on the provision of services to children in Medicaid and
CHIP.
We provided a briefing for your staff on the information contained in
this report on February 3, 2011. (See enclosure I.) As discussed at
that time, we agreed to issue this report, which transmits and updates
the information provided at the briefing.
To examine the extent to which children in Medicaid and CHIP receive
care coordination and have access to networks of care, we analyzed two
nationally representative surveys administered by HHS agencies. One
survey--the National Survey of Children's Health (NSCH)--provides
information on children's access to care coordination.[Footnote 11]
The NSCH includes a measure to identify the extent that children
needing care coordination received effective care coordination.
[Footnote 12] The second survey--the Medical Expenditure Panel Survey
(MEPS)--provides information on children's use of, and access to,
health services and specialists, which we used as a proxy for
children's access to networks of care.[Footnote 13] To assess the
reliability of these data, we reviewed relevant documentation and
interviewed agency officials knowledgeable about the data; we
determined that the data were sufficiently reliable for the purposes
of this report. (See enclosure II for additional information on our
analyses of NSCH and MEPS survey data.) To examine how selected states
are coordinating care for Medicaid and CHIP children, we selected 5 of
the 21 states identified in literature and by experts as having
implemented initiatives in their Medicaid and CHIP programs to improve
the coordination of children's care.[Footnote 14] We interviewed state
officials and others involved in these initiatives, such as physician
associations and advocacy groups that assisted in the implementation
of the initiatives. The 5 states we selected were Colorado, Illinois,
New York, North Carolina, and Oklahoma. This judgmental,
nongeneralizable sample was chosen to (1) include geographic
diversity, (2) represent a mix of small and large Medicaid and CHIP
programs, and (3) represent a mix of Medicaid and CHIP programs with
and without a large proportion of children enrolled in managed care.
To examine the extent to which annual state reports collected by CMS
provide information on the provision of services to children in
Medicaid and CHIP, we assessed federal fiscal year 2008 information
from the two key summary reports that states are required to submit to
CMS: the CMS 416 reports and the state CHIP annual reports.
We conducted this performance audit from September 2009 to April 2011
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Results in Brief:
Two nationally representative surveys from 2007 suggest that many
children in Medicaid and CHIP needing care coordination did not
receive it, and many needing access to networks of care had a problem
with accessing the needed services, as the following specifics
illustrate.
* Care coordination: NSCH survey data from 2007 reveal that 45 percent
of children in Medicaid and CHIP needed care coordination services,
and of this group, 37 percent did not receive it.
* Access to networks of care: The 2007 MEPS data reveal that 34
percent of children in Medicaid and CHIP needed care, tests, or
treatments, and of this group, 12 percent of the children's families
had problems accessing the needed services. In addition, based on the
MEPS data, 15 percent of children in Medicaid and CHIP needed to see
specialists, and of these children, 24 percent had problems seeing the
specialists they needed to see. MEPS data from 2007 also suggest that
a greater proportion of children in Medicaid and CHIP and uninsured
children experienced a problem accessing needed care and needed
specialists than privately insured children. For example, 12 percent
of children in Medicaid and CHIP reported problems accessing needed
care, tests, or treatments, compared to 16 percent of uninsured
children and 6 percent of privately insured children.
The five states we examined had initiatives designed to improve care
coordination for children in Medicaid and CHIP by having a process in
place for beneficiaries to choose or be assigned to a medical home--
typically a primary care provider--and by providing enhanced payments
to providers of care coordination services.[Footnote 15] Four of the
five states provided monthly payments--per member per month--to
providers for each patient covered by the initiative who was enrolled
with the provider. Other approaches used by the states included
increased payment rates for certain services, such as office-based
checkups, and performance-based bonuses or incentive payments for
meeting or exceeding quality standards. The standards that
participating providers were required to meet varied among states, but
included requirements such as having a system in place for patients to
contact their provider 24 hours a day and 7 days a week, tracking
referrals to other physicians, and designing care management plans for
patients. States had various methods for monitoring participating
providers. For example, North Carolina compiled quality of care
indicators from claims data and annual chart reviews and shared these
indicators with all providers in the state. State officials reported
challenges to improving care coordination for children in Medicaid and
CHIP. For example, most state representatives we spoke with said that
because specialists are in shorter supply in rural areas, obtaining
referrals to specialists was still an issue. Other challenges
identified by states included ensuring timely payments to providers
and adequate reimbursement for specialists. As of December 2010, only
one state--North Carolina--had formally evaluated its initiative.
These evaluations projected Medicaid cost savings from the initiative
due to a reduction in the use of certain services, such as emergency
room visits for enrolled patients. (See enclosure III for additional
information on care coordination initiatives in the five selected
states.)
The two required summary reports that states provide annually to CMS
are of limited use for monitoring the provision of services to
children in Medicaid and CHIP due to reporting errors, missing
information, and lack of detail. Our review of fiscal year 2008 CMS
416 reports found that 12 states made reporting errors on their
reports, and in 10 of these states errors were large enough to result
in overstatement of the extent to which children received well-child
checkups. For both the CMS 416 and the CHIP annual reports, we found
missing information, such as states not reporting required information
on the number of children in Medicaid referred for additional
services, which resulted in gaps in information on children's access.
Both annual reports lack the detail necessary to assess children's
access to care by delivery model, that is, the information needed to
monitor services provided to children in managed care versus services
provided in fee-for-service systems. Further, although the CMS 416
captures, for some states, information on the number of children
referred to other providers for treatment services, it does not
identify whether those children actually received the needed services.
More detailed information could be helpful to CMS and others for
identifying state Medicaid or CHIP programs for further review and
monitoring. In 2010, HHS reported on the information available to
monitor children's access to services in Medicaid and CHIP. In its
report, HHS recognized that the information reported in CMS 416 and
CHIP annual reports, and other data sources used for management of the
Medicaid and CHIP programs, was not always accurate and complete. HHS
committed to improving the quality of information available on
children's access to care in these programs. CMS has efforts under way
to improve state reporting on the CMS 416 and CHIP annual reports,
including training CMS staff who work with states on reporting CMS 416
information, convening a national workgroup that will provide input on
improving technical assistance and guidance to states on reporting on
EPSDT services, and plans to provide technical assistance to states on
the CHIP annual report measures.[Footnote 16; Footnote 17] As of
December 2010, these efforts did not include planning for separate
reporting on the provision of services by managed care and fee-for-
service delivery models.
Conclusions:
Although some states are expanding initiatives to help improve
children's access to care coordination services, almost one-quarter of
families with Medicaid and CHIP children who needed specialty care
reported problems accessing that care. Monitoring is important for
ensuring access to specialty care for Medicaid and CHIP children,
including the collection of information on whether needed specialty
care services for which children have been referred were received. To
appropriately inform oversight efforts and the public on the provision
of services in the Medicaid and CHIP programs, accurate and complete
reporting is needed. Ensuring the accuracy and completeness of
information collected on the provision of services to children in
Medicaid and CHIP has been a challenge for CMS despite federal
requirements for annual reports from states and a long-standing CMS
goal for states to routinely provide well-child checkups for eligible
children. CMS's recent efforts are positive steps toward helping to
ensure the usefulness of the information collected to better monitor
the provision of services. However, information is lacking on whether
those referred for treatment services ever received those services.
Continued steps to improve the accuracy and completeness of state
reports and to identify options for improving their usefulness are
warranted.
Recommendations:
In light of the need for accurate and complete information on
children's access to health services under Medicaid and CHIP, the
requirement that states report information to CMS on certain aspects
of their Medicaid and CHIP programs, and problems with accuracy and
completeness in this state reporting, we recommend that the
Administrator of CMS:
* establish a plan, with goals and time frames, to review the accuracy
and completeness of information reported on the CMS 416 and CHIP
annual reports and ensure that identified problems are corrected, and:
* work with states to identify additional improvements that could be
made to the CMS 416 and CHIP annual reports, including options for
reporting on the receipt of services separately for children in
managed care and fee-for-service delivery models, while minimizing
reporting burden, and for capturing information on the CMS 416
relating to children's receipt of treatment services for which they
are referred.
Agency Comments:
We provided a draft of this report to HHS for comment. Responding for
HHS, CMS agreed with our recommendations. The full text of CMS's
comments is reprinted in enclosure IV. CMS also provided technical
comments, which we incorporated as appropriate.
In its comments, CMS noted efforts it is planning or has under way
that begin to address our recommendations that we believe are positive
steps. These include working with states to improve EPSDT data
reporting requirements, identifying options to improve the value of
the CMS 416 and CHIP annual reports, and drafting regulatory guidance
for states for consistent reporting of managed care encounter data.
However, we note that some of CMS's efforts are toward improving data
that are voluntarily reported by states, as opposed to improving data
that are required, such as the CMS 416 and CHIP annual reports and
their underlying data. CMS's ability to monitor children's access to
services is dependent on consistent, reliable, complete, and
sufficiently detailed data from each state.
We are sending copies of this report to the Secretary of HHS and
appropriate congressional committees. The report also is available at
no charge on GAO's Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions or need additional
information, please contact me at (202) 512-7114 or iritanik@gao.gov.
Contact points for our Offices of Congressional Relations and Public
Affairs may be found on the last page of this report. GAO staff
members who made key contributions to this report are listed in
enclosure V.
Signed by:
Katherine Iritani:
Acting Director, Health Care:
Enclosures - 5:
[End of section]
Enclosure I: Medicaid and CHIP: Information on Children's Access to
Care Coordination and Networks of Care, and on States' Reports to CMS
on the Provision of Services:
Briefing for staff of the Committee on Finance, United States Senate:
Committee on Energy and Commerce, House of Representatives:
Updated:
Introduction:
In 2008, more than 36 million children in the United States received
health care coverage through Medicaid or the Children's Health
Insurance Program (CHIP).
* About 29.3 million low-income children received coverage through
Medicaid.[Footnote 18]
* About 7.4 million received coverage through CHIP.
Like all children, children in Medicaid and CHIP may have health care
conditions that could warrant primary care providers' or specialists'
care.
A significant number of children in Medicaid and CHIP do not receive
basic preventive care, which all state Medicaid and CHIP programs
generally cover.
