Transparency has long been one of the key mantras of health care reform in the U.S. In the run-up to the Affordable Care Act, President Obama promised that reform would bring “new transparency requirements and a ‘star rating’ system,” to give consumers information related to quality and cost, much as online websites like Kayak enable consumers to compare different travel options. Such transparency, many experts have argued, not only enables consumers to make better choices, but also stimulates competition and performance improvement among all providers.
Across the country, tangible progress has been made, at least with respect to quality of care. Now, most U.S. consumers can obtain performance scores on their local hospitals, nursing homes, and medical groups online through the Centers for Medicare and Medicaid Services. Many states also offer publicly available report cards for commercial medical groups. Some regions of the country even provide performance data at the level of individual clinicians for high-risk conditions like heart disease.
Ironically, however, the Medicaid sector has lagged in the transparency movement, even as Medicaid enrollment has grown to include one in five Americans. Despite the fact that Medicaid is a tax-payer funded program administered by state governments, few regions of the country make quality scores for Medicaid providers publicly available.
Transparency Challenges In Medicaid
There are valid reasons for the slow progress in advancing transparency among Medicaid providers. For one, safety-net providers may have less sophisticated health information technology systems than private providers, making accurate quality measurement logistically challenging. Additionally, quality metrics were developed with middle-class populations in mind, and some existing measures may be sub-optimal for safety-net patients. Another concern is that the safety-net suffers from a shortage of health care providers, and some stakeholders fear that additional pressures to deliver high quality care for challenging populations might serve as a deterrent to working in vulnerable communities, potentially worsening provider shortages.
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But perhaps the most compelling cause for caution in the Medicaid program is simply that transparency efforts in the commercial and Medicare sector have been bumpy. In a 2015 piece, physician-writer Lisa Rosenbaum articulated the challenges, including “notoriously inaccurate” data from electronic health records; the difficulty of obtaining sufficient data on individual doctors or small clinics to draw meaningful conclusions; and, the challenges of risk adjustment for different populations. As a result, some have questioned whether transparency for commercial and Medicare populations has resulted in the anticipated benefits.
We acknowledge these important concerns, but as a primary care physician and a health care journalist whose professional preoccupations revolve around the safety-net, we have seen first-hand that meaningful quality variation among safety-net providers exists. Whereas some safety-net groups provide high quality, reliable service, others are bureaucratic, inaccessible, and ineffective. A small but not insignificant percentage are even guilty of criminal negligence. Though imperfect, public reporting of performance scores is the first step in creating accountability among safety-net providers.
Medicaid Leaders Urge A Cautious Approach To Public Reporting
To gain insights on safety-net provider views about transparency, our teams at the Gehr Center for Health Systems Science and the Center for Health Journalism at the University of Southern California embarked on a year-long effort, interviewing key Medicaid stakeholders throughout Los Angeles County, which serves 3.9 million Medicaid recipients. As part of this initiative, we spoke with leaders of the two major Medicaid health plans, as well as dozens of Medicaid provider groups and networks.
A number of the Medicaid leaders we interviewed spoke passionately about the need for transparency. However, when we asked whether Los Angeles County Medicaid providers were ready to make their quality scores public, none felt that the time was right. Leaders’ comments echoed the above-listed concerns, including that existing metrics are not appropriate for safety-net populations; that their electronic record systems are not sophisticated enough for accurate reporting; and that social challenges among low-income patients create barriers to high-quality care.
The director of the California Department of Health Care Services, which oversees the state’s Medicaid program, confirmed that there is no state-sponsored report card for Medicaid providers, analogous to the one available for commercial providers. She also told us the state does not have plans to develop one. Similarly, we found that most other states do not offer public Medicaid provider scorecards, though many states, including California, do offer public scorecards for Medicaid at the aggregated health plan level. (One notable exception is Massachusetts, where an independent non-profit called Massachusetts Health Quality Partners, publicly reports patient experience scores for Medicaid providers in collaboration with the medical community.)
Time For Policy Change
In reflecting on these responses, we have come to believe that policy changes are needed to advance transparency in the safety net. While it will take time and innovation to overcome the important challenges with public quality reporting, these surmountable challenges should not impede progress. It is time to set a specific, near-term target for Medicaid providers to provide the same level of public accountability as commercial and Medicare currently do.
First, and most importantly, we believe that state governments, as well as the Centers for Medicare and Medicaid (CMS), should develop a mandate for Medicaid health plans to publicly report the performance of their contracted provider groups within a three-year timeframe. This will ensure that all groups will be subject to uniform requirements and reporting standards, while providing adequate time for Medicaid providers to prepare for increased scrutiny.
Second, CMS should work with leading quality organizations, such as the National Committee for Quality Assurance (NCQA), to develop a standard performance reporting tool for Medicaid, analogous to the tools used for Medicare and commercial populations. There should be significant overlap among the Medicaid tool and the Medicare and commercial tools to ensure that all providers are held to similar standards, though some modifications may be appropriate to accommodate the unique needs of safety-net patients.
Third, though many safety-net providers now use standard electronic health records, safety-net providers may require technical assistance to support their documentation processes. More resources will likely be necessary to help safety-net providers document more effectively the care they deliver, both for clinical and reporting purposes.
It would be hard to argue that our health care system has achieved President Obama’s vision for a Kayak-like system for comparing health care providers. Still, public reporting among commercial and Medicare groups has created greater accountability in these sectors, and it is time for the tax-payer funded Medicaid sector to follow suit. Low-income populations deserve the same information at their disposal as wealthier ones in making health care decisions for themselves and their families.
Date: December 19, 2018