Medicaid: Further Action Needed to Expedite Use of National Data for Program Oversight
Released: 2018-01-08T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: GAO and others have identified insufficiencies in state-reported Medicaid data that affect CMS's ability to oversee the program effectively. Recent increases in improper payments—estimated at $36.7 billion in fiscal year 2017—exacerbate concerns about program oversight.

CMS officials identified the T-MSIS initiative, which began in 2011, as its main effort to improve Medicaid data, and cited aspects of T-MSIS aimed at improving the scope and quality of state-reported data. GAO reported in January 2017 that it is unclear when T-MSIS data will be available from all states; how CMS will ensure data quality; or how the data will be used to enhance oversight of Medicaid.

GAO was asked to review states' experiences with T-MSIS implementation and planned uses of T-MSIS data. This report examines (1) states' experiences regarding T-MSIS implementation, and (2) challenges to CMS's and states' use of T-MSIS data for oversight. GAO reviewed federal laws, guidance, and internal control standards; reviewed documents and interviewed officials from eight states, selected based on their T-MSIS reporting status, location, program expenditures, and other factors; and interviewed CMS officials, CMS contractors, and individuals involved with other states' T-MSIS efforts.

section_title: What GAO Found
paragraphs: As of November 2017, 49 states had begun reporting Transformed Medicaid Statistical Information System (T-MSIS) data—a significant increase from 18 states reporting these data one year earlier. All eight states GAO reviewed identified converting their data to the T-MSIS format on an element-by-element basis as the main challenge in their reporting efforts. For some data elements, states had to expand or collapse their data to match the T-MSIS format.

With the continued implementation of T-MSIS, the Centers for Medicare & Medicaid Services (CMS) has taken an important step toward developing a reliable national repository for Medicaid data. However, data challenges have hindered states' and CMS's use of the T-MSIS data for oversight.

None of the six selected states reporting T-MSIS data in August 2017 was reporting complete data. These states said that certain unreported elements were contingent on federal or state actions, and others were not applicable to the state's Medicaid program. States did not always specify in their documentation whether they planned to report elements in the future or when they would report complete data.

Six of eight selected states expressed concerns about the comparability of T-MSIS data across states. Further, all states were interested in CMS facilitating information sharing among states. CMS has not compiled and shared information about states' data limitations, which would help states accurately compare their T-MSIS data to other states' T-MSIS data.

CMS has taken steps for the initial use of T-MSIS data, but does not have a plan or associated timeframes for using these data for oversight. As a result, important CMS goals for T-MSIS, such as reducing states' reporting burden and enhancing program integrity activities, are not being fully realized.

section_title: What GAO Recommends
paragraphs: GAO recommends that CMS (1) improve T-MSIS's completeness and comparability to expedite its use, and (2) articulate a specific oversight plan. The Department of Health and Human Services concurred with GAO's recommendations.

section_title: Letter
paragraphs: Medicaid—the joint federal-state health financing program estimated to  cover over 73 million low-income and medically needy individuals in fiscal  year 2017—allows states significant flexibility to design and implement  their programs within broad federal parameters. While this flexibility has  allowed states to fashion their programs based on their unique needs, it  also complicates oversight. The Centers for Medicare & Medicaid  Services (CMS), the agency within the Department of Health and Human  Services (HHS) that oversees Medicaid, has a critical role in monitoring  states’ compliance with federal requirements, including ensuring that  federal Medicaid payments are made appropriately. To help inform its  oversight, CMS relies on data that are submitted by states. For example,  for expenditure and utilization data that can be linked to individual  enrollees, states historically submitted data to be incorporated into CMS’s  Medicaid Statistical Information System (MSIS) data.

We and others have reported that insufficiencies in available Medicaid  data, including MSIS data, have affected CMS’s ability to ensure proper  payments and beneficiaries’ access to care. These concerns are not  new; however, recent trends in improper payments have exacerbated  concerns about Medicaid oversight. In particular, of the $596 billion in  federal and state Medicaid expenditures in fiscal year 2017, improper  payments were an estimated $36.7 billion, a significant increase from the  estimated $14.4 billion in improper payments in fiscal year 2013.

