Electronic Health Records: Ongoing Stakeholder Involvement Needed in the Department of Veterans Affairs' Modernization Effort

VA's existing EHR system is antiquated, costly to maintain, and does not fully support VA's need to exchange health records with other organizations, such as the Department of Defense. As a result, VA has undertaken a modernization effort to replace it. As VA prepares to transition from its existing EHR system to a commercial system, it has the opportunity to design standardized work processes to support the delivery of care and ensure information on veterans' care is consistently captured, regardless of site of care.

GAO was asked to review VA's EHR system configuration process. This report examines, among other objectives: (1) how VA made EHR system configuration decisions and assessed the compatibility of the commercial EHR system with its work processes; and (2) the effectiveness of VA's decision-making procedures, including ensuring key stakeholder involvement.

GAO observed national and local workshop meetings; visited planned initial implementation sites; reviewed documentation on the processes and schedule; and interviewed VA, DOD, and contractor officials.

The Department of Veterans Affairs (VA) used a multi-step process to help ensure that its future commercial electronic health record (EHR) system is configured appropriately for, and is compatible with, its clinical work processes. To configure the EHR system, which VA planned to implement initially at the Mann-Grandstaff VA Medical Center, in Spokane, Washington, in July 2020, and at the Puget Sound Health Care System in the fall of 2020, VA established 18 EHR councils comprising VA clinicians, staff, and other experts in various clinical areas and held eight national workshops between November 2018 and October 2019. At these workshops, the councils decided how to design the functionality of the EHR software to help clinicians and other staff deliver care and complete tasks such as administering medication. VA also held eight local workshops at both medical centers to help ensure that the EHR configuration supported local practices. As of March 2020, the EHR councils were continuing to meet to complete configuration decisions. Furthermore, VA plans to hold local workshops in advance of the EHR system implementation at future VA medical facilities. In April 2020, the VA Secretary announced that the department had shifted priorities to focus on caring for veterans in response to the pandemic created by COVID-19. According to program officials, at that time, they paused the implementation of the EHR system and were assessing the impact of the COVID-19 pandemic on VA's planned implementation schedule.

GAO found that VA's decision-making procedures were generally effective as demonstrated by adherence to applicable federal internal control standards for establishing structure, responsibility, and authority, and communicating internally and externally, but that VA did not always ensure key stakeholder involvement. Specifically, the councils included a wide range of stakeholders from various geographic regions. However, according to clinicians from the two initial medical facilities for implementation, VA did not always effectively communicate information to stakeholders, including medical facility clinicians and staff to ensure relevant representation at local workshop meetings. As a result, local workshops did not always include all relevant stakeholders. VA has not indicated how it plans to describe these future sessions and define key terms to ensure key stakeholder participation in local workshops. By ensuring that all relevant stakeholders are included, VA will increase the likelihood that it is obtaining input from a wide range of clinicians and staff who will use the EHR system and will increase the likelihood that when it is implemented, the EHR system will effectively support the delivery of care at VA medical centers.

GAO is recommending that VA ensure the involvement of all relevant medical facility stakeholders in the EHR system configuration decision process. VA concurred with GAO's recommendation.

Within the Department of Veterans Affairs (VA), the Veterans Health  Administration (VHA) operates one of the nation’s largest health care  systems, serving more than 6 million patients annually. VA relies on its  electronic health record (EHR) system—the Veterans Health Information  Systems and Technology Architecture (VistA)—to document the delivery  of health care services to veterans. However, in our prior work, we have  found this technically complex system, which has been in operation for  more than 30 years, is costly to maintain and does not fully support VA’s  need to electronically exchange health records with other organizations,  such as the Department of Defense (DOD) and private health care  providers. Moreover, customization of the system by VA medical facilities  has resulted in approximately 130 versions of VistA across the VA health  care system, raising questions about the consistency of the information  collected, among other issues. As such, the department has undertaken a  modernization effort to replace VistA with a commercial EHR system,  developed by Cerner Government Services, Inc., (Cerner)—a  configuration of the same system DOD is implementing.

Before VA transitions from VistA to the commercial EHR system, the  department has to make design configuration decisions—such as,  determining all the data that need to be incorporated into the EHR  system. Such data configuration decisions would enable the system to  support the work processes that VA clinicians and staff follow in delivering  care. Furthermore, the department has to assess the compatibility of the  EHR system with the processes clinicians and staff use to deliver care.  VA expects to implement the new EHR system initially at two medical  centers in 2020 before implementing it across VA. With the new system,  VA has the opportunity to reduce clinical and procedural variations, both  between VA and DOD, and across the VA health care system’s more  than 1,500 medical facilities. Such variations can cause challenges,  including ensuring information on veterans’ care is documented  consistently.

You asked us to review the VA’s Electronic Health Record Modernization  (EHRM) program’s process towards making decisions for configuring the  new EHR system. In this report, we focus on VA’s ongoing efforts to  implement its new EHR system at the two medical centers. Specifically,  we  1.  describe how VA made EHR system configuration decisions and  assessed the compatibility of the Cerner EHR system with the work  processes that medical facilities follow,  2.  evaluate the extent to which VA met its schedule for making EHR  system configuration decisions, and  3.  assess the effectiveness of VA’s system configuration decision- making procedures, including the extent to which VA ensured that key  stakeholders are involved.

To address the first objective, we reviewed available documentation on  the process VA developed to make EHR system configuration decisions,  which included establishing 18 EHR councils responsible for developing  clinical workflows, design decision matrices, and data collection  workbooks. As part of this review, we examined how configuration  decisions may vary between VA medical facilities. We also reviewed  assessments performed by VA’s EHR councils to determine the  compatibility of the commercial EHR system with the work processes VA  medical facilities follow and efforts to address any incompatibilities.

To address the second objective, we assessed VA’s EHR councils’  progress in meeting the EHRM program’s schedule for making EHR  system configuration decisions. To do this, we reviewed available data  and monthly reports from Cerner’s tracking system on the EHR councils’  progress in making these decisions. Specifically, we reviewed data on the  workflows, design decision matrices, and data collection workbooks that  the councils developed. We also compared that information to the EHRM  program’s documented schedule. To assess the reliability of these data,  we reviewed the data to determine its completeness and identified causes  for any deviations from the program’s schedule. In addition, we  interviewed officials responsible for entering and reviewing the data about  their accuracy and reliability. We also compared summary reports to data  extracts on completed workflows and design decision matrices. Based on  these steps, we determined that the data were sufficiently reliable for the  purposes of our reporting objective. Our scope focused on examining  VA’s progress in meeting its schedule for making EHR system  configuration decisions. Therefore, we did not examine Cerner’s progress  towards the actual configuration of the system or implementation of it.

To address the third objective, we reviewed documentation on VA EHR  council member roles and responsibilities and procedures to identify the  councils’ organization and governance structures for decision-making and  dispute resolution. Since VA is using the same commercial system as  DOD, we also reviewed VA’s procedures for coordinating with DOD on  the implementation of its version of the Cerner commercial EHR system,  known as Military Health System (MHS) Genesis. Furthermore, we  reviewed the procedures that VA used to select EHR council members to  ensure broad and relevant representation. To do this, we obtained a list of  EHR council participants—including chairs, members, and consultants— and analyzed the data to determine the geographic region participants  represented and the extent to which they represented VA’s central office,  Veterans Integrated Service Networks (VISN), or VA medical facilities  (including the complexity level of these medical facilities). We assessed  the reliability of data on EHR council participants through electronic  testing for missing or duplicate data, and obvious errors, and noted any  limitations found, accordingly. Lastly, we assessed the effectiveness of  VA’s decision-making procedures by comparing these procedures to  applicable standards for internal control in the federal government for  establishing structure, responsibility, and authority, and communicating  internally and externally. We also assessed VA’s procedures against  leading collaboration practices as defined in GAO’s collaboration criteria.

To further inform our work on all three objectives we observed three VA  national EHR council workshop meetings held during the period of our  review, as well as two corresponding local workshop meetings for the first  two VA medical facilities where VA plans to implement the commercial  EHR system (Mann-Grandstaff VA Medical Center in Spokane,  Washington, and VA Puget Sound Health Care System—American Lake,  Washington and Seattle, Washington divisions). In addition, we  interviewed cognizant officials from VA, DOD, and Cerner. We also  selected and contacted Veterans Service Organizations to obtain their  perspectives on the EHRM program and VA’s efforts to make system  configuration decisions. We selected organizations that we had identified  in our prior work related to VA’s electronic health record system. This  resulted in the selection of eight organizations for inclusion in our  review. The information we obtained from participants in the workshop  meetings, officials from the first two medical facilities, and the Veterans  Service Organizations is not generalizable.

We conducted this performance audit from May 2019 through June 2020  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.

VHA manages one of the largest health care delivery systems in the  United States and is responsible for overseeing the provision of health  care at VA medical facilities. VA relies on its EHR system—VistA—to  document the delivery of health care services to veterans.

To facilitate care, clinical providers access patient medical records and  document the care they provide in EHR systems. Patient information  needs to be accessible and consistent to prevent risks to patients’ safety,  particularly when shared between providers. Information that is  electronically exchanged from one provider to another must adhere to the  same standards to be consistently interpreted and used in EHRs. In our  prior work, we found that EHR technology has the potential to improve the  quality of care that patients receive and to reduce health care costs.

