PRIOR PRINTER'S NO. 3759 PRINTER'S NO. 4225
No. 2500 Session of 2004
INTRODUCED BY BAKER, REICHLEY, THOMAS, BASTIAN, BELFANTI, BOYD,
CAPPELLI, CAUSER, DENLINGER, GEIST, GINGRICH, GOOD, GOODMAN,
HARRIS, HORSEY, JAMES, MACKERETH, R. MILLER, NICKOL, PICKETT,
SCHRODER, STERN, E. Z. TAYLOR, TIGUE, WALKO, WANSACZ, WEBER,
WOJNAROSKI AND YOUNGBLOOD, APRIL 14, 2004
AS REPORTED FROM COMMITTEE ON HEALTH AND HUMAN SERVICES, HOUSE
OF REPRESENTATIVES, AS AMENDED, JUNE 29, 2004
AN ACT
1 Establishing a program to develop a disease management program
2 to improve the health care of medical assistance recipients
3 who are at risk of or diagnosed with certain ailments or
4 chronic diseases that require frequent medical attention and
5 to improve health care and health outcomes, reduce inpatient
6 hospitalization and reduce the number of emergency room
7 visits for medical assistance fee-for-service recipients
8 diagnosed with certain illnesses.
9 The General Assembly of the Commonwealth of Pennsylvania
10 hereby enacts as follows:
11 Section 1. Short title.
12 This act shall be known and may be cited as the Chronic
13 Disease Management Program Act.
14 Section 2. Legislative findings and purpose.
15 (a) Legislative findings.--The General Assembly finds and
16 declares as follows:
17 (1) Chronic diseases have reached epidemic levels in the
18 United States. Approximately one in ten Americans is
19 afflicted with a chronic illness, accounting for 90% of
1 overall health care expenditures. Most frequently, these
2 patients are treated by multiple providers whose care is not
3 coordinated, potentially leading to duplicative and
4 unnecessary services and escalating health care expenses.
5 (2) The prevalence of diabetes has increased over the
6 years so that Pennsylvania has the fifth largest adult
7 population diagnosed with diabetes.
8 (3) Pennsylvania operates the sixth largest medical
9 assistance program in the United States, covering
10 approximately 1.7 million individuals.
11 (4) Because Pennsylvania is faced with rising health
12 care costs and limited resources, it is necessary to seek new
13 ways to ensure the availability of high-quality, cost-
14 efficient health care for medical assistance recipients.
15 (5) The improved coordination in disease management
16 helps provide chronically ill patients with access to the
17 latest advances in treatment and teaches them how to be
18 active participants in their health care through health
19 education, thus reducing total health care costs.
20 (6) While disease management is not an instantaneous
21 savings, the program encourages prevention and regular
22 monitoring of patients which will improve health and
23 consequently lower health care resource use.
24 (7) Today 21 other states have implemented statewide
25 disease management programs by strengthening the chronic
26 disease management activities provided by organizations or by
27 contracting with outside vendors to act as a disease
28 management organization.
29 (8) The United States Department of Health and Human
30 Services' Centers for Medicare and Medicaid Services is
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1 urging states to implement programs to assist those with
2 chronic diseases to better manage their illnesses. In a
3 letter to state Medicaid officials, the Centers for Medicare
4 and Medicaid Services announced Federal financial
5 participation for state-operating or state-implementing or
6 administrative costs of disease management programs aimed at
7 improving health outcomes while lowering the health care
8 costs associated with these diseases.
9 (b) Purpose.--The purpose of this act is to implement a
10 Statewide program which PROGRAM IN COUNTIES EXCLUDED FROM THE <--
11 HEALTH CHOICES PROGRAM THAT would be aimed at improving health
12 outcomes while lowering the health care costs associated with
13 certain diseases through disease management activities. Disease
14 management is designed to improve the health of patients with
15 chronic illnesses by working more directly with them and their
16 health care providers on their treatment plans regarding diet,
17 adherence to medicine schedules and other self-management
18 techniques.
