- The Washington Times - Monday, September 29, 2014

Some states are better than others at providing access to care and keeping tabs on their Medicaid managed care programs, according to a federal report released Monday that raises questions about government oversight of the massive health program for the poor, which is rapidly expanding under Obamacare.

For instance, the Health and Human Services Department’s inspector general found some states required one primary care provider for every 100 enrollees, while some employed a 1-to-2,500 provider-enrollee ratio.

States have “considerable latitude” in the standards they impose, and those that found the most violations of their access-to-care requirement were the ones that went looking for them in the most direct way, such as calling up providers to assess compliance.

“State standards vary widely and are often not specific to providers who are important to the Medicaid population, such as pediatricians, obstetricians and high-demand specialists,” the inspector said. “In addition, these standards often apply to all areas within a state and do not take into account differences between urban and rural areas. Without standards for specific provider types or areas, states may not be able to hold plans accountable for ensuring adequate access to care.”

The inspector said it is important to shine a light on Medicaid, an entitlement program than serves 69 million people and cost states and the federal government a combined $460 billion in fiscal 2013. That’s because more than half the states have opted to expand Medicaid under the Affordable Care Act, and even those that have not augmented their program are seeing an uptick in enrollment.

All told, the report said the program is slated to cover up to 18 million more Americans by 2018.

The inspector general looked at 33 states with comprehensive, “full-risk” managed care programs, in which organizations take on the financial risk for delivering a suite of services in exchange for a fixed fee per enrollee from the state. The managed care organizations maintain a network of participant providers to deliver primary, specialty and acute medical services.

The inspector general found that 32 of the states impose limits on how far a person should have to travel for medical services, yet 14 of them did not impose distance or travel-time limits for specialists and 17 of them did not distinguish between urban and rural areas.

Thirty-one states specified the number of days a person should have to wait to see a primary care doctor for a routine appointment, yet those standards ranged from 10 days to 45 days. Ten of the 31 states did not specify a maximum wait time for specialists.

Also, the inspector found an array of methods to make sure providers complied with standards. Only eight states conducted their own “direct tests” — typically calls to providers to see how they comply — while several said they employed “secret shopper” method in which the caller posed as a patient.

The report said only a third of the 33 states under review identified at least one violation of their access-to-care standards between January 2008 and the start of 2013.

“When States fail to identify violations of their access standards, they are unable to correct problems and improve access to care for enrollees,” the inspector general said.

Federal oversight by the Centers for Medicare and Medicaid Services could be better, the inspector general said, as CMS officials reported that it tended to make sure states had access standards, but not whether those standards were adequate.

“CMS should work with States to ensure that these methods accurately determine plan compliance,” the inspector said, noting the agency concurred with each of their recommendations for improving oversight.

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