VistA has served as VA’s EHR system for more than 30 years. Over the  last several decades, it has evolved into a technically complex system  that comprises about 170 modules that support health care delivery at  more than 1,500 medical facilities. In addition, customization of VistA,  such as changes to the modules by the various medical facilities, has  resulted in approximately 130 versions of the system VA-wide.  Furthermore, as we have reported, VistA is costly to maintain and does  not fully support VA’s need to electronically exchange health records with  other organizations, such as DOD and community providers.

VA and DOD have historically operated separate EHR systems. In  addition to patient data from its own EHR system, VA relies on patient  data from DOD to help ensure that it has access to the necessary health  information that could assist clinicians in making informed decisions to  provide care to service members transitioning from DOD to VA’s health  care system.

We have previously reported on VA’s challenges in managing health  information technology and modernizing VistA. In 2015, we designated  VA health care as a high-risk area for the federal government, in part due  to its information technology challenges. Specifically, we identified  limitations in the capacity of VA’s existing information technology  systems, including the outdated, inefficient nature of key systems and a  lack of system interoperability, as contributors to the department’s  challenges related to health care. In our 2019 update to the high-risk  series, we stressed that VA should demonstrate commitment to  addressing its information technology challenges by stabilizing senior  leadership, building capacity, and finalizing its action plan for addressing  our recommendations, and by establishing metrics and mechanisms for  assessing and reporting progress. We also have issued numerous reports  over the last decade that highlighted the challenges facing VA in  modernizing VistA and improving EHR interoperability with DOD.

EHR Modernization Efforts, Including Goals of Improved Sharing of Health Information between VA and DOD

VA created the Office of Electronic Health Record Modernization in 2018  to lead its EHRM program effort, which was intended to result in a more  modern EHR system that would improve providers’ ability to deliver care,  and share health data, including between VA and DOD and between VA  and community providers. For example, with improved interoperability,  medical providers would have the ability to query data from other sources while managing chronically ill patients, regardless of geography, or the  network on which the data reside.

In June 2017, the VA Secretary at the time announced that the  department planned to acquire and configure the same EHR system that  DOD is currently implementing across the military health system.  According to the VA Secretary, the department decided to acquire the  same system as DOD because it would allow all of VA’s and DOD’s  patient data to reside in one system, thus assisting the departments in  their goals of enabling seamless care between VA and DOD without the  exchange and reconciliation of data between two separate systems. As  VA planned to implement the same system DOD is implementing, experts  recommended that VA and DOD coordinate to ensure that the  departments could leverage efficiencies and minimize variation between  the departments’ EHR system configurations when practical.

DOD’s initial implementation of the Cerner EHR system occurred  between February and October 2017 at four military treatment facilities in  the state of Washington. In September 2019, the system was  implemented at four additional military treatment facilities in California and  Idaho. DOD plans to continue to implement the EHR system in 23 phases  through 2023 with the next implementation expected to take place at eight  additional military treatment facilities in California and Nevada.

VA’s EHRM program originally planned to implement the Cerner EHR  system at two VA medical facilities in spring 2020 with a phased  implementation of the remaining facilities over the next decade. The  EHRM program chose the Mann-Grandstaff VA Medical Center in  Spokane, Wash. and the VA Puget Sound Health Care System in Seattle,  Wash. as its initial operating capability sites. Information gathered from  these sites will be used to help VA make EHR system configuration  decisions and standardize work processes for future locations where the  commercial EHR system will be implemented.

In August 2019, the EHRM program adjusted its schedule to implement  the commercial EHR system at these two sites in two phases, known as  capability sets 1 and 2:

Capability set 1 includes key EHR functionalities necessary to  implement the system at the Mann-Grandstaff VA Medical Center, a  level 3—that is, less complex—facility. Capability set 1 was originally  scheduled for implementation in March 2020.

Capability set 2 includes remaining functionalities necessary to  implement the system at the VA Puget Sound Health Care System, a  level 1—that is, highly complex—facility, in the fall of 2020.

In February 2020, VA postponed the implementation of the Cerner EHR  system at the Mann-Grandstaff VA Medical Center until July 2020.  According to VA officials, the additional time will allow Cerner to develop  and establish a more complete and robust training environment, as  requested by VHA clinicians and other facility staff. In addition, according  to VA EHRM program officials, the implementation delay will allow VA  and Cerner to have time to develop additional interfaces between the  Cerner EHR system and other VA systems, such as VA’s mail-order  pharmacy system. These officials told us that the delayed implementation  of the Cerner EHR system at the Mann-Grandstaff VA Medical Center  was not expected to impact VA’s timeline for implementing the EHR  system at the VA Puget Sound Health Care System in the fall of 2020.

In April 2020, the VA Secretary announced that the department had  shifted priorities to focus on caring for veterans in response to the  pandemic created by the Coronavirus Disease 2019 (COVID-19).  Further, the Secretary directed the EHRM program to allow clinicians who had been participating in EHRM program activities to focus on caring for  veterans. According to program officials, they paused the implementation  of the EHR system and were assessing the impact of the COVID-19  pandemic on VA’s planned implementation schedule.

VA Used a Multi-Step Process to Make EHR Configuration Decisions and Assess System Compatibility

VA’s EHRM program used a multi-step process to make EHR system  configuration decisions for the Cerner EHR system being implemented at  the VA Mann-Grandstaff Medical Center and Puget Sound Health Care  System. This process included forming EHR councils and convening  these councils at national and local workshops to make configuration  decisions used by VA’s contractor, Cerner, to configure the new EHR  system. The EHR councils also assessed the compatibility of the EHR  system with the processes VA clinicians and staff follow in delivering  care.

EHR councils. In fall 2018, VA’s EHRM program established 18 EHR  councils, based upon specific clinical and administrative areas, to make  VA-specific EHR system configuration decisions for these areas. Each  EHR council included subject-matter experts from VA, such as health  care providers in various clinical areas and other staff, as well as non-VA  participants from DOD and Cerner.

According to VA EHRM program officials, Cerner’s typical process for  configuring its EHR system was modified to accommodate VA’s needs,  which VA officials stated were more complex than those of Cerner’s  commercial clients. According to Cerner officials, Cerner does not  typically establish councils as part of its EHR system configuration  process.

National workshops. VA’s EHRM program planned and held eight  national workshops from November 2018 to October 2019, during which  members of all 18 EHR councils met to make standardized EHR system  configuration decisions for the VA health care system. VA’s EHRM  program utilized DOD’s version of the Cerner EHR system—MHS  Genesis—as its starting point for the EHR system configuration process.

During the workshops, Cerner assigned consultants to facilitate these workshops, who highlighted  Cerner’s commercial best practices and prepared workflow designs,  according to VA EHRM program and Cerner officials;  facilitated EHR system configuration decision discussions and noted  input from EHR council members and other session participants such  as DOD representatives; held sessions that involved members from different EHR councils for  system configuration decisions that required coordination between  councils. For example, the Business Operations Council and the  Ambulatory Council held joint sessions to address scheduling  appointments for oncology patients; was responsible for identifying and documenting recommendations for  EHR system configuration decision differences between VA sites, and  each medical facility specialty/department; and provided weekly progress updates to VA that reflected overall  progress of expected decisions to be completed compared to the  actual approved EHR system configuration decisions during national  workshops.

Over the course of the eight national workshops, EHR council members  were responsible for making EHR system configuration decisions in given clinical and  administrative areas and communicating them to Cerner; providing progress updates to VA’s EHRM program and VA  leadership; and notifying appropriate governing bodies (e.g., VHA program offices— such as the Office of Primary Care) of any local, state, federal, VISN,  and department policies that impact configuration decisions.

More specifically, each council discussed VA’s work processes and  documented relevant information that informed the configuration of the  EHR system, including:  (1) “workflows”—”process maps” that capture the start-to-finish sequence  and interactions of related steps, activities, or tasks for each work process  that VA medical facilities follow. For example, VA has a medication  administration workflow for describing the sequence of tasks needed for  scanning a patient’s wristband and administering medication. (See fig. 1.)  (2) “design decision matrices,” which are compilations of decisions and  discussion topics that identify and resolve workflow questions to inform  configuration decisions and support implementation of the EHR system.  For example, the medication administration design decision matrix  documents that clinicians should not be prevented from proceeding with  medication administration if a patient’s wristband cannot be scanned.  (See fig. 2.)  (3) “data collection workbooks,” which capture all of the data needed to  inform how the EHR system should be configured to support each  workflow, such as user privileges and preferences. For example, a data  collection workbook for medication administration includes data on user  preferences and prescribing privileges. (See fig. 3.)

The EHR system configuration decisions each council needed to make  varied significantly in quantity and topic. For example, the Ambulatory  Council, charged with focusing on primary care decisions, had over 200  EHR system configuration decisions to make, while the Behavioral Health  Council had about 100.

Once configuration decisions were made, the EHR councils assessed the  compatibility of the configuration of the Cerner EHR system with VA work  processes. To do so, VA’s EHR councils reviewed the capabilities of the  system and identified work processes that the Cerner EHR system did not  support (or only partially supported). For example, according to VA Mann- Grandstaff Medical Center staff, the Cerner EHR system did not originally  interface with VA’s Patient Centered Management Module, which  supports VA’s work processes for establishing provider-patient  relationships. However, in March 2020, VA EHRM officials told us that  the interface between the two systems would be available when the  Cerner EHR system is implemented at the Mann-Grandstaff VA Medical  Center, which was planned for July 2020. In addition, according to VA  EHRM officials, Cerner is in the process of developing EHR system  capabilities for prosthetics to support VA work processes. Furthermore,  according to VA EHRM officials, Cerner has been documenting and  tracking needed capabilities for EHR implementation and updating VA’s  EHRM program accordingly. According to EHRM program officials,  Cerner plans to include functionalities not available in capability set 1 in  either capability set 2 or future capability sets, although the development  of these capabilities is an ongoing process.

