Report: The Pursuit of Medicaid Managed Care Quality Information in Six States

Medicaid managed care is a big and growing business. The federal government and the states pay billions annually to private managed care plans to provide services to Medicaid beneficiaries. And, in the past ten years, the percentage of Medicaid beneficiaries enrolled in managed care has increased from about 55% to more than 70%. (1) At least a quarter of state Medicaid programs contract with commercial plans to deliver services to Medicaid enrollees who, by law, can only obtain needed care through the plans. Significantly, because these private contractors and vendors are publicly traded corporations, they have a fiduciary duty to maximize return on shareholder investments. This can create incentives to reduce coverage of necessary services.

States contract out the provision of Medicaid services to managed care plans based on assumptions that it would save money for the state and improve care to beneficiaries. But, how do we know whether the services are of adequate quality? In order to protect beneficiaries and to ensure that they, along with policy makers and the public, have access to information about the services managed care plans provide, state Medicaid agencies and the plans that contract with them are required by federal statute and regulation to make information about the nature and quality of services publicly available. (2)

The National Health Law Program (NHeLP) has aggressively advocated for transparency and quality in managed care, and for legal and contractual protections to ensure that beneficiaries receive high quality care. In 2008, NHeLP launched its Sunshine and Accountability Project to test adherence with the laws requiring transparency by requesting, analyzing and disseminating information about Medicaid managed care performance. With funding from The Nathan Cummings Foundation and the Public Welfare Foundation, NHeLP, with six state partners, examined the performance and transparency of Medicaid managed care in six states: Connecticut, Virginia, Florida, Missouri, New Mexico, and Washington. (3) The states were chosen to reflect a diverse mix of states as well as to take advantage of existing networks with legal services advocates in those states. These states also serve a high proportion of their Medicaid population through risk-based managed care organizations. NHeLP worked closely with the state partners to develop project materials, monitor progress, and offer assistance with analysis and problem-solving.

• A list of the specific Healthcare Effectiveness Data and Information Set (HEDIS) performance measures used by the agency to measure MCO performance in 2006, 2007, 2008, and 2009;
• Specific HEDIS performance results, as reported by each Medicaid participating MCO for the three most recent years available;
• State Medicaid standards for access to care to ensure that covered services are available within reasonable timeframes and in a manner that ensures continuity of care and adequate primary care and specialized services available;
• The State strategy for assessing, reviewing and improving the quality of available managed care services, including any reports submitted to CMS discussing the strategy; and
• The current policies and procedures for obtaining prescription drugs that are not on an MCO’s drug formulary.

• Descriptions of any physician incentive plans which the MCO uses; (4)
• Lists of specific types of providers included in the MCO network. For each provider listed, MCO were asked to include the name, location, qualifications and availability, non-English language spoken, information on whether the provider is accepting new Medicaid patients, and any other information legally required to be provided to Medicaid beneficiaries. In addition, MCOs were asked to provide any additional information that the MCO in the course of business provides enrollees or potential enrollees about physicians with which it contracts: (5)
  • Pediatricians,
  • Dentists, (6)
  • Orthopedists,
  • Dermatologists,
  • Endocrinologists,
  • Psychiatrists, (7)
  • Neurologists.
• For July 1, 2007 through June 30, 2008:

(a) the total number of requests for payment for a prescription drug covered under the state contract for which the MCO electronically approved payment at the pharmacy point of service for the prescription as written; broken down into numbers of approved requests for each therapeutic class of drug

(b) the total number of requests for payment for a prescription drug covered under the state contract for which the MCO electronically rejected payment at the pharmacy point of service because the drug is not on the MCO’s restricted drug list (also referred to as a “formulary” or “preferred drug list” or similar term), broken down into numbers of rejected requests for each therapeutic class of drug; and

(c) of the total number of electronically rejected requests described in section (b), the percentage for which payment of the original prescription, or of a substitute drug in the same therapeutic class approved by the prescribing physician, was approved by the MCO for payment within 24 hours after the initial payment rejection was rejected. (8)

States’ Responses to the Requests

All of the states except Connecticut ultimately provided most of the information requested. Response times ranged from a speedy 14 days for Virginia to 160 days for Connecticut’s incomplete response. Two of the slow-responding states, Washington and New Mexico, provided an initial response within a month stating that they needed more time to comply with the request. Four states (Virginia, Washington, New Mexico, and Missouri) requested payment for copying. In order to avoid copy costs, local partners requested that information be made available in a electronic format. The copy costs requested generally were not very high, but they would likely pose a barrier to a Medicaid beneficiary who might want to review the information.