* For example, in 2009 we estimated that 40 percent of children in
Medicaid and CHIP had not had a well-child checkup over a 2-year
period.[Footnote 19]
State Medicaid and CHIP programs and other payers have begun
implementing initiatives to improve care coordination for children and
provide access to networks of care.[Footnote 20]
* Care coordination can help children access a network of care (i.e.,
a set of providers who are available to help address a child's primary
and specialty health care needs).
The Centers for Medicare & Medicaid Services (CMS) oversees state
Medicaid and CHIP programs at the federal level and collects annual
reports. States are required under federal law:
* to annually report to CMS on the provision of a range of preventive,
diagnostic, and treatment services for eligible children, known as
Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
services,[Footnote 21] and;
* to assess the operations of their CHIP programs and report to CMS on
the results of those assessments annually.
The Children's Health Insurance Program Reauthorization Act of 2009
(CHIPRA) required GAO to study and report on certain aspects of the
access of children in Medicaid and CHIP to primary and specialty
services.[Footnote 22] This briefing provides information on:
1. The extent to which children in Medicaid and CHIP receive care
coordination and have access to networks of care.
2. How selected states are coordinating care for children in Medicaid
and CHIP.
3. The extent to which the required state reports collected by CMS
provide information on the provision of services to children in
Medicaid and CHIP.
Scope and Methodology: 1: Care Coordination and Access to Networks of
Care:
To examine the extent to which children in Medicaid and CHIP receive
care coordination and have access to networks of care, we analyzed two
nationally representative surveys administered by Department of Health
and Human Services (HHS) agencies.
* The National Survey of Children's Health (NSCH), administered by the
National Center for Health Statistics (2007 survey, most recent
available). The NSCH collected data from 91,000 parents and guardians
on health questions, including questions related to care coordination
for their children. For Medicaid- and CHIP-covered children 17 years
of age and younger, we examined children's need for care coordination
services and whether their families reported having a problem
accessing services. The NSCH only includes information for children 17
years of age and younger.
* The Medical Expenditure Panel Survey (MEPS), administered by the
Agency for Health Care Research and Quality (2005, 2006, and 2007
surveys).[Footnote 23] The MEPS collected data on more than 30,000
persons, including information from families, individuals, and their
medical providers, on use of, and access to, health services. For
Medicaid- and CHIP-covered children 17 years of age and younger, we
assessed access to networks of care by examining questions related to
children's need for care, tests, and treatment and for access to
needed specialists, and whether their families reported having a problem
accessing needed services or specialists.
- For consistency with the NSCH, we analyzed MEPS survey results for
children 17 years of age and younger.
- We also compared Medicaid- and CHIP-covered children to uninsured
and privately insured children.
Scope and Methodology: 2: State Care Coordination Initiatives:
To examine how selected states are coordinating care for Medicaid- and
CHIP-covered children, we obtained information on initiatives in five
selected states: Colorado, Illinois, New York, North Carolina, and
Oklahoma.
* The states in our nongeneralizable sample were identified in
literature and by experts as having implemented initiatives to improve
care coordination for Medicaid- and CHIP-covered children.
* The five states were selected from 21 that experts identified to
provide (1) geographic diversity, (2) a mix of small and large
Medicaid and CHIP programs, and (3) a mix of programs with and without
a large proportion of children enrolled in managed care.[Footnote 24]
Scope and Methodology: 3: Information States Report to CMS:
To examine the extent to which state reports collected by CMS provide
information on the provision of services to Medicaid- and CHIP-covered
children, we assessed federal fiscal year 2008 information from the
two key summary reports required by federal law:[Footnote 25]
* CMS 416 reports: required for state Medicaid programs, CMS 416
reports are due April 1 after the end of the federal fiscal year.
* State CHIP annual reports: required for state CHIP programs, CHIP
annual reports are due January 1 after the end of each federal fiscal
year.
We conducted this performance audit from September 2009 to April 2011
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our
findings and conclusions based on our audit objectives.
Background: Medicaid:
States operate their Medicaid programs within broad federal
requirements.
* State Medicaid programs are generally required to cover EPSDT
services.
* States may operate their Medicaid programs through various models”
for example, they may pay providers directly for services (fee-for-
service) or they may contract with managed care organizations to
provide benefits.
Background: CHIP:
As for Medicaid, states operate their CHIP programs within broad
federal requirements.
* In 2010, states administered their CHIP programs in three ways:
- 7 states administered CHIP as an expansion of their Medicaid
programs,[Footnote 26]
- 18 states administered separate, stand-alone CHIP programs, and
- 26 states had a combined program, with both a Medicaid expansion and
a separate CHIP program.
States may operate their CHIP programs through a fee-for-service
delivery model, or they may contract with managed care organizations
to provide benefits.
States are required to cover certain benefits for CHIP-covered
children:
* For example, CHIP-covered children covered under Medicaid expansion
programs must receive the same benefits, including EPSDT benefits, as
Medicaid-covered children.
Background: State Medicaid Reports:
Medicaid: Since 1990, CMS has required states to submit CMS 416
reports to the agency that contain information on the provision of
EPSDT services, such as well-child checkups, to children enrolled in
Medicaid.
* States collect information from fee-for-service providers and
managed care plans to complete the reports.
- As we have reported, states face challenges in collecting complete
and accurate information for CMS 416 reports, particularly from
managed care plans that are not reimbursed on the basis of providing
individual services.[Footnote 27]
CMS uses these reports to monitor states' progress in meeting the
agency's annual goal that states provide a well-child checkup to at
least 80 percent of children eligible to receive one.[Footnote 28] CMS
makes the state reports available on the agency's Web site.
Many states have reported using the CMS 416 to monitor Medicaid
children's utilization of preventive services.[Footnote 29]
Background: State CHIP Reports:
CHIP: Since 2002, CMS has required states to submit CHIP annual
reports. Since 2003, CMS has asked that these reports include
information on four performance measures used to assess states'
provision of services to children in CHIP:
* receipt of well-child visits during the first 15 months of life;
* receipt of well-child visits in the third, fourth, fifth, and sixth
years of life;
* use of appropriate medications in children with asthma; and;
* children's access to primary care providers.
States have flexibility in the data they use to report these measures;
for example, they may use claims data, a mixture of claims data and
medical records, or survey data.
CMS uses these reports to produce and publish a summary of state CHIP
programs and also makes them available on CMS's Web site.
1: Care Coordination and Networks of Care: Overview of Finding 1:
Two nationally representative surveys from 2007 suggest that many
Medicaid- and CHIP-covered children needing care coordination did not
receive it, and many needing access to networks of care had difficulty
accessing the needed services.[Footnote 30]
* Care Coordination:
- NSCH data from 2007 suggest that 45 percent of Medicaid- and CHIP-
covered children needed care coordination, and 37 percent of those did
not receive it.
* Access to Networks of Care:
- Access to care, tests, or treatment. MEPS data from 2007 suggest
that 34 percent of Medicaid- and CHIP-covered children needed care,
tests, or treatments, and 12 percent of those had problems accessing
the needed services.
- Access to specialists MEPS data from 2007 suggest that 15 percent of
Medicaid- and CHIP-covered children needed to see specialists, and 24
percent of those had problems seeing specialists.[Footnote 31]
1: Care Coordination and Networks of Care: NSCH Care Coordination Data:
NSCH data from 2007 suggest that 45 percent of Medicaid- and CHIP-
covered children needed care coordination, and 37 percent of those
children did not receive it.
* The NSCH measures care coordination for children who received two or
more services in the prior 12 months. For these children, the NSCH
examines survey responses related to getting help coordinating care
when needed, satisfaction with communication between health care
providers, and satisfaction with communication between health care
providers and other entities (such as schools).[Footnote 32]
* On the basis of NSCH families' reports in the 2007 survey, 45
percent of Medicaid- and CHIP-covered children 17 years of age and
younger needed care coordination services. Projected nationally, this
represents an estimated 9.4 million children.[Footnote 32]
* Of those Medicaid- and CHIP-covered children 17 years of age and
younger whose families reported needing care coordination services, 37
percent did not receive the needed services. Projected nationally,
this represents an estimated 3.5 million children.[Footnote 33]
1: Care Coordination and Networks of Care: MEPS Data on Needed Care,
Tests, or Treatment:
MEPS data from 2007 suggest that 34 percent of Medicaid- and CHIP-
covered children needed care, tests, or treatments, and 12 percent of
those had problems accessing the needed services.
* The MEPS asks families if their child needed any care, tests, or
treatment in the last 12 months. The MEPS also asks families how much
of a problem, if any, it was to get the care, tests, or treatments the
family or a doctor believed were necessary for the child. On the basis
of MEPS families' reports in the 2007 survey, 34 percent of Medicaid-
and CHIP-covered children 17 years of age and younger needed care,
tests, or treatments. Projected nationally, this represents an
estimated 7.3 million children.
* Of those Medicaid- and CHIP-covered children 17 years of age and
younger whose families reported that they needed care, tests, or
treatments, 12 percent of families reported problems accessing the
needed services. Projected nationally, this represents an estimated
844,000 children.
MEPS data from 2005 and 2006 concerning access to networks of care are
consistent with the data from 2007 reported here.
1: Care Coordination and Networks of Care: MEPS Data on Access to
Specialists:
MEPS data from 2007 suggest that 15 percent of Medicaid- and CHIP-
covered children needed to see specialists, and 24 percent of those
had problems seeing specialists.
* The MEPS asks families if their child needed to see a specialist in
the past 12 months and how much of a problem, if any, it was to see a
specialist that the child needed to see.
* On the basis of MEPS families' reports in the 2007 survey, 15
percent of Medicaid- and CHIP-covered children 17 years of age and
younger needed to see a specialist. Projected nationally, this
represents an estimated 3.2 million children.
* Of those Medicaid- and CHIP-covered children 17 years of age and
younger whose families reported that they needed to see a specialist,
24 percent of families reported problems accessing the specialist.
[Footnote 35] Projected nationally, this represents an estimated
769,000 children.
MEPS data from 2005 and 2006 concerning access to specialists are
consistent with the data from 2007 reported here.
