Federal Oversight of State Medicaid Waivers Lacking, General Accounting Office Says
Although the Bush administration maintains that it has increased the number of Medicaid waivers it approves, it has "not fully complied with the statutory and regulatory requirements" to monitor quality of care after states implement the waivers, according to a report released yesterday by the General Accounting Office, the New York Times reports. Waivers allow states to circumvent some federal regulations and have "broad discretion" to "tailor services to individual patients," the Times reports. For example, states can cover services in select regions or limit the number of beneficiaries eligible for services -- actions not normally permitted under federal Medicaid rules, according to the Times. The study, requested by Sens. Charles Grassley (R-Iowa) and John Breaux (D-La.), examined waivers that allow 15 states to cover home- and community-based care, such as therapy and assistance for essential activities, for 266,700 elderly Medicaid beneficiaries. Congress authorized home and community care in 1981 as an alternative to institutional care for elderly Medicaid beneficiaries, and since 1992, the number of beneficiaries receiving such care under waivers has tripled. Medicaid spending on such care has increased from less than $2 billion in 1992 to $15 billion in 2002, according to the Times. The GAO found problems with the quality of care in 11 of the 15 state waiver programs it examined, including failure to provide necessary services to beneficiaries. In addition, the GAO cited "medical and physical neglect" of some Medicaid beneficiaries in some cases but said that the "full extent" of the situation is unknown because "no one was enforcing basic safety and hygiene standards or systematically reviewing patients' records," the Times reports. The report also noted that several states, including Hawaii, Idaho, Iowa, Louisiana, Missouri, New Mexico, Oklahoma and Texas, have not undergone a federal quality of care review for more than a decade. Further, the study says that the federal government has renewed many waivers, which generally are in effect for three years and then can be extended, without ensuring that states employ measures to guarantee beneficiaries' health and well-being, as required by federal law.
Sara Rosenbaum, a George Washington University professor of health law and policy, said, "States prepare good plans of care for Medicaid recipients, but there's no follow-through to see if people get the care. States assume that home and community care will save money, without realizing that it takes real money to monitor the quality of care." Grassley said, "These waivers should be put on hold until the department gets a handle on the quality of care going to older and disabled Americans. Right now, there's no accountability, and that's wrong." In a letter to HHS Secretary Tommy Thompson, Grassley and Breaux requested that the Bush administration submit a detailed plan to correct the state waiver problems by July 28. CMS Administrator Tom Scully said he was "not aware of the extent" of the waiver deficiencies but added that states are responsible for "quality assurance" of such programs, the Times reports. Scully said that federal enforcement of quality of care provided under each waiver would cost "millions of dollars," according to the Times. Further, such investigations would require hundreds of additional federal employees, Scully said, adding that federal inspectors "should not be marching through private homes to evaluate care." Maureen Booth, a University of Southern Maine health policy expert, added, "The beauty of home and community care is that it's flexible, it responds to the needs of individual patients with a cadre of support workers. But to improve quality, you have to reach a whole myriad of workers employed by multiple agencies" (Pear, New York Times, 7/7).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.