Follow-Up Review: Progress Report on Evaluability of the Mississippi Coordinated Access Network
Executive Summary
Introduction
Problem Statement
During its 2009 Second Extraordinary Session, the Mississippi Legislature passed House Bill 71 (now codified as MISS. CODE ANN. Section 43-13-117 [1972]), which contained several provisions designed to control Medicaid costs, including a provision authorizing the Division of Medicaid (DOM) to implement a managed care program on or after January 1, 2010.
The DOM selected two providers to implement the Mississippi Coordinated Access Network (MSCAN) and entered into contracts with Magnolia and UnitedHealthcare to provide these services. On January 1, 2011, the division implemented MSCAN, with the goals of improving access to and quality of care and reducing state expenditures for Medicaid.
The bill included a mandate for the PEER Committee to conduct a comprehensive performance evaluation of the program by December 15, 2011. Early in the fieldwork for that review, PEER determined that the program was still not fully operational in terms of a functioning performance accountability structure and refocused the review from an evaluation of actual performance to an evaluability assessment of whether the DOM was collecting information to allow a comprehensive performance by a date certain in the future. In PEER's report #555, An Evaluability Assessment of the Mississippi Coordinated Access Network (November 15, 2011), PEER identified critical elements that the DOM needed to have in place and operable in order to conduct a comprehensive performance evaluation of MSCAN (see pages vi-vii of this summary). Appendix A, page 19 of the report, contains an executive summary of Report #555, including a brief description of the concept of managed care for delivery of Medicaid services.
After PEER issued that report, the PEER Committee voted on May 15, 2012, to conduct this follow-up review to determine what progress has been made since PEER’s initial evaluability assessment in establishing a framework for MSCAN that would allow the Division of Medicaid or a third party such as PEER to perform a comprehensive performance evaluation.
Scope and Purpose
PEER sought to address the following objectives during the course of this review:
While the initial evaluability assessment of the MSCAN program noted opportunities for improvement and steps necessary for a future comprehensive evaluation in the areas of access, quality, and cost efficiencies and effectiveness, this MSCAN review primarily focuses on the program’s quality of healthcare services.
Summary of Conclusions from PEER’s Initial Evaluability Assessment of MSCAN
As noted previously, the Division of Medicaid and the MSCAN managed care organizations (Magnolia and UnitedHealthcare) are responsible for assuring that Mississippi’s Medicaid managed care program fulfills the goals of the program, which are:
In its initial evaluability assessment, PEER identified the critical elements of an accountability structure that should be in place in order to evaluate the MSCAN program in comparison to its three primary goals:
Also, PEER identified steps needed to prepare MSCAN for future evaluations:
Additional detail to support these conclusions is available in Appendix A, page 19 of the report, which is an executive summary of PEER’s initial evaluability assessment, or in Report #555 at www.peer.ms.gov.
Status of Evaluability of the MSCAN Program
Since PEER’s initial evaluability assessment, the Division of Medicaid has completed the State Quality Assessment and Improvement Strategy and has contracted for an external quality review. Also, the managed care organizations have administered an experience of care survey to enrollees and have provided the results to DOM. However, the division has still not established health-related outcome measures for each of its selected health focus categories, which prevents DOM or a third party from objectively evaluating the actual impact that services provided have had on the health of the selected populations.
Steps Taken to Improve the Evaluability of MSCAN
Completion of State Quality Assessment and Improvement Strategy
As noted by PEER in its first evaluability assessment of MSCAN, the Centers for Medicare and Medicaid Services requires that the Division of Medicaid develop a State Quality Assessment and Improvement Strategy that incorporates goals and objectives for MSCAN and standards for quality measurement and improvement. The Division of Medicaid submitted the draft of its State Quality Assessment and Improvement Strategy to CMS in November 2011 and CMS approved it in January 2012.
Contract Entered into for External Quality Review
As noted by PEER in its first evaluability assessment of MSCAN, the Centers for Medicare and Medicaid Services requires that every state that enters into a contract for a comprehensive Medicaid managed care program obtain an independent, external review of the quality of service by a third party. The Division of Medicaid has contracted with the Carolinas Center for Medical Excellence for such a review, with the final report for the MSCAN 2011 program year due on May 17, 2013.
Completion of Consumers’ Experience of Care Survey
As noted by PEER in its first evaluability assessment of MSCAN, the Division of Medicaid requires that both managed care organizations administer an experience of care survey to MSCAN enrollees and report the results to DOM annually. Both Magnolia and UnitedHealthcare elected to utilize the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey to measure patient satisfaction. However, because the division did not conduct exit surveys for those enrollees who opted out of the program during the first open disenrollment period, the survey results provide only a partial depiction of MSCAN enrollee satisfaction and the division has no documented insight into enrollees’ reasons for opting out.
Action Still Needed to Improve the Evaluability of MSCAN: Need for Health-Related Outcome Measures
DOM currently has outcome measures for only one of its four health focus areas (diabetes). The division still must implement health-related outcomes for its three remaining health focus areas (obesity, asthma, and congestive heart failure). While output measures and target service levels ensure that DOM can monitor what services are being provided to MSCAN enrollees, the lack of health-related outcome measures prevents DOM or a third party from objectively evaluating the actual impact that MSCAN has on the quality of health of the selected populations.
Medicaid Management Information System Does Not Allow for a Direct Comparison of MSCAN to FFS Medicaid
Although the collection and reporting capabilities of the Medicaid Management Information System allow the Division of Medicaid to compare selected outpatient services of the MSCAN and fee-for-service Medicaid populations based on administrative claims data, the system can provide only limited data for prescriptions and inpatient hospital services. Thus the DOM can make only limited quality and access comparisons between the MSCAN enrollees and fee-for-service Medicaid categories of eligibility for the types of outpatient services provided by each program. Without the ability to compare directly the healthcare services provided to the respective populations, neither the Division of Medicaid nor a third party can perform a comprehensive program evaluation to determine how the MSCAN program is performing in comparison to fee-for-service Medicaid.
Program Expansion Without Validation of Performance Measures
Without first determining whether the program is achieving measurable improvements in the health of enrollees or validating the performance measures reported by the managed care organizations, the Division of Medicaid plans to expand the MSCAN program on December 1, 2012, prior to completion of the federally mandated external quality review for year one of the MSCAN program.
Recommendations