PHC4 Looks at “Super-Utilizers”

The Pennsylvania Health Care Cost Containment Council has released a new research brief on so-called super-utilizers:  a small portion of the population that consumes an inordinate amount of health care.  Super-utilizers are defined as individuals with five or more hospital admissions a year.

According to the PHC4 report,

  • Three percent of hospitalized patients accounted for 10 percent of hospital payments, or $1.25 billion, in 2016.
  • Super-utilizers accounted for three percent of hospitalized patients, 10 percent of hospital payments, 12 percent of hospital admissions, and 15 percent of hospital days.
  • 46 percent of that care was paid for by Medicare, 19 percent by Medicaid, and 19 percent was for dually eligible patients.
  • The top three reasons for admissions among super-utilizers were sepsis, heart failure, and mental health disorders.
  • Diabetes and alcohol and substance abuse disorders were among the leading causes of admission for Medicaid patients.
  • The highest rates of super-utilizers were among blacks, low-income individuals, and older people.

The PHC4 report breaks down super-utilizers by county and shows the reasons for super-utilizers’ hospital admissions.  Its side-by-side comparison of 2012 and 2016 shows a decline in super-utilizer admissions to hospitals, perhaps because of efforts by hospitals to reduce admissions and avoid Medicare penalties for avoidable hospital readmissions.

Go here to find the PHC4 report Pennsylvania’s “Super-Utilizers” of Hospital Care.

Filed under: Uncategorized

SNAP Joins Others in Letter to PA Senators

SNAP was among 27 Pennsylvania health care organizations to send a joint letter to senators Bob Casey and Pat Toomey pointing out aspects of the House-passed American Health Care Act that could jeopardize access to care for medically vulnerable Pennsylvanians.

Safety-Net Association of Pennsylvania logoAmong the issues addressed in the letter are how the House-passed proposal would detract from the role of Medicaid in fighting the state’s opioid crisis; the proposed reduction in tax credits to help purchase health insurance; the challenge posed by a per capita approach to Medicaid financing; the potential loss of health care jobs; the likelihood of large numbers of Pennsylvanians losing their health insurance and state Medicaid costs rising significantly; and the erosion of consumer protections.

See the complete letter here.

Filed under: American Health Care Act, Federal Medicaid issues, Pennsylvania Medicaid, Pennsylvania safety-net hospitals, Safety-Net Association of Pennsylvania

Pennsylvania Health Law Project Newsletter

The Pennsylvania Health Law Project has published its May newsletter.

 Included in this edition are articles on new criteria for Medicaid coverage of high-cost hepatitis C drugs and the release of a draft of the state’s proposed Medicaid quality strategy; an update on Community HealthChoices, Pennsylvania’s new program of Medicaid managed long-term services and supports; an overview of Medicaid-covered behavioral health services; a summary of recent federal proposals with implications for the state’s Medicaid program; and a report on the nomination of Teresa Miller to lead the new Department of Health and Human Services that Governor Wolf has proposed establishing.

 Find the newsletter here.

Filed under: Pennsylvania Medicaid, Pennsylvania Medicaid laws and regulations, Pennsylvania Medicaid policy

The Prospect of a Medicaid Work Requirement

Over the past three years a dozen states have proposed establishing a work requirement for eligibility for their Medicaid programs and in its proposed FY 2018, the Trump administration has called for extending the ability to impose such a requirement to all states.

But how would a Medicaid work requirement work?  To whom would it apply and what kinds of work might satisfy such a requirement for the approximately 22 million Medicaid recipients (out of 76 million total recipients) to whom it might apply?

Work requirements would have significant implications for the patients and communities that Pennsylvania safety-net hospitals serve, and possibly for the hospitals as well.

A new Commonwealth Fund report looks at these and other issues.  Go here to find the article “What Might a Medicaid Work Requirement Mean?”

Filed under: Federal Medicaid issues

New Book Addresses Social Risk Factors in Medicare

In the new book, the National Academies of Sciences, Engineering, and Medicine addresses the question of what social risk factors might be worth considering in Medicare value-based payment programs and how those risk factors might be reflected in value-based payments.