1: Care Coordination and Networks of Care:
Comparing Medicaid-and CHIP-covered children with uninsured and
privately insured children, MEPS data from 2007 show that a greater
proportion of Medicaid-and CHIP-covered children and uninsured
children experienced problems accessing needed care and needed
specialists than privately insured children.
Figure: Reported a problem accessing needed care, tests, or treatment,
2007:
[Refer to PDF for image: vertical bar graph]
Medicaid/CHIP: 12%;
Uninsured: 16%;
Private[A]: 6%.
Source: GAO analysis of 2007 MEPS data.
[A] There is a significant difference at the 95 percent confidence
level for this insurance type when compared to other insurance types.
[End of figure]
Figure: Reported a problem accessing needed specialists, 2007:
Medicaid/CHIP[A]: 24%;
Uninsured[B]: 29%;
Private: 18%.
Source: GAO analysis of 2007 MEPS data.
[A] The confidence interval for this estimate is plus or minus 6
percent at the 95 percent confidence level.
[B] The confidence interval for this estimate is plus or minus 9
percent at the 95 percent confidence level.
[End of figure]
2: Care Coordination Initiatives: Overview of Finding 2:
Initiatives in the five selected states were designed to improve care
coordination by assigning children to medical homes and increasing
payments to providers.
* Care coordination initiatives in the states we examined varied in
the populations covered and in the delivery model, but shared common
elements:
- States had processes for assigning children to a medical home.
[Footnote 36] States provided enhanced payments to providers who were
approved to participate in the states' care coordination initiatives
and provide services.
- States provided support to providers and monitored their initiatives.
* States identified challenges to improving care coordination, and
only one of the five states has conducted a formal, independent
evaluation of its program.
2: Care Coordination Initiatives: Characteristics of State Initiatives:
Table: Care coordination initiatives in the five states varied in the
populations covered and in the delivery models used.
State Initiative: Colorado-”Medical Home Initiative;
Year started: 2007;
Population covered: Medicaid: Children;
Population covered: CHIP: Children;
Delivery model: Medicaid: FFS;
Delivery model: CHIP: MC.
State Initiative: Illinois-”Health Connect;
Year started: 2007;
Population covered: Medicaid: Children and adults;
Population covered: CHIP: Children;
Delivery model: Medicaid: FFS (PCCM);
Delivery model: CHIP: FFS (PCCM).
State Initiative: New York”-Patient Centered Medical Home;
Year started: 2009;
Population covered: Medicaid:
Population covered: CHIP: [Empty];
Delivery model: Medicaid: FFS and MC;
Delivery model: CHIP: [Empty].
State Initiative: North Carolina-”Community Care of North Carolina;
Year started: 1998;
Population covered: Medicaid: Children and adults;
Population covered: CHIP: Children[A];
Delivery model: Medicaid: FFS (PCCM);
Delivery model: CHIP: FFS (PCCM)[A].
State Initiative: Oklahoma”-Sooner Care Choice;
Year started: 2009;
Population covered: Medicaid: Children and adults;
Population covered: CHIP: Children;
Delivery model: Medicaid: FFS (PCCM);
Delivery model: CHIP: FFS (PCCM).
Source: GAO analysis.
Legend:
FFS = fee-for-service;
MC = managed care;
PCCM care = primary care case coordination payments management.
[A] In October 2009, North Carolina temporarily discontinued for CHIP-
covered children.
[End of table]
2: Care Coordination Initiatives: Assigning Children to Medical Homes:
All five states' initiatives have processes for assigning children to
a medical home.
Examples of these processes included the following:
* In Illinois, once a potential enrollee becomes eligible for the
initiative, a contractor employed by the state has 5 days to issue an
initial enrollment packet to the eligible individual or family. Within
60 days of receiving this packet, the potential enrollee must choose a
primary care provider as a medical home, or be automatically assigned
to one.
* In North Carolina, it is mandatory for infants eligible for Medicaid
and children ages 1 through 18 to be enrolled in the state's
initiative. Once they are enrolled, the local county department of
social services assists each family in choosing a provider to be the
child's medical home.
2: Care Coordination Initiatives: Methods to Approve Providers for
Participation:
States used three types of methods to approve providers for
participation:
* Illinois and North Carolina used provider agreements as a condition
of approval for providers. Providers agreeing to meet certain basic
standards could participate in the initiative. For example, in
Illinois, participating providers agreed to provide preventive
services and to coordinate care for specialty services.
* In Oklahoma and Colorado, providers were approved by the state after
the state conducted a review and determined that the providers met
certain standards, such as being available 24 hours a day, 7 days a
week, by expanding their normal office hours or arranging for an
alternate provider.
* New York required its providers to be reviewed and approved as a
medical home by a nationally recognized organization”the National
Committee for Quality Assurance”in order to participate in the state's
medical home initiative.
In addition, two of the states (Oklahoma and New York) used a tiered
approach for approval, where providers were approved to a specific
tier based on their ability to provide designated levels of care
coordination services through tools they used in their practices.
2: Care Coordination Initiatives: Standards Approved Providers Must
Meet:
The standards that participating providers were required to meet
varied among states, but included requirements such as:
* having a system in place for patients to contact their provider 24
hours a day, 7 days a week (Colorado, Illinois, North Carolina,
Oklahoma);
* tracking referrals to other physicians or identifying the number of
patients with certain chronic conditions (Illinois, New York);
* designing care management plans that can include items such as the
patient's condition, a list of medications and instructions for use, a
list of symptoms for which they need to contact their providers, and
patient communication preference (Illinois, New York);
* having cultural competency, for example, providing cultural training
to staff in the practice (Colorado);
* implementing evidence-based guidelines for certain conditions (New
York); and;
* submitting quality improvement plans or performance reports
(Colorado, New York, North Carolina).
2: Care Coordination Initiatives: Types of Enhanced Payments to
Providers:
States used one or more of the following three approaches to provide
enhanced payments for the care coordination services provided through
medical homes:
* per member per month payments to providers for each patient
covered by the initiative who was enrolled with the provider;
* increased payment rates for the provision of certain services, such
as EPSDT services; and;
* performance-based bonuses or incentive payments to providers who
achieved goals such as increasing well-child screenings to a certain
percentage of children.
In addition, in the two states with tiered approvals (Oklahoma and
New York), larger payments were made to providers approved at the
higher levels.
2: Care Coordination Initiatives: Methods and Amounts for Enhanced
Payments:
Table:
State: Colorado;
Enhanced payment method: Per member per month: [Empty];
Enhanced payment method: increased payment rate: [Empty];
Enhanced payment method: Performance bonus or incentive: [Check];
Amount of enhanced payment: For Medicaid, pay for performance includes
$10 per well-child visit for ages under 5 and $40 for age 5 and older,
and for CHIP, up to $21 per child.
State: Illinois;
Enhanced payment method: Per member per month: [Check];
Enhanced payment method: increased payment rate: [Check];
Enhanced payment method: Performance bonus or incentive: [Check];
Amount of enhanced payment: Providers are paid a case management fee
of $2 per child (under age 21) per month and can receive increased
payments by billing separately for services that are normally bundled.
Providers can also receive up to $25 per patient bonus payments for
meeting or exceeding certain quality measures.
State: New York;
Enhanced payment method: Per member per month: [Check];
Enhanced payment method: increased payment rate: [Check];
Enhanced payment method: Performance bonus or incentive: [Empty];
Amount of enhanced payment: Providers in the state's fee-for-service
program can receive from about $5 to $21 (based on tier) in extra
payments for certain types of office visits, and providers in managed
care can receive $2 to $6 extra per member per month.
State: North Carolina;
Enhanced payment method: Per member per month: [Check];
Enhanced payment method: increased payment rate: [Empty];
Enhanced payment method: Performance bonus or incentive: [Empty];
Amount of enhanced payment: Providers can receive about $5 per member
per month for patients who are blind or disabled and $2.50 for other
patients.
State: Oklahoma;
Enhanced payment method: Per member per month: [Check];
Enhanced payment method: increased payment rate:
Enhanced payment method: Performance bonus or incentive: [Check];
Amount of enhanced payment: Providers can receive per member per month
payments of about $3.50 to $7.50 based on certification tier and
patient type. In addition, bonus payments are given based on
performance goals set by the practice and on the practice's meeting
national quality indicators for certain childhood screenings.
Source: GAO analysis of documentation from five selected states.
[End of table]
2: Care Coordination Initiatives: State Activities to Support
Providers and Monitor Initiatives:
States had several processes to support participating providers in
providing care coordination services.
* Four states had toll-free numbers providers could call to find
specialists who were accepting Medicaid- or CHIP-covered patients.
* Four states had staff who could come to the offices of participating
providers to provide support or answer questions related to the
program.
States also had various methods for monitoring participating providers.
* For example, North Carolina compiled quality of care indicators from
claims data and annual chart reviews and shared these indicators with
all providers in the state. These indicators included:
- number of patients admitted to emergency rooms,
- percentage of preventable readmissions to the hospital,
- number of administered diabetes examinations, and,
- number of asthma-related emergency room visits.
State officials reported that sharing the quality of care indicators
has instilled competition among the providers to improve their
performance.
2: Care Coordination Initiatives: Challenges and Formal Evaluations:
States identified some challenges to improving care coordination for
Medicaid- and CHIP-covered children. For example:
* Most state representatives we spoke with said that obtaining
referrals to specialists was still an issue in rural areas. Because
specialists for the most part are in shorter supply in rural areas, it
was hard for some providers to find specialists for their patients.
* Colorado found that some providers had not yet joined the initiative
because they believed the compensation for Medicaid- and CHIP-covered
patients was too low. Other challenges identified by states included
ensuring timely payments to providers and adequate reimbursement for
specialists.
Only one state had conducted an independent formal evaluation of its
care coordination initiative:
* North Carolina hired a contractor to evaluate the effect of its
initiative. The evaluation compared the actual cost for participants
in the initiative with an estimated cost for participants had they not
been enrolled in the initiative. The contractor estimated that the
initiative saved the state $190 million in 2009 by reducing the cost
of certain services, including inpatient, outpatient, and emergency
room services.
3: Information States Report to CMS: Overview of Finding 3:
Information states report to CMS has weaknesses that limit its
usefulness for measuring and monitoring children's access to care.
