1. Estelle B. Richman, Secretary PA Health Care Reform Lessons from Pennsylvania Health Care Reform Estelle B. Richman Secretary, Department of Public Welfare

2. Estelle B. Richman, Secretary PA Health Care Reform Presentation Overview 1.Pennsylvania Framework –Governor Rendell’s Prescription for Pennsylvania –Role of Medical Assistance program 2.Outcomes from selected initiatives 3.Lessons for national health care reform

3. Estelle B. Richman, Secretary PA Health Care Reform Governor Rendell announces major health care reform initiative in 2007

4. Estelle B. Richman, Secretary PA Health Care Reform Prescription for PA Components Rx for AffordabilityRx for AccessRx for Quality Cover All Pennsylvanians Health Care WorkforceHospital-Acquired Infections Coverage for College Students and Young Adults Removing Practice Barriers Serious Preventable Adverse Events Community Benefit Requirements Cost-Effective SitesPay for Performance Uniform Admission Criteria Co-Occurring PH/BH Disorders Chronic Care Fair Billing and Collection Practices Health Disparities Capital ExpendituresChild & Adult Wellness Small Group Insurance Reform Long Term Living Transparency of Cost and Quality Data End of Life and Palliative Care

5. Estelle B. Richman, Secretary PA Health Care Reform Medical Assistance program is key venue for PA health care reform 2.022 million (projected*) MEDICAL ASSISTANCE ENROLLMENT

6. Estelle B. Richman, Secretary PA Health Care Reform Medical Assistance is a cost driver for Pennsylvania state budget Education is biggest slice. Medical Assistance is biggest program. Distribution of State General Fund Spending

7. Estelle B. Richman, Secretary PA Health Care Reform PA Strategies & Innovations 1)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

8. Estelle B. Richman, Secretary PA Health Care Reform Cost and Quality Drivers PA business, consumers and taxpayers pay over $7.6 billion a year for unnecessary and avoidable costs.

9. Estelle B. Richman, Secretary PA Health Care Reform 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

10. Estelle B. Richman, Secretary PA Health Care Reform 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

11. Estelle B. Richman, Secretary PA Health Care Reform 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

12. Estelle B. Richman, Secretary PA Health Care Reform 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

13. Estelle B. Richman, Secretary PA Health Care Reform 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.

14. Estelle B. Richman, Secretary PA Health Care Reform 3) Reducing “Preventable Serious Adverse Events” (Never Events) National Quality Forum list includes: oSurgery performed on the wrong body part or wrong patient oForeign object left in a patient after a procedure oInfant discharged to the wrong person oDeath or serious disability from a medication error oDeath 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

15. Estelle B. Richman, Secretary PA Health Care Reform 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

16. Estelle B. Richman, Secretary PA Health Care Reform 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

17. Estelle B. Richman, Secretary PA Health Care Reform 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 PeopleExpenditures

18. Estelle B. Richman, Secretary PA Health Care Reform 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 $51,852 for one year of nursing facility care $20,892 for one year of home and community based services

19. Estelle B. Richman, Secretary PA Health Care Reform Rebalancing progress since 2006 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 2006200720082009 2010 Projected Fiscal Year % Consumers in Nursing Facilities % Consumers receiving Home & Community Based Services

20. Estelle B. Richman, Secretary PA Health Care Reform High BPDiabetesCardiovascular Disease ObesityPoor NutritionSmoking Low Physical Activity Substance AbuseSide Effects of Psychotropic Medications Poor Access to Primary Care Services Stigma Lack 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

21. Estelle B. Richman, Secretary PA Health Care Reform 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

22. Estelle B. Richman, Secretary PA Health Care Reform Southwest Connected Care UPMC for You, Allegheny County, Community Care Behavioral Health ≈ 4,200 members Southeast HEALTHCHOICES 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

23. Estelle B. Richman, Secretary PA Health Care Reform Established Joint Incentives Pool PH and BH plans Year One – Process Measures 1) Member stratification 2) Development of integrated care plan 3) Real time notification of hospital & ER admission 4) Identification of medication gaps Year Two – Add Outcome Measures 1) Reduced hospital admissions 2) Reduced ER utilization Performance Measures & Incentive Pool

