CMS' recent guidance on the design of Medicaid MLTSS programs identifies the resources that a state must have for overseeing program quality. These include resources to:
- Conduct quality-focused audits;
- Evaluate MCO/provider quality reports;
- Trend data and identify areas for systems improvement;
- Validate corrective action plans;
- Develop and evaluate PIPs;
- Review/act on member feedback; and
- Ensure critical incidents/sentinel event are reported, investigated and addressed.
CMS's guidance also specifies that the resources that a state brings to bear (number and expertise of personnel, information technology assets) should be commensurate with the size and complexity of the program.
Among the study states we found that Arizona and Tennessee have heavily leveraged the oversight infrastructure used to monitor their managed health care plans--AHCCCS6 and TennCare, longstanding Medicaid managed care programs on the medical side. The other study states have established relatively free-standing MLTSS oversight infrastructures. Some of the states (Minnesota, Tennessee, Texas, and Wisconsin) also delegate additional quality assurance and improvement activities to the EQRO (beyond those EQRO activities that are federally-mandated).
While we do not have sufficient information to offer direct comparisons among the states on resources they allocate to quality, Exhibit 2 provides a glimpse into the magnitude of staffing each state employs relative to the numbers of members in the program and number of MCOs it monitors. It is difficult to compare the staffing complement in Arizona and Tennessee with the other states due to their draw on resources from their overarching Medicaid managed care program. Excluding these two states as well as Pennsylvania (an outlier in terms of number of members enrolled--only 130), a cursory comparison shows a range of quality staffing ratios. They range from one state quality staff per 2,905 MCO members in Wisconsin to one per 21,215 MCO members in North Carolina. Since the primary focus of state quality monitoring is the MCO, perhaps a more meaningful comparison is the number of quality staff per MCO. Here too we see ranges, from approximately 0.36 state full-time equivalents (FTEs) per MCO in North Carolina to 1.75 state FTEs per MCO in Wisconsin. Our comparisons in this instance are merely descriptive, but do raise questions for future inquiry about optimal staffing levels and whether there can be economies of scale with increased numbers of MCOs without sacrificing adequate monitoring.
|EXHIBIT 2. State Staffing for Quality Management|
|TN||31,890||4||2 Units in LTSS
1 Unit in TennCare
|WI||33,000||9|| 1.5-3.0 FTE per oversight team
(1 team per MCO)
The information technology capabilities of a state and how they support the quality enterprise are part of the infrastructure as well. A quality system is obviously much enhanced with the ability to generate reports electronically and provide automated tracking. Our case study programs provide some examples of how information technology enables enhanced monitoring. Texas's web-based portal allows the state, MCOs and the EQRO to view quality reports submitted by MCOs; they intend to offer access to providers in the future. Tennessee uses a customized off-the-shelf web-based tool to track receipt of all quality reports, corrective action plans and associated communications. All submissions from an MCO require action by a state employee to accept/reject the report/corrective action plan including the rationale for the disposition. This tool also documents all communications between the MCO and the state. In addition, Tennessee makes use of GeoAccess software to identify potential deficiencies in each MCO's provider network, including LTSS providers.