Blog & News
SHADAC Advocates a Data-based Approach to Advancing Medicaid and CHIP Access Monitoring Plan (Response to CMS Request for Information)
April 29, 2021:On February 17, 2022, the Centers for Medicare & Medicaid Services (CMS) released a request for information (RFI) regarding access to coverage and care in Medicaid and the Children’s Health Insurance Program (CHIP).
SHADAC researchers focused our response on Objective 4: Question 1, which asked researchers to consider how CMS might develop a stronger Medicaid and CHIP access monitoring approach through data reporting and analysis, and is copied for reference below.
Portions of SHADAC’s response were also included as part of a larger commentary on each of the RFI’s five total objectives submitted to CMS by President and CEO Richard Besser, MD, of the Robert Wood Johnson Foundation (RWJF) on April 18, 2022.
Centers for Medicare & Medicaid Services (CMS) – Request for Information (2022) Objective 4: CMS has data available to measure, monitor, and support improvement efforts related to access to services (i.e., potential access; realized access; and beneficiary experience with care across states, delivery systems, and populations). CMS is interested in feedback about what new data sources, existing data sources (including Transformed Medicaid Statistical Information System [T-MSIS], Medicaid and CHIP Core Sets, and home and community based services (HCBS) measure set), and additional analyses could be used to meaningfully monitor and encourage equitable access within Medicaid and CHIP programs. 1. What should CMS consider when developing an access monitoring approach that is as similar as possible across Medicaid and CHIP delivery systems (e.g., fee-for-service and managed care programs) and programs (e.g., HCBS programs and dual eligibility in Medicaid and Medicare) and across services/benefits? Would including additional levels of data reporting and analyses (e.g., by delivery system or by managed care plan, etc.) make access monitoring more effective? What type of information from CMS would be useful in helping states identify and prioritize resources to address access issues for their beneficiaries? What are the most significant gaps where CMS can provide technical or other types of assistance to support states in standardized monitoring and reporting across delivery systems in areas related to access? |
Response from SHADAC
Thank you for the opportunity to help inform the development of an improved Medicaid and CHIP access monitoring plan. These comments are based on SHADAC’s experience providing data and evaluation technical assistance (TA) to states, which has given us a unique view into the day-to-day challenges and barriers that states encounter related to these issues. These comments mirror recent testimony to the Medicaid and CHIP Payment Access Commission (MACPAC) provided by SHADAC’s Deputy Director.
We present five points for your consideration, each of which are guided by the same principle, which is: That any monitoring plan should seek to minimize burden on state agencies.
First, consider an iterative approach that starts with a limited number of measures and expands over time. This will require difficult tradeoffs regarding priorities, but these tradeoffs will be worth it if the first iteration is achievable for a wide range of states. As the plan develops and more complicated measurement concepts are added, it should engage leading states by including them in additional measure selection and incentivizing them to participate in pilots that test the collection and analysis of data – sharing concrete implementation lessons with other states.
Second, support states in efforts to improve existing data with a focus on the ability to disaggregate. There are existing data streams to draw on (as documented by Urban Institute in 2017 and discussed at a recent MACPAC meeting), and while none are perfect, a successful plan should first focus on improving those. One tangible way to improve states’ existing data is to support data disaggregation efforts. There is a renewed focus and energy to promote equity within Medicaid and calls from stakeholders to see data about important groups of interest. This includes an interest in better data by race, ethnicity, sexual orientation, gender identity, disability, and geography. Improving existing data streams to better support disaggregation is a good investment and one that will meet multiple demands.
For example, the Transformed Medicaid Statistical Information System (T-MSIS) will likely play a role in monitoring service use, but there are concerns regarding the existing quality and completeness of the race and ethnicity data. We have worked with several states who are trying to improve the collection of race and ethnicity data in Medicaid—modifying question wording and expanding response options to better represent the populations they serve, making technical changes to better capture the data, and modifying instructional language and scripts for enrollment assisters to make them stronger partners in data collection. And, most importantly, they are doing this with community input. But they continue to face challenges in this work. For example, current OMB standards for demographics are dated and do not align with the most current research. Additionally, rules for collecting race and ethnicity data are not uniform across federal programs. A new access monitoring effort could serve as further impetus for federal agencies to revise the guidance on race and ethnicity and for states to take action to improve existing data collection to address this critical data gap.