CMS has acknowledged the need for improved Medicaid data. The  Transformed Medicaid Statistical Information System (T-MSIS) initiative is  the agency’s primary effort, conducted jointly with states, to improve its  collection of Medicaid expenditure and utilization data, and replace  MSIS. CMS officials cite aspects of T-MSIS that are designed to broaden  the scope and improve the quality of state-reported data, as well as the  data’s usefulness for states. For example, T-MSIS is intended to include  data not previously reported by states, such as unique provider  identification numbers and information on third-party liability, which could  be used to help enhance CMS and states’ program oversight. T-MSIS  also includes automated quality checks that should improve the quality of  data that states report.

In a January 2017 report, we examined CMS efforts to implement T-MSIS  and concluded that uncertainty existed with respect to when all states  would report T-MSIS data; how CMS will ensure the quality of these data;  and how CMS will use them for oversight purposes. You asked us to  examine states’ experiences regarding T-MSIS implementation, including  obstacles they have faced in reporting quality data, and their planned  uses of these data for oversight. In this report, we examine  1.  states’ experiences regarding the implementation of T-MSIS, including  CMS’s actions to facilitate states’ efforts; and  2.  challenges to CMS’s and states’ use of T-MSIS data for oversight.

To examine states’ experiences regarding the implementation of T- MSIS—including CMS’s actions to facilitate their efforts—we reviewed  federal laws and guidance, and interviewed CMS officials and contractors  who assisted the agency with T-MSIS implementation. We reviewed  CMS documentation of the number of states reporting T-MSIS data and  of its actions to support states’ T-MSIS implementation efforts. We also  selected a non-generalizable sample of eight states for further review:  Louisiana, Michigan, Minnesota, North Carolina, Pennsylvania, Utah,  Virginia, and Washington. We selected these states based on variation in  their T-MSIS reporting status, geographic location, program expenditures,  use of Medicaid managed care programs, and participation in CMS’s T- MSIS pilot program. For each selected state, we reviewed relevant  documents, and interviewed officials about their experiences reporting T- MSIS data and CMS’s efforts to assist them. To supplement the  information provided by our selected states, we also interviewed  individuals who were identified through background research as having  experience with other states’ T-MSIS reporting efforts. We also reviewed  prior GAO reports on Medicaid data and reports published by other  entities, such as the HHS Office of Inspector General (HHS-OIG).

To examine challenges to CMS’s and states’ use of T-MSIS data for  oversight, we reviewed CMS guidance, selected states’ documentation of  T-MSIS reporting efforts, and federal internal control standards. We also interviewed officials from CMS and selected states regarding their plans  to use these data for oversight. To assess the completeness of the T- MSIS data that selected states were reporting, we analyzed state  documents regarding unreported T-MSIS data elements and their plans to  report them in the future. These documents, which states submit to CMS,  are known as Addendum Bs. To assess the reliability of the Addendum B  data, we compared them with related documentation, such as CMS  guidance, and with information from interviews with knowledgeable CMS  and state officials. We also assessed the data for duplicate values and  clarified inconsistencies we identified. We confirmed with state officials  that their documents reflected unreported T-MSIS data elements as of  August 2017. We determined that these data were sufficiently reliable  for our purposes.

We conducted this performance audit from December 2016 through  December 2017 in accordance with generally accepted government  auditing standards. Those standards require that we plan and perform the  audit to obtain sufficient, appropriate evidence to provide a reasonable  basis for our findings and conclusions based on our audit objectives. We  believe that the evidence obtained provides a reasonable basis for our  findings and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: CMS intends for the T-MSIS initiative to provide a national data repository  that would support federal and state program management, financial  management, and program integrity activities, among other functions. T- MSIS is also intended to benefit states by reducing the number of reports  CMS requires them to submit, and by improving program efficiency by  allowing states to compare their data with other states’ data in the  national repository or with information in other CMS repositories, including  Medicare data. For example, CMS intends to use T-MSIS data for  reports that states are currently required to submit, such as Early and  Periodic Screening, Diagnostic, and Treatment Program reports.

