The Medicaid and CHIP Payment and Access Commission (MACPAC) was established in the Children's Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3) and was later expanded and funded through the Patient Protection and Affordable Care Act (P.L. 111-148). MACPAC is tasked with reviewing state and federal Medicaid and CHIP access and payment policies and making recommendations to Congress, the Secretary of Health and Human Services (HHS), and the states on a wide range of issues affecting Medicaid and CHIP populations, including health care reform. On April 11-12, the Commission met in Washington, D.C. to discuss its upcoming report to Congress, due in March. Below are summaries of their discussions.
Session I: Adult Dental Services Under Medicaid
Background: Although few states are currently covering comprehensive oral health benefits for adults on Medicaid, there are a number of initiatives underway that strive to better meet the oral health needs of low-income adults and to improve the coordination of medical and oral health care. The importance of good oral health and the negative consequences of both poor oral health and no or limited dental benefits on adults enrolled in Medicaid are substantial in terms of program cost, resource inefficiency, and lack of long term positive health outcome; this is particularly true as usual ER care can usually only provide short-term relief.
Key Issues: This session highlighted two promising initiatives to better meet the oral health needs of adults in Medicaid. Potential new programs highlighted in this session focus on:
- Multi-stakeholder partnerships that bring together hospitals, dental providers, and managed care plans to identify dental needs, fast-track treatment, coordinate care to reduce avoidable ER visits, and improve patient awareness of available services.
- Using new types of dental professionals to provide oral health services in nontraditional settings such as residential facilities for persons with disabilities and long term care facilities to eliminate barriers to care for populations most at risk of future dental disease.
Next Steps: Commissioners should provide insights on oral health care issues of particular interest which will be explored at subsequent meetings.
Session II: Draft June Report Chapter on Primary Care Payment Increase
Background: Research trends consistently show that primary care physicians are less likely to participate in Medicaid than with private health payers. Low Medicaid reimbursement can decrease patient access to care. The ACA provided for a temporary increase in primary care provider Medicaid reimbursements.
Key Issues: The implications of increasing provider payments for primary care physicians could pose both administrative and operational challenges to state Medicaid agencies, while further generating significant impacts on provider participation, enrollee access, and comprehensive evaluation. Studies hint that increases in reimbursement rates for providers could increase their willingness to take on more Medicaid patients; participation barriers also cited include low compliance, payment delays, and lengthy administrative burdens. The interviews with stakeholders study found that:
- State reimbursement rates must be equal to at least Medicare rates in 2013 and 2014 for certain primary care services.
- Reimbursement rate rollbacks in 2014 (or 2015) could be come across as a rate cut
- There is concern among policymakers and managed care organizations that payment increases could conflict with current payment policy (such as instances of negotiated agreements for sub-capitated payments for providers in managed care organizations) and/or future movements toward payment modernization, such as value-based payment models.
- There remains a continued desire among stakeholders to study the effects of increasing payments using existing data on claims, surveys, and provider enrollment; however there are not sufficient local resources available to conduct an accurate assessment.
Next Steps: MACPAC commissioners were asked to provide their thoughts on the draft chapter for the final June 2013 report to Congress.
Session III: Draft June Report Chapter on Waivers
Background: State Medicaid programs can use waivers of federal Medicaid requirements as a tool to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP). Such waivers are also used to ensure comparability and enrollees’ freedom of choice of health care providers. All states participate at least in part to the federal Medicaid waiver program with some holding multiple waivers.
Key Issues: The prevalence of waivers and frequency of renewal raises questions about their use, particularly given that in FY 2012, 41 percent of Medicaid benefit spending was classified as occurring under these waivers. The chapter and subsequent interviews conducted with state and federal officials investigates whether waivers are serving their intended purposes of providing a vehicle for testing new models of health care delivery or simply sanctioning states to forgo sections of federal law in order to repetitively reproduce small and mechanical program changes. Further research is needed into how waivers are being used and their impact on enrollees and program expenditures.
Next Steps: Commissioners will provide feedback on the draft chapter for the final June 2013 Report to Congress.
