Staffing shortages present obstacle to new access regs

Under a proposed rule published in May 2011 from the Centers for Medicare & Medicaid Services (CMS), state Medicaid agencies would have to review access to a subset of Medicaid-covered services every year, and review access to every Medicaid-covered service at least once every five years.

This is "well-intended, but couldn't come at a worse time for states," says Stephanie A. Davis, CPA, national practice leader for Mercer's Phoenix-based Government Human Services Consulting division.

States already face severe budget challenges, limited ability to revise eligibility rules, and shortages of the necessary staff to respond to the many new requirements of the Affordable Care Act (ACA), she notes.

"This rule could have the effect of delaying states' abilities to address changing economic situations in a timely manner, because of time-consuming and costly prerequisites for state plan amendment submissions," says Ms. Davis.

Although the proposed rule identifies required components of an access review, determining how a state actually demonstrates access will be a time-consuming challenge, according to Ms. Davis. "For states looking to make changes to their fee-for-service provider rates, it will be one more area to address," she says.

Performing access reviews before making rate reductions may make it difficult for states to manage their program in a timely and effective manner, adds Ms. Davis.

If the rule applies to services delivered through home and community-based programs, this is a large number of services for which there may be no commercial or private access comparisons readily available, she explains. "State resources are stretched thin, and this will tax them even more," Ms. Davis says. "The cost and complexity of the rule may be underestimated."

"Very serious constraints"

Medicaid directors make difficult decisions when the amount of money to do "everything that everyone would like" falls short, says Matt Salo, executive director of the National Association of Medicaid Directors in Washington, DC.

"To a person, they are all dedicated to providing the best health care to the most people possible, with very, very serious constraints," he says. The decision comes down to cutting people off the program, eliminating vital services that clients may rely on, or cutting provider rates, says Mr. Salo, noting that while procedures to monitor access vary by state, every state has these in place.

"What the regs do is say, 'That's not good enough. You have to undertake a very labor-intensive, one-size-fits-all approach to prove to CMS that access is not a problem," says Mr. Salo.

If a state is looking to lower provider rates, "this will probably stop them in their tracks," says Mr. Salo, because it sets out standards that are difficult or impossible to meet. "This may make providers happy because their rates aren't going to get cut. But it doesn't solve the problem of there not being enough money for everything."

Even states that aren't looking to lower reimbursement rates will still be burdened by paperwork and administrative hoops to jump through, according to Mr. Salo. "It will totally siphon away a significant workforce capacity to run the program as it is, to say nothing of trying to implement the ACA that is coming very quickly down the road," he says.

Already-understaffed programs are grappling with eligibility and enrollment systems development, and fraud and abuse prevention, notes Mr. Salo. "When you divert significant resources to do something new, it's like squeezing down a balloon. It will only pop up somewhere else," he says.

Provider groups and beneficiaries are likely to support the CMS draft rule, says Mr. Salo, but this is taking an "ostrich in the sand" approach. "The longer-range strategy by some of them is to say that if we prevent the states from doing anything — changing eligibility, cutting reimbursement rates or getting rid of benefits — then they will be forced to raise taxes to pay for this."

The bottom line, says Mr. Salo, is that Medicaid programs are left with drastic, draconian options to balance their budgets. "State budgets are in trouble now, and are making these decisions now, but 2014 is going to make it worse," he says.

State budgets will not have sufficiently recovered and expenditures will skyrocket, says Mr. Salo, and 30 million people who were previously uninsured will have access to healthcare, either through Medicaid or the exchanges to be set up by states.

"It will no longer be just about whether Medicaid has an access issue, but whether there are enough providers to see all of these people, whether they are in public or private insurance," says Mr. Salo.

The needs of different states vary due to different mixes of managed care and fee-for-service, different systems, and different cultures, says Mr. Salo. "If there are specific states CMS thinks have specific problems with access, deal with them," he says. "Don't set a 'one size fits all' trap that catches all 50 states. That is not helpful."

Contact Ms. Davis at (602) 522-6577 or and Mr. Salo at (202) 403-8621 or