GAO report is worrisome,’ according to state official

For Penny Black, the director of home and community services with the Washington Department of Social and Health Services, the GAO report, which is raising questions about quality assurance for Medicaid beneficiaries services by home and community service (HCBS) waivers, is worrisome for its potential impact on the programs, especially when political leaders say future waivers should not be approved until the quality issues are addressed. 

"If that call [by U.S. Sen. Chuck Grassley (R-IA)] to suspend the waivers is followed, it would stop many states in midprogress," Ms. Black tells State Health Watch. "That would be really troublesome."

She says that for states that have a state Medicaid plan, key elements such as licensing of home health agencies already have to be in place and thus it easily can be determined that those states are monitoring quality through licensure requirements.

Sophisticated state program

Ms. Black’s agency maintains a quality program that experts have cited as one of the best in the nation. She refers to it as a "very sophisticated automated assessment process that addresses all aspects of clients’ physical and social needs." A computerized assessment tool can flag high-risk clients and make recommendations for case managers to use in referring clients to needed services.

Algorithms built into the system can determine the hours and levels of care clients are eligible for and then identify choices that clients can make that fit within the eligible care. An automated quality assurance system can be applied against the assessment tool for a sample of the caseload to monitor policy compliance and code compliance. A subset of those audited receive in-person visits to determine if their condition is as it appears to be and whether services have been provided.

"We’ve come a long way in establishing and assuring a certain level of quality in case management," Ms. Black tells State Health Watch. "Case managers work with the providers to be sure they understand the service plan and what they are supposed to do."

She says the automated quality assurance effort started about four years ago and has been operating since 2002. A more sophisticated update is due in 2004.

The state knows the average cost of care in all settings, Ms. Black explains, and has determined that those who are treated in their home have the lowest cost (an average of $750 per month), while those in nursing homes have the highest average per-month cost ($3,600).

Many other state officials and consultants contacted by State Health Watch expressed concern that the GAO was focusing on improper methodology for assessing quality and didn’t give sufficient recognition to what states already have accomplished.

Typical auditor approach

Jim Verdier, policy research analyst with Mathematica in Princeton, NJ, sees the GAO report as demonstrating the "typical GAO auditor perspective in terms of what should be done to ensure better quality in home- and community-based services. They think in terms of inspectors, reviewing documents, and ensuring that services have been provided and documented. I don’t think that’s the way to most effectively assess quality. There’s been a lot of research sponsored by the Centers for Medicare & Medicaid Services [CMS] and others to look at how to measure customer satisfaction and type of services needed."

Mr. Verdier says that customer satisfaction should be an important part of any assessment and can be determined through beneficiary surveys and review of calls to complaint hotlines. He points out that a lot of home-care patients are reluctant to make complaints, so that systems have to be in place to address that problem.

"There’s been a lot of research aimed at ensuring better quality of care," according to Mr. Verdier, "but it was mentioned only in passing at the end of the GAO report. But that’s where the future of quality assurance is."

He acknowledges that inadequate attention has been paid to quality assurance issues, partially because quality is harder to assess when services are provided in the home. Thus, Mr. Verdier says, the GAO has done a significant service in calling attention to the problems that need to be addressed, but is off-target in recommending solutions to the problems.

He says he is skeptical of a call from Mr. Grassley to suspend the waivers until quality programs are tightened.

"Absent the waivers," he says, "people in nursing homes who could be better served in the community might not get services, and those already in the community might not get services. That would be worse than a situation with waivers in which people get the services they need but there may not be the best monitoring in place."

One problem, according to Mr. Verdier, is that many home- and community-based service providers are not always the most organized and oriented to a strong administrative infrastructure to provide the kind of review the GAO would want. "When I was a state Medicaid director, I sometimes wished providers would be better organized and give me better data, but the nature of the business still is that they don’t always invest in administrative structure the way they should," he says.

Mixed reactions

Chuck Milligan, consultant for the Falls Church, VA-based The Lewin Group, says he has mixed reactions to the GAO report, recognizing that it’s useful for GAO to take a look at waivers in programs that are growing rapidly, but also recognizing there has been a "tremendous increase" in quality assurance for home- and community-based services, with tools developed and best practice guides that all seem to have been ignored by the GAO auditors when they did their study. And there is a concern that GAO seems determined to look at the issue from a health care facility licensure model rather than looking into consumer autonomy, independence, and choice. "Many other assessment techniques are being used because of opposition to the licensure form of oversight because it can be intrusive and paternalistic," Mr. Milligan says.