Although the eight national workshops have concluded, since October  2019, these EHR councils have continued to meet as necessary, virtually,  and in person, to complete capability set 1 and 2 configuration decisions.  According to Mann-Grandstaff VA Medical Center staff, as of February  2020, VA still needed to make EHR system configuration decisions to  address online prescription refills and assigning patients to primary care  panels.

Local Workshops. After standardized EHR system configuration  decisions were made at the national workshops, they were reviewed at  local workshops for site-specific needs. To do this, from December 2018  to October 2019, VA’s EHRM program held eight local workshops at each  of the initial operating capability sites—the Mann-Grandstaff VA Medical  Center and the VA Puget Sound Health Care System.

Local workshops allowed VA and Cerner to identify variances from  standardized EHR system configuration decisions made at the national  workshops as well as manual processes that needed to be accounted for  at local medical facilities. If variances were identified, Cerner reported  them to the appropriate EHR councils. While VA tried to minimize the  variances in system configuration decisions, in certain cases, necessary  alternatives to these configuration decisions were approved for local  medical facilities if practicable. For example, according to a Cerner  official, the national emergency room triage workflow originally called for  an emergency department registrar to register a patient; in response to  input from a local workshop, VA developed an alternative workflow, in  which an emergency department registered nurse completes the step if a  VA facility does not have an emergency department registrar. If there  were no variances, EHR system configuration decisions were approved  and reported to Cerner to configure the EHR system.

According to EHRM program officials, VA plans to hold local workshops in  advance of the Cerner EHR system implementation at future VA medical  facilities to focus on site-specific configuration decisions. Cerner will  continue to facilitate these future local workshop sessions and configure  the EHR system based on decisions made at these sessions. Figure 4  provides an overview of the EHR councils’ process for making system  configuration decisions.

VA Met Its Schedule for Making Initial EHR System Configuration Decisions, and Has Formulated a Schedule for Remaining Efforts VA Met Its Schedule for Making System Configuration Decisions for Capability Set 1

VA met its schedule for making EHR system configuration decisions for  capability set 1, which was scheduled for initial implementation at the  Mann-Grandstaff VA Medical Center in July 2020. In addition, VA has  formulated a schedule for remaining EHR system configuration decisions  for capability set 2, which it planned to implement at the VA Puget Sound  Health Care System in the fall of 2020.

Our review of VA progress data shows that VA met the schedule for  making EHR system configuration decisions it had established, which  required VA’s 18 EHR councils to make at least 70 percent of decisions  needed for capability set 1 by October 18, 2019. An EHRM program  official stated that this threshold was required to enable Cerner to  configure the EHR system for the Mann-Grandstaff VA Medical Center in  anticipation of the system’s initial implementation.

According to VA’s progress data, collectively, the 18 EHR councils met  the requirement to make at least 70 percent of their total expected EHR  system configuration decisions for capability set 1. Specifically, as of early  November 2019, VA data for EHR configuration decisions needed for  capability set 1 indicated that the EHRM program had developed:

877 of 966 (or 91 percent) of workflows;

1,397 of 1,412 (or 99 percent) of design decision matrices; and

1,364 of 1,610 (or 90 percent) of data collection workbooks.

After the EHR councils collectively met VA’s goal to make 70 percent of  EHR system configuration decisions by October 18, 2019, efforts  continued to make the remaining decisions for capability set 1. In March  2020, VA data indicated that, combined, the EHR councils had developed  an additional:

9 percent of workflows—874 of 878 (or nearly 100 percent);

1 percent of design decision matrices—1,459 of 1,467 (or nearly 100

10 percent of data collection workbooks—1,746 of 1,751 (or nearly  100 percent).  (See Appendix I for additional details on specific changes from November  2019 to March 2020 by EHR councils.)

As noted earlier, though the workshop process has concluded, a VA  EHRM program official stated that they had plans to hold virtual—over  teleconference or videoconference—meetings to allow the EHR councils  to make remaining EHR system configuration decisions for capability set  1 at the Mann-Grandstaff VA Medical Center, by March 2020.

VA Has Formulated a Schedule for Capability Set 2 Configuration Decisions

VA’s EHRM program has formulated a schedule for making EHR system  configuration decisions for capability set 2, which are necessary to  support the implementation of the Cerner EHR system at the VA Puget  Sound Health Care System planned for the fall of 2020. Specifically, VA’s  EHRM program is continuing to make EHR system configuration  decisions outside of the workshop process, which concluded in October  2019. Currently, EHRM program officials have plans to hold smaller  meetings, about a fourth of the size of the national workshops, to make  EHR configuration decisions that require input from multiple councils for  capability set 2.

According to EHRM program officials, the program set a goal of  developing capability set 2 workflows, design decision matrices, and data  collection workbooks by May 2020 so that the EHR councils could start  validating the system configuration decisions at that time. EHRM program  officials anticipate that this schedule for capability set 2 gives Cerner  enough time to configure the EHR system and establish a training  environment to enable implementation of the EHR system at the VA  Puget Sound Health Care System planned for the fall of 2020. According  to program officials, capability set 2 is composed of about 90 percent of  configuration decisions for capability set 1 and 10 percent of additional  workflows and data collection workbooks. These officials also told us that,  as part of the process of making capability set 2 configuration decisions,  they would determine the effectiveness of these decisions based on the  implementation of capability set 1 at the Mann-Grandstaff VA Medical  Center and make any necessary changes.

VA’s Decision-Making Procedures Were Generally Effective, but Key Stakeholders Were Not Always Included

VA’s EHRM program established EHR council decision-making  procedures that were generally effective. In addition, the councils  included a wide range of stakeholders, in terms of geographic  representation and representation from VA central office, VISNs, and  medical facilities. However, according to EHR council participants, VA did  not always ensure adequate representation at local workshops.

VA’s EHRM Program’s Decision-Making Procedures for EHR Councils Were Generally Effective

VA’s EHRM program’s decision-making procedures for the EHR councils  were generally effective as demonstrated by adherence to applicable  federal standards for internal control. According to these standards,  management should establish an organizational structure, assign  responsibility, and delegate authority to achieve the entity’s objectives.  In addition, according to our leading collaboration practices, clarity can  come from agencies working together to define and agree on their  respective roles and responsibilities and participating agencies should  document their agreement.

VA’s EHRM program established the organizational structure, assigned  responsibility, and delegated authority for system configuration decisions  to the EHR councils. Specifically, the EHRM program developed a charter  for the councils that outlined each council chair’s responsibility for managing council  membership and ensuring it is consistent with guidelines for broad  representation; outlined council member roles and responsibilities, such as  participating in face-to-face meetings and conferences, providing  subject matter expertise, and guiding EHR system configuration  decisions; and delegated authority for EHR system configuration decisions from the  EHRM Chief Medical Officer to the council chair and members.

According to EHRM program documentation, VA established decision- making authority at the lowest level possible, beginning with the EHR  councils, to ensure timely and appropriate decision-making. Based on our  observations of national council workshop meetings, if a council had  questions that involved coordination with another council, the Cerner  consultant present would take note of the issue and coordinate a meeting  with the relevant councils to discuss the issue. For example, participants  from the Ambulatory Council met with participants from the Rehabilitation  and Acute Clinical Ancillaries Council to discuss the EHR system  configuration decisions for ordering glasses and contacts.

Based on our review of the Functional Governance Board charter and  meeting minutes, when a decision required coordination and could not be  made at the EHR council level, it was identified and escalated to the  Functional Governance Board. The Functional Governance Board  provided guidance on addressing issues or, in turn, escalated unresolved  issues to the higher-level Governance Integration Board, or if appropriate,  to a joint VA and DOD coordination process. According to EHRM program  officials, as of February 2020, there were no issues escalated from the  Functional Governance Board to the Governance Integration Board  because the council governance structure strived to make decisions at  the lowest level possible. Figure 5 provides an overview of the EHRM  program’s decision-making procedures.

With respect to collaboration, because VA is using the same system as  DOD, VA has had to coordinate with DOD on some decisions. Although  both departments have procedures for configuring the Cerner EHR  system for their individual needs, VA EHRM program officials noted the  importance of coordinating to design a system that would allow sharing of  information and tasks between VA and DOD.

According to VA EHRM program officials, for example, VA and DOD  coordination is necessary for workflows pertaining to durable orders for  life-sustaining treatments—medical treatments intended to prolong the life  of a patient who would die soon without the treatment (e.g., artificial  nutrition and hydration, and mechanical ventilation). VA and DOD’s  practices differed on how to address such treatment, and Cerner’s  process did not accommodate VA’s need to maintain durable orders  across patient encounters, so they would not need to be re-written every  time a patient changed care setting or location. VA requested changes  to the Cerner EHR system to allow it to continue to follow its current  process for documenting life-sustaining treatments, but according to DOD  officials, the proposed changes did not align with DOD’s position on such  treatments, specifically resuscitation statuses. After multiple discussions  between the VA and DOD clinicians, the two departments plan to adopt  an interim solution.

According to VA and DOD officials, VA and DOD’s joint decision-making  body, the Functional Decision Group, has met weekly to address  coordination issues since early 2019. These officials said that the joint  Functional Decision Group determined whether it could make a decision,  or whether additional information was needed and a team should be  established to work on dispute resolution between the departments. VA  EHRM program officials said that the coordination procedures for the joint  Functional Decision Group would be formalized and that the roles and  responsibilities for coordination between VA and DOD would be clearly  defined, in response to a recommendation we made in a previous  report. Specifically, VA and DOD have developed a charter for the joint  Functional Decision Group, which was signed in April 2020.

