Community Catalyst recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) around proposed regulations that make sweeping updates to Medicaid Managed Care. This important opportunity helps ensure that millions of low-income Americans have a positive experience with their health care, especially as states are shifting more and more Medicaid beneficiaries towards managed care. Over half of all Medicaid beneficiaries nationwide receive most or all of their care from managed care organizations. A major focus in Community Catalyst’s comments was urging CMS to be aggressive in reducing health disparities. Our recommendations around anti-discrimination, network adequacy, quality of care and cultural competency seek to ensure that the inclusion and considerations of vulnerable populations are interwoven throughout the new regulations. By maintaining this focus, we can start to reduce health disparities and achieve our vision of health equity, in which everyone has a fair opportunity to reach their full health potential.
Anti-Discrimination. Medicaid primarily serves low-income individuals and families that often include people with multiple chronic conditions, substance use disorders and/or behavioral health issues, and are disproportionately from communities of color. Any changes to the delivery of care for this group must take into account their needs and potential barriers to their care. To that end:
- We applaud CMS for adding sex, sexual orientation and gender identity as protected categories. Adding these protections will help eliminate some barriers to accessing care by prohibiting discriminatory plan practices or treatment avoidance due to perceived discrimination.
- We applaud CMS for adding disability as a protected category. Medicaid beneficiaries with disabilities are increasingly enrolled in managed care, and the protections outlined will help eliminate common challenges they face (e.g. lack of accessible information and services, discrimination in enrollment and difficulty navigating managed care).
- We support revising the Institutions for Mental Disease (IMD) payment exclusion, but believe this proposal could be strengthened. The proposal to lift the exclusion of short-term (15 day) stays in IMD facilities is still not sufficient to support the medical needs of people with substance use disorders. CMS should authorize clinically appropriate lengths of stay for crisis residential services as opposed to time-limited stays.
Network Adequacy. Medicaid coverage alone does not guarantee access to health care. It is important that managed care beneficiaries have access to a sufficient number of all the types of providers and services promised to them in order to manage their health. Community Catalyst urges CMS to require states and health plans to guarantee network adequacy, particularly by:
- Setting stronger, more specific network adequacy standards – Time and distance, appointment wait times, etc. – especially for rural areas, where provider access may be limited. Stronger network adequacy can address significant disparities faced by rural Americans, who are more likely to be older, lower income, living with disabilities and less healthy compared to urban and suburban populations; and
- Including more types of Essential Community Providers (ECPs), as many of them have experience providing care for vulnerable populations.
Quality of Care. Driving the reduction of disparities and improving experience of care will require careful consideration of the populations being served, both through data collection and delivery of care. We recommend that CMS:
- Improve data collection and reporting to include data stratified by race, ethnicity, primary language, gender identity, and sexual orientation. These data are vital for measuring success and for creating a long-term plan to improve health care quality for populations experiencing disparities.
- Improve provider-patient interactions by incorporating tools to assess, manage, and reduce implicit biases among health care providers. Such actions could reduce health disparities by improving the quality of care experienced by beneficiaries of color. Implicit biases may also manifest themselves in areas besides race and ethnicity, such as gender and age.
Cultural and Linguistic Competency. Patients with limited English proficiency are more likely to skip or delay needed medical care and receive lower quality care. Too often, younger family members are enlisted to act as interpreters in medical settings, increasing the risk of miscommunication and medical errors. Removing language barriers between patients and providers (e.g. through access to trained medical interpreters) is a critical step in eliminating disparities in quality of care. We recommend that CMS require:
- Uniform provider directories accessible in a variety of languages that include information on whether providers are accepting new patients, the language spoken by each provider, physical accessibility of the provider’s facilities, etc.
- Free language access services available for all languages spoken by the lesser of 5percent of the enrollee population or 500 beneficiaries
- Requiring managed care entities to offer services that ensure physical accessibility and culturally appropriate services for enrollees with disabilities
Although it is too soon to know how CMS will ultimately “makeover” Medicaid managed care, Community Catalyst feels confident that its recommendations will help advance health equity while transforming our health care system.
Community Catalyst Health Equity Team