Executive Summary
In July of 1995 the Department of Social Services (DSS) implemented a plan to move a majority of the state's Medicaid eligible population from a fee-for-service health care delivery system to a managed care system. The plan called for the staggered enrollment of certain eligible Medicaid clients -- primarily AFDC recipients -- in managed care plans. To date, DSS has authorized eleven managed care organizations (MCOs) to enroll clients. When fully implemented in January of 1997, approximately 235,000 Medicaid eligible individuals will have been transitioned to the managed care program.
This is the second in a series of reports that this office will produce regarding the state's experience with Medicaid managed care. The first report reviewed the process by which DSS selected default health plans to cover individuals who fail to choose a managed care plan. This report examines various methods of assessing the quality of health care delivery under the Medicaid managed care program.
As the constitutional officer responsible for monitoring and reporting on the overall fiscal condition of the state, the Comptroller has a basic interest in this program. Medicaid is a $2 billion annual state expenditure item accounting for over 20 percent of total General Fund spending. Therefore, the performance of the Medicaid managed care program is significant from a budgetary perspective.
Major Findings and Recommendations
The major findings of this report with respect to the state's effort to monitor quality of
care under the Medicaid managed care program are as follows:
Issue 1: Suspension of BlueCare's status as default provider for eastern
Connecticut.
On March 11, 1996, DSS suspended BlueCare's default provider status due to client over
enrollment in relation to the network's provider capacity. The suspension prompted a
legislative request for a review by the State Comptroller's office. To address the network
capacity issue, staff from the Comptroller's office conducted several meetings and
follow-up telephone interviews with key DSS personnel. In addition, this office reviewed
correspondence between DSS and BlueCare and other pertinent documentation relating to
BlueCare's provider network.
Finding: The review team has concluded that BlueCare made a good faith effort to expand its provider network as its enrollment grew. DSS, in turn, granted BlueCare appropriate leeway as it attempted to correct network deficiencies. However, DSS was justified in suspending BlueCare's default provider status for May and June of 1996, in light of BlueCare's temporary network deficiencies and rapid and continuing enrollment. Ultimately, BlueCare did eliminate the network deficiencies and was reinstated as the default provider for eastern Connecticut, effective June 1, 1996.
Issue 2: Enrollment ceilings as a measure of client access.
Enrollment ceilings were established by DSS as a preliminary indicator of a plan's ability
to meet the health care needs of its Medicaid clients, pending the implementation of
better measurements of access to care. The ceilings require managed care plans to maintain
a minimum ratio of doctors to Medicaid clients by provider type (adult and child primary
care, mental health, obstetrics-gynecology and dentistry).
As a practical matter, enrollment ceilings are of limited value in evaluating access to care. The ceilings are applied to each plan, not to each physician. Moreover, physicians may participate in more than one plan. Consequently, the ceilings do not in any way limit the total number of Medicaid and non-Medicaid patients that an individual physician within a plan may see. Total physician patient load would be a more appropriate measure of a client's access to care, but this information is not currently reported. Currently, DSS does not have the system resources to monitor the total number of patients per provider.
Recommendation: Given the limitations of the enrollment ceilings, their significance as an assessment of client access should diminish as better measures are implemented.
Issue 3: Poor participation rates for routine child care.
DSS requires that MCOs submit reports detailing their performance in areas such as
inpatient utilization, readmission rates for behavioral health, immunizations, and
prenatal care visits. To date, many of the reports submitted by the plans were late and
incomplete. Nevertheless, sufficient data were presented to raise concerns about the
federally mandated program for early and periodic screening, diagnosis and treatment
(EPSDT). The majority of plans have not met their contractual obligation for EPSDT
participation. Under managed care, there is an affirmative obligation on the part of
participating health plans to effectively manage the delivery of health care to enrollees.
Therefore, it is the responsibility of the plans to determine why enrolled children are
not participating in EPSDT at acceptable rates, and to take remedial action.
Recommendation: DSS should use all means necessary to ensure that the MCOs meet their contractual obligations for enrollee EPSDT participation and other areas of performance assessment.
Issue 4: Medicaid HEDIS
One of the difficulties faced by both the health plans and DSS in reporting and analyzing
data is the absence of a standard set of performance measures for the Medicaid population.
One effort to address this concern involves the National Committee for Quality Assurance
(NCQA). Recently, NCQA adapted a series of health plan performance measures (originally
designed for employers) to evaluate Medicaid managed care. This set of performance
measures -- known as Medicaid HEDIS -- has been endorsed by the federal Health Care
Financing Administration and by DSS, which recommends modifying current health plan
reporting requirements to incorporate Medicaid HEDIS wherever possible. In doing so, DSS
rightly cautions that Medicaid HEDIS does not include all the information needed to
evaluate Connecticut's program. Consequently, there continues to be a need for separate
reporting requirements. Despite its current limitations, Medicaid HEDIS provides a
nationally recognized standard for judging the performance of Connecticut's MCOs.
Recommendation: DSS should seek an active and direct role in any future revisions of Medicaid HEDIS in an effort to have those measurements that Connecticut has found valuable incorporated into this evaluation tool.
Issue 5: New information technology could help improve performance evaluation.
DSS is in the process of implementing a new data tracking system called AIM -- for
Advanced Information Management. Under AIM, MCOs will transmit patient encounter data for
validation and storage on the system. DSS will have the capacity to replicate reports
currently generated by the MCOs and have the capability to analyze information by any data
field in the AIM system, including, but not limited to, geographic region, provider, age
or procedure. Consolidation of encounter data may also provide DSS with the opportunity to
issue "report cards" for each MCO, in an effort to assist Medicaid eligibles
with plan selection.
Recommendation: Additional resources will be required to maximize the full potential of AIM. However, the Comptroller's office believes that the benefits derived through centralized data analysis, in terms of program management, justify the additional expense.
Issue 6: The Medicaid Managed Care Council
The Medicaid Managed Care Council was formed to advise DSS on the implementation of
Medicaid managed care and to monitor the program as it develops. Council members represent
a broad spectrum of stakeholders involved in the delivery and oversight of health care in
Connecticut. The collective experience of the membership is considerable and the Council
performs a valuable and much needed oversight function. Unfortunately, no one is assigned
to the Council as staff on a full-time basis, limiting its ability to review and report on
the large volume of data brought to its attention.
Recommendation: The review team recommends that the Council hire a full-time staff person with the appropriate technical background to assist with the ongoing analysis of the Medicaid managed care program.