Improving Medicaid’s Continuity of Coverage and Quality of Care

1. Improving Medicaid’s 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. Medicaid’s 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.

9. 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.

10. Similar Changes in CHIPRA • Created performance-based funding incentives for increasing children’s enrollment. • Based on 5 of 8 enrollment or renewal simplification policies for children and • Actual increases in children’s 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

12. 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

13. 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 children’s e-health record • Demonstration project to reduce child obesity

16. 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.

17. 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.

19. 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

20. 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.

21. 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 43:6, 2086-2105. • Bindman A, et al. Medicaid re-enrollment policies and children's risk of hospitalizations for ambulatory care sensitive conditions. Med Care. 2008;46(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 Care–Sensitive 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 Aug;57 (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). 2004;23(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.