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Senate of Pennsylvania
Session of 2017 - 2018 Regular Session


Posted: February 13, 2017 02:55 PM
From: Senator Scott Martin
To: All Senate members
Subject: Pennsylvania Medicaid Total Population Quality Health Initiative
In the near future, I plan to introduce legislation that will serve to procure a solution to reduce state Medicaid expenditures while improving enrollee members’ health and overall quality of medical care.

This legislation will direct the Pennsylvania (PA) Department of Human Services to issue a Request for Proposal (RFP) for a Total Population Quality Health Initiative that infuses Evidence Based Medicine (EBM) into every Members’ health decision and integrate physical and behavioral health.

One of the primary goals of this effort is to achieve the “Triple AIM”— improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care.

This legislation will not replace the roles of MCOs or Primary Care Providers in PA, but will introduce an additional service intended to fill the current gaps in care and seamlessly integrate between existing services for PA Medicaid members. The additional services being introduced with this legislation will increase engagement and strengthen each member’s understanding of their current health care options. The existing health care system will be supplemented in order to deliver better care, spend program dollars smartly, foster healthier living, improve transparency into the delivery system and put members at the center of healthcare decisions. Member engagement will span the full spectrum of medical issues: from genetic makeup, to life habits, to acute diseases. At any phase, members will become more informed, empowered, and engaged health care consumers.

The program will demonstrate its system improvement capabilities the most with “Super-utilizers,” defined as members who frequently utilize emergency services over the course of a year. The program will also improve healthcare outcomes with members with frequent acute inpatient admissions and hospital re-admissions. Members will be engaged and savings will be achieved by reducing unnecessary emergency visits; unnecessary hospital admissions and readmissions; unnecessary operations and reoperations; unnecessary outpatient visits; and accelerating access to needed care.

Alaska passed similar legislation for their "super-utilizer" population and realized a net savings of 12.5 percent in annual Medicaid costs for their participating population. Spending on emergency room visits decreased by 25 percent; hospital admissions decreased by 17 percent; mental health services decreased over 5 percent and spending on durable medical equipment decreased by more than 25 percent. This success led to Alaska expanding the program to their entire Medicaid population. The federal government and other States are also currently exploring this approach which has been identified by the National Governors Association as a successful system approach.

For FY 2015-16, more than $23 billion was spent on the 2,661,843 enrollees in Pennsylvania’s Medicaid program. By November 2016, just one year later, Medicaid enrollment reached 2,814,173. Pennsylvania spends more per capita for Medicaid enrollees than almost every other state and with our current and forecasted budget deficits, and DHSs’ budget growing by approximately $500 million per year, the bleeding has to stop. Medicaid expansion and the looming decrease in federal Medicaid funding require that action be taken now to mitigate the situation.

Pennsylvania has an opportunity to be a leader in reforming Medicaid. If we improve healthcare outcomes and reduce spending, it is a win-win for all of our citizens.

I hope you will join me in co-sponsoring this legislation. Please contact Cindy Lonergan with any questions at 717-787-6535.

Introduced as SB600