* Reporting errors: States report data that fall outside of
permissible ranges or that are contrary to instructions provided by
CMS (CMS 416).
* Missing information: States do not report certain categories of data
(CMS 416 and CHIP annual report).
* Lack of detail: States report summary information that lacks detail
on services children receive by delivery model (CMS 416 and CHIP
annual report) and whether children actually receive the services they
need (CMS 416).
Internal control standards specify that agencies should collect
information to monitor program objectives in order to determine
whether the agencies are meeting their strategic goals.[Footnote 37]
3: Information States Report to CMS: Reporting Errors:
Several states made reporting errors on their CMS 416 reports in
fiscal year 2008, resulting in overstatement of the extent to which
children received well-child checkups.
* States are required to report the percentage of eligible children
who received at least one well-child checkup, known as the participant
ratio.
- Valid participant ratios cannot be larger than 100, as this would
mean more children received a checkup than were eligible to receive one.
- In fiscal year 2008, 12 states reported participant ratios over 100
for at least one age group.
- Ten of the 12 states had errors large enough to affect their overall
participant ratios, with the amount of overstatement ranging from 1 to
14 percent.
* Even with overstated overall participant ratios, few states met or
exceeded CMS's 80 percent goal. In fiscal year 2008, only 2 states met
or exceeded CMS's goal, and the nationwide participant ratio was 63
percent.
3: Information States Report to CMS: Missing Information:
Several states provided reports with missing information in fiscal
year 2008, which resulted in gaps in information on children's access
to care.
* On the CMS 416, states are required to report the number of children
who are referred for additional services as a result of health
problems identified during well-child checkups.
- In fiscal year 2008, 42 states reported information on referrals
made, and 9 states did not report any information on the number of
referrals made.
On the CHIP annual report, CMS specifies that states are required to
report on the four performance measures only to the extent that
information is available to the state.
* In fiscal year 2008, 18 states did not report all measures to CMS-10
states reported on three measures, 6 states reported on two measures,
and 2 states reported on one measure.
3: Information States Report to CMS: Lack of Detail:
CMS 416 and CHIP annual reports lack detail necessary to assess access
by delivery model. Specifically, these reports do not distinguish
between children in fee-for-service and those in managed care delivery
models, and so potential access problems unique to a particular
delivery model cannot be assessed.[Footnote 38]
* Different delivery models may provide different incentives that have
unintended, negative effects. For example, in managed care models,
when states provide a set payment amount in advance to provide
services to beneficiaries, it may create an incentive to underserve or
deny access to needed care.
- For example, in a 2010 report examining children's access to dental
services, we compared CMS 416 information from states using only fee-
for-service with CMS 416 information from states using predominately
managed care. This comparison suggested that children in managed care
received fewer dental services, although comprehensive and reliable
information to more thoroughly examine this difference was not
available.[Footnote 39]
* In addition, although the CMS 416 captures, for some states,
information on the number of children referred to other providers for
treatment services, it does not identify whether those children
actually received the needed services.
3: Information States Report to CMS: HHS Recognizes Weaknesses:
HHS has recognized the weaknesses in available Medicaid and CHIP
information.
* In September 2010, HHS published a report in which it reviewed
available information on the quality of care for children in Medicaid
and CHIP, including information on children's access to care.[Footnote
40]
HHS concluded that:
* wide variation exists in the accuracy and completeness of state
information on the quality of care received by children enrolled in
Medicaid and CHIP, and;
* Medicaid and CHIP information submitted to CMS by the states,
including the CMS 416, CHIP annual report, and other information used
to manage the programs, is not sufficiently complete, accurate, or
timely to meet objectives of evaluating program performance or the
quality of care beneficiaries receive.
3: Information States Report to CMS: CMS Efforts to Improve Medicaid
and CHIP Reporting:
CMS officials reported that they have recently taken positive steps to
improve Medicaid and CHIP data reporting.
* In October 2010, CMS provided training for CMS EPSDT coordinators
and other staff who work with states on reporting information on the
CMS 416.
* In December 2010, CMS convened the first meeting of the National
EPSDT Workgroup, which will provide input on reporting on EPSDT
services and ways to improve technical assistance and guidance to
states, among other items.
* CMS has also formed an internal work group to improve the Medicaid
Statistical Information System (MSIS), which collects data from states
on enrollment and service utilization.[Footnote 41] These data could
be useful to CMS and others to examine provision of services for
children.
Starting in 2011, CMS will provide technical assistance to states on
three of the four performance measures on the CHIP annual report with
the goal of improving consistent collection and uniform reporting of
these measures in conjunction with a CHIPRA-mandated quality measures
initiative.[Footnote 42]
Starting in 2013 for CHIP annual reports, CMS will require states to
report additional information collected through satisfaction surveys
of beneficiaries, including information on access to primary and
specialty services, access to networks of care, and care coordination,
as required under federal law.
However, CMS officials have indicated that they do not plan to require
states to report on the provision of services to Medicaid- and CHIP-
covered children by delivery model; that is, to report information on
children in managed care separately from information on children in
fee-for-service. Officials said that reporting separately by delivery
model would be an additional burden on the states.
As a result, it will still not be possible to assess access to care
for Medicaid-and CHIP-covered children by delivery model.
[End of Enclosure I]
Enclosure II: Scope and Methodology for NSCH and MEPS Analyses:
To examine the extent to which Medicaid-and CHIP-covered children
receive care coordination and have access to networks of care, we
analyzed two nationally representative surveys conducted by the
Department of Health and Human Services (HHS). We analyzed the
National Survey of Children's Health (NSCH) to examine the extent to
which Medicaid-and CHIP-covered children receive care coordination. We
examined the Medical Expenditure Panel Survey (MEPS) to examine the
extent to which Medicaid-and CHIP-covered children have access to
networks of care.
To assess the reliability of the NSCH and MEPS data, we spoke with
knowledgeable agency officials and reviewed related documentation and
compared our results to published data. We determined that the NSCH
and MEPS data were sufficiently reliable for the purposes of our
engagement.
National Survey of Children's Health (NSCH):
The NSCH is a nationally representative survey conducted by HHS's
Centers for Disease Control and Prevention (CDC). The NSCH includes a
variety of health indicators developed by the Maternal and Child
Health Bureau in collaboration with CDC's National Center for Health
Statistics and a national technical expert panel.[Footnote 43] Our
analysis was based on the 2007 NSCH, the most recent data available.
Data in the NSCH are compiled through a random-digit-dialed sample of
households with children 17 years of age or younger from each of the
50 states and the District of Columbia.[Footnote 44] One child was
randomly selected from all children in each identified household to be
the subject of the survey, and the respondent was a parent or guardian
who knew about the child's health and health care. We analyzed NSCH's
measure of effective care coordination to estimate the extent to which
Medicaid-and CHIP-covered children 17 years of age and younger needed
care coordination and the extent to which those needing care
coordination received it.
The NSCH care coordination measure classifies children as needing care
coordination if their parent or guardian responded that:
1. during the prior 12 months the child used services in two or more
of the following categories: preventive medical, preventive dental,
mental health care, or specialist services; and:
2. the family received help coordinating the child's care among the
different doctors or services used, or could have used extra help
coordinating the child's care among the different providers and
services.
The NSCH measure classifies children as receiving effective care
coordination if they needed care coordination and their parent or
guardian responded that:[Footnote 45]
1. they received help coordinating care, did not need extra help
coordinating, or usually received the extra help in coordinating their
child's care when extra help was needed; and:
2. they were very satisfied with the doctor's communication with other
health care providers, when such communication was needed; and:
3. they were very satisfied with the doctor's communication with other
entities (such as schools, child care providers, and special
educational programs), when such communication was needed.
Medical Expenditure Panel Survey:
The MEPS is a nationally representative survey administered by HHS's
Agency for Healthcare Research and Quality (AHRQ) that provides
information on children's use of, and access to, health services. Our
analysis of MEPS was based on data from the 2005, 2006, and 2007
surveys.[Footnote 46] We obtained data from the MEPS household
component. The household component of MEPS collects data from a sample
of families and individuals in selected communities across the United
States. The sample is drawn from a nationally representative subsample
of households that participated in the prior year's National Health
Interview Survey (NHIS), a survey conducted by the National Center for
Health Statistics at CDC. The MEPS household survey uses several
rounds of interviewing covering 2 full calendar years. The MEPS is
continuously fielded; each year a new sample of households is
introduced into the study. The MEPS collects information for each
person in the household based on information provided by one adult
member of the household. This information includes demographic
characteristics, self-reported health conditions, reasons for medical
visits, use of medical services including preventive services, and
health insurance coverage.
We analyzed data for several different MEPS questions as proxies for
whether children 17 years of age and younger had access to networks of
care, specifically:
* In the last 12 months, did you or a doctor believe [your child]
needed any care, tests, or treatment?
* If yes, in the last 12 months, how much of a problem, if any, was it
to get the care, tests, or treatments you or a doctor believed
necessary [for your child]?
* In the last 12 months, did you or a doctor think [your child] needed
to see a specialist?
* If yes, in the last 12 months, how much of a problem, if any, was it
to see a specialist that [your child] needed to see?
We analyzed MEPS questions for children 17 years of age and younger to
be consistent with the ages analyzed in the NSCH.
[End of Enclosure II]
Enclosure III: Summary of Care Coordination Initiatives in Five
Selected States:
To examine how selected states are coordinating care for Medicaid- and
CHIP-covered children, we reviewed literature and spoke with experts
and stakeholders about state efforts to improve care coordination. We
identified 21 states that were developing or had implemented care
coordination programs for Medicaid- and CHIP-covered children. We
selected 5 of the 21 states for a more detailed review: Colorado,
Illinois, New York, North Carolina, and Oklahoma. This judgmental
sample was chosen to (1) include geographic diversity, (2) represent a
mix of small and large Medicaid and CHIP programs, and (3) include
states with a large share of Medicaid- and CHIP-covered children
enrolled in managed care, as well as states with few or no children
enrolled in managed care. In each state, we interviewed state
officials and obtained information about the state care coordination
initiative. We also interviewed officials from other groups involved
in the state initiatives, such as physician associations and child
advocacy groups.
