The Medicaid and CHIP Payment and Access Commission (MACPAC) described concerns with major findings highlighted in its March 2020 Report to Congress, released March 13.
The detailed analysis covered Medicaid disproportionate share hospital (DSH) payments that support safety net hospitals, state reporting on the quality of care provided by either Medicaid or the Children’s Health Insurance Program (CHIP), and the timeliness and quality of evaluations of Medicaid demonstrations.
As in previous years, the commission found little meaningful relationship between allotments to Medicaid DSHs and the size of the uninsured population, the extent and sources of hospital uncompensated care, or the number of hospitals with high uncompensated care levels.
MACPAC noted that an upward trend it uncovered for uncompensated care costs should be interpreted cautiously. Hospitals reported $39.9 billion in charity care and bad debt expenses on Medicare cost reports in FY 2017, a 7.4 percent increase from FY 2016. However, because of a recent change in Medicare cost report definitions, MACPAC believes the uncompensated care component of these costs cannot be directly compared with the amount reported prior to the implementation of Accountable Care Act coverage expansions. Other mitigating factors were cited as well.
In terms of mandatory quality measure reporting, MACPAC found more needs to be done to ensure states can report all required quality data for children enrolled in Medicaid and CHIP and behavioral health measures for adults enrolled in Medicaid. The commission identified challenges that include accessing certain data, adhering to the core set of technical specifications and having sufficient administrative capacity. MACPAC found that states will be unable to fully prepare for mandatory reporting until the Centers for Medicare and Medicaid Services (CMS) provides further guidance. In preparation for the FY 2024 implementation of the core set reporting mandate. CMS is considering strategies to address the concerns and challenges that states and plans face. CMS is also considering ways to make core set reporting less burdensome.
Regarding demonstration programs under Section 1115 of the Social Security Act, MACPAC convened an expert roundtable in November 2019 to discuss the challenges states face when monitoring and evaluation are required by the statute. As of January 2020, there were 65 approved Section 1115 demonstrations underway in 47 states, with another 45 demonstration actions pending approval. All states are required to submit a series of evaluations for each demonstration, including an evaluation design, an interim report and a summative report. However, when planning and designing evaluations, states continue to struggle with methodological challenges, such as the determination of comparison groups and data availability. The U.S. Government Accountability Office has repeatedly expressed concerns about the quality of evaluations, the timeliness of public release of evaluation findings and the extent to which evaluations are used for policy decisions.
Evaluation requirements have evolved over the last two decades as Congress and CMS have implemented changes to improve evaluation quality and processes. States and CMS are required to post evaluation findings on their websites, though findings are typically not broadly disseminated. Roundtable participants discussed how wider dissemination of evaluation findings could expand their reach. MACPAC did not identify a need for further legislative or regulatory actions in its report, but it will continue to monitor evaluations and usefulness findings for decision making.
Overall, MACPAC provides policy and data analysis that assist in making recommendations to Congress, Secretary of the Department of Health and Human Services and the states on issues affecting Medicaid and CHIP. It is required by statute to submit reports to Congress by March 15 and June 15 annually.