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By Monica E. Oss

There is a lot of measurement going on in health and human services – but is that data being used to shape policy? The answer to that question is “yes,” if you’re with the Medicaid program in Pennsylvania. David K. Kelley, M.D., Chief Medical Officer at the Office of Medical Assistance Programs, Pennsylvania Department of Human Services, closed day one at The OPEN MINDS Technology & Informatics Institute with some great illustrations of how data can shape policy in his session, Leveraging The Power Of Analytics To Shape Medicaid Policy & Practices For Complex Consumers: The Experience of Pennsylvania’s Medicaid Program.

David K. Kelley, M.D., M.P.A., Chief Medical Officer, Office of Medical Assistance Programs, Pennsylvania Department of Human Services

Pennsylvania’s Medicaid plan is pushing the envelope when it comes to “value” with initiatives to; Improve NCQA HEDIS® and CAHPS® scores; improve population health while reducing inappropriate utilization; evaluate efficiency of managed care and providers; and developing new payment models. And the use of analytics is key to these initiatives. There are four examples in Dr. Kelley’s presentation that really brought this to life:

Medicaid Health Plans Payment – Pennsylvania Medicaid is in the re-procurement process for its Medicaid health plans (see Pennsylvania Medicaid Health Plans Out To Bid With New Focus On Physical/Behavioral Coordination) – and using analytics to put its money where its policy rhetoric is. In the new contracts, health plans can earn up to 1.5% of premium by meeting or exceeding the 50th percentile benchmarks for eight measures – three perinatal measures, two outcome measures (diabetes and hypertension control), two access to care measures (dental, adolescent well child visit), and one utilization measure (30 day all cause readmission rate). In addition, health plans are required to demonstrate that they will move a minimum amount of their provider reimbursement to value-based payments – 7.5% in year one, 15% in year two, and 30% in year three (see Department of Human Services Secretary Announces Innovative Changes to Medicaid in Pennsylvania and Pennsylvania RFP 06-15 Seeking HealthChoices Physical Health Services For All Zones Commonwealth-Wide).

Integrated Behavioral Health/Primary Care Initiative – Pennsylvania has a Medicaid system with a behavioral health carve-out, which brings with it care coordination challenges. In 2016, the state will launch an initiative to encourage coordinated care for consumers with serious persistent mental illness (SPMI) and substance use disorder (SUD). The initiative will be funded with $20 million per year – $10 million for the health plans and $10 million for the managed behavioral health plans. An ICP is the collection, integration, and documentation of key physical and behavioral health information that is used to develop a joint care plan for purposes of care management, and at least 500 members must receive an ICP that has been used in care management activity by both the physical health (PH) and behavioral health (BH) MCO.

Why focus on integrated care management? Dr. Kelley shared some data showing the rate of co-morbid conditions with behavioral health and the high rate of readmission.


Pediatric Antipsychotic Medication Use Strategy – Another Pennsylvania Medicaid initiative for 2016 involves assuring the appropriate use of pediatric prescriptions, particularly antipsychotic medications. Recent analysis funded by the Medicaid program found antipsychotic medication use four times higher for youth ages 6-18 in foster care (22%) than other children in Medicaid (5%), and there is an indication that 56% of pediatric use is not approved. As a result, in 2016 there will be consistent prior authorization process for all children under 18-years old; telephonic psychiatric consultative service primary care physicians (PCP); and a monthly dashboard tracking results.

Substance Use Disorders Approach – Data about addiction treatment in the Medicaid plan are the basis for a new approach to this treatment area in 2016. Data items that have the attention of policymakers include, 60% of beneficiaries receiving buprenorphine only received the medication – with no other therapies. For the 40% receiving any type of behavioral health service, 33% also use benzodiazepines. Based on these statistics, the state is planning a new approach in 2016. The Medicaid health plans will be required to provide a health home program for pregnant women with an addictive disorder. Looking ahead to 2017, the Pennsylvania Patient-Centered Medical Home (PCMH) Advisory Council has recommended DHS consider development of a broader health home program for those living with a substance use disorder (SUD).

These four Pennsylvania Medicaid initiatives show the power of metrics-based policy making – and an example of best management practices for executives in health plans and provider organizations. For more, don’t miss the upcoming session, Market, Math & Metrics: Three Keys To Optimizing Your Strategy, from OPEN MINDS Senior Associate, Joseph P. Naughton-Travers, Ed.M., on February 11, at The 2016 OPEN MINDS Performance Management Institute.

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