All five state initiatives were designed to improve care coordination
by assigning children to medical homes and increasing payments to
providers approved to participate in the initiative. Each state
implemented its own version of a medical home with varying
requirements for the care coordination services provided through the
medical home. Tables 1 through 5 provide an overview and a description
of some key characteristics about each state‘s care coordination
initiative. Specifically, for each state we provide information on the
populations covered, provider participation requirements, provider
payment methods, the type of state monitoring and support of
providers, and the findings of any formal evaluations.[Footnote 47]
The following tables provide information on similarities and
differences across the five states‘ initiatives. For example, while
three methods were used for paying providers, the extent to which they
were used varied across the states. The three payment methods are (1)
per member per month payments, where providers receive a nominal
monthly payment for each patient covered by the initiative and
enrolled with the provider; (2) increased payment rates for certain
services, such as well-child visits, provided to patients enrolled in
the initiative; and (3) performance-based bonus payments or incentive
payments to providers who meet state-established quality goals.
Table 1: Description of Colorado‘s Care Coordination Initiative,
Colorado Medical Homes for Children:
Initiative overview:
Colorado started its initiative in 2007 to increase Medicaid- and CHIP-
covered children‘s access to a medical home. In addition, Colorado
uses the initiative to ensure that Medicaid children receive Early and
Periodic Screening, Diagnostic and Treatment (EPSDT) services.
* In 2009, 236,000 Medicaid-covered and 67,000 CHIP-covered children
participated in the program. Adults are not included in the program.
* Medicaid-covered children receive care through a fee-for-service
delivery model, and CHIP-covered children receive care through a
managed care delivery model.
* Primary care and specialty care providers can participate in the
initiative once they are approved as a medical home.
Provider participation requirements:
Providers are approved to participate in the state‘s medical home
initiative by completing several steps. For example, providers must:
* complete a Medical Home Index, which rates providers in areas such
as cultural competencies, management of chronic conditions,
preparation of a care plan that involves family members, and
coordination with community agencies and schools as appropriate.
* submit a quality improvement plan.
* meet or be working toward meeting the state‘s medical home
standards, such as being available to patients 24 hours a day, 7 days
a week; being culturally competent; and respecting the role of the
family in a patient‘s health care.
Provider payment:
Colorado providers participating in the initiative receive a
performance payment for providing well-child visits. The state has
different rates for Medicaid and CHIP.
* For Medicaid, providers receive an additional $10 per well-child
visit for children under the age of 5, and $40 per well-child visit
for children 5 and over.
* For CHIP, primary care and obstetrics and gynecology providers
receive up to an additional $21 for well-child visits.
Monitoring, support, and evaluation:
Colorado uses various methods to monitor and support providers.
* State officials visit providers who have applied to become a medical
home to assess their capacity to function as a medical home.
* The state helps providers participating in the program refer
patients to other providers by compiling, verifying, and sharing lists
of providers who are eligible and participating in Medicaid and CHIP.
* The state helps providers become medical homes by paying a nonprofit
health advocacy group to train providers in medical home standards and
to inform them of incentive payments.[A]
Although the state has not conducted a formal (external) evaluation of
its initiative, it has, in collaboration with a nonprofit
organization, compared services and outcomes of children enrolled in
medical homes with children not enrolled in medical homes. The study
found that children in medical homes had lower emergency room
admissions and more well-child visits than children not in medical homes
Source: GAO analysis of state data.
[A] In addition to funds and support from the state, Colorado‘s
providers also receive assistance from a nonprofit organization that
supports practices that are becoming medical homes.
[End of table]
Table 2: Description of Illinois‘s Care Coordination Initiative,
Illinois Health Connect:
Initiative overview:
Illinois started its initiative in 2007 to establish a medical home
and care coordination services for Medicaid and CHIP beneficiaries not
enrolled in a Medicaid managed care plan. It is available to
beneficiaries statewide.
* Illinois‘s initiative is available to Medicaid- and CHIP-covered
children. The initiative is also available to adults with Medicaid
coverage.
* As of June 2009, about 1 million Medicaid- and CHIP-covered children
were enrolled with providers participating in the state‘s initiative.
* Care is delivered through a fee-for-service delivery model.
* Only primary care providers can participate in the program.
Provider participation requirements:
Primary care physicians are approved to participate in the state‘s
medical home initiative by signing an agreement with the state to meet
certain care coordination standards. For example, providers agree to:
* maintain routine, urgent, and as-needed appointment standards,
including:
- routine preventive care available within 5 weeks of the date
request, including within 2 weeks of the date request for infants less
than 6 months;
- urgent care appointments for those not determined to be emergency
should be provided within 24 hours;
- appointments for enrollee problems or complaints not deemed serious
available within 3 weeks of the date of request;
- initial prenatal appointments without expressed problems: 1st
trimester within 2 weeks, 2nd trimester within 1 week, 3rd trimester
within 3 days; and;
- upon notification of a hospitalization or emergency room visit;
follow-up appointment available within 7 days of discharge from the
hospital.
* maintain hospital admitting and/or delivery privileges or make
arrangements for such privileges, and;
* establish a care plan for individuals with chronic diseases that
includes a list of medicines the patient is taking with dosages and
when to take them, and a list of symptoms so patients know when to
contact their provider.
Provider payment:
Illinois providers participating in the initiative are paid in three
ways.[A] They receive:
* a $2 per member per month payment for each child under the age of 21
for whom the provider serves as the medical home;[B]
* enhanced reimbursement rates for a number of selected office-based
services; and;
* bonus payments when they meet or exceed certain quality goals or
outcomes.
Monitoring, support, and evaluation:
The state works in conjunction with a contractor that administers the
day-to-day operations of the initiative to monitor and support
providers that participate in the initiative. For example, the state:
*
monitors practices by conducting routine visits to providers‘ offices,
as well as visits to investigate complaints received from patients and
other providers;
* monitors the frequency with which beneficiaries switch providers and
the reasons cited for switching;
* recently identified specific clinical areas that it will monitor
using claims data, such as asthma management, diabetes management,
immunizations, and developmental screenings;
* monitors the availability of providers on a statewide, regional,
county, city, and zip code level; and;
* established an electronic data portal to support improvements and
care coordination by allowing providers to access claims-based
reports, including patient lists, patient conditions, and histories of
services provided.
Although the state had not conducted a formal (external) evaluation,
state officials internally analyzed claims data for fiscal years 2007
through 2009 by analyzing changes in per member per month costs since
the implementation of the initiative, and they estimated savings of
$217 million.
Source: GAO analysis of state data.
[A] In addition to the three payment types, providers receive one-time
funding from the state for their first year as a participant in the
initiative.
[B] Payments for other patients are slightly higher: $3 per adult, and
$4 per disabled or elderly patient.
[End of table]
Table 3: Description of New York's Care Coordination Initiative,
Patient-Centered Medical Home:
Initiative overview:
New York started its initiative in 2009 to provide financial
incentives for providers to become medical homes for Medicaid
patients;
* New York's initiative is available to Medicaid-covered
children and adults. CHIP-covered children are not covered by the
initiative;
* The initiative is available to those that receive care
in a fee-for-service delivery model as well as those receiving care in
a managed care delivery model;
* Only primary care providers
participate in the program.
Provider participation requirements:
Providers are approved to participate in the state's medical home
initiative once they have been officially recognized by the Patient-
Centered Medical Home program of the National Committee for Quality
Assurance (NCQA).[A] Providers can be recognized at one of three
different medical home tiers, depending on the amount and level of
services the practice offers. Areas in which physician practices are
evaluated and scored include:
* using written standards on patient access and communication with
patients;
* using electronic health information to track patients' medical
conditions and important diagnoses;
* implementing evidence-based guidelines for at least three medical
conditions;
* tracking referrals to other physicians; and;
* conducting performance reports for the practice or by provider.
Provider payment:
Providers recognized as a medical home receive two types of enhanced
payments. The type of payment is based on the delivery model in which
their Medicaid and CHIP patients are enrolled, and the amount of the
payment increase is based on the provider's medical home tier;
* For children served under a managed care model, an additional per
member per month payment is made, with larger payment increases for
physicians recognized at higher medical home tiers. Tier 1 providers
are paid a $2 per member per month, tier 2 providers are paid an
additional $4 per member per month, and tier 3 providers are paid an
additional $6 per member per month;
* For children served under fee-for-service model, payment amounts are
increased for certain office-based services. The amount of the payment
increase can range from about $5 to $21, depending on the medical home
tier of the practice, with the higher tiers receiving larger payment
increases.
Monitoring, support, and evaluation:
New York officials told us in 2010 that because the program was so new
that they had not yet established a process to monitor or evaluate
outcomes of the initiative. They added that since the initiative began
the number of physicians and practices that had been recognized as a
medical home had dramatically increased.[B].
Source: GAO analysis of state data.
[A] NCQA is a nationally recognized not-for-profit organization that
develops health care quality and performance standards and accredits
health plans, physicians, and other health care providers. NCQA
assesses and scores physician practices using standards that emphasize
the use of systematic, patient-centered, and coordinated care
management processes.
[B] According to a state official, prior to the state's implementation
of the initiative the number of physicians with NCQA recognition was
about 300, but has increased three-fold since implementation of the
state's initiative.
[End of table]
Table 4: Description of North Carolina's Care Coordination Initiative,
Community Care of North Carolina:
Initiative overview:
In 1998, North Carolina expanded an existing care coordination
initiative that focused on certain populations, and introduced
Community Care of North Carolina, a system of health and community
networks across the state, to implement care coordination statewide[A];
* North Carolina's initiative is available to Medicaid-covered
children.[B] The initiative is also available to adults with
Medicaid coverage;
* Enrollment in the initiative is mandatory for Medicaid-covered
children ages 1-18;
* As of March 2010, nearly 800,000 Medicaid-covered children were
enrolled in Community Care of North Carolina;
* Care is provided through a fee-for-service delivery model;
* Most of the providers participating in the initiative are primary
care providers, because specialists do not typically meet some of the
requirements for approval.