Within the community of those who work in home- and community-based care, he says, there is a movement to accept consumer choice, allowing consumers to take risk with dignity by living in the community.

Mr. Milligan says Sen. Grassley’s call for a moratorium "would be a significant setback. I hope that CMS will keep on top of the issue without suspending waivers."

Milligan agreed with GAO that it is important to delineate roles between the federal government and the states. States, he says, should submit and manage the waiver to incorporate a safety process reached through a consensus with consumers and providers.

"States should carefully think through how they want to exercise oversight," he says. "The federal role, then, should be to monitor that state assurances to consumers are fulfilled. The federal role should not be to impose a predetermined set of oversight measures."

States addressing problems

At the National Academy for State Health Policy in Portland, ME, senior program director Robert Mollica tells State Health Watch that states are addressing some of the weaknesses that GAO pointed out in its report. And CMS identified what he sees as some very realistic limitations on its ability to commit the staff and resources that would be needed to follow the GAO recommendations.

"I didn’t see in the report anything on the impact of what states actually are doing," he says.

The issue of a large number of beneficiaries not getting authorized services is very complicated, according to Mr. Mollica.

He notes that often a worker shortage is a reason for not all patients getting the services they need or want. "If agencies don’t have the workers, they can’t deliver the care. It’s true, however, that the more you invest in quality, the better the system will be."

He notes that consumers often define quality in terms of the control they can exercise over services and their ability to identify the services and providers that meet their preferences. "We need to balance what consumers prefer with what the federal and state agencies are required to ensure," he says. "We should be making sure that people don’t deteriorate because the services they receive are ineffective, that beneficiaries are not put in danger."

Need for federal expectations

John Williams, long-term care financing unit director for the Utah Department of Health in Salt Lake City, and a member of the National Association of State Medicaid Directors’ long-term care technical advisory group, says that, overall, GAO’s observations in the report are pretty factual and on target. "I agree with the CMS response that program performance should be primarily a state responsibility. CMS should set general boundaries within which states can operate their programs. CMS should build the superstructure on which states build their programs. There is a good foundation they could focus with more direct expectations. I’d like to see them go from technical assistance to setting forth expectations."

Mr. Williams says he thinks it is reasonable for CMS to expect states to put a quality assurance plan in their waiver application and renewals and to report on the progress they make toward implementing that plan.

"GAO is correct that CMS has not required the states to report what they are doing about quality," he says. "The report also is on target that there has been a lot of inconsistency from region to region. We’ve told CMS that it can’t work if they don’t have a common regional structure. I think the states and the central office are on the same page and it’s the regions that need to change."

Mr. Williams says that a National Association of State Medicaid Directors quality assurance technical advisory group has polled states on criteria for evaluating progress and heard that the highest priorities were quality-of-life issues. However, they were unable to come up with a way to compare quality-of-life data across states and so see a need to drop back to health-and-safety issues.

Taking quality more seriously

Former Oregon official Roger Auerbach, who now consults with The Lewin Group, says the GAO report signals a commitment by the agency to take quality assurance in waiver programs more seriously than it has in the past.

He says that while the GAO’s recommendations were reasonable, the tone of the report saying that CMS essentially has not been doing anything was not helpful. And, he says, state responses have been substantial since the late 1990s.

Minnesota Medicaid director Mary Kennedy says she found the GAO report "not quite on target," while the CMS response struck her as being quite good. "I don’t think we want to replicate a nursing home type of certification," she says.

She reports that Minnesota has case managers for all beneficiaries with HCBS waivers and that the case managers must develop plans that address their clients’ needs and wishes.

"We hope to improve linking consumer satisfaction data with data on their health needs to be sure those needs are all being addressed," Ms. Kennedy says.

[Contact Ms. Kennedy at (651) 297-7515; Mr. Auerbach at (503) 224-2596; Mr. Williams at (801) 538-6021; Mr. Mollica at (207) 874-6524; Mr. Milligan at 703) 269-5627; Mr. Verdier at (202) 484-4520; and Ms. Black at (360) 725-2311.]