Title: Improving Medicaid’s Continuity of Coverage and Quality of Care
1Improving 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
2Introduction
- 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.
3Medicaids 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.
4Continuity 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.
5Procedures 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
6Churning 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
7Average 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.
8Why 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.
9Ways 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.
10Similar 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.
11Congressional 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
12Current 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
13Current 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
14New York Experience Feasibility of Comparing
MCOs Fee-for-Service in Medicaid
Reproduced from Roohan, et al. 2006.
15CHIPRA 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
16Medicaid 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.
17MCQA - 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.
18MCQA - 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.
19MCQA 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
20MCQA 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.
21Expected 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
22References
- 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.