T-MSIS is designed to capture significantly more data from states than is  the case with MSIS, thereby collecting data not previously reported that  should provide CMS and states with information to enhance their  oversight efforts. T-MSIS includes the five data files that were collected  through MSIS: an eligibility file and four claims files (inpatient, long-term  care, pharmacy, and other). The scope of data to be collected from these  five previously defined MSIS files has expanded to include more detailed  information on enrollees, such as their citizenship, immigration, and  disability status; and expanded diagnosis and procedure codes  associated with their treatments.

Additionally, T-MSIS requires states to report three new data files on (1)  providers, (2) third-party liability, and (3) managed care organizations  (MCO).

The provider file includes a unique identifier for each provider, as well  as data fields to show provider specialty and practice locations. Each  of these identifiers can assist CMS and state oversight by providing  information on provider referrals, Medicaid payments to specific  providers, and identifying ineligible providers.

The third-party liability file includes data on whether a beneficiary has  any health insurance in addition to Medicaid, or other potential  sources of funds that could reduce Medicaid’s expenditures. Medicaid  is generally the payer of last resort, meaning if Medicaid enrollees  have another source of health care coverage, that source should pay,  to the extent of its liability, before Medicaid does. Information on  beneficiaries’ other sources of coverage could help ensure that  Medicaid pays only those expenditures for which it is liable.

The managed care file includes more detailed information on MCOs,  such as type and name of managed care plans, covered eligibility  groups, service areas, and reimbursement arrangements. In addition  to identifying which MCOs are reporting encounter data as required,  this file could help CMS’s oversight by allowing the agency to identify  excess plan profits and volatility of expenditures for some beneficiary  groups across states.

In total, T-MSIS includes approximately 1,400 data elements, according  to CMS. Many of these elements, however, have content that is used in  more than one of the eight T-MSIS files. For example, the element “DATE  OF BIRTH” is required in five T-MSIS files—Eligibility, Claim Inpatient,  Claim Long-term Care, Claim Prescription, and Claim Other. CMS  requires states to report all T-MSIS elements that are applicable to their  programs, and has worked closely with states to facilitate their efforts to  report these data. For example, before CMS approves a state for  reporting T-MSIS data, states must complete a number of activities,  including developing detailed work plans and completing a series of data  testing phases. For a state to meet CMS’s requirements for submitting  T-MSIS data, it must report data for all eight files, but not necessarily all  elements within each file.

In addition, T-MSIS includes aspects aimed at improving the timeliness  and accuracy of data submitted by states. For example, CMS requires  states to report T-MSIS data monthly, rather than quarterly, as was the  case with MSIS. Regarding data accuracy, T-MSIS includes  approximately 2,800 automated quality checks that provide states with  feedback on data format and consistency, according to CMS; this is in  contrast to MSIS, which had relatively few automated checks. Other  quality checks are to ensure logical relationships across T-MSIS files.

Both we and the HHS-OIG have previously recommended that CMS take  steps to address the quality of T-MSIS data. In our January 2017 report,  we recommended that CMS take immediate steps to assess and improve  T-MSIS data. As part of that effort, we noted that CMS could refine their  T-MSIS data priority areas to identify those that are critical for reducing  improper payments and expedite efforts to assess and ensure their  quality. CMS agreed with our recommendation, but as of September  2017, the agency had not implemented it. More recently, the HHS-OIG  reported that CMS and states continue to have concerns regarding the  completeness and reliability of T-MSIS data, echoing concerns raised in  its 2013 review of CMS’s T-MSIS pilot program. The HHS-OIG noted it  was concerned that CMS and states would delay further efforts rather  than assign the resources needed to address the outstanding challenges,  and reaffirmed its 2013 recommendation that CMS establish a deadline  for when T-MSIS data will be available for program analysis and other  management functions.

