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Report
Criticizes Federal Oversight of State Medicaid
By ROBERT PEAR
WASHINGTON
- The Bush administration has allowed states to make vast changes in
Medicaid but has not held them accountable for the quality of care they
provide to poor elderly and disabled people, Congressional investigators
said today. The
administration often boasts that it has approved record numbers of Medicaid
waivers, which exempt states from some federal regulations and give them
broad discretion to decide who gets what services. But
the investigators, from the General Accounting Office, said the secretary of
health and human services, Tommy G. Thompson, had "not fully complied
with the statutory and regulatory requirements" to monitor the quality
of care under such waivers. The
accounting office examined 15 of the largest waivers, covering services to
266,700 elderly people in 15 states and found problems with the quality of
care in 11 of the programs. In many cases, Medicaid beneficiaries simply did
not receive the services they were supposed to receive. The
Medicaid beneficiaries were all eligible for nursing-home care but chose to
stay in the community with friends and relatives. Rather than pay the high
cost of institutional care, the states promised to provide a wide range of
social and medical services known as home and community-based care. The
General Accounting Office said, however, that the states often failed to
provide those services and that the federal Department of Health and Human
Services took no action to protect patients. The
federal government and the states spent more than $258 billion on Medicaid
last year, with the federal share accounting for 57 percent. Thomas
A. Scully, administrator of the federal Centers for Medicare and Medicaid
Services, said in an interview that he was "not aware of the extent of
the problem." In
written comments included in the report, Mr. Scully said states were
responsible for "quality assurance." For the federal government to
review the quality of care provided under every waiver, he said, would
require a new investment of millions of dollars and hundreds of additional
federal employees. In any event, he said, federal inspectors should not be
marching through private homes to evaluate care. The
study was requested by Senators Charles E. Grassley, Republican of Iowa, and
John B. Breaux, Democrat of Louisiana. They favor home and community care as
an option under Medicaid, but expressed alarm at the findings in the report. "These
waivers should be put on hold until the department gets a handle on the
quality of care going to older and disabled Americans," said Mr.
Grassley, the chairman of the Senate Finance Committee. "Right now
there's no accountability, and that's wrong." In
a letter to Secretary Thompson, the senators asked the Bush administration
to submit a detailed plan for corrective action by July 28. The
effect of a waiver is to exempt a state from certain provisions of federal
law and regulations. Waivers allow states to provide services in selected
geographic areas or to specific populations and to limit the number of
people served or the total spent, actions not usually allowed under the
Medicaid statute. For
years, Medicaid favored institutional care. Congress authorized home and
community care as an alternative in 1981. Since
1992, the number of Medicaid beneficiaries receiving such care under federal
waivers has tripled, to 800,000, and it is expected to continue growing.
With waivers, states can tailor services to individual patients, including
those with Alzheimer's disease, traumatic brain injuries, mental retardation
and AIDS. More
than half the people receiving home and community care under Medicaid
waivers are 65 or older. They receive all sorts of therapy, as well as
assistance with bathing, dressing, shopping and other essential activities
they cannot perform themselves. In some states, the patients direct their
own care, by hiring and training their own workers. Medicaid
spending on such care soared to $15 billion last year, from less than $2
billion in 1992. As
former governors, President Bush and Mr. Thompson have repeatedly said they
want to give states more control over Medicaid by speeding the approval of
federal waivers. Sara Rosenbaum, a
professor of health law and policy at George Washington University, 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." The Congressional
investigators found "medical and physical neglect" of some
Medicaid recipients. But they said the full extent of such problems was
unknown, because no one was enforcing basic safety and hygiene standards or
systematically reviewing patients' records. More than a dozen
state waiver programs covering tens of thousands of people have gone more
than a decade without any federal review of the quality of care, the
accounting office said. These programs were in Hawaii, Idaho, Iowa,
Louisiana, Missouri, New Mexico, Oklahoma and Texas. A waiver is
normally approved for three years and can be extended, at a state's request,
for five years at a time if the state shows that it has safeguards to
protect the health and welfare of Medicaid beneficiaries. But the accounting
office said federal officials had renewed many waivers without confirming
that states had such safeguards. Many states sign
contracts with social service agencies to manage care for Medicaid
recipients, but never review the quality of care or verify that services
were actually provided, the report said. In Oklahoma, it said, 27 percent of
Medicaid recipients received none of their authorized personal care
services, and 49 percent received only half of the authorized services. Maureen Booth, a
health policy expert at the University of Southern Maine, said the strengths
of home and community care also complicated the task of guaranteeing its
quality. "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," Ms. Booth said.
"But to improve quality, you have to reach a whole myriad of workers
employed by multiple agencies." Copyright ©
2002 Global Action on Aging
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