Diversity is a hallmark of the state-federal Medicaid program. The saying goes: "If you've seen one Medicaid program, you've seen one Medicaid program." In terms of MLTSS quality, the same holds true to a large extent. CMS has always accorded states discretion in the design and operation of their Medicaid programs, including quality monitoring, as long as they adhere to Medicaid regulations. States' responsibility to exercise administrative authority over their Medicaid programs is one of those expectations. Administrative authority requires that the Medicaid agency assume ultimate responsibility for oversight of any program functions it contracts out or delegates to other entities. But even administrative authority can be implemented in a manner as seen fit by a particular state, as long as approved by CMS.
Flexibility is also an underlying tenet of Medicaid MLTSS--affording MCOs opportunity to coordinate and deliver care in innovative ways suitable to the needs and desires of beneficiaries with long-term disability. Flexibility encourages innovation and allows the states and MCOs to be responsive to local conditions, cultures and the diversity of the MLTSS population. CMS acknowledges that states have options for how they address the essential elements of a MLTSS program outlined in its recent guidance document. Not surprising, across the programs studied we found a fair amount of variability in how states structure quality oversight in their MLTSS programs. By and large, however, all have integrated into their quality strategies the quality-related structures and processes delineated by CMS' guidance on the essential elements in MLTSS programs--but differently.23
While it would be imprudent to stifle diversity in how states design their quality infrastructures, processes and procedures, an argument can be made for more uniformity in measuring the impact of MLTSS on beneficiaries' lives, particularly outcomes related to health, experience of care and quality of life. In the commercial health marketplace as well as in Medicaid and Medicare, there has been a convergence toward adoption of rigorously tested health effectiveness and experience of care metrics as exemplified by Health Effectiveness Data and Information Set (HEDIS) and Consumer Assessment Health Care Providers and System (CAHPS),24 respectively. Measures as these allow for "apple-to-apple comparisons" across providers, plans and states and are widely used by commercial plans, hospitals, providers and federally-funded programs across the nation.25 Another initiative along these lines is CMS' recent specification of a core set of health care quality measures for Medicaid-eligible adults as required by Section 2701 of the Affordable Care Act.26 Items in this set are based largely on previously tested items and draw upon both HEDIS and CAHPS. However, the focus of these measures is on health care, not on LTSS. To fill this gap, CMS has invested in the development and testing of an HCBS Experience of Care survey for Medicaid programs for which CAHPS certification will be sought. This initiative will result in a cross-population survey so that "apples-to-apples" comparisons can be made across programs that serve the frail elderly, adults with disability, and persons with IDD. The instrument will be appropriate for use in both the FFS and MLTSS settings and thus will afford comparison between consumer-experiencedcare in those environments as well. At least one of the MLTSS programs in our study was intending to participate in the testing of this new survey.
In closing, we reiterate that the quality enterprise in MLTSS--for states, MCOs, providers and EQROs--is one with multiple and simultaneously moving parts. It requires sufficient investments in personnel and information technology resources as well as leadership's commitment to keep all engaged and aligned. As this report demonstrates, there are several tacks that states can take for assessing MCO and provider performance and for monitoring member well-being. We hope that the information on the myriad of ways states structure MLTSS quality management will be helpful to states embarking upon new programs as well as to those established programs that may be taking a second look at different options for quality.