Provider participation requirements:
Providers are approved to participate in the initiative by signing an
agreement with the state.[C] Services they agree to provide include:
* being available for medical consultation 24 hours a day, 7 days a
week;
* offering preventive services;
* arranging referrals as needed;
* providing translation services;
* referring and coordinating care;
* implementing quality improvement and disease management initiatives;
* conducting medical chart audits, and;
* reducing inappropriate utilization of services.
Provider payment:
North Carolina pays providers a per member per month
payment. This payment is based on the number of aged, blind, or
disabled beneficiaries for whom a provider serves as a medical home.
The following rates are paid monthly:
* $5 for each aged, blind, or disabled patient, and $2.50 for other
patients.
Monitoring, support, and evaluation:
North Carolina monitors several
health care measures that are collected from claims data and annual
chart reviews. Measures that are monitored include:
* preventable hospital readmissions as a percentage of total hospital
admissions;
* percentage of providers who use electronic prescribing, and;
* rates of emergency room visits for asthma patients.
The state has funded two external evaluations of the Community Care of
North Carolina:
* A study by Mercer Consulting Group estimated that for state fiscal
year 2009 savings from the program were between $187 and $195 million.
Estimated savings were determined by comparing state costs under
Community Care of North Carolina to projections of what state costs
would have been under the previous program using historical data;
* An earlier study of the program's initial disease management
initiatives conducted by the University of North Carolina's Cecil G.
Sheps Center estimated Medicaid savings of $3.3 million for people with
asthma and $2.1 million for diabetes patients between 2000 and 2002.
Much of these cost savings came from a reduction in hospital and
emergency room admissions. Estimated savings were determined by
comparing the average per member per month costs for these patients
under the Community Care of North Carolina program with costs prior to
the implementation of the program.[D].
Source: GAO analysis of state data.
[A] The state's existing care coordination initiative focused on
patients with diabetes and asthma.
[B] According to a North Carolina official, in October 2009, North
Carolina temporarily discontinued care coordination payments for CHIP-
covered children because the state lacked data needed to determine the
program's effect on CHIP costs. The state plans to resume these
payments after they have implemented a system to collect the needed
data.
[C] By signing the agreement with the state, providers become a member
in 1 of the 14 geographic networks established across the state. Each
network has a clinical director who provides leadership and is a leader
in the local medical community. The providers govern their local
network and hold regular medical management meetings, where they look
at data related to their local network and compare their outcomes to
those of other networks in the state.
[D] T.C Ricketts, et al., "Evaluation of Community Care of North
Carolina Asthma and Diabetes Management Initiatives: January 2000-
December 2002," The Cecil G. Sheps Center for Health Services Research,
Chapel Hill, NC (Apr. 15, 2004), available at [hyperlink,
http://www.communitycarenc.com/PDFDocs/Sheps%20Eval.pdf].
[End of table]
Table 5: Description of Oklahoma's Care Coordination Initiative,
SoonerCare Choice:
Initiative overview:
In 2009, Oklahoma transitioned its Medicaid program from a managed
care delivery model to a fee-for-service model called SoonerCare
Choice that utilizes a primary care case management system to provide
a medical home[A];
* Oklahoma's initiative is available to Medicaid-and CHIP-covered
children. The initiative is also available to adults with Medicaid
coverage;
* In state fiscal year 2009, approximately 438,000 children
participated in the initiative;
* Specialists cannot serve as a medical home.
Provider participation requirements:
Providers are approved to participate in the initiative by signing an
agreement with the state. The state requirements include a minimum and
maximum number of patients per provider. At a minimum, all
participating providers must serve at least 50 Medicaid-and CHIP-
covered patients. The maximum number of patients is 2,500 for
physicians and 1,250 for mid-level providers, such as nurse
practitioners. Practices can be approved at one of three tiers based
on their ability to meet the different requirements at each tier.
Tier 1: Entry-level medical home:
Providers must:
* provide or coordinate all medically necessary primary and preventive
services;
* organize clinical data in paper or electronic format;
* review all medications a patient is taking and maintain a medication
list; maintain a system to track, test, and follow-up on results;
* maintain a system to track referrals including self-reported
referrals;
* provide care coordination including family participation; and;
* provide patient education and support.
Tier 2: Advanced-level medical home:
In addition to Tier 1 requirements, providers must accept electronic
communications from the state's Medicaid office;
* provide 24 hours a day, 7 days a week availability;
* make after-hours care available to patients (provider must be
available at least 30 hours per week and have open scheduling and walk-
ins to provide continuity of care);
* use mental health and substance abuse screening and referral;
* use data from state Medicaid office to identify and track patients
inside and outside of their practice;
* coordinate care for patients who receive care outside the primary
care provider location; and;
* promote access and communication with patients.
Tier 3: Optimal-level medical home:
In addition to Tier 1 and 2 requirements, providers must:
* organize and train staff in roles for care management, and create
and maintain a prepared and proactive care team;
* provide timely call-back to patients;
* use health assessments to characterize patient needs and risks;
* document patient self-management plan for those with chronic disease;
* develop a primary care provider-led health care team;
* provide after-visit follow-up for patients;
* adopt specific evidence-based clinical practice guidelines on
preventive and chronic care; and;
* use medication reconciliation to avoid adverse interactions.
Provider payment:
Oklahoma pays providers participating in the initiative in two ways:
per member per month coordination payment and performance-based
payments;
* Per member per month care coordination payments differ by patient
type and; provider tier:
Type of practice: Children only;
Tier 1: $3.58;
Tier 2: $4.65;
Tier 3: $6.12.
Type of practice: Children and adults;
Tier 1: $4.33;
Tier 2: $5.64;
Tier 3: $7.50.
Type of practice: Adults only;
Tier 1: $5.02;
Tier 2: $6.53;
Tier 3: $8.69.
* Performance payments are paid quarterly to providers that achieve
different quality goals, related to providing well-child health
examinations and reduction of emergency room visits.
Monitoring, support, and evaluation:
The state monitors and supports providers in numerous ways. For
example, the state:
* maintains a database to monitor participating providers and
practices, and uses the database to help medical homes identify
specialists for patient referrals, and monitor the number of patients
served by providers;
* has developed a medical home review tool and is conducting
educational reviews of providers and practices participating in the
state initiative to identify the extent to which providers are
providing the medical home services required for their respective
tier; and;
* maintains a log of calls, which are categorized and tracked from year
to year, that the state agency has received on access-related issues.
The state has not conducted a formal (external) evaluation of this care
coordination program.
Source: GAO analysis of state data.
[A] The state also has two smaller care coordination initiatives for
high-risk patients.
[End of table]
[End of Enclosure III]
Enclosure IV: Comments from the Department of Health and Human
Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for Legislation:
Washington, DC 20201:
March 18, 2011:
Katherine Iritani:
Acting Director, Health Care:
U.S. Government Accountability Office:
441 G Street N.W.
Washington, DC 20548:
Dear Ms. Iritani:
Attached are comments on the U.S. Government Accountability Office's
(GAO) correspondence entitled: "Medicaid and CHIP: Reports for
Monitoring Children's Health Care Services Need Improvement" (GAO-11-
293R).
The Department appreciates the opportunity to review this
correspondence before its publication.
Sincerely,
Signed by:
Jim R. Esquea:
Assistant Secretary for Legislation:
Attachment:
[End of letter]
General Comments Of The Department Of Health And Human Services (HHS)
On The Government Accountability Office's (GAO) Draft Correspondence
Entitled, "Medicaid And Chip: Reports For Monitoring Children's Health
Care Services Need Improvement" (GAO-11-293R):
Thank you for the opportunity to review and comment on this draft
report.
GAO issued two recommendations to the Department. We concur with both
recommendations and offer comments below, particularly regarding the
second recommendation as written.
GAO Recommendation:
The Administrator of CMS should establish a plan, with goals and time
frames, to review the accuracy and completeness of information
reported on the CMS-416 and CHIP Annual Reports and ensure identified
problems are corrected.
Centers for Medicare & Medicaid Services (CMS) Response:
We agree with this recommendation and are already engaged in efforts
with States to improve the accuracy and completeness of information
collected by the CMS-416 and CHIP Annual Reports. As stated, these
efforts could benefit from establishing precise goals and concrete
timeframes.
The CMS is currently undertaking the following steps to address this
concern:
1) Over the past 18 months, the Center for Medicaid, CHIP and Survey &
Certification (CMCS) within CMS has been working closely with States
to improve their understanding of EPSDT and the data reporting
requirements. CMS held two "EPSDT Listening Sessions" in late 2009 to
obtain input from State Medicaid Programs and national organizations
on recommendations for improving service delivery, and monitoring and
assessment of health outcomes related to EPSDT. In addition, CMS has
held three EPSDT training sessions for CMS staff in both the Central
Office and Regional Offices. One of these training sessions, held in
October 2010, focused solely on the new data collection requirements
for the CMS-416. CMS issued a revised form CMS-416 and instructions in
late December 2010 that included changes as required by CHIPRA as well
as requested by the Oral Health Technical Advisory Group (an advisory
group made up of state Medicaid dental directors). The changes will
provide CMS and States with a more complete profile of dental services
provided to children. CMCS also currently serves on the National
Academy for State Health Policy EPSDT Advisory Committee, a group that
includes State EPSDT staff and provides guidance to State Medicaid
staff administering the EPSDT benefit.
2) Additionally, in December 2010, CMS established a National EPSDT
Improvement Workgroup which includes several sub-workgroups including
a Data Improvement SubWorkgroup. The workgroup members represent a
wide range of perspectives, experience with and knowledge of EPSDT.
The members also have experience with the challenges States have faced
in collecting and reporting useful Medicaid and CHIP performance data.
The members of the Data Improvement Sub-Workgroup will lend their
expertise to inform CMS' development of a plan for improving the
quality and usefulness of the data reported on the CMS-416.
3) In an effort to reduce variation in the accuracy and completeness
of data submitted to CMS via the CMS-416, an internal EPSDT workgroup
at CMS has begun developing a set of data validation methods,
including instituting a number of data integrity checks and procedures
for monitoring and flagging questionable data or substantial year-to-
year variation. Until more automated processes are in place, the
workgroup is discussing how to implement a process for conducting
regular internal audits of all changes made to EPSDT databases to
reduce and prevent the possibility of data reporting errors by CMS.
