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March 14, 2001
Tommy G. Thompson Dear Secretary Thompson: We are writing regarding the recently issued HCFA 2001-F regulations implementing the Medicaid managed care provisions of the Balanced Budget Act of 1997. We appreciate that the Administration is giving interested parties an opportunity to comment on the regulation and to provide input as to the potential impact the ruling could have on Medicaid recipients and their providers. The Association for Health Center Affiliated Health Plans is made up of managed care plans that were started by, and continue to be governed in the majority by, community health centers. In total, members of the Association represent over 900,000 Medicaid and SCHIP enrollees nationwide. Due to their strong ties to core safety net providers, these health plans share a commitment to ensuring that medically underserved people have access to quality health care and that the primary providers to this population have secure environments. We want to clearly state at the outset that we believe strongly that managed care can not only work within the Medicaid environment, but can actually increase access to and quality of care. Through plan-wide quality management activities, MCOs can promote consistent and efficient practices among providers, can ensure care is coordinated and managed, and can promote expanding access into new care areas and for new populations. All of our members return significant resources to their health center providers in order to increase their opportunities to care for the underserved. It is in this spirit that we comment on the positive aspects of the new regulations and offer concerns about potential negative impacts on the viability of the Medicaid program. In addressing the new regulations, we would like to express our appreciation of the new approach to setting rates. By moving away from the Upper Payment Limit methodology, HCFA is explicitly acknowledging the growth of the managed care program and its increasing distance from fee-for-service. The very fundamentals of managed care (quality measurement and improvement; performance tracking; care management; member services; grievance procedures; etc.) were not present under FFS, making comparisons to that benchmark questionable at best. The new methodology will more appropriately recognize the comprehensive package of services and controls that managed care organizations provide and the complexities of serving the populations they care for. In reviewing the regulations there seem to be several common underlying themes. These undercurrents may not set the best stage for maximizing the potential benefits that we believe the program can bring to its recipients. First, there is a sense that without strict regulatory oversight, the managed care organizations would at best not be attentive to the rights of their enrollees, and at worst would ignore the interests of those in their care. We do not agree that this is a necessary assumption. Certainly, there are MCOs that have been involved with Medicaid who have not been attentive enough to the people they serve, or whose missions are not compatible with involvement in a public trust. However, for the most part, and particularly for our members, patient rights and protections are foremost. The current of questionable trust in these regulations sets an uncomfortable dynamic between the plans and the program – one that cannot benefit the recipients in the end. We want to work with the administration and our states in a partnership to make the Medicaid program better and look forward to the opportunity to do so. Second, the demand for uniformity across the states contradicts the original intent of the Medicaid program. Medicaid is a state-federal partnership program within which the federal government establishes floor rules from which states can build. This was the whole intent of the waiver program as well. Certainly this has not always produced the best results for recipients in some of the “leaner” Medicaid states (and this always needs to be focused on and addressed), but conversely it allows for creativity and geographic/cultural specificity in program design. Just as it is appropriate to expect that programs will be tailored to ensure that individuals are treated in the culture and language they understand, so should states be able to model programs in ways that best serve they individuality of their populations and environs. These regulations speak far more strongly to uniformity. While this may not be the explicit intent, it is the implicit result. It is appropriate for the regulations to identify good, strong, patient-oriented minimum standards and benefits that everyone must adhere to, however, states should be given latitude after that fact in developing quality assurance programs, accountability standards, and other program management approaches. Third, there is significant micromanagement across the substantive areas of the regulations. MCOs and states are expected to develop systems and report information to a degree that the integrity of the whole program is jeopardized. In reviewing the specificity required in these regulations, one cannot help but be reminded of the experience of the Medicare program. Medicare managed care did not work because the oversight and micromanagement of the health plans drove them out of the business. Even the best intentioned cannot survive in an environment that has someone constantly looking over the shoulder and requiring proving oneself at every moment. MCOs serving the Medicaid population already have significant reporting requirements to state Departments of Human/Social Services, Health, and Business Regulation in addition to NCQA. The added reporting burdens overshadow the more important activities of focusing on providing quality care and producing positive health outcomes. In some cases this kind of micro managing might be necessary, some providers and plans may need oversight to ensure that recipients are cared for appropriately. However, imposing on all because of the impropriety of some is counterproductive, and may end up being the straw that breaks the program. Turning to specific regulations, there are several key items that are of particular concern to us.
