Improving Medicaid’s Continuity of Coverage and Quality of Care

1
Improving Medicaids Continuity of Coverage and
Quality of Care

• Leighton Ku, Patricia MacTaggart,
• Fouad Pervez and Sara Rosenbaum
• George Washington Univ.
• Dept. of Health Policy
• July 2009

2
Introduction

• ACAP commissioned report and legislative
  proposal, Medicaid Continuous Quality Act.
• Addresses two key issues
• Medicaid coverage is often interrupted due to
  inefficient administrative practices.
• Efforts to monitor and improve quality in
  Medicaid are lopsided and apply only to the
  minority of enrollees who are members of
  capitated managed care plans.
• Overall goals are to improve Medicaid coverage
  and quality and to reduce uninsurance.

3
Medicaids Leaky Sieve

• In employer-sponsored insurance people join when
  they get a job. Open enrollment once a year, but
  unless they make a change, the default is to keep
  the same insurance.
• Medicaid often enrolls people for 6 months at a
  time (or shorter) and requires monthly or
  quarterly reporting of income.
• Requires active renewal. Default is that if you
  fail to submit documents properly on time, you
  are dropped from coverage.
• Many paperwork barriers and cumbersome practices.
• As a result, people may drop out of coverage even
  if they are still eligible. Often rejoin a few
  months later.

4
Continuity of Care in Medicaid

• A simple measure is how many months of the year
  an average person is enrolled in Medicaid.
• Overall 78 average. Disabled have best
  continuity (90), non-elderly adults have worst
  (68).

Continuity Index (100 perfect)
Source GW analyses of Medicaid Statistical
Information System data, primarily from FY 2006,
supplemented by 2005 2004 data for a few states.
5
Procedures Make a Difference

• Washington state ended 12 mo. continuous
  enrollment renewal. Child enrollment fell by
  5. When reinstated, enrolled came back.1
• Florida had a default renewal process for
  children. After requiring active renewal, the
  risk of disenrollment climbed10-fold.2
• After California extended renewal period for
  children from 3-6 months to 12 months,
  hospitalizations for preventable conditions like
  asthma fell by 26.3
• Renewal policies for parents often more stringent
  than for children. In 9 states (including CA
  OH), renewal periods are shorter for parents.1

6
Churning in Medicaid Causes

• Disruptions in continuity of care and
  interruptions of preventive primary care.4
• Increases hospitalizations for avoidable
  conditions that can be treated by better primary
  care diabetes, heart failure, asthma, etc. For
  adults almost 4-fold greater risk.5
• Decreases breast cancer screening and higher risk
  of poor outcomes.6
• Higher average monthly medical expenses.
• Higher administrative expenses for re-enrollment.
  (In CA, 180 to enroll a child.)7
• More people uninsured at any given time.4

7
Average Monthly Medicaid Costs Decline When
Adults Are Enrolled Longer 12 months costs just
42 more than 6 months
Source GW analyses of 2006 Medical Expenditure
Panel Survey, controlling for age, gender,
health status, disability, pregnancy, income,
education, etc.
8
Why Do Costs Decline?

• Longer coverage permits better prevention and
  disease management, leading to fewer serious
  illnesses and hospitalizations.
• People often enroll in Medicaid when they have an
  immediate medical problem, after months of being
  uninsured. So pent-up demand for services at the
  beginning, but then a slow down.

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Ways to Increase Retention

• Augment 12 month continuous eligibility now
  state option for children and pregnant women.
• Expand income eligibility range.
• Simplify renewal processes. Do not require
  face-to-face renewal.
• Eliminate assets test.
• Self-attestation of income and residency.
• Use automated data from other programs.
• Continue coverage while reviewing eligibility.
• Default reenrollment into prior MCO.
• More language assistance.
• Lower or eliminate premiums.

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Similar Changes in CHIPRA

• Created performance-based funding incentives for
  increasing childrens enrollment.
• Based on 5 of 8 enrollment or renewal
  simplification policies for children and
• Actual increases in childrens enrollment
• Qualifying states earn more federal Medicaid
  dollars per child covered above the baseline.

11
Congressional Interest in Continuous Eligibility

• Health reform proposals in Senate and House seem
  interested in concepts, particularly requiring
  12-month continuous eligibility as part of a
  broader effort to expand Medicaid eligibility.
• Rep. Gene Green (D-TX) introduced bills for
  12-month continuous eligibility

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Current Federal Medicaid Quality Requirements

• Managed Care Organizations (MCOs)
• Ongoing quality monitoring and improvement
  required
• Develop Quality Assessment and Performance
  Improvement (QAPI) strategy for timely access and
  quality of care
• Annual external independent review of quality,
  outcomes, timeliness and access to services
• Primary Care Case Management (PCCM)
• Fee-for Service Arrangements
• No comparable requirements

