Report Asks About Quality Assurance in Medicaid Managed Care for Children

A new report questions what metrics policy makers are using to evaluate whether or not children enrolled in Medicaid managed care organizations (MCOs) are receiving quality care, given the public investment these programs receive.

The report, from the nonpartisan Georgetown University Center for Children and Families (CCF), said that state Medicaid agencies and CMS do not use 1 common measurement for measuring quality of care.

Data and transparency about the quality of care for children are scant, the report said. There is no publicly accessible national database with information on how well individual MCOs are serving enrolled children.

For instance, there is no national database regarding the performance of individual MCOs with respect to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, which are a guaranteed benefit providing care to children with special needs.

There are existing federal requirements relating to the transparency of data that would allow state comparison of individual MCO performance, but CMS is reconsidering those requirements.

In May 2016, CMS said it would begin implementing new MCO rules from 2017 to 2019. Last year, after President Donald Trump took office, CMS said it would start rolling back “burdensome regulations.” If the requirements that do exist are weakened, the public will have less information with which to determine whether individual Medicaid MCOs are doing a good job, according to the report.

Transparency is important because it can lead to program improvements, allow head-to-head comparisons of MCOs, and allow the public and lawmakers to decide if state Medicaid agencies are being effective at spending taxpayer money, said Andy Schneider, a research professor at the Center for Children and Families and the author of the report.

Federal and state governments are projected to spend about $275 billion paying MCOs in fiscal year 2018 for all enrolled populations.

Among the questions that need to be asked, he said, are:

• What are the right measures for MCO performance about the quality of care for children?
• How can those in the field persuade state Medicaid agencies to require MCOs to report on those measures, validate the data, and post the results?
• How should those advocating for improvement in childrens’ health use those results to improve MCO performance?

Medicaid MCOs contract with state agencies and assume financial risk for the provision of covered services to enrollees. They are incentivized not only to provide care coordination to reduce unnecessary use of high-cost services, but also to limit enrollee access to services and shift risk to providers.

Nearly 40% of the nation’s children—37 million—are covered by Medicaid. Of those, over two-thirds are enrolled in MCOs.

Not every state Medicaid program uses an MCO, but of the 24 that do, more than 80% of Medicaid beneficiaries who are children are enrolled in MCOs.

As of March 2017, a total of 275 Medicaid MCOs operated in 38 states and the District of Columbia to provide covered services to Medicaid beneficiaries; 12 state Medicaid programs did not contract with MCOs.

Part of the problem is that what states do report is done on a CMS-416 form, which aggregates all Medicaid data; it does not differentiate whether the service is fee-for-service or coming from an MCO. The CMS-416 has significant limits in terms of what it reports on EPSDT data, the report said. As an example, the form does not tell whether patients are getting the follow-up services that may be needed as a result of a screen or evaluation, which the report called “key to EPSDT’s benefit guarantee for children.”

In addition, state Medicaid agencies and CMS are not aligned on quality measures, the report stated. CMS has developed a Child Core Set of Health Care Quality Measures with 26 measures in 6 categories, but the state reporting is voluntary and not all states report on all measures. Different state Medicaid agencies also use different measures in assessing the quality of care received by children enrolled in MCOs, the report said.

The report was funded by the Robert Wood Johnson Foundation.