According to EHR council participants, VA and DOD had been developing  their coordination procedures as system configuration decisions were  made, and decisions that required input from both departments may not  have been as timely as they could have been. According to EHRM  program officials, the departments ultimately were able to address most  decisions and coordination on remaining decisions was ongoing as of  March 2020.

VA’s EHRM Program Included a Wide Range of Participants at National and Local Workshops, but Did Not Always Ensure the Involvement of Key Stakeholders

VA’s EHRM Program Largely Met EHR Council Charter Goals for  Representation  VA generally included a wide range of stakeholders in its 18 EHR  councils. Specifically, VA was largely in line with its EHR councils’  charter goals to include about 60 percent of council members from the  field, with the remainder from the central office, and to have  representatives from a range of geographic locations and with sufficient  experience and expertise:

VA data show that EHR councils had about 58 percent (607 of 1,039)  of its members representing the field and about 40 percent (415 of  1,039) representing VA’s central office, roughly in line with VA’s  goals.

The councils included participants from a variety of geographic  regions, including each of its 18 VISNs, with the most participants  representing VISN 20, which oversees the two medical facilities where  the new EHR system is scheduled to be initially implemented.

Participants primarily represented the most complex level of VA  medical facilities. Specifically, VA data show that about 83 percent  (861 of 1,039) of participants represented level 1 VA medical facilities,  whereas about 3 percent (33 of 1,039) and 7 percent (75 of 1,039)  represented medium (level 2) and low (level 3) complexity VA medical  facilities, respectively. EHRM program officials said that the majority  of participants represented higher-complexity facilities because  participants were drawn from national experts and published authors,  and often performed VA-specific processes. Furthermore, smaller  medical centers had fewer resources so clinicians were more likely to  be needed to continue providing patient care at those facilities and  less likely to be available to serve on councils.

According to a voluntary questionnaire VA asked council participants  to complete, about 37 percent of the 304 participants who completed  the survey had at least 6 years of experience at VA; 29 percent had at  least 16 years of experience; and, 19 percent had more than 25 years  of experience.

In addition to participants from the VA, we observed that EHR council  national workshop meetings included participants from outside of the  department—such as clinicians from DOD sites and commercial  health care systems that had already implemented Cerner’s EHR  system. These participants provided support for discussions and  insight into industry best practices.

While the EHR councils included a wide range of participants, in  September and October 2019, council participants from both of the initial  operating capability sites raised concerns that the councils did not include  adequate representation from specialty areas at national workshop  meetings. Specifically, these officials said that an insufficient number of  specialty physicians, including pulmonologists and gastroenterologists,  were included. In addition, VA’s summary from the last workshop,  national workshop 8, observed that additional subject matter experts  representing medical specialties should be included in the EHR system  configuration decision process to enhance collaboration and decision- making.

EHRM program officials, including the Chief Medical Officer and  Ambulatory Council chairs, said they had not included certain specialists  and scheduled workshops on specialty areas, such as pulmonology and  gastroenterology as they decided to focus first on more foundational  decisions, such as those for primary care. Starting in November 2019,  following the completion of the eight national workshops, VA EHR  councils continued to meet, as necessary, to complete capability set 1  and 2 configuration decisions and had begun to include clinicians from  specialty areas in these meetings. VA plans to continue these meetings  through September 2020. VA’s approach of including clinicians from  specialty areas in ongoing configuration decision meetings is generally  consistent with our leading collaboration practice that agencies should  ensure that all relevant participants be included in any collaborative effort  they undertake.

By including relevant participants, the program increases the likelihood  that it has considered input from participants with unique knowledge,  skills, and abilities. Further, including relevant participants increases the  likelihood that when implemented, the EHR system will be properly  configured to meet the needs of clinicians, and effectively support their  efforts to deliver care.

VA’s EHRM Program Did Not Always Include Key Stakeholders at Its  Local Workshops  Local workshops at the Mann-Grandstaff VA Medical Center and VA  Puget Sound Health Care System did not always include representation  from relevant stakeholders, including facility clinicians and staff.  Specifically, multiple participants in the local workshop meetings,  including clinicians and department leads, at these facilities said that VA’s  EHRM program did not always effectively communicate information about  local workshop meetings to facility clinicians and staff to facilitate the  designation of staff to participate and ensure relevant representation at  local workshops. Local workshop participants stated that they did not  always know which local workshop meetings they needed to attend,  because they did not receive adequate information about the session  topics.

This is inconsistent with key collaboration practices identified in our prior  work to ensure that relevant participants be included in any collaborative  effort and that participating entities have agreed on common  terminology. Furthermore, standards for internal control in the federal  government call for effective communication and information sharing.

Local workshop participants, including clinicians and department leads  from medical facilities said that differences in the use of terminology  between VA and Cerner sometimes made it challenging to identify the  clinicians and staff that should attend local workshop meetings. For  example, some officials reported that they did not believe that a meeting  on “charge services” would be relevant to their work given that VA does  not typically bill veterans for services. However, they later learned that the  meeting actually covered topics beyond billing, such as capturing  workload data that was relevant to their work.

Because Cerner and VA did not always effectively communicate  regarding workshop content for local workshops, local workshops did not  always include all relevant stakeholders. As previously stated, VA plans  to hold local workshops in advance of the Cerner EHR system  implementation at future VA medical facilities. However, VA has not  indicated how it will improve the ways in which it describes the topics of  these workshops, including providing sufficient detail and defining key  terms. If VA improves communication on workshop meeting topics, the  EHRM program can increase the likelihood that it will obtain appropriate  input from facility clinicians and staff at local workshops to consider in  design decisions for the implementation of the EHR system.

VA met its schedule for making the needed system configuration  decisions that would enable the department to implement its new EHR  system at the first VA medical facility, which was planned for July 2020. In  addition, VA has formulated a schedule for making the remaining EHR  system configuration decisions before implementing the system at  additional facilities planned for fall 2020.

VA’s EHRM program was generally effective in establishing decision- making procedures that were consistent with applicable federal standards  for internal control. However, VA did not always ensure the involvement  of relevant stakeholders, including medical facility clinicians and staff, in  the system configuration decisions. Specifically, VA did not always clarify  terminology and include adequate detail in descriptions of local workshop  sessions to medical facility clinicians and staff to ensure relevant  representation at local workshop meetings. Participation of such  stakeholders is critical to ensuring that the EHR system is configured to  meet the needs of clinicians and support the delivery of clinical care.

We are making the following recommendation to VA:  For implementation of the EHR system at future VA medical facilities, we  recommend that the Secretary of VA direct the EHRM Executive Director  to clarify terminology and include adequate detail in descriptions of local  workshop sessions to facilitate the participation of all relevant  stakeholders including medical facility clinicians and staff.  (Recommendation 1)

We provided a draft of this report to VA and DOD for comment. In its  comments, reproduced in appendix II, VA concurred with our  recommendation and described steps that it planned to take to address it.  Specifically, VA noted that it planned and designed its workshops to  enable collaboration between clinical and administrative experts and end- users so that the EHR system is designed, validated, and configured to  promote interoperability and quality care for veterans. VA stated that it is  further refining local workshop agendas and descriptions to facilitate VA  subject matter expert identification and participation. VA also provided  technical comments on the report, which we incorporated as appropriate.  DOD provided technical comments on the report, which we incorporated  as appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Secretaries of VA and DOD, and other interested parties.  In addition, the report is available at no charge on the GAO website at  http://www.gao.gov.

If you or your staffs have any questions about this report, please contact  Debra A. Draper at (202) 512-7114 or DraperD@gao.gov or Carol C.  Harris at (202) 512-4456 or HarrisCC@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix III.

Appendix I: Status of Electronic Health Record System Configuration Decisions, as of November 2019 and March 2020

Data collection workbooks. All EHR councils completed at least 80 percent of expected data collection workbooks. Specifically, by November 2019, three of the 18 councils completed 100 percent of them and by March 2020, each of the councils had completed 100 percent of their data collection workbooks. Table 3 shows the number of data collection workbooks completed in comparison to the total expected for each of the 18 EHR councils based on data from November 13, 2019 and March 26, 2020.

Appendix III: GAO Contact and Staff Acknowledgments

In addition to the individuals named above, Mark Bird (Assistant Director),  Michael Zose (Assistant Director), Merry Woo (Analyst-in-Charge),  Bianca Eugene, and Paris Hawkins made key contributions to this report.  Also contributing were Jennie F. Apter, Giselle Hicks, Monica Perez- Nelson, and Ethiene Salgado-Rodriguez.

The Department of Veterans Affairs is replacing its outdated electronic health record system with a commercial system to better support patient care. VA held several workshops to allow stakeholders—clinicians, staff, and other experts—to weigh in on the configuration of the new software that will help it deliver care and administer medication.

While VA made its configuration decisions on time, it is assessing the impact of the COVID-19 pandemic on its planned implementation schedule. Our recommendation will help VA effectively communicate with key stakeholders to ensure they are involved in final decision-making for the modernized system.


Medicare and Medicaid: Alignment of Managed Care Plans for Dual-Eligible Beneficiaries

Congress authorized the establishment of D-SNPs in 2003 to address the unique needs of dual-eligible beneficiaries. For example, D-SNPs are required to provide certain specialized services targeted at the needs of dual-eligible beneficiaries, such as health risk assessments. D-SNPs must have approval of state Medicaid agencies to operate, and states can require D-SNPs to coordinate with Medicaid.