section_title: Despite Challenges Converting State Data to the T-MSIS Format, Nearly All States are Reporting T-MSIS Data, and CMS Has Shifted Its Focus to Improving Data Quality
paragraphs: Despite challenges converting their data to the T-MSIS format, most  states were reporting T-MSIS data as of November 2017, representing  significant progress over the past year. With most states reporting, CMS  has shifted its efforts to working with states to improve the quality of T- MSIS data.
subsections: section_title: Overall, 49 States Are Reporting T-MSIS Data; Selected States Identified Converting their Data into the T-MSIS Format as a Significant Reporting Challenge
paragraphs: As of November 2017, 49 states have begun reporting T-MSIS data, a  significant increase from the 18 states that had started reporting these  data in October 2016. These reporting states represent over 97 percent of  the 2017 Medicaid population nationwide. CMS officials told us that they  expect all states to report T-MSIS data by 2018. (See fig. 1.)

As of November 2017, all eight of our selected states were reporting T- MSIS data, with seven of them having begun in September 2016 or  later. Selected states’ estimated spending a collective $14.16 million on  their efforts to report T-MSIS data from October 2011 through June 2017,  ranging from approximately $850,000 in Virginia to $4.42 million in  Minnesota. (See table 1.) The age and scope of states’ existing  Medicaid Management Information Systems (MMIS) were among the  factors that affected certain states’ spending and timing on this effort.

Mapping the data—the process by which states convert their data to the  T-MSIS format on an element-by-element basis—was the primary  challenge our eight selected states identified in reporting T-MSIS data. In  some cases, before converting their data to the T-MSIS format, states  had to obtain data they had not previously collected from other state  entities, MCOs, or providers. For example, Minnesota had to begin  collecting information on denied claims from MCOs, and Utah had to  collect third-party liability information from other state agencies. In  addition, while some state data elements could be converted to the T- MSIS format fairly easily, because the relationships between the two were  clear, the conversion of other data elements was more complicated. For  example, the T-MSIS data element for male and female is “M” and “F,”  respectively. Accordingly, in states that identified gender by a numeric  value, “1” for male and “2” for female, the conversion to T-MSIS for this  element was a fairly straightforward one-to-one relationship. However, for  other data elements, the conversion process was more complex,  requiring states to expand or collapse their data to match the T-MSIS  format. (See fig. 2.) Selected states shared examples of steps they took  to convert state data to the T-MSIS format.

Louisiana officials noted that they had to map the state’s single  durable medical equipment (DME) element to multiple specific T- MSIS DME elements, such as DME pharmacy or DME orthotics.

Virginia officials said they had to combine three state ambulance  service provider elements into a single T-MSIS element.

In addition, individuals who had experience with other states’ T-MSIS  reporting efforts also noted that states may not have always collapsed  categories in the same way. For example, one state collapsed its 109  provider categories to match T-MSIS’s 57 provider categories, according  to an individual who worked with the state on this effort. This individual  noted that there were 32 state provider elements that did not directly  match a specific T-MSIS element, so the state grouped them all into the  “other” T-MSIS element.

Changes in CMS’s data reporting requirements further complicated some  states’ efforts to convert their data to the T-MSIS format, according to  officials from our selected states. CMS updated the T-MSIS data  dictionary—the document that defines the required T-MSIS elements and  their reporting formats—twice in 2013 and again in November 2015.  According to CMS officials, they updated the data dictionary to clarify and  remove inconsistencies from guidance in response to feedback from  states. Some of the selected states reported that the changes included in  this update required considerable rework, and in some cases, delayed  their T-MSIS reporting. For example, Washington officials noted that the  2015 update became available at the point it was completing a T-MSIS  testing phase. Due to the rework required to comply with the new data  specifications, the state’s efforts to report T-MSIS data were delayed by  nearly one year. Similarly, Minnesota officials also cited rework  associated with changes to the 2015 data dictionary, which contributed to  delays in their efforts to report T-MSIS data.

section_title: CMS’s Efforts to Support States Have Shifted from Reporting T-MSIS Data to Improving T-MSIS Data Quality
paragraphs: Over the past six years, CMS has relied on a variety of mechanisms to  support states’ efforts to report T-MSIS data.

