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Transcript for audio podcast: Oversight of Quality of Care in Medicaid Home and Community-based Services Waiver Programs

From the Office of Inspector General of Department of Health and Human Services

http://www.oig.hhs.gov

Roberta Baskin, Director of Media Communications, sits down with Meridith Seife, Deputy Regional Inspector General for the Office of Evaluation and Inspections in Washington DC to discuss the recent report Quality of Care Oversight in Medicaid Waiver Programs.

[Roberta Baskin] I'm Roberta Baskin, the Director of Media Communications, speaking with Meridith Seife, a Deputy Regional Inspector General for the Office of Evaluation and Inspections. And we're talking about a report called Quality of Care Oversight in Medicaid Waiver Programs. So first Meridith tell me a bit about home and community-based services? How has Medicaid funding of these services changed over time?

[Meridith Seife] Well, there's been a huge shift in how long-term care services are provided in Medicaid. A decade ago, States would provide the vast majority of care in nursing homes. And, nowadays, States are providing more and more care in individuals' homes and other community settings.

This type of care is most commonly provided through what's known as a waiver program.

[Roberta Baskin] What prompted you to focus on the quality of care in waiver programs?

[Meridith Seife] Well, these programs primarily serve the elderly and the disabled - people who are among Medicaid's most vulnerable populations. And the very nature of the programs puts them at risk of receiving inadequate care. Most programs allow beneficiaries to be cared for by nonprofessionals without medical training.

And, what's more, beneficiaries receiving care in their homes are often alone and isolated from observers who might detect abuse or mistreatment. This is very different from the situation in nursing homes, where there are a lot of people who can detect and report potential abuse.

[Roberta Baskin] How do States, and the Centers for Medicare and Medicaid (also known as CMS), make sure that individuals get adequate care in these waiver programs?

[Meridith Seife] When States develop a waiver program, they have to abide by certain Federal regulations, known as assurances. We evaluated the three assurances related to quality of care. These assurances require that each State provide beneficiaries with an adequate plan of care, qualified providers, and the necessary safeguards to protect their health and welfare.

Beginning in 2004, CMS developed a new process for ensuring that States meet these requirements. States now develop their own systems to ensure the quality of their programs. And, CMS evaluates the States every 3 to 5 years to make sure that those monitoring systems are working properly. Our report is the first national evaluation of this new quality review process.

[Roberta Baskin] And, what did you find in your review?

[Meridith Seife] Well, we went through the data that CMS collected, and we saw that CMS was aware of a lot of significant problems. CMS's data showed that 7 of the 25 States we reviewed did not have adequate systems in place to ensure the quality of care.

[Roberta Baskin] What were the most common problems?

[Meridith Seife] The most common problem we uncovered had to do with the how States' monitored beneficiaries' plans of care. For example, one State didn't have any monitoring system at all. Others had systems in place, but weren't fixing the problems that were found.

Another issue was how States made sure that caregivers were qualified. Several States didn't ensure that the providers had the proper training before starting work. And two States didn't even perform criminal background checks before letting caregivers go into patients' homes.

Finally, some States weren't keeping track of instances of alleged abuse and neglect by a caregiver.

[Roberta Baskin] Those sound like significant problems. What steps did CMS take to correct them?

[Meridith Seife] Well, 4 of the 7 States with significant problems corrected them. However, that leaves three States that did not adequately address these problems - sometimes even years after they were first uncovered.

[Roberta Baskin] Can CMS require States to fix the serious problems?

[Meridith Seife] CMS has relatively few tools to compel States to fix significant problems.

At the same time, we found that CMS often didn't use the few tools that it did have to compel States to fix problems. For example, it did not always require failing States to develop corrective action plans, which is a useful tool that requires States to complete certain actions within specific timeframes.

[Roberta Baskin] So, what is OIG recommending that CMS do to address these issues?

We recommend that CMS provide additional guidance to States to help them meet requirements, and that CMS develop corrective action plans for States that fail to meet all requirements.

We also recommend that CMS develop new approaches to address the continual failure of some States to meet requirements, like either halting new enrollment or withholding a portion of Federal funding.

[Roberta Baskin] Meridith Seife, for the Office of Evaluation and Inspections. Thank you for sharing this important work on Quality of Care Oversight in Medicaid Waiver Programs.

[Meridith Seife] Thank you Roberta.

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