Session IV: Draft June Report Chapter on Maternity Care in Medicaid and CHIP
Background: The Medicaid and CHIP programs jointly cover an income-variable portion of the costs of maternity care for a sizeable percentage of low-income women; data shows that Medicaid and CHIP paid for 46 percent of the almost 4 million births that took place in 2010. Eligibility for maternity care varies across many states (at or above 185 percent of the federal poverty in 38 states plus the District of Columbia), and often has multiple eligibility pathways in each state.
Key Issues: This session provided background on Medicaid and CHIP eligibility for maternity care with regard to coverage, eligibility standards, service utilization, and information related to the types of programs available to advance maternal health and birth outcomes. Also discussed were matters related to implementation of certain provisions within the Patient Protection and Affordable Care Act (ACA). MACPAC staff presented ACA policy provisions that are aimed at decreasing cost, improving maternal and baby outcomes, and decreasing the level of dependence on Medicaid and CHIP for care. Specific policy policies within ACA include decreased enrollment in Medicaid due to increased eligibility for coverage (varies by state but women with incomes between 138 and 400 percent of the federal poverty line may now be eligible for assistance and benefits through the exchanges, CHIP, or waiver programs). The law also streamlines and revises eligibility pathways for maternity services and federally mandates benefits maternity care under essential health benefits. Of note, staff mentioned that health program enrollment changes come October may create confusion or churning depending on which program states chose to offer maternity care services.
Next Steps: Commissioners were asked to comment on the draft chapter, and consider priorities for future tracking and research by MACPAC staff.
Session V: Draft June Report Chapter: Literature Review on Access for People with Disabilities
Background: Disabled Medicaid enrollees under age 65 have diverse health needs ranging from physical mobility and cognitive limitations to assistance with self-care or basic everyday activities. According to MACPAC’s March 2012 Report to Congress, in FY 2008, acute care services, comprising of hospital and physician services, behavior health services, prescription drugs, and laboratory and imaging, contributed to 74 percent of spending among adults with disabilities eligible for Medicaid who were not dually eligible for Medicare. Medicaid-only enrollees constitute 62 percent of adult beneficiaries under age 65 qualifying for Medicaid solely on the basis of disability.
Key Issues: In order to gauge the quality and accessibility of care for this major subpopulation, MACPAC staff began a review of literature to determine any major information gaps that would benefit from additional research. Staff concluded that additional focus studies and fact-finding in several key areas would result in better evidenced-based policy prescriptions in Medicaid. Specifically they recommend:
- Quantified impacts in service and trends in care accessibility for the disabled Medicaid subpopulation measured before and after large programmatic changes, including state-level access measures
- A thoughtful analysis examining connections between service use, barriers to care, and care delivery efficiency and suitability
- Medicaid specific data regarding disability competency among participating clinicians; and ease of accessibility of diagnostic equipment, clinical practices, and office processes
- Service delivery best practice information for people with disabilities
Next Steps: Commissioners will provide input on research and comments on the draft chapter.
Session VI: Draft June Report Chapter on Program Integrity
Background: For the June 2013 report, MACPAC staff provided a comprehensive status update on program integrity changes made at the federal level since the release of the March 2012 Report to Congress.
Key Issues: The draft chapter presents an overall summary of Medicaid program integrity actions from an administrative perspective at both the state and federal level and discusses possible future opportunities to improve the efficiency and effectiveness of program integrity initiatives within the Medicaid. A summary of program integrity improvements undertaken in the past year include:
- HHS Secretary Sebelius, through Centers for Medicare and Medicaid Services (CMS), has undertaken some initiative recommended by the MACPAC Commission including revision updates by the Medicaid Integrity Group (MIG) of its comprehensive national Medicaid program integrity strategy.
- Both CMS and states are working toward more effectively allocating program resources and enhancing program integrity rules in order to better allocate federal resources and without placing undue burdens or regulations on providers or states and balancing the diverse needs of individual programs.
- A more concerted effort needs to be taken to better delineate the specific roles and responsibilities of administering programs and both the state and federal levels with regard to integrity strategy. The creation of broad view goals will also be needed to better elucidate larger opportunities for program improvement.
- There exist many opportunities for Medicaid integrity improvement programs, which should be researched and with best stream-lined practices given to policy-makers in the future
Next Steps: Commissioners will provide feedback on the draft chapter for the final June 2013 Report to Congress.