CMS assigned technical assistants to help states understand the T- MSIS requirements, prioritize steps to report T-MSIS data, and serve  as a resource on technical issues. The majority of selected states  had positive comments about the technical assistance they received.  For example, Pennsylvania officials said its technical assistant  regularly met with them, answered any questions they had, and  facilitated their efforts to complete T-MSIS testing.

CMS began hosting national webinars covering a range of topics,  including clarification on specific T-MSIS elements that CMS identified  as challenging or subject to error, and updates on the nationwide  implementation. The webinars also provided an opportunity for states  to ask CMS questions about T-MSIS requirements.

CMS established web-based avenues through which the agency  could compile and disseminate information, as well as elicit questions  from states and contractors. For example, CMS provided an electronic  option for states to submit questions regarding policy and technical  issues.

CMS took additional steps to help states, including creating a  SharePoint web site through which states are notified about changes  in guidance.

With nearly all states having begun reporting T-MSIS data, CMS has  shifted its efforts to improving the quality of the T-MSIS data reported,  and these efforts are still evolving. For example, to provide states with  immediate feedback on their reported T-MSIS data, CMS created an  online “operational dashboard” for each state, which provides specific  information on errors in its reported data. Using information on the  operational dashboard, states can identify the frequency and cause of  certain errors, which facilitates their efforts to resolve them more  expeditiously and to improve future submissions. All six of the selected  states reporting T-MSIS data had positive comments about the value of  the operational dashboard, with some of them noting that the feedback on  errors was a significant improvement from their experience with MSIS,  where feedback had a considerable time-lag. More recently, according to  agency officials, CMS has initiated a pilot study with four states to identify  anomalies in their reported data that merit further attention, obtain  feedback on automated quality measures, and determine the best  approach for ongoing quality review. While work on the pilot is ongoing,  CMS officials anticipate using what they learned to expand the agency’s  quality review to include all states.

In addition, CMS has turned to external stakeholders to evaluate the  quality of T-MSIS data. Specifically, CMS has shared T-MSIS data with a  Technical Expert Panel it formed to obtain feedback on inconsistencies  and other quality concerns. According to CMS officials, the Technical  Expert Panel focused on a preliminary set of T-MSIS data from a limited  number of states. The agency officials noted that Technical Expert Panel  members include individuals from HHS’s Office of the Actuary, the  Congressional Budget Office, and the Medicaid and CHIP Payment and  Access Commission, among others. Panel participants analyzed the T- MSIS data from 11 states on the specific topics in which they have  expertise. According to CMS officials, the panel is to provide its results to  the agency in a summary report.

section_title: Data Completeness and Comparability Concerns Hinder CMS’s and States’ Use of T-MSIS for Oversight
paragraphs: Ongoing data concerns raise questions about how soon—and to what  extent—T-MSIS data will be sufficient to achieve the goals of improving  CMS’s and states’ ability to use Medicaid data for oversight. For example,  none of the six selected states that were reporting T-MSIS data as of  August 2017 were reporting complete data at that time. In reviewing  selected states’ documentation of unreported data elements, we  determined that the number of unreported data elements ranged from  about 80 elements to 260 elements. Although T-MSIS includes about  1,400 data elements, the number of data elements relevant to each state  varies, in part, because certain elements may not be applicable to all  states and others may be populated at the state’s discretion. In addition,  the content of some data elements are present in more than one of the  eight T-MSIS files. As a result, the number of unreported elements may  overstate the extent of state efforts needed to report complete T-MSIS  data.

Our selected states provided a range of reasons for not reporting T-MSIS  data elements, including that certain elements were contingent on federal  or state actions. In other cases, state officials indicated that data  elements were too costly to report, so they would not be reporting them.  We identified further examples of where certain data elements were not  applicable to states’ Medicaid programs, and therefore were not  required. (See table 2.)

