Estelle Richman

Estelle B. Richman, Secretary

PA Health Care Reform

Lessons from Pennsylvania Health Care Reform

Estelle B. RichmanSecretary, Department of Public Welfare



Presentation Overview

1. Pennsylvania Framework – Governor Rendell’s Prescription for

Pennsylvania – Role of Medical Assistance program

2. Outcomes from selected initiatives3. Lessons for national health care

reform



Governor Rendell announces major health care reform

initiative in 2007



Prescription for PA ComponentsRx for

Affordability Rx for Access Rx for QualityCover All Pennsylvanians

Health Care Workforce Hospital-Acquired Infections

Coverage for College Students and Young Adults

Removing Practice Barriers

Serious Preventable Adverse Events

Community Benefit Requirements

Cost-Effective Sites Pay for Performance

Uniform Admission Criteria

Co-Occurring PH/BH Disorders

Chronic Care

Fair Billing and Collection Practices

Health Disparities

Capital Expenditures Child & Adult Wellness

Small Group Insurance Reform

Long Term Living

Transparency of Cost and Quality Data

End of Life and Palliative Care



Medical Assistance program is key venue for PA health care reform

1,000,000

1,250,000

1,500,000

1,750,000

2,000,000

1991

-92

1993

-94

1995

-96

1997

-98

1999

-00

2001

-02

2003

-04

2005

-06

2007

-08

2009

-10*

2.022 million (projected*)

MEDICAL ASSISTANCE ENROLLMENT



Medical Assistance is a cost driver for Pennsylvania state budget

Higher Education8%

Debt Service4%

All Other DPW Human Service

Programs18%

Medical Assistance

16%

Pre K-12 Education

37%

All Other12%

Corrections5%

Education is biggest slice.

Medical Assistance is

biggest program.

Education is biggest slice.

Medical Assistance is

biggest program.

Distribution of State General Fund Spending



PA Strategies & Innovations1) Improve chronic care management

2) Reduce Healthcare Acquired Infections

3) Reduce “Preventable Serious Adverse Effects”

4) Rebalance Long Term Care System

5) Establish combined Physical Health / Behavioral Health homes

6) Pay for Performance



Cost and Quality Drivers

PA business, consumers and

taxpayers pay over $7.6 billion a year for

unnecessary and avoidable costs.



1) Improving outcomes for persons with chronic conditions• Strategy: Regional collaboratives with 20-32

practices each using a medical home model • diabetes• pediatric asthma

• May 2008 – launch Southeast PA collaborative

• Today - 400 health care providers in 170 medical practices serving 1 million statewide



Diabetes: Year One results• 195% increase in number of patients with self-

management goals • 142% increase in number of patients getting annual

foot exams• 71% increase in the number of patients getting eye

exams• 43% increase in the number of patients who have

lowered their cholesterol below 130• 25% increase in the number of patients who

lowered their blood pressure below 140/90



Chronic care: more results• Pediatric asthma:

– Doubled the number of patients with a documented asthma action plan on how to take controller medications, avoid asthma triggers, and what to do in the event of an attack

• Cost savings data (preliminary) – Inpatient and outpatient hospitalization costs went

down by 26%– ER costs were reduced by 18.4%– Overall costs were reduced by 15.9% ($46.37) per

member per month



2) Reducing number of health care acquired infections

• PA Health Care Cost Containment Commission study identified 27,949 hospital acquired infections in 2007

• Patients with HAIs are 6 times more likely to die than other patients

• Average bill if HAI is nearly 5½ times higher than for patients with no HAI

• Adds up to over $3 billion hospital charges



PA passes groundbreaking HAI Prevention Legislation (2007)

• Legislation requires hospitals, nursing homes and ambulatory surgical facilities to:

• Submit an infection control plan• Report HAIs throughout their facility and • Implement electronic infection control surveillance.

• Year one outcomes: the infection rate in PA hospitals dropped 7.8 percent resulting in an estimated savings of $372 million.



3) Reducing “Preventable Serious Adverse Events” (Never Events)

• National Quality Forum list includes:o Surgery performed on the wrong body part or wrong patient o Foreign object left in a patient after a procedure o Infant discharged to the wrong person o Death or serious disability from a medication error o Death or serious disability from a fall while being cared for in a

health care facility

• Core concept: physicians and hospitals will not be paid for PSAEs or for correcting them

• Primary goal is to improve quality and outcomes – not cost containment



Reform began with MA Bulletin, now statewide in statute

• January 2008 – DPW issued Bulletin covering Medical Assistance providers.