Congress included a provision in statute for GAO to review D-SNPs’ integration with state Medicaid programs. This report, among other objectives, (1) describes what is known about selected states’ experiences with aligned enrollment in D-SNPs, and (2) examines CMS’s oversight of aligned enrollment.

GAO reviewed relevant federal guidance and internal control standards. GAO also interviewed Medicaid officials in seven selected states and reviewed available documentation. The states (Arizona, Florida, Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) were selected, in part, for variation in experiences with aligned enrollment. GAO also interviewed officials from CMS, beneficiary groups, and companies that offered D-SNPs and Medicaid MCOs.

Dual-eligible beneficiaries are Medicare beneficiaries who are also enrolled in the Medicaid program in their state. In certain states, they may receive both types of benefits through private managed care plans. As of January 2019, about 386,000 such individuals were enrolled in both a private Medicare plan known as a dual-eligible special needs plan (D-SNP) and a Medicaid managed care organization (MCO) that were offered by the same or related companies. This arrangement, known as aligned enrollment, may create opportunities for better coordination between Medicare's acute care services and Medicaid's long-term services and supports, such as nursing facility care or personal care services.

Medicaid officials in seven selected states described challenges with aligned enrollment. One challenge cited by officials in six of the states was using D-SNP and Medicare data to implement and evaluate aligned enrollment. For example, officials in one state said they cannot separate D-SNP quality data for just their state, because some D-SNPs report data spanning multiple states to the Centers for Medicare & Medicaid Services (CMS). As of December 2019, CMS officials said they are determining the best way for D-SNPs to report these quality data.

CMS has assisted states with aligned enrollment, but lacks quality information on the experiences of dual-eligible beneficiaries who have aligned enrollment through a process known as default enrollment. With default enrollment, states allow automatic assignment of beneficiaries who are enrolled in a Medicaid MCO and are about to become eligible for Medicare to the D-SNP aligned with that MCO. However, CMS's monthly reports on default enrollment do not include information on beneficiaries who choose to disenroll in the first 90 days after being default enrolled, a time frame specified in regulation. According to one beneficiary group, some beneficiaries may disenroll, because they did not realize they were default enrolled and their provider is not in the D-SNP's network. Quality information on the experiences of dual-eligible beneficiaries after default enrollment would allow CMS to better identify the extent to which beneficiaries face challenges and to determine how, if at all, to address the challenges.

GAO recommends that CMS take steps to obtain quality information on the experiences of dual-eligible beneficiaries who have been default enrolled into D-SNPs. The Department of Health and Human Services concurred with the recommendation.

In 2017, about 12 million of Medicare’s over 61 million beneficiaries were  also enrolled in Medicaid. These individuals, known as dual-eligible  beneficiaries, are often in poorer health and require more care than other  Medicare and Medicaid beneficiaries. As such, in 2019, the Centers for  Medicare & Medicaid Services (CMS), which administers Medicare and  oversees Medicaid, established better care for dual-eligible beneficiaries  as one of its 16 strategic initiatives. Dual-eligible beneficiaries can face  challenges in dealing with the separate Medicare and Medicaid programs,  which have different or overlapping sets of benefits, provider networks,  and payment policies. For example, the Medicare program is generally  responsible for covering dual-eligible beneficiaries’ primary and acute  care, including hospitalizations and physician services, while state  Medicaid programs are generally responsible for covering their long-term  services and supports, such as nursing facility care or personal care  services. The fragmentation between these separate programs can lead  to poorly coordinated care for dual-eligible beneficiaries.

In certain states, dual-eligible beneficiaries may receive Medicare  benefits, Medicaid benefits, or both types of benefits through private  managed care plans. Like other Medicare beneficiaries, dual-eligible  beneficiaries can choose to enroll in Medicare Advantage (MA) plans,  which are the private plan alternative to traditional Medicare and generally  must cover all traditional Medicare benefits. In particular, as of January  2019, about 2.2 million dual-eligible beneficiaries in 42 states and the  District of Columbia had chosen to enroll in dual-eligible special needs  plans (D-SNP), which are a type of MA plan. Congress first authorized the  establishment of D-SNPs in 2003 to address the unique needs of dual- eligible beneficiaries. D-SNPs are required to provide certain specialized  services targeted at the needs of dual-eligible beneficiaries, such as  performing health risk assessments and creating individualized care  plans. Since January 2013, federal law has required all D-SNPs to have a  contract with each state in which it wants to operate. In addition, some  states require or allow Medicaid beneficiaries, including dual-eligible  beneficiaries, to receive their Medicaid benefits through a Medicaid  managed care organization (MCO).

The Bipartisan Budget Act of 2018 directed CMS to assist states that are  interested in using D-SNPs as a platform for integration with state  Medicaid programs, among other things. Some states have pursued  such integration through the use of an arrangement known as aligned  enrollment. Aligned enrollment occurs when a dual-eligible beneficiary is  enrolled in a D-SNP and Medicaid MCO that are offered by the same or  related companies. Some studies suggest that aligned enrollment may  create opportunities for the company or companies to better coordinate  care and integrate benefits, which may help prevent unnecessary  hospitalizations and institutionalizations.

The Bipartisan Budget Act of 2018 includes a provision for us to review  the integration between D-SNPs and state Medicaid programs. This  report  1.  describes what is known about the extent to which states have  encouraged aligned enrollment of dual-eligible beneficiaries in D- SNPs,  2.  describes what is known about selected states’ experiences with  3.  examines CMS’s role in and oversight of states’ use of aligned  enrollment.

To describe what is known about the extent to which states have  encouraged aligned enrollment of dual-eligible beneficiaries in D-SNPs,  we reviewed published materials from the Integrated Care Resource  Center (a CMS initiative to provide technical assistance, which is  operated by contractors) and others. To corroborate this information, we  interviewed officials from CMS, the Integrated Care Resource Center, and  Medicaid agencies in seven selected states. We selected the seven  states (Arizona, Florida, Kansas, New Jersey, Pennsylvania, Tennessee,  and Virginia) based on the variation in their experiences with aligned  enrollment in D-SNPs, the number of D-SNP enrollees, and their length of  time using a managed care delivery system to provide long-term services  and supports in Medicaid, also referred to as managed long-term services and supports (MLTSS). We limited our scope to states with MLTSS, in  part, because about 80 percent of Medicaid spending on relevant dual- eligible beneficiaries was for long-term services and supports in 2013, the  most recent year such data were available. We reviewed the selected  states’ contracts with D-SNPs and other available documentation to  corroborate evidence gathered in these interviews. We also received data  on aligned enrollment from five of the seven selected states. We  assessed the reliability of the state-reported data by checking for internal  consistency and comparing the state-reported data to published  information, and we determined the data were sufficiently reliable for the  purposes of this report.

To describe what is known about selected states’ experiences with  aligned enrollment, we interviewed Medicaid officials in each of the seven  selected states and CMS officials. In addition, we reviewed available  documentation to corroborate officials’ statements. To supplement this  information, we interviewed seven beneficiary groups, which included  nonprofit organizations, State Health Insurance Assistance Programs in  two of our seven selected states, and the long-term care ombudsman in  one selected state. We also interviewed three companies that offered D- SNPs and Medicaid MCOs, and these companies varied in their number  of D-SNP enrollees and number of selected states served. The  perspectives of the Medicaid officials and other groups interviewed in the  seven selected states are not generalizable, but provided us with valuable  insight on states’ experiences with aligned enrollment.

To examine CMS’s role in and oversight of states’ use of aligned  enrollment, we reviewed CMS’s policies and procedures on D-SNPs and  aligned enrollment and assessed them against federal internal control  standards related to information and communication. We also interviewed CMS officials, Medicaid officials in each selected state,  beneficiary groups, and companies that offered D-SNPs and Medicaid  MCOs, as previously discussed.

We conducted this performance audit from February 2019 to March 2020  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.

Medicare and Medicaid Coverage for Dual-Eligible Beneficiaries

Dual-eligible beneficiaries qualify for both Medicare and Medicaid, and  may enroll in and receive benefits covered by each program. Individuals  ages 65 or older can qualify for Medicare based on age, and individuals  ages 18 to 64 can qualify for Medicare based on disability. Medicaid  eligibility varies by state, but beneficiaries may qualify based on having a  low level of income, a need for nursing home care, high medical  expenses, or other criteria.

For dual-eligible beneficiaries, Medicare is the primary payer for any  benefits covered by both programs. As a result, Medicare is the primary  payer for acute and post-acute care, such as physician services,  hospitalizations, prescription drugs, and skilled nursing facility care. For  many dual-eligible beneficiaries, Medicaid covers benefits not covered by  Medicare. This includes long-term services and supports, which may  include nursing home care, personal care services, or adult day care.  Whether Medicaid covers these benefits varies between the two main  categories of dual-eligible beneficiaries. Those in the first category are  known as full-benefit, dual-eligible beneficiaries, because they may  receive all Medicaid benefits, in addition to Medicare benefits. Medicaid  also pays for their Medicare premiums and, in some cases, the cost- sharing for their Medicare benefits. Those in the second category are  known as partial-benefit, dual-eligible beneficiaries, because Medicaid  assistance is limited to payment of their Medicare premiums and, in some  cases, the cost-sharing for their Medicare benefits. Partial-benefit, dual- eligible beneficiaries have limited income and assets, but their income  and assets are not low enough to qualify them for full Medicaid benefits in  their state.