Although CMS requires states to report all T-MSIS data elements  applicable to their program, CMS officials said they did not specify a  reporting deadline for states, and selected states’ documentation to CMS  did not always include the reasons they did not report certain elements, or  whether or when they planned to report them. Due to the lack of clarity  and completeness in selected states’ documentation, we were not able to  identify the reasons for all unreported data elements. However, among  our selected states, Virginia’s documentation more clearly specified  most—but not all—of the reasons it was not reporting 260 T-MSIS  elements.

Virginia identified 167 elements that its MMIS did not capture, and  noted that once the state’s new Medicaid information system is fully  implemented in 2019, the state will be able to report them.

Virginia identified 16 elements as pending other state or related  actions.

Virginia identified 18 elements as pending the implementation of HHS  efforts.

Virginia identified 53 elements as not applicable to aspects of its  Medicaid program.

Without complete information from all states on unreported data elements  and their plans to report them, it is unclear when—and to what extent—T- MSIS data will be available to use for oversight, which is inconsistent with  federal internal control standards for using quality information to achieve  objectives.

In some cases, data elements important for program oversight were not  reported by two or more of the six selected states reporting T-MSIS data,  limiting T-MSIS’s usefulness for oversight in these areas. (See table 3.)

Another factor affecting the ability of CMS and states to use T-MSIS data  for oversight is that not all of the 49 states submitting T-MSIS data are  submitting current data. According to CMS officials, before beginning to  report T-MSIS data, each state stops reporting MSIS data. At that point,  there is a temporary gap in the state’s reporting until it receives CMS’s  approval to begin reporting T-MSIS data. After a state gets CMS’s  approval, it must first submit the T-MSIS data that correspond to the date  that it stopped submitting MSIS data; the data for previous months is  known as “catch up” data. Once a state reports that data, it then shifts to  reporting current T-MSIS data. According to CMS, as of November 2017,  42 of the 49 states reporting T-MSIS data were reporting current data; the  remaining 7 states were still reporting catch up data for previous  months.

Regarding the comparability of T-MSIS data across states, state officials  we interviewed cited concerns that could affect their use of T-MSIS for  oversight. Officials from most selected states cited the benefit that a  national repository of T-MSIS data could provide by allowing them to  compare their Medicaid program data—such as spending or utilization  rates—to other states, which could potentially improve their oversight.  However, concerns about comparability of the data make officials from  most selected states hesitant to use the data for this purpose. In  particular, officials from six of eight selected states, and other individuals  we interviewed, are not confident that the decisions states made when  converting their data to the T-MSIS format were consistent across states.  An individual who worked with other states on T-MSIS reporting efforts  noted that states may have made different decisions about what types of  providers to include as part of the “all other” category of providers within  T-MSIS. While one state he worked with included a range of provider  types, such as licensed drug and alcohol counselors and non-emergency  medical transportation providers, in the “all other” T-MSIS provider  category, other states may have made different decisions. Some state  officials and individuals working with states noted that states’ different  decisions may complicate their ability to use the data for cross-state  comparisons. Further, officials from some of the selected states noted  that they were not familiar with the quality of other states’ T-MSIS data.

CMS has begun to take steps to address the quality of the T-MSIS data;  however, its efforts are still evolving. For example, in May 2017, CMS  identified 12 data quality priority areas for states to focus on for improving  the accuracy and consistency of T-MSIS data, including accurately  categorizing beneficiaries into T-MSIS eligibility groups and ensuring  consistency related to MCO reporting. CMS has worked to identify  existing or develop new guidance for each of these priority areas, and to  compile the guidance in a central location for states’ reference. As of  August 2017, CMS officials said they compiled guidance for 11 of the 12  areas, and intended to continue work with states on these priorities.

In addition, CMS has not created a mechanism to disseminate  information about states’ data limitations or states’ efforts to improve and  use the data, which also affects their utility for oversight. Officials from  four of the eight selected states said that learning more about other  states’ T-MSIS data could help allay their concerns about comparability,  and two of the four states said it could also help them address their own  data quality issues. Additionally, officials from all eight selected states  were interested in opportunities to learn more about other states’ use of  the data.

