Providers could see pay raises or patient volume increase as a result of states boosting efforts to track whether fee-for-service Medicaid patients have adequate access to care.
The pledges from states appeared in an initial series of reports each state had to submit to the CMS by October and were posted by the agency earlier this month.
In 2015, the CMSfinalized a rule requiring states to compile annual reports that assess how easy it is for fee-for-service Medicaid beneficiaries to receive primary care; pre- and post-natal obstetric services; and see specialists and behavioral health experts, among other services.
Medicaid fee-for-service patients tend to disproportionately include those with complex medical needs and they may have trouble finding providers, especially specialists, according to Katherine Hempstead, a senior adviser at the Robert Wood Johnson Foundation.
They are individuals with disabilities and the elderly, although there are a small number of nonelderly or disabled adults and children not enrolled in managed care.
States reported that access to care was generally good for fee-for-service beneficiaries, but officials lacked scientific data to measure access, relying on anecdotes such as lack of calls to state Medicaid hotlines instead.
For instance, the call center in Washington state can log the number of callers who need assistance with “finding a provider.” However, the system does not currently track whether the caller is fee-for-service or in managed care. The state committed to establish a more robust set of metrics for future reports.
The CMS determined that the major rule on Medicaid managed care finalized in April 2016 established adequate provider network standards for beneficiaries in private plans, so they are excluded from the reporting requirement. Of the 75.2 million beneficiaries now in Medicaid, 73% were in private plans in 2016, up from 55% in 2013, according to PricewaterhouseCoopers.
Some states such as Alabama and Indiana did note high patient-to-provider ratios for some specialists including cardiologists and oncologists. They said they would check to see if that resulted in care issues.
If the CMS identifies problems with access, states are required to develop and submit a corrective plan within 90 days and must remediate the deficiency within a year's time.
States that fail to fix access problems could be ousted from Medicaid. To correct access issues, the CMS suggests states can increase payments or modify provider licensing and scope of practice policies.
However, all bets are off if Congress moves forward with plans to convert Medicaid into a block grant program, said Tricia Brooks, senior fellow at Georgetown University Center for Children and Families.
"The steps that Congress is taking to potentially restructure Medicaid financing that would involve significant cuts would undermine state efforts to address any access problems in the future," Brooks said.