24. Estelle B. Richman, Secretary PA Health Care Reform 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

25. Estelle B. Richman, Secretary PA Health Care Reform Slide 25 P4P MeasureAvoidable DeathsAvoidable Hospital Costs Breast Cancer Screening 500 - 1,900$212 million - $232 million Cervical Cancer Screening 600 - 800N/A Cholesterol Management 7,000 - 17,000$34 million - $115 million Controlling High Blood Pressure14,000 - 34,000$425 million - $1.1 billion Diabetes Care - HbA1c Control3,000 - 12,000$550 million - $1.3 billion Prenatal Care 1,000 - 1,600N/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

26. Estelle B. Richman, Secretary PA Health Care Reform Performance Measures (2007-08) HEDIS ® Measures 1.Breast Cancer Screening 2.Cervical Cancer Screening 3.Cholesterol Management for People with Cardiovascular Conditions: LDL Control <100 4.Comprehensive Diabetes Care: LDL Control <100 5.Comprehensive Diabetes Care: HbA1c Poorly Controlled 6.Controlling High Blood Pressure 7.Frequency of Ongoing Prenatal Care: ≥81% of the Expected Number of Prenatal Care Visits 8.ER Utilization 9.Adolescent Well-Care Visits 10.Prenatal Care in the First Trimester 11.Use of Appropriate Medications for People with Asthma PAPM Measures 1 12.Early Blood Lead Screening: 19 Months 13.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.

27. Estelle B. Richman, Secretary PA Health Care Reform 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)2004200520062007 HC Wtd Avg35.2%37.9%37.7%38.6% 90 th Percentile BM41.6%46.5%44.1%42.3% 75 th Percentile BM36.5%41.0%37.2%37.7% 50 th Percentile BM32.0%34.1%31.3%33.1% 1.Arrows indicate a statistically significant change from the previous year.

28. Estelle B. Richman, Secretary PA Health Care Reform Slide 28 Comprehensive Diabetes Care: LDL Control <100 (Continued) The HealthChoices weighted average has remained above the 50 th percentile benchmark since CY 2004, and above the 75 th 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 50 th percentile benchmark – 2 plans exceeded the 75 th percentile benchmark – 1 plan exceeded the 90 th percentile benchmark OVERALL, RATES ARE IMPROVING FOR THIS MEASURE

29. Estelle B. Richman, Secretary PA Health Care Reform Slide 29 Early Blood Lead Screening: 19 Months Measure Description: 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)2004200520062007 HC Wtd Avg61.5%55.3%58.4%59.6% Note: This is a PAPM measure, therefore, NCQA benchmarks are not applicable. 1.Arrows indicate a statistically significant change from the previous year. 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.

30. Estelle B. Richman, Secretary PA Health Care Reform 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

31. Estelle B. Richman, Secretary PA Health Care Reform Slide 31 Prenatal Care in the First Trimester Measure Description: The percentage of women who received prenatal care during their first trimester of pregnancy. Rate (CY)2004200520062007 HC Wtd Avg82.3%84.2%82.7%82.2% 90 th Percentile BM89.5%91.5% 91.7% 75 th Percentile BM86.4%88.1%88.7%88.6% 50 th Percentile BM81.3%83.3%84.2%84.0% 1.Arrows indicate a statistically significant change from the previous year.

32. Estelle B. Richman, Secretary PA Health Care Reform 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 50 th 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: – 2 plans exceeded the 50 th percentile benchmark – 1 plan exceeded the 75 th percentile benchmark – 1 plan exceeded the 90 th percentile benchmark WHILE LARGE RATE INCREASES ARE NOT EXPECTED FOR SUSTAINING MEASURES, RATES ARE NOT IMPROVING FOR THIS MEASURE

33. Estelle B. Richman, Secretary PA Health Care Reform 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

34. Estelle B. Richman, Secretary PA Health Care Reform Lessons from Pennsylvania Health Care Reform Estelle B. Richman Secretary, Department of Public Welfare