Tenn. officials say encounter data on five measures show access to care improving under TennCare
TennCare Access
January 31, 1998
5 minutes read
Amid continuing complaints over access problems in the TennCare program, state officials released a report Dec. 30, which they say shows improvement in access to preventive services and ambulatory care.
A key part of the report shows service rates per 1,000 members for five measures—mammography screening, pap smears, well-child visits (for children ages three to six), dental visits and inpatient admissions for people with certain ambulatory-sensitive conditions. The rates are reported by health plan and by region for 1995 and 1996 and statewide for the entire Medicaid population in 1993, the last year of the Medicaid fee-for-service program.
State officials emphasized improvements in the measures from 1995 to 1996.
Four out of five measures showed improvement from 1995 to 1996, according to a press release from the Department of Health. Only the rate of well-child visits did not improve from 1995 to 1996. The rate of well-child visits was for children from ages 3 to 6 only.
However, compared with rates for the Medicaid population in 1993, the year before the managed care program was launched, only three out of five measures showed improvement, according to a report prepared by First Mental Health, Inc., the external quality reviewer.
Dental visits in 1995 and 1996 were below the 1993 level. The rate of pap smears in 1995 was also below the 1993 level. The 1996 rate "approximated" or exceeded the 1993 level, depending on the method used to report performance.
The external reviewer said the lower rate of pap smears compared with 1993 was due to the poor performance of two plans, Prudential and Access Med Plus. Also reporting pap smear rates significantly below 1993 levels for both years were T.L.C and Phoenix. It will have to be determined whether the low rates represent "a true failure to provide services or some problem with data capture at the MCO," the report said. If the lower rates are due to failure to provide service, more outreach may be needed to encourage women to make appointments for screens.
TennCare Medical Director Wendy Long, MD, said TennCare officials have asked Access Med Plus, one of the largest TennCare plans to take corrective action on its pap smear screening rate. She noted that Access Med Plus has capitated its laboratory services, and it’s possible that the move has resulted in underreporting of pap smear screening.
No single plan stood out for either consistently superior or consistently poor results, state officials say. All 12 MCOs demonstrated different strengths and weaknesses.
The state used two methods to examine service rates—HEDIS, the Health Plan Employer Data and Information Set, which is the most widely used tool for measuring health plan performance, and the "member-year" method, the traditional way of examining Medicaid service rates.
Dr. Long said that because of the tendency of Medicaid recipients to move in and out of eligibility, using only HEDIS would not have provided a comprehensive picture. Whereas HEDIS measures take into account only those health plan members who are continuously enrolled for the reporting period with no more than one 45-day break, the member-year method accounts for shorter-term enrollments.
Neither method is better than the other, Dr. Long said. Rather, each offers a different perspective. The important thing, she said, is to be aware of those differences and to be consistent in comparisons.
"The MCOs performed significantly better when we looked only at those enrollees who were continually enrolled for a year," she said. "Under both methodologies, I think the TennCare program appears to be performing well."
While state officials say they have hard data demonstrating improved delivery of services, how much this will sway public opinion and policy remains to be seen. The TennCare Legislative Oversight Committee regularly holds hearings during which providers and consumers bring their complaints before it.
"I was always told that one of the best ways to lie is with numbers," said Iris Snider, MD, president of the Tennessee chapter of the American Academy of Pediatrics. Dr. Snider calls TennCare a "disaster" that has disenchanted providers throughout the state with red tape, mismanagement and "harassment."
Although she hadn’t seen the state’s report, Dr. Snider said she doesn’t believe the program’s operations have improved since TennCare was started and expressed skepticism of the state’s data.
Dr. Long noted that with a program as big as TennCare, which serves 1.2 million people, there are bound to be problems. "Even when you have statistics that show that the program is performing very well, there are going to be certain individuals that are going to have trouble accessing care," she said. "It’s not a perfect program, and some people may be having real bad problems." Anecdotal evidence can be valuable in pinpointing shortcomings, but objective data are what are needed to evaluate the program’s impact, Dr. Long said.
"Under the old Medicaid program, there wasn’t a forum to get some of these stories out," said John Harkey, president of Harkey & Associates, a Nashville-based managed care research and consulting firm. "There is a forum now, and they’re important stories to tell, but I think the data approach is what you really want."
He said he’d have to agree with Dr. Long’s assessment of improved access under the program. "By and large, under TennCare it looks like things were better than under Medicaid, in terms of preventive care," Mr. Harkey remarks.The indicators TennCare officials selected good for their report are a "good start", he said.
"The comparison of Medicaid populations over time is a difficult issue that they seem to have handled fairly well with the two different methods," said Mr. Harkey.
Data collection difficult
Data collection has been a struggle for TennCare, largely because it is difficult to get claims information from capitated environments when providers don’t need to submit claims in order to get paid.
"As we’re seeing the MCOs capitate additional services, there’s this ongoing issue of how they’re going to get these data," Dr. Long said.
One health plan, Phoenix Healthcare Corp., has decided to discontinue capitation of its primary care physicians. D. Mark Mahler, MD, corporate medical director for Phoenix, which has about 160,000 TennCare enrollees, said data collection problems figured heavily in that decision.
Blue Cross/Blue Shield of Tennessee is going in the opposite direction. The insurer is instituting capitation for primary care doctors under its Blue Care plan, whose 500,000 enrollees make it the largest
TennCare plan, and data collection is playing a part in that decision as well. "We’re constantly evaluating different methods in order to enhance the way we’re going to get information when we move into [a capitated] situation," said Jane Havens, manager of clinical effectiveness for Blue Care.
Both Ms. Havens and Dr. Mahler say results from the state’s report cards will help guide their quality improvement efforts. "We have better results than what we did three years ago, but we want to improve on that," Ms. Haven noted.
Dr. Long said more data-driven reports are forthcoming, including studies on pediatric asthma and adult diabetes and a survey of parents with children enrolled in TennCare on their ability to access care. Last spring, TennCare released a study on perinatal services last spring which is available at www.state.tn.us/health/tenncare/
—Mary Darby
Contact Dr. Long at (615)532-9853 and Mr. Harkey at (615)385-4131.
Tenn. officials say encounter data on five measures show access to care improving under TennCare
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