Despite Challenges Converting State Data to the T-MSIS Format, Nearly All States are Reporting T-MSIS Data, and CMS Has Shifted Its Focus to Improving Data Quality

Despite challenges converting their data to the T-MSIS format, most  states were reporting T-MSIS data as of November 2017, representing  significant progress over the past year. Overall, 49 States Are Reporting T-MSIS Data; Selected States Identified Converting their Data into the T-MSIS Format as a Significant Reporting Challenge

As of November 2017, 49 states have begun reporting T-MSIS data, a  significant increase from the 18 states that had started reporting these  data in October 2016. 1.) However, for  other data elements, the conversion process was more complex,  requiring states to expand or collapse their data to match the T-MSIS  format. 2.) In addition, individuals who had experience with other states’ T-MSIS  reporting efforts also noted that states may not have always collapsed  categories in the same way. Data Completeness and Comparability Concerns Hinder CMS’s and States’ Use of T-MSIS for Oversight

Ongoing data concerns raise questions about how soon—and to what  extent—T-MSIS data will be sufficient to achieve the goals of improving  CMS’s and states’ ability to use Medicaid data for oversight. Although CMS requires states to report all T-MSIS data elements  applicable to their program, CMS officials said they did not specify a  reporting deadline for states, and selected states’ documentation to CMS  did not always include the reasons they did not report certain elements, or  whether or when they planned to report them. In some cases, data elements important for program oversight were not  reported by two or more of the six selected states reporting T-MSIS data,  limiting T-MSIS’s usefulness for oversight in these areas. Regarding the comparability of T-MSIS data across states, state officials  we interviewed cited concerns that could affect their use of T-MSIS for  oversight. Additionally, officials from all eight selected states  were interested in opportunities to learn more about other states’ use of  the data. The lack of an effort to facilitate information sharing is inconsistent with  CMS’s goals for T-MSIS and with federal internal control standards for  using and communicating quality information to achieve objectives. Although CMS has taken steps to begin using T-MSIS data, it has not yet  fully articulated a plan for how and when it will use T-MSIS data for its  own broader oversight efforts of state Medicaid programs. These preliminary efforts are consistent with one of CMS’s stated goals  for T-MSIS, which is to reduce states’ reporting burden by relying on T- MSIS data in place of separate reports that states currently submit, and  officials from six of eight selected states indicated that such an effort  would reduce their reporting burden. Conclusions

As part of its efforts to address longstanding concerns about the data  available to oversee the Medicaid program, CMS has taken important  steps toward developing a reliable national repository for Medicaid data. In the interim, improper Medicaid payments continue to increase,  reaching $36.7 billion in fiscal year 2017. Such steps should include, but are not limited to, efforts to obtain complete information from all states on unreported T-MSIS  data elements and their plans to report applicable data elements;  identify and share information across states on known T-MSIS data  limitations to improve data comparability; and  implement mechanisms, such as the Learning Collaborative, by which  states can collaborate on an ongoing basis to improve the  completeness, comparability, and utility of T-MSIS data.
Why GAO Did This Study

GAO and others have identified insufficiencies in state-reported Medicaid data that affect CMS's ability to oversee the program effectively. Recent increases in improper payments—estimated at $36.7 billion in fiscal year 2017—exacerbate concerns about program oversight.
CMS officials identified the T-MSIS initiative, which began in 2011, as its main effort to improve Medicaid data, and cited aspects of T-MSIS aimed at improving the scope and quality of state-reported data. GAO reported in January 2017 that it is unclear when T-MSIS data will be available from all states; how CMS will ensure data quality; or how the data will be used to enhance oversight of Medicaid.
GAO was asked to review states' experiences with T-MSIS implementation and planned uses of T-MSIS data. This report examines (1) states' experiences regarding T-MSIS implementation, and (2) challenges to CMS's and states' use of T-MSIS data for oversight. GAO reviewed federal laws, guidance, and internal control standards; reviewed documents and interviewed officials from eight states, selected based on their T-MSIS reporting status, location, program expenditures, and other factors; and interviewed CMS officials, CMS contractors, and individuals involved with other states' T-MSIS efforts.

What GAO Found

As of November 2017, 49 states had begun reporting Transformed Medicaid Statistical Information System (T-MSIS) data—a significant increase from 18 states reporting these data one year earlier. All eight states GAO reviewed identified converting their data to the T-MSIS format on an element-by-element basis as the main challenge in their reporting efforts. For some data elements, states had to expand or collapse their data to match the T-MSIS format.
With the continued implementation of T-MSIS, the Centers for Medicare & Medicaid Services (CMS) has taken an important step toward developing a reliable national repository for Medicaid data. However, data challenges have hindered states' and CMS's use of the T-MSIS data for oversight.
None of the six selected states reporting T-MSIS data in August 2017 was reporting complete data. These states said that certain unreported elements were contingent on federal or state actions, and others were not applicable to the state's Medicaid program. States did not always specify in their documentation whether they planned to report elements in the future or when they would report complete data.
Six of eight selected states expressed concerns about the comparability of T-MSIS data across states. Further, all states were interested in CMS facilitating information sharing among states. CMS has not compiled and shared information about states' data limitations, which would help states accurately compare their T-MSIS data to other states' T-MSIS data.
CMS has taken steps for the initial use of T-MSIS data, but does not have a plan or associated timeframes for using these data for oversight. As a result, important CMS goals for T-MSIS, such as reducing states' reporting burden and enhancing program integrity activities, are not being fully realized.

What GAO Recommends

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