As we talked with states a few other issues pertinent to quality in MLTSS emerged. The first of these was how aspects of their quality management system had developed since program inception. Several states' comments revolved around the evolution of performance measures. Michigan had decreased the number of measures dramatically over time, from approximately 50 to fewer than 20. They were motivated to scale back due the expense associated with the EQRO having to validate the larger number of measures.
Wisconsin told us that they had moved from relying exclusively on process measures to more of a balance between process and member outcome measures. Comments by two other states were more of an aspirational nature regarding future developments in measurement--one wishing to incorporate more outcome measures (Texas) and another hoping to use HCBS Experience of Care measures under development by CMS (Tennessee).22 Related to the discussions surrounding outcome measures was one state's observation that they had evolved their PIPs from an administrative focus to ones concentrating on quality of care improvements and health outcomes (Texas).
Other changes noted were increased standardization of MCO processes allowing for more effective state oversight (Wisconsin), expanding the EQRO's role (Texas), increasing the number and expertise of state monitoring staff (North Carolina), and developing an individually-based critical incident monitoring system (Michigan).
In addition, a couple of states (Tennessee, Texas) noted that MLTSS quality monitoring is much more data-driven and that they were using more sophisticated data systems for evaluating the provision of care than they had under the 1915(c) waiver programs. Tennessee in particular pointed to the EVV system (described earlier in this report) that it implemented at the outset of its MLTSS program. While not making any comparison to service receipt performance under the predecessor 1915(c) waiver, they cited recent performance of greater than 96% of scheduled in-home visits delivered, and 99.7% delivered on time. They attribute this achievement to the EVV system with the ability to resolve missed/late visits in real-time. More related to member health outcomes, Texas has empirical evidence of improved treatment of Chronic Obstructed Pulmonary Disease under its MLTSS program, and Pennsylvania cited an increase in competitive employment as a positive program impact.
Another topic we explored was states' experience with the flexibility afforded in the Medicaid managed care regulations for quality management as compared to the more prescriptive requirements associated with the 1915(c) HCBS waiver requirements. Tennessee acknowledged that the 1915(c) requirements influenced the design of their quality strategy but that they appreciated the ability to customize the quality management approach in their MLTSS program. North Carolina mentioned that the 1915(b) authority allows them to contract with select providers who offer higher quality care, whereas otherwise they would have to adhere to the "any qualified provider" stipulation under Medicaid FFS. And, at the time of our interview, Michigan was in discussions with CMS to substitute MCO accreditation for state audits, augmented by EQRO record reviews; that flexibility is not a current option under the 1915(c) waiver authority.