VISIT STATE HEALTH COMPARE
Publication
SHADAC Newsletter - January 2017
The SHADAC newsletter contains updates on SHADAC activities, news from the states, resource updates, and blog highlights. Subscribe to our newsletter here.
Blog & News
State Medicaid Access Review Monitoring Plans (ARMPs): An Early Look at Data Sources Used by States
December 13, 2016:
In November 2015, the Centers for Medicare and Medicaid Services (CMS) issued a final rule implementing Medicaid’s “equal access” provision, nearly 25 years after the statute was enacted and more than four years after the rule was initially proposed. One piece of the final rule requires that states develop Access Review Monitoring Plans (ARMPs) to address and analyze the extent to which the health care needs of Medicaid fee-for-service (FFS) beneficiaries are met, the availability of health care and providers, changes to beneficiary utilization, as well as comparisons of payment rates.
ARMP Requirements
CMS grants states significant flexibility in selecting measures and defining their approach to the plans. However, states are required to analyze certain services (described below) and incorporate beneficiary and provider input on ARMPs. Final baseline reports were due to CMS on October 1, 2016; states are required to submit a revised plan every three years or in the event of a FFS rate reduction or a high volume of complaints about access to a service in a particular geographic area.
Limitations of ARMPs
ARMPs are meant to support CMS’s goal of assuring access to covered services in FFS Medicaid, but they are not without limitations. Notably, the plans only cover access and payment rates for FFS beneficiaries, and states have increasingly turned to managed care for delivery of care to Medicaid beneficiaries. States may also struggle with the availability of timely data and the challenge of conducting data analysis and producing triennial plans without federal funding. Despite these limitations, baseline ARMPs may shed light on states’ access priorities and approaches to analysis.
Examining ARMP Data Sources: Our Approach
In an effort to identify the range of data states leveraged in ARMPs, SHADAC researchers performed a key word search online and on State Medicaid and Dept. of Health websites during the month of November 2016 (one month after final reports were due) to identify draft or, if available, final ARMPs. We then abstracted key information about data sources and service categories to a table. We identified a total of 43 ARMPs, of which 19 were final. The summary below is based on all plans, including draft plans but relying on final plans when available.
Service Categories
All states are required to cover access to primary care, including dental services, specialty, behavioral health, obstetrics and gynecology (including labor and delivery), and home health services. These services were included for analysis in all plans identified. However, although the final rule included dental services in its definition of primary care, only 29 of the 43 states included these services in ARMPs. One state explicitly excluded dental services from analysis based on their interpretation of the final rule’s requirements for analysis of primary care. Some ARMPs examined services beyond those required in the final rule such as durable medical equipment (AZ), transportation (IN), and nursing facility services (PA).
Results: Data Sources Used
Nearly every state analyzed access using Medicaid Management Information Systems (MMIS) data (i.e., provider, individual enrollment and/or claims data), which states are required to use for mechanized claims processing and information retrieval. Approximately fifteen also included FFS Consumer Assessment of Healthcare Providers and Systems (CAHPS) data in their analyses, and many states said they would try to leverage data from the national CAHPS survey in future analyses where state level FFS CAHPS data wasn’t currently available. Eight states included (or would include in future plans) beneficiary reported access issues from call center data. Some states explored additional data sources including Census data (CA, CT, NV, ME), state-specific surveys (e.g., CO Health Access Surveys and MN Health Care Access Survey), and Healthcare Effectiveness Data and Information Set (HEDIS) measures (OH, MA, MN, SC, CT).
Potential Limitations to Reliance on MMIS Data
As mentioned above, states rely heavily on MMIS data for access analyses. Though this may reduce the administrative burden of data collection, MMIS data may not provide a complete picture of access. There are well-documented limitations to using MMIS data for patient identification as well as uncertain validity of encounter data and completeness of diagnosis information. Moreover these data were not intended for use in research. States will likely need to supplement MMIS data with other data sources to ensure an accurate reflection of access in their ARMPs.
Looking Ahead: How CMS Can Support State Efforts to Measures Access
Initial state plans are currently under CMS review. Plans are expected to change over time resulting from this review and as priorities, delivery systems, and data availability shift over time. Going forward, CMS can support states by identifying and disseminating promising data sources and approaches to measuring access, especially those not commonly used by states, and sharing solutions to common barriers to access data collection and analysis.
Awarded Grant
Eligibility Criteria for HCBS and the Affordable Care Act (December 2016)
Principal Investigator: Brant Fries, PhD, University of Michigan
The goal of this study is to examine Medicaid long-term medical care eligibility criteria across states, and in particular, how the nursing facility level of care (LOC) criteria affect access to care through home and community-based services (HCBS). The researchers will compare LOC policies across four states that have adopted a standardized, comprehensive assessment instrument, the interRAI Home Care instrument. They will apply state-specific algorithms to data from a fifth state to measure each state’s relative degree of access to HBCS.
Grant Products & Publications
Using Standardized Data to Compare Access to Long-Term Services and Supports in Five U.S. States
(July 2017, Presentation at 21st IAGG World Congress of Gerontology & Geriatrics)
Awarded Grant
How Much Better is Medicaid than Marketplace Coverage at Easing the Burden of Out-of-Pocket Spending for Near-Poor Adults? (December 2016)
Principal Investigator: Frederic Blavin, PhD, The Urban Institute
The goal of this study is to inform expansion and non-expansion states of the effect of Medicaid expansion on out-of-pocket spending and the overall resources available to families. Using data from the 2014-2016 Current Population Survey Annual Social and Economic Supplement, the applicants will conduct a difference-in-differences analysis, using the 2014 Medicaid expansion as a natural experiment, to address the following research questions:
- Compared to marketplace coverage, what is the impact of the Medicaid expansion on reducing premium and non-premium out-of-pocket health spending among low-income adults with incomes between 100 and 138% FPL? In other words, among those in this income group, how much would out-of-pocket health spending in nonexpansion states change if states either expanded Medicaid or made Marketplace benefits and cost-sharing comparable with Medicaid?
- What is the impact of the Medicaid expansion on out-of-pocket health spending among adults with incomes below 100% FPL in expansion states, relative to similar adults in nonexpansion states without access to Medicaid or Marketplace subsidies?
- How do these changes in out-of-pocket spending affect the overall resources available to families?
Publications
Medicaid vs. Marketplace Coverage for Near-Poor Adults: Effects on Out-of-Pocket Spending and Coverage
(June 2018, Presentation)
"Medicaid Versus Marketplace Coverage for Near-Poor Adults: Effects On Out-Of-Pocket Spending"
(February 2018, Health Affairs)
Impact of Medicaid vs. Marketplace Coverage on Out-of-Pocket Spending for Near-Poor Adults
(December 2017, SHARE Webinar)
Medicaid vs. Marketplace Coverage for Near-Poor Adults: Impact on Out-of-Pocket Spending Burdens
(November 2017, Presentation)
Blog & News
Video: Angie Fertig Discusses SHARE-Funded Study of Pent-Up Demand among New Medicaid Enrollees
November 11, 2016:Dr. Angie Fertig, Research Investigator at Medica Research Institute (MRI), is featured in a new MRI Investigator Video in which she discusses her SHARE-funded analysis of pent-up demand among new Medicaid enrollees under the ACA. Check out the video below.
Additional information about this analysis can be found on Dr. Fertig's SHARE grantee page.
Angela Fertig PhD-2016 from Medica Research Institute on Vimeo.