CMS officials acknowledged the benefits of a mechanism to disseminate  information about states’ data limitations more broadly, and to facilitate  information sharing among states. CMS officials told us that they plan to  launch a Learning Collaborative with states to facilitate feedback and  collaboration. This effort could address a range of data-related topics,  including data quality. CMS officials told us they were taking actions to  put the Learning Collaborative in place, and may launch the collaborative  in early 2018.

The lack of an effort to facilitate information sharing is inconsistent with  CMS’s goals for T-MSIS and with federal internal control standards for  using and communicating quality information to achieve objectives.  Absent such an effort, CMS is missing an opportunity to help states  understand ways they could improve the quality of their T-MSIS data and  facilitate states’ use of the data for oversight. CMS is also missing an  opportunity to expedite quality improvements that could result from states  conducting their own independent analyses.

Although CMS has taken steps to begin using T-MSIS data, it has not yet  fully articulated a plan for how and when it will use T-MSIS data for its  own broader oversight efforts of state Medicaid programs. For example,  according to CMS officials, the agency has begun to use T-MSIS data to  generate Money Follow the Person reports, and has begun exploring  additional uses of T-MSIS data to reduce states’ reporting burden.  These preliminary efforts are consistent with one of CMS’s stated goals  for T-MSIS, which is to reduce states’ reporting burden by relying on T- MSIS data in place of separate reports that states currently submit, and  officials from six of eight selected states indicated that such an effort  would reduce their reporting burden.

However, as of August 2017, CMS officials acknowledged that they had  yet to outline how best to use T-MSIS data for program monitoring,  oversight, and management, because they were still largely focused on  working with the remaining states to begin reporting T-MSIS data,  analyzing the quality and usability of the T-MSIS data, and preparing the  data for research purposes. CMS’s lack of a specific plan and time frames  for using T-MSIS data is inconsistent with federal internal control  standards related to using and communicating quality information to  achieve objectives. Absent a specific plan and time frames, CMS’s ability  to use these data to oversee the program, including ensuring proper  payments and beneficiaries’ access to services, is limited.

section_title: Conclusions
paragraphs: As part of its efforts to address longstanding concerns about the data  available to oversee the Medicaid program, CMS has taken important  steps toward developing a reliable national repository for Medicaid data.  T-MSIS has the potential to improve CMS’s ability to identify improper  payments, help ensure beneficiaries’ access to services, and improve  program transparency, among other benefits. By providing more  standardized data on various aspects of Medicaid—such as spending or  utilization rates—states could be better positioned to compare their  programs to other states, thereby improving their ability to identify  program inefficiencies or opportunities for improvement.

Implementing the T-MSIS initiative has been a significant undertaking.  Over the past 6 years, CMS has worked closely with states and has  reached a point where nearly all states are reporting T-MSIS data. While  recognizing the progress that has been made, more work needs to be  done before CMS or states can use these data for program oversight. It  remains unclear when all states will report complete and comparable T- MSIS data, and how CMS and states will use them to improve oversight.  In the interim, improper Medicaid payments continue to increase,  reaching $36.7 billion in fiscal year 2017. Further delays in T-MSIS’s use  limit CMS’s ability to reverse that trend in the near term, underscoring the  need for CMS to take additional steps to expedite the use of the data.

section_title: Recommendations for Executive Action
paragraphs: We are making the following two recommendations to CMS.