• June 2009 – “Preventable Serious Adverse Events Act of 2009” signed into law covering health care facilities statewide

• June 2010 – Deadline for DPW to develop a new bulletin addressing PSAEs in nursing facilities



10%

15%

20%

25%

2000 2010 2020 2030

4) Rebalancing to address needs of seniors and persons with disabilities

• 162,000 Pennsylvanians with disabilities also need long term care services

65 & Older

• PA will have more seniors (ages 65+) than school age kids by the year 2030

Under 18



Seniors and people with disabilities use largest share of MA resources

Seniors and Persons with Disabilities are 36% of enrollment, but account for 69% of program expenditures

Elderly

Disabled

Families

Adults w/o Children

14%

22%

59%

5%

32%

37%

25%

6%

Number of Eligible People Expenditures



Goal: Rebalance the

Long-Term Care System • Rebalancing Goal:

50/50 split between home & community based and institutional care

• This more cost effective approach is in line with what consumers want

010

,000

20,0

0030

,000

40,0

00

$51,852 for one year of nursing facility care

$20,892 for one year of home and community based services



Rebalancing progress since 2006

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

2006 2007 2008 2009 2010 ProjectedFiscal Year

% Consumers in Nursing Facilities

% Consumers receiving Home & Community Based Services



High BP Diabetes Cardiovascular Disease

Obesity Poor Nutrition Smoking

Low Physical ActivitySubstance Abuse Side Effects of

Psychotropic Medications

Poor Access to Primary Care Services

StigmaLack of Cross-Discipline

Training

SMI reduces life expectancy by 25 years --- Many risk factors are preventable

5) Establishing Accountable Physical / Behavioral Health Care Homes Pilot



Structure of the pilot

• Target population: Adults (18+) in southeast and southwest PA in participating health plans

• Diagnosis: schizophrenia, major mood disorder, psychotic disorder NOS, borderline personality disorder

• Defined performance measures • Shared incentive pool for managed care and

behavioral health plans



Southwest Connected CareUPMC for You, Allegheny County, Community Care Behavioral Health≈ 4,200 members

SoutheastHEALTHCHOICES HealthConnections

Keystone Mercy Health Plan, Bucks, Montgomery, Delaware Co

& Magellan Health Services≈ 3,600 members

•Provider engagement and medical home•Consumer engagement•Data management and information exchange•Coordination of hospital discharge and follow-up •Pharmacy management•Appropriate ED use for behavioral health treatment•Alcohol and substance abuse treatment/care coordination •Co-location of resources

Key elements of coordination



Established Joint Incentives PoolPH and BH plans

Year One – Process Measures

1) Member stratification

2) Development of integrated care plan3) Real time notification of hospital & ER admission4) Identification of medication gaps

Year Two – Add Outcome Measures

1) Reduced hospital admissions

2) Reduced ER utilization

Performance Measures & Incentive Pool



• Through P4P, DPW is shifting from “paying for care” to “paying for quality care”

• HealthChoices program performance has improved since P4P implementation

• The HealthChoices weighted average improved for 10 of 13 P4P measures

6) Pay for performance realigns HealthChoices incentives



Slide 25

P4P Measure Avoidable Deaths Avoidable Hospital Costs

Breast Cancer Screening 500 - 1,900 $212 million - $232 million

Cervical Cancer Screening 600 - 800 N/A

Cholesterol Management 7,000 - 17,000 $34 million - $115 million

Controlling High Blood Pressure 14,000 - 34,000 $425 million - $1.1 billion

Diabetes Care - HbA1c Control 3,000 - 12,000 $550 million - $1.3 billion

Prenatal Care 1,000 - 1,600 N/A

Source: 2008 NCQA The State of Health Care Quality, pp. 15-16. Available at: http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf.

National Estimates of Avoidable Deaths and Hospital Costs

Goal: improve quality of care and reduce avoidable costs



Performance Measures (2007-08)HEDIS® Measures1. Breast Cancer Screening2. Cervical Cancer Screening3. Cholesterol Management for People with Cardiovascular Conditions: LDL Control <1004. Comprehensive Diabetes Care: LDL Control <1005. Comprehensive Diabetes Care: HbA1c Poorly Controlled6. Controlling High Blood Pressure7. Frequency of Ongoing Prenatal Care: ≥81% of the Expected Number of Prenatal Care

Visits8. ER Utilization9. Adolescent Well-Care Visits10. Prenatal Care in the First Trimester11. Use of Appropriate Medications for People with Asthma

PAPM Measures1

12. Early Blood Lead Screening: 19 Months13. Early Blood Lead Screening: 3 Years

1 The PAPM measures will be replaced by the HEDIS measure Lead Screening in Children in the 2008/2009 P4P Program.



Slide 27

Comprehensive Diabetes Care: LDL Control <100

Measure Description:

The percentage of adults with Diabetes whose cholesterol level was adequately controlled (LDL-C <100mg/dL) during the measurement year.

