Medicaid Managed Care Transparency: Advocacy Around External Quality Review Reports

As anyone who cares about children’s health knows, it is important to know how Medicaid managed care organizations (MCOs) are performing for the children enrolled in their plans. Access to quality data on a plan-specific basis is a vital part of determining which plans are doing the job well and which plans are falling short. We can only hold MCOs accountable when we know whether or not the enrolled children are getting their immunizations, well-child visits and other important care and treatment.

A new report out from the National Health Law Program’s (NHeLP) David Machledt offers an in-depth look at how the external quality review process can increase managed care transparency around these quality measures and serve as a tool for advocates seeking to improve managed care performance for children.

External Quality Review (EQR) is a mandatory yearly process in which the state Medicaid agency contracts with an independent organization known as an External Quality Review Organization (EQRO) to review and validate the performance of its managed care entities. The state Medicaid agency must post the Annual Technical Report that summarizes the EQRO’s findings. Under the 2016 Medicaid managed care regulations, the report must include:

  • An analysis of how each plan is doing with regards to quality, timeliness, and access;
  • Recommendations for each plan to improve the accessibility and quality of services;
  • A summary of the extent to which each plan implemented the quality improvement projects recommended in the previous year; and
  • Comparisons of performance between plans.

There is a lot of promise in this process. Machledt explains that, “Comparable data, when publicly available, promotes accountability and allows individuals to critically evaluate care quality across plans and over time. It also makes it easier for plans to share best practices.” Further, he shows how some states even leverage the EQR process to measure health disparities and address health inequities. Michigan’s requirement that the reviewing organization include performance results broken out by race and ethnicity revealed that White and Asian women enrolled in Medicaid were more likely to receive postpartum care than their African American counterparts.

Sounds like a great place to get started pushing for better plan performance and health equity, right? Unfortunately, Machledt’s investigation shows that not all states post their Annual Technical Reports in a timely manner or on an easily accessible page on the Medicaid agency’s website. The data, when it is made available, is most often not from the current year due to contract timing and quality reporting conventions. Further, because state agencies decide which quality measures the EQRO has to validate, there is wide variation in the number and type of performance measures included in their reports. Michigan is a ahead of the curve as it is the only state we know of that requires data to be reported by race and ethnicity.

Machledt’s findings are consistent with our observations. We’ve been reviewing state websites and collecting information about MCOs, with an eye towards their performance for kids. We read through the Annual Technical Reports for child-specific quality measures using the Child Core Set as our guide. Some reports are comprehensive and offer results on performance measures beyond the ones included in the Child Core Set. Pennsylvania reports state-specific performance measures, in addition to measures from the Child Core Set. Others are sparse, presenting less than a handful of measures and none that are particularly useful to assessing MCO performance for kids; Missouri presented only one measure related to kids for 2018. In Iowa, we found their annual report presented 22 child-specific quality measures but only for one of the state’s two MCOs  (the other MCO did not begin participating in the Iowa Medicaid program in time for review).

The federal government pays a 75 percent match to help defray the state costs for EQRO reviews. But, based on our findings, and Machledt’s report, most states do not fully capitalize on this cost-effective tool. CMS and state agencies could ask more of the organizations when it comes to performance data, especially data for kids. The EQR report is an essential part of oversight and accountability but it can only be of value if it’s done well. Until then, we will continue to be left in the dark on how MCOs are serving kids.