• Connecticut The MCOs took at least two months to respond, and generally three months to do so. One managed care plan, AmeriChoice (United Heathcare) told the state partner that the state Medicaid agency had instructed the plan not to respond until it received further instructions.Eventually, however, it and the other two plans (Aetna Better Health and Community Health Network of CT) did provide complete responses regarding physician incentives and provider networks. No pharmacy data was requested or provided because pharmacy benefits, along with dental and mental health benefits, are carved out from the MCOs in Connecticut.
• Florida The state partner sent requests to 15 managed care plans. Five plans provided minimal partial responses: One plan, Universal HealthCare, had not responded two months after the response was sent. Eventually, however the plan was responsive and attempted to cooperate. It answered the questions about physician incentives and provider networks. It also indicated a willingness to provide the pharmacy data. After several emails and calls, it provided data which appeared to be unresponsive and incomprehensible. The plan underwent some major personnel changes and indicated a willingness to cooperate in the future.
  • Two plans, Sunshine and Healthease called but did not send information to the state partner. Sunshine explained that they had just opened and did not have all the information requested.
  • Prestige, Jackson Health Plan, Preferred Medical Plan, and Amerigroup, provided minimal, partial responses (such as provider handbooks which did not indicate whether providers were accepting new patients or whether networks included specialists ). Preferred Medical Plan provided some statistics in response to the question about pharmacy denials but stated that providing the requested data would cost upwards of $10,000 in programming costs.
  • Molina Healthcare of Florida directed the local partner to the state for the information sought on pharmacy denials and noted that most of the information requested “is only available by court order or subpoena.” They also suggested that the pharmacy information be obtained from the state Medicaid agency.
  • UnitedHealthcare refused to provide responses to the requests for information about physician incentive programs and the provider network unless the state partner provided the name and contact information of a beneficiary enrolled in the plan. It would not answer the question about pharmacy requests without a subpoena “or citation of legal authority.”
  • None of the other plans contacted: Humana, Total Health Choice, Freedom Health, Personal Health Plan, Vista/Buena Vista, and Citrus Health Care responded.
  • One plan, the Health Care District of Palm Beach County, sent a letter referring the state partner to their website. This was surprising, because no request had been sent to that plan. (10)
• Missouri Health Care USA, and Children’s Mercy (Family Health Partners) provided nearly complete and prompt responses. Other plans’ responses were spotty. The pharmacy information for Health Care USA was missing some information, but they made an attempt to provide the requested information. Both Blue Advantage Plus and Harmony both indicated that they were unaware of any obligation to provide a response, but referred to their website for provider listings. No information was found for physician incentive plans for either plan. Blue Cross BlueShield of Kansas City provided some information but also asserted that it had no obligation to provide the information. Missouri Care Health Plan (Aetna) sent its member handbook and provider directory, but the directory did not indicate providers’ qualifications or whether a provider was accepting new patients. After a follow up request, the plan stated that it did not have a physician incentive plan. It deflected the request for pharmacy information, indicating that the information “should be released by the MO HealthNet Division as they receive encounter information.” Molina Healthcare of Missouri provided some of the information requested, indicating that there was no physician incentive plans, referring to its website for information about participating providers, and referring to the state Medicaid agency for information about prescription drug claims. At the same time, the letter stated that it “considers much of the information you requested, confidential and protected and we are unable to provide you with that information. The information is only available by court order or subpoena and most likely not in the specific format you have requested.” (11) The state partner sent a follow up letter, to which Molina did not respond.
• New Mexico Shortly after the state partner sent out requests, representatives from several MCOs called to ask why the information was being requested. Two plans subsequently sent links to information on their websites. Lawyers representing two other plans called the state partner and asked why the state partner was requesting the information. A little more than a month after the response was mailed, BlueCross BlueShield sent a provider list and physician incentive plan. They reported that they did not have pharmacy data because they had only been participating in Medicaid since October 2008. Amerigroup provided a nearly complete response; however, they cautioned that they had only been providing services in NM for a little over a year so they did not have the pharmacy data requested, and they were not warranting that their provider directory was complete. Evercare did not respond to two letter requests, one sent in December and a follow-up in March. Molina Healthcare of New Mexico directed the local partner to the state for the information sought on pharmacy denials and noted that most of the information requested “is only available by court order or subpoena.”
  • Lovelace provided an incomplete response, which it supplemented on request. Molina responded quickly that it had no physician incentive plans and referred to the website for its contracted providers. It suggested that the state partner should try to get the information about prescription drugs from the state. Presbyterian Salud Health Plan responded after about four months. It noted that it was not required to provide the information, but provided a copy of the quality incentive program aimed at encouraging physicians not to have prescriptions denied (because of prescribing off formulary or failing to get prior authorization) and a link to the website where the provider directory could be found. It denied having the requested pharmacy information, but offered to discuss whether it could provide other information that might be useful.
• Virginia All five plans contacted, Anthem, Amerigroup, Optima, CareNet, and Premier, eventually responded to the requests and provided information in response to the first two requests, but none provided information in response to the question about pharmacy refusals. Amerigroup’ provider list included the physician specialties requested, but not the providers’ qualifications.
• Washington None of the plans provided the requested information; they either responded that they would only comply with a request made by a particular beneficiary or did not respond at all. Two plans, Columbia United Providers and Community Health Plan of Washington responded promptly that they would not provide the requested information unless made by an individual beneficiary. After being reminded by letter, about two months after the original request, Group Health Cooperative wrote to the state partner to indicate that they would not respond to the requests unless it was made on behalf of a particular enrollee. Also after a reminder, Regence Blue Shield responded to the request made to Asuris Northwest Health, giving a similar response. Molina Healthcare of Washington, the largest Medicaid managed care plan in Washington state by number of members, did not respond. (12)