Rate (CY) 2004 2005 2006 2007

HC Wtd Avg 35.2% 37.9% 37.7% 38.6%

90th Percentile BM 41.6% 46.5% 44.1% 42.3%

75th Percentile BM 36.5% 41.0% 37.2% 37.7%

50th Percentile BM 32.0% 34.1% 31.3% 33.1%

1. Arrows indicate a statistically significant change from the previous year.

HealthChoices Weighted Average and Plan-Specific Rates by Calendar Year

0%

20%

40%

60%

80%

100%

HC Wtd Avg ACPA AMHP GHP HP KMHP UHP UPMC

CY 2004 (Baseline) CY 2005 (P4P Year 1) CY 2006 (P4P Year 2) CY 2007 (P4P Year 3)

CY 2007 50th Percentile BM CY 2007 75th Percentile BM CY 2007 90th Percentile BM



Slide 28

Comprehensive Diabetes Care: LDL Control <100

(Continued)

• The HealthChoices weighted average has remained above the 50th percentile benchmark since CY 2004, and above the 75th percentile benchmark in CY 2006 and CY 2007

• From CY 2006 to CY 2007, the rates for 4 plans increased, with a statistically significant increase for 2 of these plans

• In CY 2007, rates for 5 plans exceeded national benchmarks:

– 2 plans exceeded the 50th percentile benchmark


– 1 plan exceeded the 90th percentile benchmark

OVERALL, RATES ARE IMPROVING FOR THIS MEASURE



Slide 29

Early Blood Lead Screening: 19 Months


The percentage of members under 19 months who live in a high lead area and received at least one blood lead screening exam.

Rate (CY) 2004 2005 2006 2007

HC Wtd Avg 61.5% 55.3% 58.4% 59.6%

Note: This is a PAPM measure, therefore, NCQA benchmarks are not applicable.


0%

20%

40%

60%

80%

100%


CY 2005 (Baseline) CY 2006 (P4P Year 2) CY 2007 (P4P Year 3)


2. This measure became a P4P measure in CY 2006 during the second year of the P4P program, therefore, CY 2005 serves as the baseline for this measure.



Slide 30

Early Blood Lead Screening: 19 Months

(Continued)

• Since inclusion of this measure in the P4P program, the HealthChoices weighted average has:

– Continually increased, increasing by 4.3% from CY 2005 to CY 2007

– Shown a statistically significant increase in CY 2006 and CY 2007

• From CY 2006 to CY 2007, the rates for 4 plans improved, with a statistically significant increase for 1 of these plans

OVERALL, RATES ARE IMPROVING FOR THIS MEASURE



Slide 31

Prenatal Care in the First Trimester


The percentage of women who received prenatal care during their first trimester of pregnancy.

Rate (CY) 2004 2005 2006 2007

HC Wtd Avg 82.3% 84.2% 82.7% 82.2%

90th Percentile BM 89.5% 91.5% 91.5% 91.7%

75th Percentile BM 86.4% 88.1% 88.7% 88.6%

50th Percentile BM 81.3% 83.3% 84.2% 84.0%


0%

20%

40%

60%

80%

100%


CY 2004 (Baseline) CY 2005 (P4P Year 1) CY 2006 (P4P Year 2) CY 2007 (P4P Year 3)

CY 2007 50th Percentile BM CY 2007 75th Percentile BM CY 2007 90th Percentile BM




Slide 32

Prenatal Care in the First Trimester

(Continued)

• The HealthChoices weighted average has:

– Declined slightly since P4P implementation in CY 2005

– Been below the 50th percentile benchmark in CY 2006 and CY 2007

• The rates for 4 plans decreased from CY 2006 to CY 2007, with a statistically significant decrease for 1 of these plans

• In CY 2007, rates for 4 plans exceeded national benchmarks:




WHILE LARGE RATE INCREASES ARE NOT EXPECTED FOR SUSTAINING MEASURES, RATES ARE NOT IMPROVING FOR THIS MEASURE



Lessons from PA: “must haves” for national health care reform• Payment reform – create change with

meaningful financial incentives• Need to pay for quality, not billable units

• Breakdown silos and create new partnerships

• Need capacity to measure quality• Health Information Technology will be key to

national health care reform



Lessons from Pennsylvania Health Care Reform

Estelle B. RichmanSecretary, Department of Public Welfare

Health & Medicine

Estelle Richman