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Current Approaches Used for MCOs
CAHPS patient surveys for experiences in last 6
months HEDIS clinical performance measures for
those enrolled continuously for past year.
Based on NCQA.
HEDIS-like Similar to HEDIS, but do not
require continuous enrollment
14
New York Experience Feasibility of Comparing
MCOs Fee-for-Service in Medicaid
Reproduced from Roohan, et al. 2006.
15
CHIPRA New Plans for Measuring Quality of Care
for Children

• Develop and implement evidence-based measures for
  children Core set of measures based on AHRQ and
  CMS efforts
• Encourage development and dissemination of model
  childrens e-health record
• Demonstration project to reduce child obesity

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Medicaid Continuous Quality Act - 1

• Improving Continuity of Coverage
• Require 12-month continuous eligibility for
  children, adults, disabled and elderly (with some
  exceptions). States can begin upon enactment,
  must implement by Oct. 1, 2010.
• Done in context of broader Medicaid expansions.
• Assume federal govt will boost funding to states
  to offset additional costs of expansions.

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MCQA - 2

• Develop performance-based funding incentives for
  states.
• To qualify states must adopt 3 out of 5
• Eliminate face-to-face requirement
• Use administrative renewals
• Use enhanced data-sharing of eligibility info
• Extend pending status before eligibility renewal
  has been reviewed
• Default re-enrollment in prior MCO, if within 6
  months. But may choose alternative plan.

18
MCQA - 3

• HHS will require increased reporting about
  enrollment and retention, including computing
  enrollment continuity ratios.
• HHS will develop regulations to allocate 500
  million per year to states, based on 3-of-5 and
  performance in retention. Will be available for
  FY 2013 and beyond, although actual payments will
  lag at most 12 months to accumulate data.
• Parallels CHIPRA Medicaid performance bonuses for
  children.

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MCQA 4

• Will increase Medicaid matching rate to 90 for
  development of data-sharing systems. (Law
  already permits 75 funding for operations of
  systems.)
• Improving Quality Efforts in Medicaid
• Develop system and process to be used by states
  to report on quality of care for MCOs, PCCM and
  fee-for-service providers
• Be able to compare quality measures
• Across systems or by state
• Head-to-head comparisons possible with comparable
  measures

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MCQA 5

• Consult advisory group in developing system
  state officials, health care providers
  consumers, national groups with expertise in
  quality, performance measurement and public
  reporting, other voluntary organizations
• Measures reviewed by National Quality Forum
• Initial reports within two years of enactment
• Measures include duration of insurance coverage,
  preventive services availability effectiveness,
  acute condition treatments follow-up, chronic
  physical behavioral health treatment
  management, availability of ambulatory
  inpatient care, other relevant measures.

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Expected Impacts of MCQA

• Reduce the number of uninsured people
• Increase security of Medicaid coverage
• Improve continuity and quality of medical care to
  improve health outcomes
• Strengthen quality monitoring in all parts of
  Medicaid
• Gradually improve Medicaid quality of care

22
References

• Cohen Ross D Marks C. Challenges of Providing
  Health Care Coverage for Children and Parents in
  a Recession A 50 State Update on Eligibility
  Rules, Enrollment Procedures, and Cost-Sharing
  Practices in Medicaid and SCHIP in 2009. Kaiser
  Commission on Medicaid and the Uninsured, January
  2009.
• Herndon JB, et al. The Effect of Renewal Policy
  Changes on SCHIP Disenrollment. 2008 Hlth Serv
  Res 436, 2086-2105.
• Bindman A, et al. Medicaid re-enrollment policies
  and children's risk of hospitalizations for
  ambulatory care sensitive conditions. Med Care.
  200846(10)1049-54.
• Ku L Cohen Ross D. Staying Covered The
  Importance Of Retaining Health Insurance For
  Low-Income Families. Commonwealth Fund. December
  2002. Summer L Mann C. Instability of Public
  Health Insurance Coverage. Commonwealth Fund.
  June 2006.
• Bindman A, et al. Interruptions in Medicaid
  Coverage and Risk for Hospitalization for
  Ambulatory CareSensitive Conditions. Ann. Intl.
  Med. 2008 149 854-60.
• Koroukian SM, et al. Screening mammography was
  used more, and more frequently, by longer than
  shorter term Medicaid enrollees. J Clin
  Epidemiol. 2004 Aug57 (8)824-31. Bradley CJ, et
  al. Cancer, Medicaid enrollment, and survival
  disparities. Cancer. 2005 Apr 15 103 (8)1712-8.
  
• Fairbrother G. How Much Does Churning in
  Medi-Cal Cost? California Endowment, April 2005.
  Fairbrother G, et al. Costs of enrolling children
  in Medicaid and SCHIP. Health Aff (Millwood).
  200423(1)237-43
• Roohan, P.J., et. al. Quality Measurement in
  Medicaid Managed Care and Fee-for-Service The
  New York State Experience. American Journal of
  Medical Quality 21(3) 185-191, 2006.