Medicaid and CHIP: Reports for Monitoring Children's Health Care Services Need Improvement

Medicaid and the Children's Health Insurance Program (CHIP)--two joint federal-state health care programs for low-income families and children--play a critical role in addressing the health care needs of children. In 2008, more than 36 million children in the United States received health care coverage through Medicaid or CHIP. Like all children, children covered by Medicaid and CHIP may have health care conditions that could warrant care from primary care or specialist providers. At the same time, a significant number of children in Medicaid and CHIP may not be receiving basic preventive care, which these programs generally cover. For example, we reported in 2009 that, on the basis of parents' reports in national surveys, about 40 percent of children in Medicaid and CHIP had not had a well-child checkup over a 2-year period. Many state Medicaid and CHIP programs and other health care purchasers have started initiatives to improve care coordination for children and provide children with access to networks of care. For the purposes of this report, care coordination is broadly defined as a process in which an individual or group helps to arrange a patient's primary and specialty health care services. Care coordination can be provided by primary care providers or through other individuals such as social workers or case managers. Care coordination activities can include communication--sharing information among participants in a patient's care--and linking patients to community resources. Care coordination can help children gain access to a network of care, that is, a set of providers who are available to help address the primary and specialty health care needs of a patient. The Centers for Medicare & Medicaid Services (CMS), an agency within the Department of Health and Human Services (HHS), oversees state Medicaid and CHIP programs at the federal level and collects annual reports. States are required, under federal law, to annually report to CMS on the provision of a range of preventive, diagnostic, and treatment services for eligible children, known as Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services. States generally provide Medicaid and CHIP services through two service delivery and financing models--fee-for-service and managed care. Under a fee-for-service model, states pay providers for each covered service for which the providers bill the state. Under a managed care model, states contract with managed care plans, such as health maintenance organizations, to provide or arrange for medical services, and prospectively pay the plans a fixed monthly fee per enrollee. Concerns have been raised about delivery model incentives and health care service utilization. In contrast, because providers are paid for each covered service provided in fee-for-service models, there may be an incentive to provide more services to beneficiaries than necessary. As a result, interest in understanding access to, and use of, services by delivery model in Medicaid and CHIP has been long-standing. In the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Congress required that we study Medicaid and CHIP children's access to primary and specialty care, including the extent to which care coordination is provided for children's care in Medicaid and CHIP and information on children's access to networks of care. In addition, Congress required that we study, as appropriate, information on the degree of availability of services for children in Medicaid and CHIP. This report examines 1) the extent to which children in Medicaid and CHIP receive care coordination and have access to networks of care, 2) how selected states are coordinating care for children in Medicaid and CHIP, and 3) the extent to which required state reports collected by CMS provide information on the provision of services to children in Medicaid and CHIP.

Two nationally representative surveys from 2007 suggest that many children in Medicaid and CHIP needing care coordination did not receive it, and many needing access to networks of care had a problem with accessing the needed services, as the following specifics illustrate. 1) Care coordination: NSCH survey data from 2007 reveal that 45 percent of children in Medicaid and CHIP needed care coordination services, and of this group, 37 percent did not receive it. 2) Access to networks of care: The 2007 MEPS data reveal that 34 percent of children in Medicaid and CHIP needed care, tests, or treatments, and of this group, 12 percent of the children's families had problems accessing the needed services. In addition, based on the MEPS data, 15 percent of children in Medicaid and CHIP needed to see specialists, and of these children, 24 percent had problems seeing the specialists they needed to see. MEPS data from 2007 also suggest that a greater proportion of children in Medicaid and CHIP and uninsured children experienced a problem accessing needed care and needed specialists than privately insured children. The five states we examined had initiatives designed to improve care coordination for children in Medicaid and CHIP by having a process in place for beneficiaries to choose or be assigned to a medical home--typically a primary care provider--and by providing enhanced payments to providers of care coordination services. Four of the five states provided monthly payments--per member per month--to providers for each patient covered by the initiative who was enrolled with the provider. States had various methods for monitoring participating providers. State officials reported challenges to improving care coordination for children in Medicaid and CHIP. Other challenges identified by states included ensuring timely payments to providers and adequate reimbursement for specialists. As of December 2010, only one state--North Carolina--had formally evaluated its initiative. The two required summary reports that states provide annually to CMS are of limited use for monitoring the provision of services to children in Medicaid and CHIP due to reporting errors, missing information, and lack of detail. Our review of fiscal year 2008 CMS 416 reports found that 12 states made reporting errors on their reports, and in 10 of these states errors were large enough to result in overstatement of the extent to which children received well-child checkups. For both the CMS 416 and the CHIP annual reports, we found missing information, such as states not reporting required information on the number of children in Medicaid referred for additional services, which resulted in gaps in information on children's access. Both annual reports lack the detail necessary to assess children's access to care by delivery model, that is, the information needed to monitor services provided to children in managed care versus services provided in fee-for-service systems. In light of the need for accurate and complete information on children's access to health services under Medicaid and CHIP, the requirement that states report information to CMS on certain aspects of their Medicaid and CHIP programs, and problems with accuracy and completeness in this state reporting, we recommend that the Administrator of CMS establish a plan, with goals and time frames, to review the accuracy and completeness of information reported on the CMS 416 and CHIP annual reports and ensure that identified problems are corrected, and work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children's receipt of treatment services for which they are referred.