Improving Quality Care to Vulnerable Populations

The Department of Health and Human Services (HHS) and its agency, the Centers for Medicaid & Medicare Services (CMS) have taken steps to improve quality of and access to health care for vulnerable populations, but gaps remain.

• Nationally representative data suggest that a large proportion of children and adults in Medicaid have certain health conditions, particularly obesity, that can be identified or managed by preventive services, and adults’ receipt of preventive services varies widely. For children in Medicaid, who generally are entitled to coverage of comprehensive health screenings, including well-child check ups, as part of the federally required Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, most but not all states reported they monitored or set goals related to children’s utilization of preventive services and had undertaken initiatives to promote their provision. For adults in Medicaid, for whom states’ Medicaid coverage of preventive services is generally not required, most states reported that they covered most but not all of eight recommended preventive services that GAO reviewed. For children in Medicaid, CMS oversees the provision of preventive services through state EPSDT reports and reviews of EPSDT programs, but gaps in oversight remain; for adults, oversight is more limited.
  

  Highlights of GAO-09-578 (PDF)

• National representative data suggest that almost one-quarter of families with Medicaid and CHIP children who needed specialty care reported problems accessing that care. Additionally, the two required summary reports that states provide annually to CMS—the Early and Periodic Screening, Diagnostic and Treatment report (also known as CMS 416 reports) and the CHIP annual report—are of limited use for monitoring the provision of services to children in Medicaid and CHIP due to reporting errors, missing information, and lack of detail. For both the CMS 416 and the CHIP annual reports, we found missing information, such as states not reporting required information on the number of children in Medicaid referred for additional services, which resulted in gaps in information on children’s access. Both annual reports also lack the detail necessary to assess children’s access to care by the two delivery and financing models through which states generally provide Medicaid and CHIP services, that is, the information needed to monitor services provided to children in managed care versus services provided in fee-for-service systems.
  

  Full Report of GAO-11-293R (PDF)

• Medicaid and CHIP play a critical role in addressing the health care needs of children. Access to health care for children in Medicaid and CHIP is affected, in part, by the number of physicians who are participating—that is, who are not only enrolled in state Medicaid and CHIP programs, but also providing services to these children. According to our 2010 national survey of physicians, more than three-quarters of primary and specialty care physicians are enrolled as Medicaid and CHIP providers and serving children in those programs. However, nationwide, physicians participating in Medicaid and CHIP are generally more willing to accept privately insured children as new patients than Medicaid and CHIP children. Physicians also reported experiencing much greater difficulty referring children in Medicaid and CHIP to specialty care, compared to privately insured children. Nonparticipating physicians most commonly cite administrative issues such as low and delayed reimbursement and provider enrollment requirements as limiting their willingness to serve children in these programs.

  Highlights of GAO-11-624 (PDF)

• Although Medicaid’s health care coverage includes dental care, many of the 30 million low-income children enrolled experience difficulty finding a dentist to treat them. Almost all states described initiatives to improve access to dental services, such as simplifying claims processing and increasing reimbursement rates, but access rates remain low and states reported that long-standing barriers hinder further improvement. CMS has taken steps to strengthen its oversight of Medicaid dental services for children, including reviewing provision of services in 17 states, establishing guidance on dental policy, and facilitating collaboration among stakeholders. However, CMS did not plan to perform more reviews at the time we evaluated their efforts, even though other states had utilization rates well below HHS’s 2010 target for low-income children receiving a preventive dental service. States also reported needing more CMS support, including guidance on setting dental payment rates, on quality initiatives, and on promoting outreach.
  

  Highlights of GAO-09-723 (PDF), Full report of GAO-10-112T

• Access to health care services for American Indians and Alaska Natives has been a long-standing concern. The Indian Health Service (IHS), an agency within the Department of Health and Human Services (HHS), is charged with providing health care to the approximately 1.9 million American Indians and Alaska Natives who are members or descendants of federally recognized tribes. When care at an IHS-funded facility is unavailable, IHS’s contract health services (CHS) program pays for care from external providers if the patient meets certain requirements and funding is available. To examine program funding needs, IHS collects data on unfunded services—services for which funding was not available—from the federal and tribal CHS programs. However, due to deficiencies in IHS’s oversight of data collection, the data on unfunded services that IHS uses to estimate these needs were incomplete and inconsistent. In November 2010, IHS created a workgroup to examine weaknesses in its current data and explore other sources of data to estimate need. As of September 2011, IHS was continuing to develop a new method to estimate need. Additionally, external providers that GAO interviewed noted challenges receiving communications from IHS about CHS policies and procedures related to payment.

  Highlights of GAO-11-767 (PDF)

• The greater New Orleans area--Jefferson, Orleans, Plaquemines, and St. Bernard parishes--continues to face challenges in restoring health care services disrupted by Hurricane Katrina in August 2005, including primary care and mental health services to low-income populations.
• Following the hurricane and the subsequent flooding, the hospitals and clinics that this area’s low-income population relied on as its main source of primary care closed because of the significant damage they had sustained. Although provider organizations were able to reopen some health care clinics, gaps remained in the availability of health care services in the greater New Orleans area. In 2007, HHS awarded the $100 million Primary Care Access and Stabilization Grant (PCASG) to Louisiana to help restore primary care services to the low-income population. PCASG fund recipients reported that they used these funds to hire or retain health care providers and other staff, add primary care services, and open new sites. Despite efforts to restore access to primary care services, PCASG fund recipients continue to face significant challenges in hiring and retaining staff and referring patients to other providers, and these challenges have grown since Hurricane Katrina.
  