CMS also recently developed a crosswalk and additional guidance to
assist States in collecting and reporting CMS-416 data that is more
complete, accurate, and user-friendly. The crosswalk is a two-page
instructional resource that defines each line of the CMS-416 using
more simplified and straightforward terms, provides examples of
potential responses, and provides edit checks in a notes column. The
document will be issued to States in the coming months.
4) Major efforts are also underway to improve information on access
and quality of care provided through the CHIP annual reports. CHIPRA
gives CMS new authority and resources to monitor the services provided
to children enrolled in Medicaid and CHIP. These provisions are
helping CMS build an infrastructure for Medicaid/CHIP to measure and
report on health care access and quality for children using a uniform
set of tools across the States. This infrastructure has included
indentifying an initial core set of child health quality measures for
voluntary use by States, $100 million in grant funding to States to
develop quality and performance measurement tools and strategies, and
developing a Pediatric Quality Measures Program to refine the core
quality measures and assist States in analyzing the data yielded from
these efforts for use in quality improvement efforts. In February
2011, CMS issued technical specifications for the standardized
reporting of the CHIPRA core set of measures and CMS is now developing
plans for providing States with technical assistance on collecting the
data and using the information for quality improvement purposes. (See:
[hyperlink,
http://www.cms.gov/MedicaidCHIPQualPrac/Downloads/CHIPRACoreSetTechManua
l.pdf])
GAO Recommendation:
The Administrator of CMS should work with States to identify
additional improvements that could be made to the CMS-416 and CHIP
Annual Reports, including options for reporting on the receipt of
services separately for children in managed care and fee-for-service
delivery models, while minimizing reporting burden, and for capturing
information on the CMS-416 relating to children's receipt of treatment
services for which they are referred.
CMS Response:
We agree with this recommendation. Over the past year CMS has been
working to identify options for improving the value of the CMS-416 as
well as the CHIP Annual Reports. CMS is striving to strike a balance
between targeting resources to upgrade existing data collection tools
and investing in new tools that can ultimately reduce the duplication
of efforts. CMS is also striving to enhance CMS and the States'
collective capacity to address the complex challenge of ensuring
access to care for the diverse population groups that Medicaid and
CHIP serve. CMS' goal is to work together with States to determine the
data reporting elements that will be most effective in measuring
quality and performance of these programs. In general, CMS is
interested in working with States and stakeholders to develop data and
a set of measures that will achieve consistency across States and
ensure a higher quality of valued information.
CMCS Data Strategy:
The CMS is currently working with States through its CHIPRA quality
demonstration grantees and its Technical Advisory Groups, (which are
state workgroups that focus on policy areas such as quality, oral
health, mental health, managed care, and coverage) to strengthen
systems for measuring and collecting data on access and quality. In
addition, efforts are now underway under the leadership of our Data
and Systems Group to develop a larger strategy to meet the data and
information exchange needs of CMS and the States. Two such efforts to
improve the timeliness and accuracy of data reported deserve note. CMS
is investing considerable resources in improving the Medicaid
Statistical Information System and expanding the use of electronic
health records (EHRs). Both of these information sources have
efficiencies and capacities to collect more detailed information than
either the CMS-416 or CHIP Annual Reports. Though widespread adoption
of EHRs is not expected until 2014, leveraging EHRs where possible
today, and working toward a future in which data are electronically
collected and shared, is an investment that CMS expects will have a
great value over time in not only improving the quality of care, but
also in improving CMS's capacity to monitor services provided to
beneficiaries.
It is our aim that with the help of the National EPSDT Workgroup,
which will be discussing, among other things, the use of EHRs to
collect information on children's use of services as required by
EPSDT, there may be additional enhancements to the CMS-416 that
enlighten the way we collect data now and in the future, and help
improve upon the quality of information available to States and CMS.
Information Sources for Monitoring Access and Quality
Starting in 2013, CHIPRA requires CHIP programs and CHIP Medicaid
Expansion programs to include in their CHIP Annual Report data from a
monitoring tool, the Consumer Assessment of Healthcare Providers and
Systems (CARPS).[Footnote 1] The CAHPS survey tool is also a component
of the CHIPRA initial core set of quality measures for voluntary use
by State Medicaid/CHIP programs. It includes a number of questions
about beneficiaries' satisfaction in accessing primary and specialty
care, including questions about the ease of receiving needed care.
While the CMS-416 could be expanded to collect more detailed
information on children's receipt of needed services, it would
duplicate information now being requested of States through CAHPS. As
we work to make modifications to the CMS-416 to improve the accuracy
of the information it captures, we believe the use of CARPS in the
future will prove to capture beneficiaries' experiences in accessing
EPSDT benefits in an even more useful manner.
Several surveys conducted by the Department of Health and Human
Services analyzed for this GAO report (the National Survey of
Children's Health and the Medical Expenditure Panel Survey) are also
excellent tools to answer questions about the extent to which children
in Medicaid and CHIP nationwide have access to networks of care and
coordinated care.
Although the surveys are not State-specific, they offer insights into
services provided to children enrolled in Medicaid/CHIP and collect
individual data that can be stratified by demographic and health
characteristics that are useful for monitoring access to quality care.
Managed Care Improvement Initiative:
The CMS also has a number of tools and a new initiative underway for
monitoring access and quality of care in managed care arrangements.
With respect to the CMS-416, current instructions specify that data
reported on the form must include services delivered to individuals in
both fee-for-service or managed care arrangements. While CMS
recognizes the challenges States face in collecting service use data
from plans that use a capitated payment system, we are committed to
working with States to identify the most critical data elements that
will enable both the Federal government and the States to more
effectively monitor and oversee access to care provided through
managed care delivery systems. In particular, we are working to
improve collection and reporting of encounter data. CMS is in the
process of drafting regulatory guidance on reporting of encounter data
to CMS in a consistent format across programs. Ultimately, programs
will be required to report data more frequently to ensure an ongoing
flow of accurate and timely information, thus improving CMS' oversight
capabilities.
In addition, Medicaid and now CHIP programs that contract with prepaid
managed care organizations are required to conduct annual external
quality reviews (EQR). The EQRs are required by Congress, and CHIPRA
requires that CMS report on an annual basis the lessons learned from
the EQRs. CMS is now in the process of updating its protocols for EQRs
and will issue new guidance to States to strengthen the collection and
validation of encounter data on services provided by managed care
organizations.
Improving the quality of information available on children's access to
care in Medicaid and CHIP is one of CMS's key priorities, and the onus
of improving the data collected rests both on the States and CMS. It
is our view that the collection of data reported on the CMS-416 and
CHIP Annual Reports will benefit from these targeted efforts, as well
as CMS-wide efforts underway to improve the collection and reporting
of data on quality of care measures more broadly. We appreciate the
efforts that went into this report and look forward to working with
the GAO on this and other issues.
Enclosure IV Footnote:
[1] Currently, 33 States are either CHIP combination or Medicaid
Expansion programs.
[End of Enclosure IV]
Enclosure V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Katherine Iritani, Acting Director, (202) 512-7114 or iritanik@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Catina Bradley, Assistant
Director; Tim Bushfield; Sean DeBlieck; Alison Goestch; Laura Henry;
Shirin Hormozi; Hannah Locke; Roseanne Price; and Hemi Tewarson made
key contributions to this report. Martha Kelly and Suzanne Worth,
Assistant Directors, provided technical assistance.
[End of Enclosure V]
Related GAO Products:
Oral Health: Efforts Under Way to Improve Children's Access to Dental
Services, but Sustained Attention Needed to Address Ongoing Concerns.
[hyperlink, http://www.gao.gov/products/GAO-11-96]. Washington, D.C.:
November 30, 2010.
Health Care Delivery: Features of Integrated Systems Support Patient
Care Strategies and Access to Care, but Systems Face Challenges.
[hyperlink, http://www.gao.gov/products/GAO-11-49]. Washington, D.C.:
November 16, 2010.
Medicaid Managed Care: CMS's Oversight of States' Rate Setting Needs
Improvement. [hyperlink, http://www.gao.gov/products/GAO-10-810].
Washington, D.C.: August 4, 2010.
Medicaid Preventive Services: Concerted Efforts Needed to Ensure
Beneficiaries Receive Services. [hyperlink,
http://www.gao.gov/products/GAO-09-578]. Washington, D.C.: August
14, 2009.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of
Children's Dental Services. [hyperlink,
http://www.gao.gov/products/GAO-07-826T]. Washington, D.C.: May 2,
2007.
Medicaid Managed Care: Access and Quality Requirements Specific to Low-
Income and Other Special Needs Enrollees. [hyperlink,
http://www.gao.gov/products/GAO-05-44R]. Washington, D.C.:
December 8, 2004.
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's
Access to Care. [hyperlink, http://www.gao.gov/products/GAO-03-222].
Washington, D.C.: January 14, 2003.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health
Screening Services. [hyperlink,
http://www.gao.gov/products/GAO-01-749]. Washington, D.C.: July 13,
2001.
[End of section]
Footnotes:
[1] State Medicaid programs generally cover children under 21 years of
age; however, state CHIP programs generally cover children 18 years of
age and younger.
[2] For the 2009 report, we examined national surveys conducted by the
Department of Health and Human Services from 2003 through 2006. The
surveys included information from parents, or other adults in the
household, of children in Medicaid and CHIP about the receipt of well-
child checkups. See GAO, Medicaid Preventive Services: Concerted
Efforts Needed to Ensure Beneficiaries Receive Services, [hyperlink,
http://www.gao.gov/products/GAO-09-578] (Washington, D.C.: Aug. 14,
2009). See the list of related GAO products at the end of this report.
[3] There are also other definitions of care coordination. See GAO,
Health Care Delivery: Features of Integrated Systems Support Patient
Care Strategies and Access to Care, but Systems Face Challenges,
[hyperlink, http://www.gao.gov/products/GAO-11-49] (Washington, D.C.:
Nov. 16, 2010).
[4] See 42 U.S.C. § 1396a(a)(43).