19 Section 3. Definitions.
20 The following words and phrases when used in this act shall
21 have the meanings given to them in this section unless the
22 context clearly indicates otherwise:
23 "Certain ailments or diseases." The term includes, but is
24 not limited to, chronic medical conditions such as asthma,
25 diabetes, congestive heart failure and high-risk pregnancies.
26 "Department." The Department of Public Welfare of the
27 Commonwealth.
28 "Disease management program." A set of interventions
29 designed to improve the health of individuals, especially those
30 with certain ailments or diseases. A disease management program
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1 may include:
2 (1) Identification of patients and matching the
3 intervention with need.
4 (2) Support for adherence to evidence-based medical
5 practice guidelines, including providing medical treatment
6 guidelines to physicians and other health care providers and
7 providing support services to assist the health care provider
8 in monitoring the patient.
9 (3) Services designed to enhance patient management and
10 adherence to an individualized treatment plan, routine
11 reporting and feedback loops and collection and analysis of
12 process and outcome measures.
13 "Program." The Chronic Disease Management Program
14 implemented under section 4.
15 Section 4. Establishment.
16 The department is authorized to administer the Chronic
17 Disease Management Program for medical assistance fee-for-
18 service program recipients, designed to address over-utilization
19 or under-utilization or the inappropriate use of health care
20 services, including prescription drugs, that may affect the
21 total cost of health care utilization by medical assistance
22 recipients with certain ailments or diseases. The department may
23 contract for the development or implementation of the Chronic
24 Disease Management Program authorized by this act.
25 Section 5. Duties of department.
26 The department shall:
27 (1) Develop and implement the Chronic Disease Management
28 Program in order to improve health care of and reduce costs
29 for the medical assistance fee-for-service program and its
30 recipients.
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1 (2) Implement the program Statewide IN COUNTIES EXCLUDED <--
2 FROM THE HEALTH CHOICES PROGRAM.
3 (3) Profile medical assistance recipients within a
4 select number of certain ailments and disease diagnosis
5 categories. The assessment shall focus on those diagnosis
6 areas that present the greatest opportunity for impact to
7 improved health care and cost reduction AS DETERMINED BY THE <--
8 DEPARTMENT.
9 (4) Issue a request for proposals or otherwise solicit
10 bids from potential vendors to manage recipients with select
11 chronic diseases following the conclusion of the profiling of
12 medical assistance recipients. THE DEPARTMENT MAY MEET THIS <--
13 REQUIREMENT BY REQUIRING ITS ENHANCED PRIMARY CARE CASE
14 MANAGEMENT VENDOR TO OPERATE DISEASE MANAGEMENT PROGRAMS OR
15 USING INTERNAL DEPARTMENTAL RESOURCES.
16 (5) Amend the medical assistance State plan and seek any
17 waivers necessary from the Centers for Medicare and Medicaid
18 Services of the United States Department of Health and Human
19 Services to implement this section.
20 Section 6. Reports.
21 The department shall submit a progress report regarding
22 chronic disease management measures undertaken pursuant to this
23 act to the Governor, the chairman and minority chairman of the
24 Public Health and Welfare Committee of the Senate, the chairman
25 and minority chairman of the Health and Human Services Committee
26 of the House of Representatives, the chairman and minority
27 chairman of the Appropriations Committee of the Senate and the
28 chairman and minority chairman of the Appropriations Committee
29 of the House of Representatives by January 1, 2005 and annually
30 thereafter. The report shall include information regarding the
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1 implementation of the Chronic Disease Management Program into
2 the medical assistance fee-for-service program to include the
3 contractor, services to be provided by the contractor, the
4 recipient population to be targeted, the disease identified for
5 management, the potential improvements to recipient health care
6 and the resulting reduction in costs to the medical assistance
7 program and savings from cost avoidance through hospital stays,
8 emergency room visits and any other preventive measures that
9 will be obtained through the Chronic Disease Management Program.
10 The report shall document evidence to meet the requirements of
11 section 2(b).
12 SECTION 7. EXPIRATION. <--
13 THIS ACT SHALL EXPIRE FOUR YEARS FROM ITS EFFECTIVE DATE.
14 Section 7 8. Effective date. <--
15 This act shall take effect immediately.
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