The Administrator of CMS, in partnership with the states, should take  additional steps to expedite the use of T-MSIS data for program  oversight. Such steps should include, but are not limited to, efforts to obtain complete information from all states on unreported T-MSIS  data elements and their plans to report applicable data elements;  identify and share information across states on known T-MSIS data  limitations to improve data comparability; and  implement mechanisms, such as the Learning Collaborative, by which  states can collaborate on an ongoing basis to improve the  completeness, comparability, and utility of T-MSIS data.  (Recommendation 1)

The Administrator of CMS should articulate a specific plan and associated  time frames for using T-MSIS data for oversight. (Recommendation 2)

section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS for comment. In its written  comments, HHS concurred with our recommendations, and noted that  strong Medicaid data can help the federal government and the states  move toward better health outcomes and improve program integrity,  performance, and financial management. With most states now reporting  T-MSIS data, HHS highlighted efforts it has taken to improve the quality  of T-MSIS data. For example, HHS developed a database on data quality  findings, which could be used to identify solutions for common problems  across states, and has begun to develop a data quality scorecard for T- MSIS users, which aggregates data quality findings in a user-friendly tool.  Regarding taking steps to expedite the use of T-MSIS data for program  oversight, HHS stated that it will (1) continue to work to obtain complete  T-MSIS information from all states; (2) take additional steps to share  information across states on T-MSIS data limitations; and (3) implement  ways for states to collaborate regarding T-MSIS. HHS also noted that it is  in the process of developing a plan for using T-MSIS data for oversight.  HHS emphasized that it is dependent on states—and their available  staffing and resources—to address data quality and reporting issues.  HHS also provided technical comments, which we incorporated as  appropriate. HHS’s comments are reprinted in appendix I.

As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees, the Secretary of HHS, and other interested  parties. In addition, the report will be available at no charge on the GAO  website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs can be found on the last  page of this report. Major contributors to this report are listed in appendix  II.

section_title: Appendix I: Comments from the Department of Health and Human Services

section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
paragraphs: Carolyn L. Yocom, (202) 512-7114 or yocomc@gao.gov.

section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, individuals making key  contributions to this report include Susan Anthony (Assistant Director),  Manuel Buentello (Analyst-in-Charge), Anna Bonelli, and Robin Burke.  Also contributing were Muriel Brown, Drew Long, and Jennifer Rudisill.

Fast facts: State-reported data help the federal government oversee the Medicaid program, which made an estimated $36.7 billion in payment errors in 2017. However, there have been longstanding concerns that those data are not sufficient for effective oversight.

To help, federal administrators established a new data repository. Nearly all states now submit data that could be used to improve oversight and program management. However, concerns persist over the completeness and comparability of state data.

We recommended federal administrators take steps to expedite collection of complete and comparable data, and draft a plan for how they will use the data.

Question-summary annotations: questions: question: How had T-MSIS reporting volume changed as of November 2017 compared to one year earlier?
answer: As of November 2017, 49 states had begun reporting Transformed Medicaid Statistical Information System (T-MSIS) data—a significant increase from 18 states reporting these data one year earlier.

question: What did states identify as their biggest challenge in their reporting efforts?
answer: All eight states GAO reviewed identified converting their data to the T-MSIS format on an element-by-element basis as the main challenge in their reporting efforts.
child_questions: question: What did states have to do to match the T-MSIS format?
answer: For some data elements, states had to expand or collapse their data to match the T-MSIS format.

questions: question: How were T-MSIS data reports in August 2017 inadequate?
answer: None of the six selected states reporting T-MSIS data in August 2017 was reporting complete data.
child_questions: question: How did states justify this inadequacy?
answer: These states said that certain unreported elements were contingent on federal or state actions, and others were not applicable to the state's Medicaid program.

question: What did states specify about future reporting?
answer: States did not always specify in their documentation whether they planned to report elements in the future or when they would report complete data.

questions: question: What was GAO asked to review?
answer: GAO was asked to review states' experiences with T-MSIS implementation and planned uses of T-MSIS data.

question: What does this report examine?
answer: This report examines (1) states' experiences regarding T-MSIS implementation, and (2) challenges to CMS's and states' use of T-MSIS data for oversight.
child_questions: question: How did GAO collect data for this report?
answer: GAO reviewed federal laws, guidance, and internal control standards; reviewed documents and interviewed officials from eight states, selected based on their T-MSIS reporting status, location, program expenditures, and other factors; and interviewed CMS officials, CMS contractors, and individuals involved with other states' T-MSIS efforts.