Third, states need both direct funding and hands-on technical assistance to support this work. We appreciate CMS’s understanding that states will need assistance to implement the access monitoring framework. However, based on our work with states, we think this needs to go beyond documentation and uniform measure specifications. To do this well, states should have access to experts who can provide practical, hands-on advice that is responsive to their specific needs. The type of assistance needed will vary and needs to be flexible, from states who are further along in their process and may seek help troubleshooting a particular coding challenge to other states whose request might require more fundamental support, such as walking through the requirements to assess staff and training needs, setting priorities, and help developing contract amendments or RFPs. We would also recommend that any TA effort include a forum for states to discuss implementation challenges with their peers.
The funding provided to states for this effort should also be flexible. It should support direct costs like system modifications, but also things like stakeholder engagement, which is critical to the iteration and improvement of the monitoring plan, and related data collection, but will also allow the results of this monitoring to be shared in a meaningful way.
Fourth, some areas of Medicaid access monitoring are best addressed through federal data collection. We believe that the access monitoring effort would benefit from periodic fielding of a 50-state Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey aimed at both children and adults and administered by the federal government. The federal government has a long and successful track record of fielding high-quality surveys that produce estimates for all 50 states, including a one-time National Medicaid Adult CAHPS survey.
While this undertaking would be resource intensive, it seems to us to be the most efficient way to collect comparable information on important facets of access, like enrollee experience, and a starting point for comparing individuals enrolled in fee-for-service versus managed care.
Finally, it is critical to treat states as a full partner in this process, including the communication of results. It goes without saying that states should be consulted in the development of the monitoring plan, but they should also be consulted when the data are being released, preferably beforehand. Ideally, they should have access to analytic files so that they can do their own data runs and share customized findings with stakeholders. Finally, once the data are collected, there should be a commitment that the data be published or released in some format in a timely manner.
Blog & News
Covid-19 Vaccine Hesitancy in the U.S. has Reached a Plateau: Evidence from the Household Pulse Survey
April 1, 2022:Previous analysis produced by SHADAC using data from the Household Pulse Survey (HPS) showed promising evidence of a reduction in COVID-19 vaccine hesitancy during the first three months of 2021. However, though this report highlighted an overall decline in hesitancy, it also showed disparities in the level of hesitancy between demographic and socioeconomic groups. In an effort to continually illuminate barriers to vaccine receipt, this blog provides an updated look at vaccine hesitancy among U.S. adults (age 18 and older) using HPS data from January through October 2021.
The Household Pulse Survey is an ongoing weekly tracking survey designed to measure the impact of the COVID-19 pandemic. These data provide multiple snapshots of COVID-19 vaccine hesitancy and are the only data source to do so at the state level over time. Click on any graphic throughout this blog to view it in full-screen mode. |
The HPS allows respondents to identify multiple reasons for not receiving all vaccine doses.
For the survey period of January 6-July 5 the reasons listed on the survey form included:
1) Concerned about possible side effects 2) Plan to wait and see if it is safe and may get it later 3) Think other people need it more than I do right now 4) Don't know if a vaccine will work |
5) Don't trust the vaccine
6) Don't trust the government
7) Don't believe I need a vaccine
8) Don't like vaccines
|
9) Concerned about the cost of a COVID-19 vaccine 10) My doctor has not recommended it 11) Other reason |
For the survey period of July -October 11 the reasons listed on the survey form changed to include:
1) Concerned about possible side effects 2) Plan to wait and see if it is safe and may get it later 3) Don't know if a vaccine will protect me 4) Don't trust the vaccine |
5) Don't trust the government
6) Don't believe I need a vaccine
7) Don't think COVID-19 is that big of a threat
8) My doctor has not recommended it
|
9) Concerned about the cost of a COVID-19 vaccine 10) Hard for me to get a vaccine 11) Experienced side effects from 1st dose of vaccine 12) Believe one dose is enough to protect me |
Because the reasons for not receiving a vaccine changed between these two periods, they will be reported separately in our analysis.i
Share of adults who received or plan to receive all COVID-19 vaccine doses plateaued at the end of 2021.