For Medicare, dual-eligible beneficiaries can choose to receive their  Medicare services from either traditional Medicare or from MA plans.  These options differ in key ways. For example, traditional Medicare may  have a more extensive provider network than MA plans. However, MA  plans may cover additional benefits, such as vision or dental care, which  are generally not covered under traditional Medicare. If dual-eligible  beneficiaries choose to enroll in MA plans, they may also have the choice  between regular MA plans and D-SNPs, which offer certain services  targeted at the needs of dual-eligible beneficiaries. For example, D-SNPs  are required to perform health risk assessments, create individualized  care plans, and provide an interdisciplinary care team for each beneficiary  enrolled. They may also cover transportation services, home  modifications, or other specialized services that are more likely to be used  by dual-eligible beneficiaries.

For Medicaid, states may allow or require Medicaid beneficiaries,  including dual-eligible beneficiaries, to receive their Medicaid benefits  through an MCO. In this managed care model, Medicaid MCOs are  responsible for arranging for and paying providers’ claims for a specific  set of Medicaid benefits provided to beneficiaries. More recently, some  states have created new Medicaid managed care programs or expanded  the benefits covered by existing Medicaid managed care programs in  order to include additional populations previously covered through  Medicaid fee-for-service. The new populations include seniors, persons  with disabilities, and those who need long-term services and supports— many of whom may be dually eligible.

Aligned Enrollment in D- SNPs in States with MLTSS

A dual-eligible beneficiary may be able to enroll in a D-SNP and Medicaid  MCO that are offered by the same or related companies, an arrangement  known as aligned enrollment. In states with MLTSS, aligned enrollment  means the same or related companies provide a beneficiary’s Medicare  benefits, such as primary and acute care, through a D-SNP and Medicaid  benefits, such as long-term services and supports, through a Medicaid  MCO.

State Medicaid agencies enter into contracts with both D-SNPs and  Medicaid MCOs, and these contracts may include provisions to facilitate  and encourage aligned enrollment. Since January 2013, all D-SNPs have  been required to have an executed contract with the Medicaid agency in  each state in which it operates. A state can enter into contracts with all,  some, or none of the D-SNPs seeking to operate in the state, and any D- SNPs that the state declines to contract with cannot operate in the state.  Each year, CMS reviews D-SNPs’ contracts with states to ensure that  they include eight required elements, including the D-SNP’s responsibility  for providing or arranging the provision of Medicaid benefits, among other  things. According to CMS officials, in these reviews, CMS does not  collect information regarding whether states are imposing requirements  pertaining to aligned enrollment. States also have contracts with Medicaid  MCOs, which can include requirements that could facilitate or encourage  aligned enrollment.

As shown in table 1, CMS’s Integrated Care Resource Center has  identified five types of approaches that states can use to encourage  aligned enrollment. For example, states can manage which D-SNPs  operate in the state, such as only allowing D-SNPs with an aligned  Medicaid MCO (that is, a MCO offered by the same company or a related  company). This gives dual-eligible beneficiaries greater options for  choosing aligned enrollment. As another example, states can allow the  automatic assignment of certain dual-eligible beneficiaries to a D-SNP  aligned with a Medicaid MCO, a process known as default enrollment.  Default enrollment, which requires CMS approval, can directly increase  the number of dual-eligible beneficiaries with aligned enrollment.

Coordinated Care for Dual-Eligible Beneficiaries Inside and Outside of D- SNPs

In addition to D-SNPs with aligned enrollment, two other types of  Medicare plans—Medicare-Medicaid plans and Program of All-Inclusive  Care for the Elderly plans—exclusively or primarily serve dual-eligible  beneficiaries and are responsible for both Medicare and Medicaid  benefits. These three types of Medicare plans jointly served  approximately 818,000 dual-eligible beneficiaries as of January 2019.

Aligned enrollment in D-SNPs: As of January 2019, approximately  386,000 dual-eligible beneficiaries enrolled in D-SNPs had aligned  enrollment, according to a report by the Medicare Payment Advisory  Commission. This includes beneficiaries in a subset of D-SNPs that  have been designated as fully integrated D-SNPs, which must meet  additional specific requirements. For example, they must provide both  Medicare and Medicaid benefits through a single managed care plan.  In addition, the Medicaid benefits provided by the fully integrated D- SNPs must include long-term services and supports.

Medicare-Medicaid plans: As of January 2019, approximately  388,000 dual-eligible beneficiaries in nine states were enrolled in  these types of plans. These plans, which were established through  CMS’s Financial Alignment Initiative, provide all Medicare benefits  and all or almost all Medicaid benefits, and have some administrative  processes that have been combined. In April 2019, CMS sent a  letter to state Medicaid directors inviting additional states to express  interest in the use of Medicare-Medicaid plans.

Program of All-Inclusive Care for the Elderly plans: As of January  2019, approximately 44,000 beneficiaries in 31 states were enrolled in  these types of plans. Most, but not all, are full-benefit, dual-eligible  beneficiaries, and they are ages 55 or older and need the level of care  provided in a nursing home. The plans are provider-sponsored and  provide all Medicare and Medicaid benefits. In addition, each plan is  required to have a physical site to provide adult day services.

Most States that Can Encourage Aligned Enrollment Have Begun to Do So

As of July 2019, of the 19 states with MLTSS and where aligned  enrollment of dual-eligible beneficiaries in D-SNPs is possible, 16 have  implemented at least one of the five approaches to encourage aligned  enrollment identified by CMS’s Integrated Care Resource Center. (See  fig. 1.) Of those 16 states, 11 managed which D-SNPs operate in the  state, which is the foundation for promoting aligned enrollment, according  to officials from the Integrated Care Resource Center.

Of our seven selected states, all of them had implemented at least one of  the five approaches to encourage aligned enrollment in 2019. The three  most common approaches among our selected states were (1) managing  which D-SNPs operate in the state; (2) limiting D-SNP enrollment to full- benefit, dual-eligible beneficiaries; and (3) encouraging D-SNP marketing  to better support informed beneficiary decision-making. The details of the  approaches implemented in each state varied widely.

Managing which D-SNPs operate in the state. Five of the seven  selected states (Arizona, New Jersey, Pennsylvania, Tennessee, and  Virginia) managed which D-SNPs operated in 2019, but they varied in  how they implemented this approach. For example, when Virginia  established its Medicaid MLTSS program in 2017, only one D-SNP  operated in the state, and Virginia required the companies with Medicaid  MLTSS contracts to also start offering D-SNPs within 3 years. In contrast,  when Pennsylvania and Tennessee implemented this approach, multiple  D-SNPs already operated in each state. Pennsylvania and Tennessee  required new D-SNPs to have aligned Medicaid MCOs, but allowed  existing D-SNPs to continue operating. As a result, beneficiaries had the  choice between D-SNPs that had aligned Medicaid MCOs and D-SNPs  that did not have aligned Medicaid MCOs. Medicaid officials in these two  states told us they chose not to cancel existing D-SNPs that did not have  aligned Medicaid MCOs, as doing so could have disrupted beneficiary- provider relationships.

As a result of the selected states’ differing approaches to managing which  D-SNPs operated, the proportion of aligned to unaligned D-SNPs in each  state varied. (See fig. 2.)

Limiting D-SNP enrollment to full-benefit, dual-eligible beneficiaries.  Five of the selected states (Arizona, Kansas, New Jersey, Pennsylvania,  and Virginia) limited D-SNP enrollment in some or all of their D-SNPs to  full-benefit, dual-eligible beneficiaries in 2019. In particular, Arizona and  New Jersey Medicaid officials said that limiting D-SNP enrollment to full- benefit, dual-eligible beneficiaries allowed D-SNPs to provide a more  straightforward benefit package. In turn, this can be more easily  described in D-SNP materials and communications, which may help  beneficiaries to make more informed decisions around aligned  enrollment.

Encouraging D-SNP marketing to better support informed  beneficiary decision-making. Five of the selected states (Arizona, New  Jersey, Pennsylvania, Tennessee, and Virginia) took steps to encourage  D-SNP marketing to support informed beneficiary decision-making in  2019. For example, Arizona and Pennsylvania encouraged D-SNPs to  directly market themselves to beneficiaries in the D-SNP’s aligned  Medicaid MCO, in order to promote aligned enrollment. In addition, New  Jersey Medicaid officials told us they review D-SNP marketing and work  directly with D-SNPs to develop standard marketing language. In  particular, the officials said some D-SNPs had marketed themselves as  offering certain extra benefits, but those benefits were already a standard  part of the state’s Medicaid package. The officials said they worked with  the D-SNPs to correct the marketing, and they also developed standard  language for marketing in the state. This can help reduce beneficiary  confusion when making enrollment decisions.

Automatically assigning certain beneficiaries to plans with aligned  enrollment. Four selected states (Arizona, Florida, Pennsylvania, and  Tennessee) allowed automatic assignment of certain beneficiaries to  plans with aligned enrollment in 2019. For example, Arizona,  Pennsylvania, and Tennessee allowed default enrollment by which  certain Medicaid beneficiaries were automatically assigned to aligned D- SNPs. Under federal rules, beneficiaries have the opportunity to opt out  prior to being default enrolled and select a different source of Medicare  coverage; they also have the opportunity to disenroll within the first 90  days after default enrollment and select a different source of Medicare  coverage.

In addition, Florida and Pennsylvania automatically assigned certain dual- eligible beneficiaries to aligned Medicaid MCOs. For example, Florida law  requires the state Medicaid agency to automatically assign certain D-SNP  enrollees to aligned MLTSS plans when beneficiaries become eligible for  long-term services and supports and have not voluntarily chosen an  MLTSS plan.

