Patient advocates are hopeful the CMS will take action because of the report.
“It's high time to focus more on this issue,” said Joan Alker, executive director of the Georgetown Center for Children and Families. “We've got more and more Medicaid beneficiaries going into managed care at a time state governments have been under resource pressure.”
The CMS will likely follow up on OIG's recommendations in some form, Alker said. The agency already indicated this summer that it was drafting a sweeping new rule to update managed Medicaid regulations that have been in place since the late 1990s.
Other health experts agreed with Alker, but questioned if CMS action will help the average beneficiary.
“I honestly don't think adding more rules will make much difference to real patients,” said Paul Guppy, vice president for research at the Washington Policy Center, a conservative-leaning think tank. “It's just the nature of a top-down bureaucratic system; it has a hard time meeting the needs of individual patients.”
Others fear that no action from CMS will likely mean no change at the state level.
In Kentucky for instance, finding a mental and substance abuse provider remains difficult, despite network adequacy requirements, according to Sheila Schuster, a clinical psychologist and executive director of the Advocacy Action Network, an umbrella organization that includes several health advocacy organizations.
Kentucky's Cabinet for Health and Family Services, which oversees Medicaid, “say we trust our managed-care organizations, that they have guidelines and the plans are meeting them, and we're telling them people are getting hurt,” Schuster said.
A spokesperson for the Cabinet for Health and Family Services did not return a request for comment by deadline.
Other Medicaid officials said they have little reason to question the information they receive from plans regarding network adequacy.
In Rhode Island for instance, if plans were not providing up-to-date, accurate reports on network adequacy, beneficiary complaints would be coming to the state, which is not occurring, said Jacqueline Kelley, chief legal officer for the state's Health and Human Services department.
“When they have complaints, clients are not reluctant to call us directly,” Kelley said.
Arizona officials questioned the assumption in OIG's report that additional oversight or rules from the CMS would automatically mean improved care for beneficiaries. That reasoning shows the OIG's basic misunderstanding about Medicaid managed care, Coury said.
“Health plans manage provider relationships and are best able to determine what is needed in a particular community,” Coury said. “Medicaid managed care is not and should not be about managing to artificial rules that create additional layers of bureaucracies.”
For instance, Medicaid beneficiaries in rural areas by default must travel farther than others for care and enforcing rules about distance won't change that, she argued.
Colorado officials had similar concerns that more federal rules won't equal a fix. For instance, the state admits that it has no policies in place governing how quickly Medicaid beneficiaries should get access to specialists.
“The reason for this is the difficulty all states have in recruiting specialists who will accept Medicaid,” said Marc Williams, a spokesman for Colorado's Department of Health Care Policy and Financing. “That challenge is then exacerbated when states place access to care standards on those specialty providers, resulting in an even greater shortage of specialty-care providers.”
