Medicaid panel to study access to care, quality

Washington -- A new Medicaid commission's first order of business includes examining managed care plans' role in Medicaid and looking at how better to coordinate care for people eligible for both Medicaid and Medicare, the commission's chair said at its inaugural meeting on Sept. 23-24.

The Medicaid and CHIP Payment and Access Commission, or MACPAC, was created by the Children's Health Insurance Program Reauthorization Act that President Obama signed in February 2009. MACPAC will advise Congress on Medicaid and CHIP the way the Medicare Payment and Advisory Commission advises Congress on Medicare.

MACPAC is charged with a small mountain of work. Its duties include reviewing how access to care and quality of care are affected by Medicaid pay, as well as state enrollment and eligibility policies. The commission will examine other potential barriers to care, such as language and transportation. MACPAC is expected to create an early warning system to identify doctor and other health professional shortage areas. In addition, it must review alternatives to medical liability policies.

"It is an overwhelming agenda," said MACPAC Chair Diane Rowland, ScD. She also is executive director of the Kaiser Commission on Medicaid and the Uninsured.

MACPAC will report to Congress twice annually -- March 15 and June 15 -- on important issues affecting Medicaid and CHIP.

The panel has 17 commissioners, including four physicians. The members are not paid salaries but will receive travel allowances.

Managed care contract evaluation

Rowland said the commission should look into the increasingly important role of managed care plans in Medicaid.

States steadily have moved more Medicaid enrollees from fee-for-service to managed care plans: 71% of enrollees were in managed care plans in 2008, up from 56% in 2000, according to the Kaiser Family Foundation.

But states might not be spelling out Medicaid managed care plans' responsibilities adequately, said Julie Hudman, PhD, director of the Washington, D.C., Dept. of Health Care Finance, its Medicaid agency; and Andrew Allison, PhD, executive director of the Kansas Health Policy Authority, the state's Medicaid agency. Both gave presentations to the commission.

"Our [contract] does not have the teeth in it that we need to hold our managed care organizations to account," Allison said.

Hudman told the commission that she realized there were flaws in the Medicaid managed care contracts for the District of Columbia when a baby born with sleep apnea died this summer. The Medicaid health plan denied the mother's request to visit a specialty clinic the day before her baby died because the mother didn't have the right referral.

The Medicaid plan subcontracted nursing care for the baby to another organization, creating confusion about who ultimately was responsible for care, she said. Hudman said the incident highlighted a flaw in the system, and that states should monitor subcontracting closely and fundamentally spell out what they're paying for when they contract with Medicaid managed care organizations.

Coordinating care for disabled and elderly Medicaid enrollees will be an important MACPAC focus, Rowland said. These enrollees -- many of whom also are eligible for Medicare -- require some of the most expensive care covered by Medicaid. Although only 10% of Medicaid enrollees are 65 and older, they accounted for 25% of Medicaid spending in 2007, she said. The disabled are 15% of the Medicaid population but accounted for 42% of program spending in 2007.

Assessing care patients receive

MACPAC Vice Chair David Sundwall, MD, said he wants the public to understand the benefit of having health insurance. Like Rowland, he wants to look at Medicaid enrollees' outcomes. "Having insurance doesn't guarantee access to health care or good health," said Dr. Sundwall, a family physician and executive director of the Utah Dept. of Health.

Rowland asked: "Once someone is eligible for Medicaid or CHIP, what happens to them?"

One of the difficulties MACPAC faces is figuring out how well states are handling Medicaid and CHIP enrollees, said Urban Institute Senior Fellow Genevieve Kenney, who gave a presentation to MACPAC on gaps in knowledge about Medicaid. "We don't know much about variation in access to care across states."

Dr. Sundwall said he wants to make sure that the views of conservative states such as Utah are heard. He has spoken out about the burden states will face under a 2014 Medicaid expansion to cover 16 million more people. Full federal funding for the expansion through 2016 will decrease to 90% on average by 2020. "There are state concerns, and they are legitimate," he said.

Physicians most frequently cite Medicaid's relatively low fees as the reason they can't take more Medicaid patients. On average, Medicaid paid 72% of Medicare rates in 2008, equal to 56% of private insurance pay, Peter Cunningham, PhD, a senior fellow with the Center for Studying Health System Change, told the panel.

The American Medical Association would like MACPAC to take a close look at physician pay, which varies widely among the states, said AMA President Cecil B. Wilson, MD. "In too many states, these rates are inadequate, which can lead to patient access problems."

Eleven states in 2008 had Medicaid rates at least equal to Medicare rates, Cunningham said, noting that other factors can influence patient access.

Doctors' locations, practice sizes and ages also can play a role in whether Medicaid patients have access to care, he told MACPAC. He suggested that the overall supply of physicians could be more of a barrier to Medicaid access than low Medicaid fees. Physicians are more likely to see Medicaid patients if they practice in rural areas or in larger groups or if doctors are young, Cunningham said.

"Physicians in rural areas know there aren't many other options for rural patients," Cunningham said. Doctors in larger groups might have more administrative help than solo physicians with completing the paperwork that Medicaid and CHIP require, he added.

He said increasing Medicaid physician participation will require an approach that deals with these and other issues.