Engaging counselors to assist beneficiaries with aligned enrollment  decisions. Two of the seven selected states (Arizona and Pennsylvania)  engaged enrollment counselors to encourage aligned enrollment in 2019.  For example, Arizona’s state Medicaid office works with the state’s Aging  and Disability Resource Center and State Health Insurance Assistance  Program counselors to increase beneficiary understanding of aligned  enrollment and options to enroll in aligned plans. In 2019, Pennsylvania’s  contracts with D-SNPs required collaboration between the D-SNPs and  the state’s independent enrollment broker that assists beneficiaries with  Medicaid enrollment.

In addition to there being variation in the selected states’ use of  approaches to encourage aligned enrollment, the proportion of D-SNP  enrollees with aligned enrollment varied from 20 percent in Pennsylvania  to 100 percent in New Jersey among the selected states that were able to  provide data for 2019. (See fig. 3.) There can be multiple reasons for the  varied levels of aligned enrollment between D-SNPs and MLTSS. For  example, Arizona recently entered into new Medicaid MCO contracts, and  this resulted in changes to the parts of the state served by each Medicaid  MCO. According to state Medicaid officials, these new contracts  somewhat reduced the extent of aligned enrollment.

Medicaid Officials in Selected States Described Challenges with Aligned Enrollment

Medicaid officials in the seven selected states described various  challenges with aligned enrollment. The most common challenge  mentioned was difficulty using D-SNP data to implement and evaluate  aligned enrollment policies. Medicaid officials in the selected states told  us many of these challenges require ongoing monitoring and  collaboration with CMS and the companies offering D-SNPs.

Difficulty using data to implement and evaluate aligned enrollment.  Medicaid officials in six of the selected states (Florida, Kansas, New  Jersey, Pennsylvania, Tennessee, and Virginia) told us that using D-SNP  and Medicare data to implement and evaluate aligned enrollment policies  can be difficult. For example, Tennessee Medicaid officials told us that  getting the data from CMS needed for default enrollment was a challenge.  In particular, they said that, when the state was first starting to implement  default enrollment, they had challenges with getting data from CMS in a  timely fashion to identify which Medicaid beneficiaries were about to  become dually eligible for Medicare, particularly those with eligibility due  to disability. This meant that the state could not provide D-SNPs with  the information needed by the D-SNPs to send notices to those  beneficiaries in the required time frame. CMS officials also  acknowledged that its data do not always identify individuals becoming  eligible for Medicare early enough for D-SNPs to send notices in the  required time frame. Tennessee Medicaid officials told us that CMS has  worked with the state on this issue and it has now become easier for the  state to receive the needed data. Furthermore, CMS and its Integrated  Care Resource Center have also developed materials and, according to  CMS officials, provided ongoing technical assistance for states on  accessing data for default enrollment and other aspects of  implementation of aligned enrollment.

Medicaid officials in Virginia and New Jersey described related  challenges with using D-SNP data to determine whether their policies  work. Virginia Medicaid officials told us that it can be difficult to evaluate  the health benefits of aligned enrollment, because data on quality  measures can span multiple states. Specifically, one of the state’s D- SNPs operates in multiple states and therefore reports health outcome  data to CMS for its entire service area. Virginia Medicaid officials told us  they are not able to separate data for Virginia residents from those of  other states. As a result, they said they currently cannot determine the  effect of their aligned enrollment policies, and they plan to require the D- SNP to report Virginia-specific quality data in the future. New Jersey  Medicaid officials described a challenge with receiving the relevant data  to evaluate health outcomes for dual-eligible beneficiaries with aligned  enrollment. The state has CMS approval to receive Medicare data directly  from CMS. However, as of November 2019, the state’s data vendor was  not in compliance with federal Medicare data security requirements for  storing certain data, which meant that the state could not accept the  Medicare data.

The Bipartisan Budget Act of 2018 encourages CMS to require reporting  of MA quality measures, including D-SNP quality measures, at the plan  level. However, CMS has identified several challenges to developing  such a requirement. One challenge CMS has identified is that about two- thirds to three-quarters of D-SNPs would not have reliable ratings, for  example, because those plans had too few participants in the survey.  Another challenge CMS has identified is the additional complexity and  administrative burden for plans completing this reporting. As of December  2019, CMS officials told us they are continuing to work to determine the  best reporting level for each quality measure. They also plan to collect  additional feedback from stakeholders and a technical expert panel.

Difficulties with information dual-eligible beneficiaries receive about  Medicare enrollment choices. Medicaid officials in five of the selected  states (Kansas, New Jersey, Pennsylvania, Tennessee, and Virginia) told  us they have experienced challenges in ensuring that beneficiaries  receive quality information about their Medicare enrollment choices. For  example, in 2019, Pennsylvania’s contracts with D-SNPs required  collaboration between the D-SNPs and the state’s independent  enrollment broker that assists beneficiaries with Medicaid enrollment.  However, Pennsylvania Medicaid officials told us the state’s independent  enrollment broker did not have the capacity to provide this type of  assistance in addition to its primary responsibility of assisting  beneficiaries with Medicaid enrollment.

As another example, Virginia Medicaid officials told us they have faced  challenges using state D-SNP contracts to regulate D-SNP marketing.  They told us that certain provisions in the state’s contracts with D-SNPs  were intended to regulate the extent of D-SNP marketing in 2019. In  particular, each D-SNP was supposed to only market to beneficiaries  enrolled in that D-SNP’s aligned Medicaid MCO, which was intended to  increase the extent of aligned enrollment in the state. However, state  Medicaid officials told us that D-SNPs had different interpretations of the  contract provisions, and one D-SNP had billboards and television  advertisements available to the general public. Due to the difficulty of  enforcement, among other reasons, Virginia Medicaid officials told us  they chose to not include these provisions in the D-SNP contracts for  2020.

Through the Integrated Care Resource Center, CMS has developed  materials describing how states can regulate D-SNP marketing in their  contracts with D-SNPs, and the agency reviews and may disapprove D- SNP marketing materials that do not follow federal requirements. CMS  officials also told us they make themselves available to states to explain  how to include marketing restrictions in the contracts that states have with  D-SNPs.

Limits of staff knowledge. Medicaid officials in four of the selected  states (Florida, Kansas, New Jersey, and Pennsylvania) told us that  limited staff knowledge of Medicare presents a challenge. For example,  Medicaid officials in Kansas told us only one or two staff in the state’s  Medicaid agency are knowledgeable about Medicare and would have the  knowledge to implement aligned enrollment approaches. Similarly,  Medicaid officials in Florida said they only recently learned about one of  the approaches for encouraging aligned enrollment, which is that the  state can decline to contract with certain D-SNPs. In addition, New Jersey  and Pennsylvania Medicaid officials told us staff knowledge of Medicare  is limited and that they would like to increase their level of knowledge as  they continue to foster aligned enrollment.

Competition from look-alike MA plans targeted to dual-eligible  beneficiaries. Medicaid officials in four of our selected states (Arizona,  Pennsylvania, Tennessee, and Virginia) identified certain MA plans that  are so-called “look-alike” plans to the D-SNPs, which create a potential  challenge to fostering aligned enrollment. According to CMS, look-alike  plans are MA plans that are designed for and marketed exclusively to  dual-eligible beneficiaries, but that are not D-SNPs. Therefore, look-alike  plans do not need a contract with the state to operate and do not have to  comply with state approaches that foster aligned enrollment.

Medicaid officials from our selected states and the Medicare Payment  Advisory Commission gave examples of the impact of look-alike plans.  For example, Tennessee Medicaid officials told us that dual-eligible  beneficiaries in look-alike plans do not receive care coordination between  Medicare and Medicaid, in contrast with dual-eligible beneficiaries in D- SNPs, which are required to provide such coordination. In addition,  Arizona Medicaid officials told us that look-alike plans have affected  levels of aligned enrollment in the state. Similarly, according to the  Medicare Payment Advisory Commission, look-alike plans can undermine  states’ efforts to develop D-SNPs that integrate Medicare and Medicaid  by encouraging dual-eligible beneficiaries to instead enroll in look-alike  plans.

CMS has also identified look-alike plans as a challenge and is  considering some steps in response. In 2018, CMS revised its marketing  guidelines to prohibit look-alike plans from marketing themselves as  designed for dual-eligible beneficiaries and as having a relationship with  the state Medicaid agency. In its April 2019 policy update for MA plans,  CMS said that look-alike plans enable companies to offer plans that  circumvent state and federal requirements for D-SNPs, which undermines  efforts to improve the quality of care. In February 2020, CMS published  a proposed rule that, if finalized, would prohibit the offering of MA plans  whose enrollment of dual-eligible beneficiaries exceeds specific projected  or actual enrollment thresholds in states with a D-SNP. According to  CMS, this would prevent look-alikes from undermining the statutory and  regulatory framework for D-SNPs.

Extent of overlapping provider networks. Medicaid officials in two of  our selected states (Pennsylvania and Tennessee) reported challenges  with aligned D-SNPs and Medicaid MCOs that do not have completely  overlapping networks of relevant providers. That is, even though the D- SNP and Medicaid MCO are offered by the same or related companies,  certain providers may be in only the D-SNP network or only the Medicaid  MCO network—but not both. For example, representatives from a  beneficiary group in Pennsylvania told us that a dual-eligible beneficiary’s  provider may be in the Medicaid MCO network, but not the D-SNP  network. This can disrupt that beneficiary’s continuity of care if he or she  is default enrolled into the D-SNP. There are no requirements for the  state or D-SNP to ensure that a beneficiary’s primary care provider is in  the D-SNP into which he or she is default enrolled. CMS’s model for the  notice sent to beneficiaries identified for default enrollment suggests (but  does not require) that the D-SNP include information on whether or not  the beneficiary’s primary care provider is in the D-SNP’s network.

