More than 50 million people receive healthcare through state-managed Medicaid programs, but the quality of that care varies widely and receives little federal scrutiny, a government audit has found.
Each state is largely free to set its own standards for care, including the distance a patient travels to see a doctor, the time a patient must wait for an appointment and the patient-to-doctor ratio within certain regions.
As a result, federal officials say they don't know whether a state’s standards “are adequate to ensure access to care.”
While setting standards is a state responsibility, the audit says the federal government should strengthen its oversight and provide more guidance to states about how to run a managed Medicaid program.
Without proper standards, the report warned that “states may not be able to hold plans accountable for ensuring adequate access to care.”
Most states set some limits on accessibility, such as distance and wait time for care.
Officials in 32 states must ensure there is a doctor within a certain distance of all patients, ranging from 5 miles in Arizona to 100 miles in Delaware. Most states also limit the time a patient should wait for an appointment, ranging from 10 days in California and Pennsylvania to 60 days in Massachusetts.
State leaders test their standards differently, and sometimes inadequately, which the audit cautioned could mean that they are “unable to correct problems to improve care.”
Most states rely on information reported to them by insurance companies hired to oversee the care, which the audit said makes it harder to identify problems. Only eight states conducted outside assessments such as “secret shopper” phone calls to doctor’s offices.
The Centers for Medicaid & Medicare Services (CMS), which oversees the Medicaid programs, largely concurred with the recommendations and in some cases agreed to deepen its efforts.
An official from CMS said the agency is weighing options to better communicate the federal standards and plans to address this issue “through the development of additional guidance to states.”