1. Choice of managed care entity and out-of-network access Section 438.52(b)(2)(B): Choice of managed care entity and out-of-network access. One of the underpinnings of managed care, and one that quality of care rests a great deal upon, is the ability of MCOs to credential their providers and to monitor the quality of their care. This is one of the greatest assets of the managed care approach. Patients are able to expect a certain high standard, and plans have a mechanism to hold providers accountable for delivering quality to their patients. Without the ability to collect information, measure outcomes and hold providers to a high standard of care, there is no tangible way for MCO’s to deliver on this guarantee. In the end, this places the quality of care for the patient in jeopardy. While it is reasonable, and often good medicine, to allow individuals to continue a regimen of care with their existing provider, there needs to be a reasonable time period within which the patient and/or provider can be brought into the managed care system. To not do this means that the MCOs will be in the position of being held responsible for care over which they have no control. The members of AHCAHP hold quality of care in very high regard. Along with extensive quality management programs within each plan, the organization has established an association-wide quality management committee to analyze performance on HEDIS measures, to establish internal benchmarking projects on key outcome indicators, and to provide mutual support to efforts to improve quality. These efforts reach down into their provider networks where patient satisfaction surveys and quality improvement programs are used to identify areas needing improvement and to raise the standards. Our HEDIS scores show that these efforts pay off for the patients. This section of the regulations would call into question the plans’ abilities to ensure the quality of services being provided by out-of-network providers. The second problem raised by this section is the effect it will have on care management and coordination. Again, one of the strengths of managed care is the ability to provide comprehensive care from a constellation of providers and sources under a single coordinated treatment plan. However, when a primary provider outside of the plan’s purview is treating a patient, the ability to manage the care and ensure that quality providers are meeting all of the patient’s needs is jeopardized. In the end, while this does not guarantee bad care is being delivered, it certainly cannot ensure that good quality care is. It is important to remember that lack of coordination and care management and the resulting negative impact on health was one of the primary reasons that the fee-for-service system was abandoned. Section 438.240: Quality assessment and performance improvement. There is no question that ensuring the quality of care provided to recipients is a top requirement. As noted above, members of AHCAHP are so concerned about delivering a quality product and producing positive health outcomes they we have instituted an association QM program on top of those of each of our plans. However, this section creates an inability for states, and MCOs, to create their own standards based on the populations they serve. In order to ensure that all populations are potentially protected, this regulation imposes requirements on states and MCOs regardless of whom they serve and the environments within which they operate. It is important to provide a framework for quality assurance monitoring and performance improvement, and to impose the requirement to develop a concrete, time bound evaluation plan with measurable outcomes and improvement strategies. However, beyond that the states should be able to fashion the specifics of the plan and identify the outcome measures that are most important and relevant to the populations they serve. Section 438.208(f)(h): Coordination of care and treatment plans. This regulation places the MCO in the position of micromanaging the physician - patient relationship. Within the context of plan-level quality and performance standards, utilization review, and the other mechanisms used to ensure that patients are receiving comprehensive care, these regulations serve only to disrupt the critical two-way relationship we are trying to support. Section 438.242: Grievance and appeal process. Perhaps more than any of the others, this section threatens injury to the viability of the Medicaid program. It will require extensive training, development of new materials, and revamping of MCO and state reporting practices. This section significantly increases the complexities of the grievance process to the point that one has to question whether patients will be able to understand it. This approach will create a lengthy and cumbersome process that will delay reconciliation of complaints and minor problems and may very well deter patients from filing grievances altogether. We are strong believers in patient rights and in ensuring that patients receive the care they need, however, the level of prescriptive specificity in this subpart creates an untenable environment even for us. This is the type of approach that most damaged the Medicare managed care program and may well have the same impact here. The members of AHCAHP occupy a unique niche in that we were created by community health centers to provide care to the medically underserved. We define ourselves as safety net providers and are firmly committed to expanding opportunities for people to have access to quality health care. We encourage the administration to take a fresh look at these regulations and to implement a strategy that allows for state to state variation within a framework that ensures Medicaid patients receive quality care from dedicated providers. We believe that by working together HCFA, state Medicaid Directors, MCOs, providers, and consumers can improve the Medicaid program, create innovative approaches to caring for the underserved populations, and vastly improve health outcomes in the people we serve. The members of AHCAHP are committed to this and appreciate the administration for opening the door to the dialogue.
Sincerely,
Cc: Mary Kay Manthos, DHHS PJB:mbj |