A debate has raged in Kansas for years over KanCare, the privatized Medicaid plan enacted by Sam Brownback in 2013.
Brownback and his successor, Jeff Colyer, have touted the program as a tremendous success that has saved the state $1 billion while improving care for 400,000 low-income and disabled Kansans.
Democrats, provider groups and people who care for disabled Kansans have said it’s rife with billing problems, secrecy and decisions based more on money than quality care.
So on April 28, 2017, legislators directed their independent auditors to find out whether KanCare is working.
After a year of work, those auditors recently released their determination: the state’s data is so bad, there’s no way to know.
“These data issues limited our ability to conclude with certainty on KanCare’s effect on service use and limited our ability to interpret cost trends,” the auditors wrote. “More significantly, data reliability issues entirely prevented us from evaluating KanCare’s effect on beneficiaries’ health outcomes.”
In an email, Kansas Department of Health and Environment Secretary Jeff Andersen said the agency disputed some of the auditors' conclusions about KanCare's effect on Medicaid costs, which he said didn't take into the effect of state and federal policy changes.
But he didn't dispute their conclusions about the shortcomings of the data on patient outcomes, which he said he became aware of after he was appointed in January.
He said KDHE has requested more money to hire additional state employees and strengthen oversight of KanCare, including data verification.
He also noted that under the KanCare contracts, the private companies that the state hired to administer KanCare could face penalties of "upwards of $3 million" if they fail to submit accurate and timely data.
"We intend to enforce their contractual obligations to ensure program integrity,” Andersen said.
Sean Gatewood and Barb Conant, co-directors of a group for people on KanCare called the KanCare Advocates Network, said the auditors’ conclusions were unsurprising.
They and others have said for years that they’ve struggled to get good data on the program out of the state in a timely fashion.
“The LPA (Legislative Post Audit) findings confirm what stakeholders, advocates and providers have been voicing concerns about,” the group said in a statement.
Gatewood said one of the problems with getting data is that the state placed all Kansas Medicaid services under three private insurance companies — Amerigroup, Sunflower State Health Plan and UnitedHealthcare — that aren't subject to open records laws and can claim that the information they have is proprietary.
The Star reported last year that the companies also have made the process of getting and keeping disability support services under Medicaid more secretive.
Gatewood and Conant said the administration should address the data problems and and a backlog of Medicaid applications before it proceeds with major additions to KanCare, like a work requirement.
The auditors wanted to study how the switch to KanCare affected people’s usage of 12 major Medicaid services.
But they wrote that “significant data reliability issues” prevented them from evaluating services such as outpatient care, prescription drugs and disability services.
In some cases the data issues were due to policy changes that prevented year-to-year comparisons. But the auditors found significant outliers, inaccuracies and extreme fluctuations that gave them no confidence they could do a true analysis.
So they looked at only five services: primary care, behavioral health, dental, nursing facilities and inpatient hospital care.
They found that KanCare increased the use of primary care substantially, by 45 percent, and more modestly increased the use of dental (15 percent) and behavioral health (8 percent) services.
That seemed to reinforce what Brownback and Colyer have said for years about KanCare improving health outcomes and decreasing costs by getting people preventive care that keeps them out of hospitals and nursing homes.
But the auditors found that KanCare also increased inpatient hospital care by 2 percent and increased nursing facility care by 16 percent.
“It was not immediately clear to us or KDHE officials the reason for this increase,” the auditors wrote of the nursing home care, “but it is clearly inconsistent with KanCare’s goal to reduce Medicaid costs for the elderly through increased care coordination.”
The auditors also said they couldn’t evaluate whether there were enough doctors and other medical providers in the KanCare networks because the data the insurance companies submitted to the state “had duplicative, missing and outdated provider information.”
They also said that while KDHE tracks whether the claims the companies pass on to the state from medical providers are allowable under Medicaid, it has no system to track whether those claims are accurate.
That’s important because the reimbursements that the three KanCare companies get from the state are based in part on how much they’ve paid in claims in past years. And the auditors discovered that one of the companies, Sunflower State Health Plan, had inappropriately included the interest it paid to providers on late claims.
“Including interest in its claims payments may have inappropriately inflated state payments to Sunflower,” the auditors wrote.
In a written response to the auditors, KDHE Secretary Andersen said the state doesn’t have enough staff to vet the accuracy of the claims data very often but would be looking at ways to audit it at least once a year.
He also said Sunflower State Health Plan had been told to stop including interest in its claims data and KDHE is considering asking the company to reimburse the state.
Kansas Rep. Dan Hawkins, a Wichita Republican who sits on the legislative audit committee and a KanCare oversight committee, said he has confidence in Andersen.
He said when Andersen took over KDHE the agency was “really in a bad way,” but he’s trying to turn it around.
Still, even before the audit was released, Hawkins said he was in talks with the Kansas Health Institute, a Topeka nonprofit, about doing its own collection and analysis of KanCare data.
Hawkins said KanCare has become very politicized and having an independent third party handle the data might move the public debate forward.
“Why not use KHI to get the data out there to see what’s going on, bad or good?” Hawkins said.
Hawkins said at the next KanCare oversight committee meeting in August he expects to talk about what stakeholders should collaborate with KHI and what measures they should look at to evaluate KanCare.
KHI president and CEO Robert St. Peter said his organization is ready to help.
“Despite the huge amount of information that’s been generated about KanCare, it seems like there’s just as many questions now about whether the program works as there was when it started,” St. Peter said. “The goal of this is to really close that loop.”
Andersen said KDHE is also on board.
"Our intent is to be transparent with consumers and the public regarding Medicaid service delivery," Andersen said. "We look forward to working with the Kansas Health Institute moving forward to serve as an independent third party to ensure that all data related to the program is accurately being shared.”