[5] For this report, we refer to the EPSDT periodic screening services
as well-child checkups. Under the EPSDT benefit, children also must
receive coverage of treatment and other services necessary to correct
or ameliorate health conditions discovered through well-child
checkups. 42 U.S.C. §§ 1396a(a)(10), 1396d(4)(A).
[6] See 42 U.S.C. § 1397hh(a).
[7] We have long recommended that agencies collect information for
overseeing the programs they administer. Internal control standards
specify that agencies should collect information to monitor program
objectives in order to determine whether the agencies are meeting
their strategic goals. See GAO, Standards for Internal Control in the
Federal Government, [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
November 1999).
[8] Under federal law, CMS must develop and set annual goals for each
state for the participation of eligible children in EPSDT services. 42
U.S.C. § 1396d(r)(5).
[9] In some cases, children may receive care through a Primary Care
Case Management (PCCM) model. Under a PCCM model, primary care
providers are prepaid a small amount for each enrollee to manage and
coordinate the enrollee‘s health care. Providers are paid on a fee-for-
service basis for care that they provide.
[10] Pub. L. No. 111-3, § 402(d), 123 Stat. 84. In conjunction with
this study, we are also separately examining primary care and
specialty care physicians‘ willingness to serve children in Medicaid
and CHIP, which was also required under CHIPRA. As we agreed with your
staff, we plan to issue a separate report in 2011.
[11] The NSCH is administered by HHS‘s National Center for Health
Statistics, which collects data from parents and guardians on their
children‘s health and use of medical services. The NSCH collects
information about children 17 years of age and younger. We analyzed
the NSCH‘s measure of effective care coordination from 2007 (the most
recent data available) for children 17 years of age and younger.
[12] The NSCH identifies children needing care coordination and
assesses whether or not these children received effective care
coordination. The NSCH classifies children as needing care
coordination if the child received services from two or more different
categories of care (preventive medical, preventive dental, mental
health care, or specialist services), and the family received any help
or needed extra help coordinating the child‘s care. The NSCH
classifies these children as receiving effective care coordination if
they usually received extra help coordinating care when it was needed,
and were very satisfied with communication between doctors, and
communication between doctors and other entities when such
communication was needed. For the purposes of our report, we
classified children as not receiving care coordination if the NSCH
indicated that they did not receive effective care coordination when
needed.
[13] The MEPS is administered by HHS‘s Agency for Health Care Research
and Quality, which collects data from individuals and their medical
providers on, among other things, health status, use of medical care
services, and access to care. For consistency with NSCH, we analyzed
MEPS survey results for children 17 years of age and younger. We
analyzed data related to access to networks of care for children 17
years of age and younger from the 2005, 2006, and 2007 surveys: (a)
the proportion of children who had problems receiving needed care,
tests, or treatments, and (b) the proportion who experienced problems
accessing needed specialists. Although 2008 MEPS survey data were
available, the questions we examined related to access to networks of
care were no longer included. As a result, we were unable to compare
the 2008 data to the data for 2005, 2006, and 2007.
[14] The Patient Protection and Affordable Care Act, enacted on March
23, 2010, provides states with a new option for offering health homes
(i.e., a designated provider, a team of health care professionals
operating with such a provider, or a health team) for Medicaid
beneficiaries with chronic conditions beginning in January 2011.
Subject to CMS approval, states may make Medicaid payments for health
home services, including comprehensive care management, care
coordination, and comprehensive transitional care, provided by a team
of health care professionals. Pub. L. No. 111-148, § 2703, 124 Stat.
119, 319 (Mar. 23, 2010). CMS provided state Medicaid and health
officials with preliminary guidance on the implementation of health
homes in November 2010. We did not assess the implementation of this
option by states in this review.
[15] We did not identify a commonly accepted definition of a medical
home. For purposes of this report, a medical home is generally a
provider who is able to both provide and coordinate comprehensive
health care services for patients.
[16] Under CHIPRA, HHS must publish a set of core measures for
evaluating the quality of care provided to children in Medicaid and
CHIP, which states may choose to use for reporting to HHS. Pub. L. No.
111-3, § 401(a), 123 Stat. 72. HHS published a set of 24 measures on
December 29, 2010, which include three performance measures from the
CHIP annual report.
[17] CHIPRA requires states to expand the information included in CHIP
annual reports. Pub. L. No. 111-3, § 402(a), 123 Stat. 82. In
accordance with this mandate, beginning in 2013, CMS will require
states to report additional information for their CHIP beneficiaries
through satisfaction surveys, including information on access to
primary and specialty services, access to networks of care, and care
coordination for beneficiaries.
[18] State Medicaid programs generally cover children under 21 years
of age; however, state CHIP programs generally cover children 18 years
of age and younger.
[19] GAO, Medicaid Preventive Services: Concerted Efforts Needed to
Ensure Beneficiaries Receive Services, [hyperlink,
http://www.gao.gov/products/GAO-09-578] (Washington, D.C.: Aug. 14,
2009).
[20] For purposes of this briefing, care coordination is broadly
defined as a process in which an individual or group helps arrange
primary and specialty health care services. Care coordination can be
provided by primary care providers or through other individuals, such
as social workers or case managers.
[21] The EPSDT benefit generally entitles eligible children to receive
coverage of periodic screening services that include a comprehensive
health and developmental history, a comprehensive physical
examination, appropriate immunizations, laboratory tests, and health
education. For the purposes of this briefing, we also refer to EPSDT
screening services as well-child checkups. States are also required to
cover other EPSDT services, such as vision, dental, and hearing
services, and further diagnostic or treatment services necessary to
correct or ameliorate health conditions discovered through well-child
checkups.
[22] Pub. L No. 111-3, § 402(d), 123 Stat. 8, 84 (2009).
[23] Although 2008 MEPS data were available, the questions we examined
related to access to networks of care were no longer included.
As a result, we were unable to compare the 2008 data to the data for
2005, 2006, and 2007.
[24] Under managed care, states provide a set payment amount in
advance to managed care organizations to provide services to
beneficiaries.
[25] Fiscal year 2008 is the most recent year for which there was
reporting from all states.
[26] This includes the District of Columbia.
[27] See GAO, Medicaid: Concerns Remain about Sufficiency of Data for
Oversight of Children's Dental Services, [hyperlink,
http://www.gao.gov/products/GAO-07-826T] (Washington, D.C.: May 2,
2007).
[28] Since 1990, CMS has been required under federal law to develop
and set annual participation goals for each state for participation of
eligible children in EPSDT services.
[29] See [hyperlink, http://www.gao.gov/products/GAO-09-578].
[30] All percentage estimates from MEPS and NSCH data have a margin of
error of plus or minus 5 percent or less at the 95 percent confidence
level, unless otherwise noted.
[31] The confidence interval for this estimate is plus or minus 6
percent at the 95 percent confidence level.
[32] The NSCH measures whether children needing care coordination
received effective care coordination. The NSCH classifies children as
needing care coordination if the child received services from two or
more different categories of care (preventive medical, preventive
dental, mental health care, or specialist services), and the family
received any help or needed extra help coordinating the child's care.
The NSCH classifies these children as receiving effective care
coordination if they usually received extra help coordinating care
when it was needed, and were very satisfied with communication between
doctors, and communication between doctors and other entities when
such communication was needed. For the purposes of this briefing, we
classified children as not receiving care coordination if the NSCH
indicated that they did not receive effective care coordination when
needed.
[33] For privately insured children, the 2007 NSCH survey suggests
that 41 percent of children 17 years of age and younger, or an
estimated 18 million, needed care coordination services.
[34] For privately insured children 17 years of age and younger whose
families reported needing care coordination services, the 2007 NSCH
survey suggests that 26 percent, or an estimated 5 million, did not
receive the needed services.
[35] The confidence interval for this estimate is plus or minus 6
percent at the 95 percent confidence level.
[36] For purposes of this briefing, a medical home is generally
defined as a provider who is able to both provide and coordinate
comprehensive health care services for patients.
[37] See GAO, Standards for Internal Control in the Federal
Government, [hyperlink,
http://www.gao.gov/products/GAO/AIMD-00-21.3.1] (Washington, D.C.:
November 1999).
[38] Although the CMS 416 collects the number of children enrolled in
managed care, it does not collect separate information on receipt of
services for these children. As with the CMS 416, performance measures
are not reported separately by delivery model on the CHIP annual
report. States are allowed to only report performance measures for the
delivery model with the largest number of enrollees.
[39] See GAO, Oral Health: Efforts Under Way to Improve Children's
Access to Dental Services, but Sustained Attention Needed to Address
Ongoing Concerns, [hyperlink, http://www.gao.gov/products/GAO-11-96]
(Washington, D.C.: Nov. 30, 2010).
[40] Under CHIPRA, HHS is required to collect information on the
quality of care provided to Medicaid- and CHIP-enrolled children from
states and analyze and report these data beginning in September 2010
and annually thereafter.
[41] MSIS is a CMS system that collects eligibility and claims data
from states. CMS uses this system to produce eligibility and program
characteristics.
[42] Under CHIPRA, HHS must publish a core set of measures for
evaluating the quality of care provided to Medicaid- and CHIP-covered
children, which states may choose to use for reporting to HHS. HHS
published a set of 24 measures on December 29, 2010, which include
three performance measures from the CHIP annual report: receipt of
well-child visits during the first 15 months of life; receipt of well-
child visits in the third, fourth, fifth, and sixth years of life; and
children's access to primary care providers.
[43] The expert panel includes representatives from other federal
agencies, state Title V leaders, family organizations, and child
health researchers.
[44] The NSCH only includes information for children 17 years of age
or younger.
[45] For purposes of our report, we classified children as not
receiving care coordination if the NSCH indicated that they did not
receive effective care coordination when needed.
[46] Although 2008 MEPS survey data were available, the questions we
examined related to access to networks of care were no longer
included. As result, we were unable to compare the 2008 data to the
data for 2005, 2006, and 2007.
[47] For the purposes of this report, a formal evaluation is a study or
assessment of the care coordination initiative that is conducted by an
external research entity. Some states completed internal reviews and
studies as part of the process of overseeing their initiatives. While
we provide information on the findings of internal state studies, we do
not report them as formal evaluations.
[End of section]
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