From July through October 2021, the percent of people who have received or plan to receive all COVID-19 doses plateaued at around 80.0 percent.ii,iii This was after an initial jump from 9.6 percent in January to 67.6 percent in April. The initial increase drew mainly from the “Definitely planning to receive a vaccine” and “Probably going to receive a vaccine” groups. The percent of people who “Received a dose, but do not plan to receive all doses,” “Haven’t received a dose and are unsure about getting a vaccine,” “Haven’t received a dose and are probably not getting a vaccine,” and “Haven’t received a dose and definitely are not getting a vaccine” has also remained stable over the same period. Collectively, these four groups, which we define as being “hesitant,” dropped from a rate of 21.1 percent in January to 14.8 percent in July, where it’s remained since.
Vaccine Hesitancy varied by state, but nearly all states saw a reduction.
Nationally, 14.6 percent of adults reported being hesitant about the COVID-19 vaccine in October 2021. This varied across states, from a high of 28.9 percent in Wyoming to a low of 5.4 percent in the District of Columbia (D.C.).
The national rate of adult vaccine hesitancy decreased from 14.8 percent in July to 14.6 percent in October—a 0.2 percentage-point (PP) decrease. This overall decrease, though not significantly large, was reflected in 26 states plus D.C., which also saw promising reductions in vaccine hesitancy. Twenty-four states did not show reductions in hesitancy over that time period.
Concerns over possible side effects remains the top reason reported for vaccine hesitancy.
Of the 21.1 percent of people who reported hesitancy in January, nearly half (48.3 percent) cited “Concerns over possible side effects” as a reason.iv This continued to be the most reported reason for hesitancy, with 53.8 percent who were hesitant in October citing it as a reason. The percent of people reporting “Plan to wait and see if it is safe” declined over the 10-month period, from 42.1 percent in January to 30.4 percent in October, and dropped from the second to the fourth most reported reason behind “Don’t trust COVID-19 vaccine” and “Don’t trust the government.” This shift in reasoning behind vaccine hesitancy highlights a major barrier to vaccination goals, as establishing trust is a potentially more difficult and imprecise process than quelling fears of side effects.
When examining survey responses from January and October 2021, our analysis found that both the number of reasons for hesitancy (2.5 per person and 2.9 per person, respectively) and the most common reason for hesitancy (“concerns over possible side effects”) remained statistically unchanged between the two survey periods. Our analysis also found that the rankings of the reasons for hesitancy held within subpopulations by region, race/ethnicity, and income, as highlighted in the following sections.
Disparities in vaccine hesitancy improved over time, though many remain.
As with our previous analysis of the HPS, both overall hesitancy and disparities in vaccine hesitancy between demographic and socioeconomic groups has improved, though unevenly. The most notable reduction comes among Black adults, who registered a high of 32.9 percent in January and dropped down to 12.2 percent in October. This decline in vaccine hesitancy essentially closed the gap between Black adults and other racial/ethnical groups. Unfortunately, the rate of decline seems to have reached a plateau among certain demographics. For example, among White adults the hesitancy rate stabilized at around 15.0 percent between July and October.
Similar patterns appear when looking within and across income level. Those making less than $25,000 reported the highest level of hesitancy in January at 28.3 percent, but have shown a marked reduction down to 17.5 percent in October. This has significantly closed the gap in hesitancy between this group and those at higher income levels. However, once again, changes within subgroups appear to have reached a stable level of hesitancy. Among those making $50,000-$74,999 this appears to be around 12.0 percent, while for those making $150,000 or more, this appears to be around 7.0 percent.
