Medicaid Managed Care: Transparency Tips for Advocates

In the world of Medicaid managed care, as Ringo might say, transparency don’t come easy.

That is one take-away from a lawsuit filed earlier this week by the Better Government Association (BGA), which describes itself as “Illinois’ non-partisan full-service watchdog,” against the state’s Medicaid agency, the Department of Healthcare and Family Services (HFS), which runs the fifth largest Medicaid program in the country.   The agency contracts with a Medicaid managed care organization (MCO), Meridian Health Plan, to furnish services to 36,000 current and former foster care youth; over the past 12 months, the agency paid the MCO $210 million under this contract.  Meridian is a subsidiary of Centene, which describes itself as “the largest Medicaid managed care organization in the U.S.”

The short of it is that BGA wants to see the performance data contained in the slide decks that Meridian presents to DHS every quarter describing its compliance with timeliness and quality of care standards in its contract with the agency.  BGA requested the slide decks under the state Freedom of Information Act.  HFS provided the slides but redacted them extensively on grounds that most of the data constituted “trade secrets.” You can see just how extensively here.  BGA then sued HFS in state court, asking for the unredacted slides.

BGA’s experience is troubling but not entirely surprising.  State Medicaid agencies vary considerably in transparency about the performance of individual MCOs for children.  Iowa’s Medicaid agency maintains a child health dashboard with data reflecting the performance of each of the MCOs with which it contracts.  (As it happens, one of these is a Centene subsidiary, Iowa Total Care).  HFS, in contrast, posts a report card that provides star ratings for individual MCOs on, among other dimensions, “keeping kids healthy” (five stars means highest performance, one the lowest).  The ratings are for Cook County only, and HFS does not provide the data on which the ratings are based.  The Kansas Medicaid agency has neither a child health dashboard nor a report card.

In states that operate Medicaid managed care on a non-transparent basis, children and other beneficiaries enrolled in MCOs are at a huge disadvantage. The MCOs are their Medicaid coverage; if they don’t perform, the children don’t receive the services they need. Just as high performance by an MCO should be rewarded,  low performance needs to be identified and improved.  The MCOs, and the state Medicaid agencies that contract with them, know what the data say about each MCO’s performance.  The public does not.  As a result, there is no public pressure on a low-performing MCO to up its game, or on the state Medicaid agency to insist that it do so.  What the public doesn’t know can hurt the kids.

Transparency is doable.  It doesn’t increase administrative burden; MCOs already collect and report performance data to state agencies.  It doesn’t cost money; states (and the federal government) are already paying MCOs to report the data and are already supporting information systems to collect and analyze it.  And it promotes compliance by MCOs with their obligations under their contracts with the state Medicaid agency; if management knows that data on its organization’s performance will be public, it will have an additional incentive to ensure that performance is high.  Similarly, state Medicaid agencies will want to be viewed as successful in contracting only with high-performing MCOs.

CCF has developed an Advocate’s Guide to help child health advocates realize the potential of transparency as a tool for MCO accountability.  The Guide explains why Medicaid MCOs matter for children and pregnant women; what the basic MCO performance requirements are for these populations; and what performance information is, or at least should be, publicly available.  It also includes examples of transparency and suggestions for how advocates can improve transparency in their states.

Of course, not all Medicaid agencies, and not all MCOs, will be receptive to calls for transparency about their performance for children, pregnant women, or other enrollees.  The situation unfolding in Illinois is a case in point.  The Guide does not solve for it; the courts will have to do so.  But to state the obvious, Medicaid is not a trade secret.  It’s a public insurance program; the benefits it offers are entirely paid for with federal and state funds; and the MCOs are stewards of those funds and the health of the children and pregnant women they enroll.  Transparency about their performance should be the norm, not the exception.  The hope here is that the Guide will help some child health advocates solve for that.

Because — wait for it — transparency don’t come easy.


Andy Schneider is a Research Professor at the Georgetown University McCourt School of Public Policy.