We’ve all heard the observation that putting a Medicaid
or CHIP card in a parent’s hand doesn’t necessarily mean that a child will get
all the health care he or she needs–many of us have probably said it
ourselves. For coverage to
translate to care, kids and parents need access to the right providers at the
right time. How is your state
doing on access for Medicaid beneficiaries? How would access be affected by changes in the payment rates
to providers? You might find it
difficult to answer these questions, since much of the access data we have
comes from national sources and the effect of payment rates on access in a
given local area is not always clear.
States have not, to date, reported regularly on comprehensive measures
of access in Medicaid. And as the
adage suggests, it’s next to impossible to improve performance without
measuring the outcomes of interest.
CMS has moved to address the lack of access measures with
proposed new guidelines for states that encourage them to measure and analyze
access in Medicaid. The proposed
rules come in response both to lawsuits from providers challenging state
payment rates and to recommendations from the Medicaid and CHIP Payment and
Access Commission, which was created in the CHIPRA law and expanded by the
ACA. They build on longstanding
federal law that requires that states ensure that medical services are available
to Medicaid beneficiaries at least to the extent that they are available to the
general population in the same geographic area. Separate federal laws apply to the availability of services
through Medicaid managed care, so these proposed rules apply only to
fee-for-service Medicaid beneficiaries.
The proposal states that CMS plans to write additional rules that apply
to access to care within managed care.
The proposed rule envisions states undertaking an ongoing
process to measure access so that each service (physician visits, dental
visits, hospital services, etc) is measured at least once every five
years. When states propose to
adjust provider payment rates, an analysis of the effect on access would need
to be part of the state plan amendment.
The proposed rule aims to create a consistent national approach to
analyzing and documenting access in Medicaid, but it doesn’t establish a
single, uniform process for measurement.
Instead, it allows states to develop metrics that reflect their own
circumstances and priorities.
This new attention for measuring and maintaining access
to care is an important step all by itself. But in reviewing the proposed rule, a couple of points stood
out: First, CMS strongly suggests
that beneficiaries’ experiences of care should be the
“primary determinant” of whether access is
sufficient. That means asking
families whether they have difficulty getting an appointment or whether they
can find the right specialist–it’s a great way to keep patients at the center
of decisions about Medicaid.
Second, the proposed rule expects that states will solicit public
comment on both their access measures and in payment policy changes that could
impact access. This improves
transparency and gives advocates and families a chance to weigh in on these
With the Affordable Care Act, we’re moving closer to
universal coverage, including millions of new enrollees in Medicaid. We’ll need to monitor access issues
even more closely to ensure that the possession of a Medicaid card means the
right care is available when it’s needed.
These proposed rules represent a solid start in making sure that
essential measurement happens.