Patterns of reduced vaccine hesitancy followed by rate leveling continued to be true among groups with fewer connections to the health care system, as proxied by insurance status. Hesitancy rates have fallen generally across all insurance statuses; however, the uninsured and those with Medicaid coverage continue to have the highest rates of hesitancy, at 24.5 percent and 22.1 percent in October as compared to those with ESI/Military, Direct Purchase, or Medicare coverage.
Note: All changes and differences in this post are statistically significant at the 95% confidence level unless otherwise noted.
Related Reading
SHADAC Blog: Vaccine Hesitancy Decreased During the First Three Months of the Year: New Evidence from the Household Pulse Survey
SHADAC Blog Series: Measuring Coronavirus Impacts with the Census Bureau's New Household Pulse Survey: Utilizing the Data and Understanding the Methodology
i U.S. Census Bureau. (2021, November 3). 2021 Household Pulse Survey User Notes [Phase 3.2]. https://www2.census.gov/programs-surveys/demo/technical-documentation/hhp/Phase3-2_2021_Household_Pulse_Survey_User_Notes_11032021.pdf
ii This only includes primary series doses and excludes booster doses.
iii This percentage is higher than administratively reported COVID-19 vaccine receipt. The differences are due to both the inclusion of those who “Plan to receive all vaccine doses” and the known discrepancies between administrative and survey data.
iv The HPS allows those who are “Probably going to receive a vaccine” to report reasons for hesitancy; however, this group is not included in our definition of “hesitant.”
Publication
New SHADAC Brief Summarizes Study of Effects of Medicaid Expansion on Physician Participation
With the Affordable Care Act's (ACA) expansion of Medicaid, approximately 15 million people were able to enroll in the program - many of whom were previously uninsured. However, researchers have long worried that an expansion of insurance coverage would not translate to an equal expansion in access to care. A particular point of concern is the worry that these newly eligible and enrolled individuals would not be able to find enough physicians who participate in Medicaid to treat them.
Existing research has traditionally relied on physician survey data to study trends in physician acceptance of Medicaid and the factors associated with participation in the Medicaid program. For example, under contract with the Medicaid and CHIP Payment and Access Commission (MACPAC), SHADAC researchers used data from the National Electronic Health Records Survey (NEHRS) to create state-level estimates of physician participation in Medicaid before and after expansion and to study the physician- and practice-level characteristics associated with participation.
However, a new study led by Dr. Hannah Neprash is the first to provide direct answers about how clinicians responded to the Medicaid expansion. In their paper, "The effect of Medicaid expansion on Medicaid participation, payer mix, and labor supply in primary care” published in the December 2021 issue of the Journal of Health Economics, Dr. Neprash and her co-authors use all-payer claims and practice management data from 2012 through 2017 to examine how clinicians changed their labor supply and payer mix in response to Medicaid expansion.
This brief summarizes key findings from this study, including the effect of expansion on the number of Medicaid appointments and number of Medicaid patients seen by primary care clinicians (i.e., Medicaid participation), the total number of appointments provided (i.e., their labor supply) and the share of those appointments paid for by Medicaid versus private coverage or other payers (i.e., payer mix). The study also compares the relative change in participation in states subject to the Medicaid expansion compared to the change in states not subject to the expansion, estimating a causal effect of expansion on clinician participation in Medicaid.
Click on the image to the upper right to access and download a PDF of the full brief.
Related Resources
Physician Acceptance of New Medicaid Patients: Findings from the National Electronic Health Records Survey (MACPAC Fact Sheet)
Explore Physician Acceptance of New Medicaid Patients through Two New Measures on SHADAC’s State Health Compare and in a New MACPAC Factsheet (SHADAC Blog)
Physicians who accept new Medicaid patients (State Health Compare Data Measure)