Session VII: Draft June Report Chapter on Data
Background: Federal administrative data on both CHIP and Medicaid provide a comprehensive representation of the programs, which in aggregate cost an estimated $450 billion in FY 2012 and with a served population of about 80 million people for at least a portion of 2012.
Key Issues: Improving data collection for Medicaid and CHIP incur some needed tradeoffs due to the existing size and expected growth of the programs warrant increased investment at both the state and federal level. Since March 2012, CMS has made progress on improving the quality of Medicaid and CHIP data through initiatives that include:
- Medicaid Information Technology Architecture (MITA), which establishes uniform set of guidelines and standards for state-operated Medicaid and CHIP data systems that are financed through federal dollars.
- MACPro, a web-based system designed to collect state plan, waiver, and other programmatic documents in a structured and consistent format
- Revamped Medicaid Statistical Information System (T-MSIS), which amasses existing person-level and claims-level MSIS data submitted by states
Future drafts will more thoroughly address state perspectives on federal data.
Next Steps: Commissioners will provide comments on the chapter proposed for the June 2013 report.
Session VIII: Plan Perspectives on State Enrollment Policies for Medicaid Managed Care
Background: States are increasingly interested in using managed care arrangements for populations with extensive health care needs. Preliminary Findings of a 10-state case study of their managed care enrollment policies, based on interviews with state officials, enrollment brokers, and beneficiary representatives, was presented previously during the February 2013 meeting.
Key Issues: MACPAC Commissioners are now seeking input from two Medicaid managed care organizations on their perceptions of state enrollment policies:
- CareSource is a Medicaid managed care plan with experience in providing coverage to Medicaid enrollees in several states that are at various stages of using risk-based managed care for their Medicaid enrollees, including Ohio, certain areas of Indiana, Kentucky, and has just left Michigan after 9 years.
- Amerigroup, a Medicaid managed care plan based in Texas, has extensive experience in enrolling enrollees with complex needs. Texas recently expanded its managed care into several rural regions of the state, which included expanding managed care for persons with disabilities in those regions.
Next Steps: Major points from this panel discussion will be included in the Commission’s ongoing dialog of managed care for high-cost, high-need beneficiaries. MACPAC staff plan to incorporate the 10-state case study final report into discussion at the May Commission meeting.
Session IX: Care Coordination for People Dually Eligible for Medicare and Medicaid
Background: As CMS moves to implement trials of approaches for new financing and service delivery service for dual eligible beneficiaries, such as capitated and fee-for-service care coordination model, substantial uncertainty remains regarding the efficiency of past efforts, the difference between future and previous efforts, and potential future outcomes. MACPAC staff examined quantitative evidence of past savings models that aimed to improve care coordination and integration, which included a fully integrated special needs plans, PACE, and fee-for-service care coordination and partially integrated models both in Medicare or Medicaid.
Key Issues: The research studies reviewed here can reveal the potential efficacy of strategies crafted to better dual eligible care more cost effectively. Substantial data trends are presented below:
- Improvements in quality. A fair number of models predict a lessening of possible avoidable hospitalizations; however other quality indicators such as lessening nursing home use and mortality are not present.
- There is variable evidence of net savings from care coordination. In some cases, costs of care coordination can often outweigh savings from changes in service use and expenditures.
- Acute-care savings, vs. Long-term services and supports (LTSS) savings. Currently, care coordination can improve quality and lower costs, with evidence of savings mostly on the acute-care side as opposed to the long term services and supports.
- Shared Savings Approach Uncertainties. The evidence of potential for acute-care savings from care coordination and integration means shared-savings approaches that remain uncertain between the two programs.
- Targeting. Research confirms the importance of establishing well-targeted interventions for specific subsets of the widely varying (Need for LTSS use vs. single serving individuals) dually eligible population.
- Performance monitoring. Efforts to assess existing programs are hindered by the absence of standardized data which would allow standardized comparisons across many facets. Performance monitoring for all programs requires us to focus on closing gaps in measurement, such as measures of access to care, quality of care, experience and satisfaction with care, and health outcomes for populations under 65 with disabilities.
Next Steps: Commissioners should provide comment on this issue and recognize priorities for future work.