CMS officials said they did not know of any complaints the agency has  received on the issue. They also said they have not analyzed how the  provider network of a D-SNP compares to the provider network of its  aligned Medicaid MCO. Furthermore, in the preamble to the default  enrollment final rule issued in April 2018, CMS said that it did not include  any criteria related to provider networks, but that network adequacy  requirements would apply and states can use their contracts with D-SNPs  to create requirements for continuity of care. One state that does this is  Tennessee, which specifically requires D-SNPs to develop provider  networks that have substantial overlap with the provider network of their  aligned Medicaid MCOs. The state also requires D-SNPs to ensure  continuity of care for beneficiaries who have been default enrolled. For  example, Tennessee Medicaid officials said that if a beneficiary who has  been default enrolled has a long-standing primary care provider with the  D-SNP’s aligned Medicaid MCO, the state requires the D-SNP to  continue covering services by that provider for at least 30 days and to  attempt to contract with the provider.

CMS Has Assisted States with Aligned Enrollment, but Lacks Quality Information on the Experience of Beneficiaries Whose Aligned Enrollment Was Due to Default Enrollment

CMS has assisted states with aligned enrollment. In particular, CMS has  provided technical assistance to states on implementing the various  approaches that encourage aligned enrollment. One way that CMS has  done this is through its Integrated Care Resource Center, which has  developed materials on how states can use their contracts with D-SNPs  to align enrollment and promote integration. The Integrated Care  Resource Center has also facilitated peer-to-peer assistance between  states. For example, Integrated Care Resource Center officials said they  facilitated conversations and assistance between state Medicaid officials  in New Jersey and Pennsylvania on D-SNP marketing. Medicaid officials  in six of our selected states said they had utilized CMS’s technical  assistance, and they had overall positive views of CMS’s assistance.

CMS reviews some aspects of the contracts between states and D-SNPs,  including checking that the contracts include the eight required elements.

According to CMS officials, in these reviews, CMS does not collect  information regarding whether states are imposing requirements  pertaining to aligned enrollment. CMS’s program audits of MA plans  similarly do not include reviews of such state requirements pertaining to  aligned enrollment.

CMS has a direct role with one aspect of aligned enrollment: default  enrollment. In particular, CMS approves D-SNPs to receive beneficiaries  through default enrollment, and it processes the enrollment transactions  of beneficiaries being default enrolled.

D-SNPs’ approval for default enrollment: Before a D-SNP can  receive beneficiaries through default enrollment, it must submit a  proposal to CMS for approval. CMS reviews the D-SNP’s proposal  and checks that the D-SNP meets an established list of requirements  outlined in regulation. Among other requirements, the D-SNP must  demonstrate it has the state’s support for default enrollment and that  the required elements have been included in its template for the  notice that is sent to beneficiaries identified for default enrollment.  CMS also checks that the D-SNP is not facing any CMS enrollment  sanctions and that the D-SNP has a quality rating of three or more  stars. CMS grants approval for up to 5 years if it determines the D- SNP meets these requirements.

Default enrollment transactions: CMS processes the enrollment  transactions of dual-eligible beneficiaries being default enrolled, and it  tracks these transactions in a monthly report. The monthly report lists  the total number of beneficiaries identified for default enrollment for  each applicable D-SNP, and the report lists numbers for certain  subsets of beneficiaries who were ultimately not default enrolled.  These subsets include beneficiaries who opted out prior to being  default enrolled and beneficiaries whose default enrollment was not  allowed by CMS for various reasons.

Despite its direct role in default enrollment, CMS lacks quality information  on the experiences of dual-eligible beneficiaries after they are default  enrolled. This is inconsistent with federal internal control standards on  information and communication, which state that management should use  quality information to achieve the agency’s objectives. In particular, the  monthly reports on enrollment transactions do not include data on the  extent to which dual-eligible beneficiaries choose to disenroll after being  default enrolled. Although the reports include data on the number of  beneficiaries who opt out prior to being default enrolled (which CMS  officials said was low), they do not include data on beneficiaries who  choose to disenroll in the first 90 days after being default enrolled. This  90-day time frame for disenrollment is specified by federal regulation, and  beneficiaries may choose to disenroll for various reasons. For example,  one reason for disenrollment given by one beneficiary group we  interviewed is that some beneficiaries may not realize they have been  default enrolled into a D-SNP until they next see their provider, and that  provider may not be in the D-SNP’s provider network. They said that  beneficiaries may not have seen the notice or other information about  being default enrolled, or they may not have understood the information.  In addition, CMS cannot systematically review beneficiary complaints for  trends or concerns related to default enrollment. Dual-eligible  beneficiaries, like other Medicare beneficiaries, can submit complaints to  CMS. These complaints are entered in the agency’s complaint tracking  module, and D-SNP account managers, like other MA plan account  managers, are responsible for monitoring complaints. CMS officials said  that the D-SNP account managers have not identified any trends or  concerns about default enrollment. However, CMS officials said default  enrollment is not tracked as a distinct category in the complaint tracking  module, and the guidance on monitoring complaints that is provided to  the D-SNP account managers does not direct them to look for issues  explicitly related to default enrollment. Quality information on the  experiences of dual-eligible beneficiaries after they are default enrolled  would allow CMS to better identify the extent to which these beneficiaries  face challenges as a result of default enrollment and to determine how, if  at all, to address the challenges.

Future studies may provide CMS with additional information on  beneficiaries in D-SNPs with aligned enrollment, but that information will  not be available until 2022 or later. In particular, federal law directs the  Medicare Payment Advisory Commission, in consultation with the  Medicaid and CHIP Payment and Access Commission, to compare the  quality of the different types of D-SNPs, including those with aligned  enrollment, as well as comparing them to other types of plans. The  commission is to develop an initial report by 2022 with subsequent  reports afterward.

Better care for dual-eligible beneficiaries is one of CMS’s strategic  initiatives, and the agency has supported states’ decisions to encourage  aligned enrollment in order to encourage better coordination of care.  However, CMS lacks quality information on the experiences of  beneficiaries who have aligned enrollment as the result of the use of  default enrollment. For example, CMS’s monthly reports on default  enrollment do not include data on beneficiaries who choose to disenroll  after being default enrolled. CMS lacks this information even though  selected states and others have reported challenges that could affect the  care received by those beneficiaries. Quality information on the  experiences of these dual-eligible beneficiaries would allow CMS to better  identify the extent to which beneficiaries are facing challenges as a result  of default enrollment and to determine how, if at all, to address those  challenges.

We are making the following recommendation to CMS:  The Administrator of CMS should take steps to obtain quality information  on the experiences of dual-eligible beneficiaries who have been default  enrolled into D-SNPs, such as by obtaining information about the extent  to which and reasons that beneficiaries disenroll from a D-SNP after  being default enrolled. (Recommendation 1)

We provided a draft of this report to the Department of Health and Human  Services (HHS) for comment. In its comments, reproduced in appendix I,  HHS concurred with our recommendation. HHS stated that it is committed  to increasing the number of dual-eligible beneficiaries in integrated care  and that it supports states with these efforts, such as the use of aligned  enrollment. HHS also said that it has not identified any trends or areas of  concern in its monitoring of beneficiaries who opted out prior to being  default enrolled. In response to our recommendation, HHS stated it will  evaluate opportunities to obtain more information on dual-eligible  beneficiaries who disenroll from a D-SNP after being default enrolled.  HHS also provided technical comments, which we incorporated as  appropriate.

We are sending copies of this report to the appropriate congressional  committees, the Administrator of the Centers for Medicare & Medicaid  Services, and other interested parties. In addition, the report is 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 cosgrovej@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix II.

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

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Martin T. Gahart (Assistant  Director), Corissa Kiyan-Fukumoto (Analyst-in-Charge), Jason Coates,  Kelly Krinn, Virginia Lefever, Drew Long, Jennifer Rudisill, and Ethiene  Salgado-Rodriguez made key contributions to this report.

Medicare and Medicaid: Additional Oversight Needed of CMS’s  Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries.  GAO-16-31. Washington, D.C.: December 18, 2015.

Disabled Dual-Eligible Beneficiaries: Integration of Medicare and  Medicaid Benefits May Not Lead to Expected Medicare Savings.  GAO-14-523. Washington, D.C.: August 29, 2014.

Medicare and Medicaid: Consumer Protection Requirements Affecting  Dual-Eligible Beneficiaries Vary across Programs, Payment Systems, and  States. GAO-13-100. Washington, D.C.: December 5, 2012.

Medicare Special Needs Plans: CMS Should Improve Information  Available about Dual-Eligible Plans’ Performance. GAO-12-864.  Washington, D.C.: September 13, 2012.

Medicare and Medicaid: Implementing State Demonstrations for Dual  Eligibles Has Proven Challenging. GAO/HEHS-00-94. Washington, D.C.:  August 18, 2000.

Eligible for both Medicare and Medicaid? In certain states you can get coverage from both programs through “aligned plans,” that is, private plans provided by the same or related companies. This arrangement is intended to better coordinate benefits and care delivery.

Some states support the automatic assignment of “dual-eligible” beneficiaries to aligned plans. Finding out more about these beneficiaries’ experiences could help the Centers for Medicare & Medicaid Services determine whether this practice poses any challenges to coordinating care.

We recommended collecting information on the experiences of beneficiaries assigned to aligned plans.