  Highlights of GAO-09-588 (PDF), Highlights of GAO-10-273T

• As a result of the hurricane and its aftermath, many children experienced psychological trauma, which can have long-lasting effects. Stakeholder organizations most frequently identified a lack of mental health providers and sustainability of funding as barriers to providing mental health services to children in the greater New Orleans area; they most frequently identified a lack of transportation, competing family priorities, and concern regarding stigma as barriers to families’ obtaining services for children. A range of federal programs, including grant programs, address some of the most frequently identified barriers to providing and obtaining mental health services for children, but much of the funding they have supplied is temporary.
  

  Highlights of GAO-09-563 (PDF), Full report of GAO-09-935T

• The nation's 1.4 million nursing home residents are a highly vulnerable population of elderly and disabled individuals. The federal government plays a key role in ensuring that they receive appropriate care by setting quality requirements that nursing homes must meet to participate in the Medicare and Medicaid programs. CMS's oversight of the quality of nursing home care has increased significantly in recent years, but several CMS initiatives — including its enforcement policy against homes that do not meet federal requirements — require refinement. Furthermore, CMS's management of nursing home enforcement is hampered by its fragmented and incomplete enforcement data system and a policy that allows some homes with the worst compliance histories to escape immediate sanctions. In addition, while CMS can temporarily take over management of a nursing home instead of terminating it from participating in Medicare and Medicaid when nursing homes place residents at risk of death or serious injury or at widespread risk of actual harm, this authority is rarely used. Officials from 46 states and seven CMS regional offices identified several obstacles to using federal temporary management, including time constraints, a lack of qualified temporary managers, and inadequate funding to pay for a temporary manager. GAO has found that CMS’s oversight of state survey agencies’ complaint investigation processes, through its performance standards system and complaints database, is hampered by data reliability issues. Performance measures are also not always reliable, due in part to inadequate sample sizes and inconsistent interpretation of some standards by CMS reviewers.
  

  Highlights of GAO-07-241 (PDF), Full report of GAO-10-37R, Highlights of GAO-10-70, Highlights of GAO-11-280

• Similarly, allegations about quality of care problems have raised questions about the oversight of long-term care hospitals (LTCH), which provide care to individuals with multiple acute or chronic conditions. Medicare pays for about 80 percent of patients admitted to LTCHs. CMS collects some data on the quality of care at LTCHs, but the data are limited. For example, CMS does not currently collect data on quality measures—information used to evaluate how health care is delivered—from LTCHs because, unlike other types of hospitals, LTCHs are not yet required to report them. Additionally, CMS’s oversight of state survey agency and LTCH accrediting organizations survey activities is limited.
  

  Highlights of GAO-11-810 (PDF)

^ Back to topWhat Needs to Be Done

To improve access to medical and dental services for Medicaid and CHIP beneficiaries, CMS should

• ensure that state EPSDT programs are regularly reviewed and expedite its efforts to provide guidance to states on coverage of obesity-related services for Medicaid children, and consider the need to provide similar guidance regarding coverage of obesity screening and counseling, and other recommended services, for adults.
  

  Highlights of GAO-09-578 (PDF)

• establish a plan, with goals and time frames, to review the accuracy and completeness of information reported on the CMS 416 and CHIP annual reports and ensure that identified problems are corrected; and,
• work with states to identify additional improvements that could be made to the CMS 416 and CHIP annual reports, including options for reporting on the receipt of services separately for children in managed care and fee-for-service delivery models, while minimizing reporting burden, and for capturing information on the CMS 416 relating to children’s receipt of treatment services for which they are referred.
  

  Full Report of GAO-11-293R (PDF)

• develop a plan to review dental services in states with low utilization rates, ensure that states found to have inadequate managed care provider networks strengthen their networks, develop additional guidance, and identify ways to improve sharing of promising practices among states.
  

  Highlights of GAO-09-723 (PDF)

Action should be taken by CMS to strengthen federal oversight of the safety and care of patients. Specifically, CMS should

• improve its monitoring of nursing homes with records of serious care problems by addressing state agency and nursing home surveyor issues related to CMS’s survey methodology and guidance, workforce shortages and insufficient training, inconsistencies in the focus and frequency of the supervisory review of deficiencies, and external pressure from the nursing home industry.
  

  Highlights of GAO-10-70 (PDF), Highlights of GAO-07-373

• strengthen oversight of complaint investigations, such as improving the reliability of its complaints database and clarify guidance for its state performance standards to assure more consistent interpretation.
  

  Highlights of GAO-11-280 (PDF)

• create and maintain lists of qualified temporary managers; develop information that identifies best practices such as when and how to use the sanction; and develop guidance for states to help ensure the longer-term compliance of homes that have undergone temporary management.
  

  Highlights of GAO-10-37R (PDF)

• strengthen its oversight of LTCHs by improving available data on quality of care and by improving oversight of LTCH survey activities.
  

  Highlights of GAO-11-810 (PDF)

Additionally, to develop more accurate data for estimating the funds needed for the CHS program and improving IHS oversight, HHS should direct IHS to ensure funded services data are accurately recorded, CHS program funds managment is improved, and provider communication is enhanced.

Highlights of GAO-11-767 (PDF)

^ Back to topKey Reports

Budget and Spending

Nursing Homes

Nursing Homes

Nursing Homes

Nursing Homes

Medicaid

Medicaid Preventive Services

Medicaid and CHIP

Medicaid and CHIP

Long-Term Care Hospitals

Indian Health Service

Hurricane Katrina

Hurricane Katrina

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