By Joe Touschner

We’ve all heard the observation that putting a Medicaid or CHIP card in a parent’s hand doesn’t necessarily mean that a child will get all the health care he or she needs–many of us have probably said it ourselves.  For coverage to translate to care, kids and parents need access to the right providers at the right time.  How is your state doing on access for Medicaid beneficiaries?  How would access be affected by changes in the payment rates to providers?  You might find it difficult to answer these questions, since much of the access data we have comes from national sources and the effect of payment rates on access in a given local area is not always clear.  States have not, to date, reported regularly on comprehensive measures of access in Medicaid.  And as the adage suggests, it’s next to impossible to improve performance without measuring the outcomes of interest.

CMS has moved to address the lack of access measures with proposed new guidelines for states that encourage them to measure and analyze access in Medicaid. The proposed rules come in response both to lawsuits from providers challenging state payment rates and to recommendations from the Medicaid and CHIP Payment and Access Commission, which was created in the CHIPRA law and expanded by the ACA.  They build on longstanding federal law that requires that states ensure that medical services are available to Medicaid beneficiaries at least to the extent that they are available to the general population in the same geographic area.  Separate federal laws apply to the availability of services through Medicaid managed care, so these proposed rules apply only to fee-for-service Medicaid beneficiaries.  The proposal states that CMS plans to write additional rules that apply to access to care within managed care.

The proposed rule envisions states undertaking an ongoing process to measure access so that each service (physician visits, dental visits, hospital services, etc) is measured at least once every five years.  When states propose to adjust provider payment rates, an analysis of the effect on access would need to be part of the state plan amendment.  The proposed rule aims to create a consistent national approach to analyzing and documenting access in Medicaid, but it doesn’t establish a single, uniform process for measurement.  Instead, it allows states to develop metrics that reflect their own circumstances and priorities.

This new attention for measuring and maintaining access to care is an important step all by itself.  But in reviewing the proposed rule, a couple of points stood out:  First, CMS strongly suggests that beneficiaries’ experiences of care should be the

“primary determinant” of whether access is sufficient.  That means asking families whether they have difficulty getting an appointment or whether they can find the right specialist–it’s a great way to keep patients at the center of decisions about Medicaid.  Second, the proposed rule expects that states will solicit public comment on both their access measures and in payment policy changes that could impact access.  This improves transparency and gives advocates and families a chance to weigh in on these important decisions.

With the Affordable Care Act, we’re moving closer to universal coverage, including millions of new enrollees in Medicaid.  We’ll need to monitor access issues even more closely to ensure that the possession of a Medicaid card means the right care is available when it’s needed.  These proposed rules represent a solid start in making sure that essential measurement happens.