The book, the culmination of a five-part NASEM process, focuses on five social risk factors:

  • socio-economic position
  • race, ethnicity, and cultural context
  • gender
  • social relationships
  • residential and community context

Addressing such factors in Medicare value-based payments, the book finds, can help achieve four important goals:

  • reduce disparities in access, quality, and outcomes
  • improve the qualify and efficiency of care for all patients
  • foster fair and accurate reporting
  • compensate provides fairly

Doing so also can help prevent five types of unintended consequences from a failure to address social risk factors in Medicare payment policy:

  • providers avoiding patients with social risk factors
  • reducing incentives to improve the quality of care for patients with social risk factors
  • underpaying providers that serve disproportionately large numbers of patients with social risk factors
  • a perception of different medical standards for different populations
  • obscuring disparities in care and outcomes

The kinds of patients these social risk factors seek to identify are precisely those served by Pennsylvania safety-net hospitals in far greater numbers than other community hospitals throughout the state.

Learn more about social risk factors and their potential role in Medicare value-based payment policy in the new book Accounting for Social Risk Factors in Medicare Payment, which can be downloaded free of charge here, from the web site of the National Academies of Sciences, Engineering, and Medicine.

Filed under: Pennsylvania safety-net hospitals

PA Medicaid to Expand Access to Hep C Drugs

Pennsylvania’s Medicaid program will make treatment for hepatitis C more readily available to Medicaid beneficiaries beginning on July 1, state officials have announced.

In recent years, new drugs have become available that effectively cure hepatitis C but their exceptionally high costs led many insurers, including most state Medicaid programs, to limit access to those drugs until patients show more advanced signs of the disease.  A year ago the Pennsylvania Department of Human Services’ pharmacy and therapeutics committee recommended expanding access to these drugs for Pennsylvania Medicaid beneficiaries and now, that recommendation has been adopted and that expansion will begin with the new state fiscal year on July 1.

Under the new criteria, patients with lower scores of severity of hepatitis C will become eligible for treatment.  Previously, Medicaid patients were required to show more advanced signs of illness before the medicine was provided to them.

Learn more about the Pennsylvania Medicaid program’s revised approach to serving Medicaid patients with hepatitis C in this Philadelphia Inquirer article.

Filed under: Pennsylvania Medicaid policy

Hospital Uncompensated Care Down

As was surely expected, reforms introduced through implementation of the Affordable Care Act have driven down uncompensated care costs for many hospitals.

How much?

A new study published by the Commonwealth Fund offers the following findings:

  • uncompensated care declines in expansion states are substantial relative to profit margins;
  • for every dollar of uncompensated care costs hospitals in expansion states had in 2013, the Affordable Care Act erased 41 cents by 2015; and
  • Medicaid expansion reduced uncompensated care burdens for safety-net hospitals that are not made whole by Medicaid disproportionate share payments (Medicaid DSH).

Learn more, including how the decline in uncompensated care costs affected different kinds of hospitals in different kinds of states, in the report “The Impact of the ACA’s Medicaid Expansion on Hospitals’ Uncompensated Care Burden and the Potential Effects of Repeal,” which can be found here, on the Commonwealth Fund’s web site.

Filed under: Affordable Care Act, Pennsylvania safety-net hospitals

Pennsylvania Health Law Project Newsletter

The Pennsylvania Health Law Project has published its April 2017 newsletter.

Included in this edition are articles about:

  • the budget bill passed by the state House and its potential impact on Medicaid in Pennsylvania;
  • the potential impact on Medicaid of the American Health Care Act under consideration by Congress;
  • an update on Community HealthChoices, the state’s new program of managed long-term services and supports for seniors struggling to continue living in the community;
  • information on the income verification process for those seeking to apply for or renew Medicaid eligibility; and
  • the process of shifting prescriptions from Medicaid to Medicare.

Find the latest edition of PA Health Law News here.

Filed under: Pennsylvania Medicaid policy, Pennsylvania proposed FY 2018 budget

Department Consolidation in PA?

Is it a good idea to consolidate Pennsylvania’s Human Services, Aging, Health, and Drug and Alcohol Programs departments into a single new Department of Health and Human Services?

Governor Tom Wolf offered such a proposal in his FY 2018 budget message and the Pennsylvania General Assembly is now weighing the merits of this proposal.

To explain more about its intentions and plans, the Wolf administration has established a web page that explains the proposed consolidation, which it refers to as “unification.”  Included on the web page are a general description of the proposal, explanations of the benefits the administration believes it offers, a proposed organizational table for the new Department of Health and Human Services, and a link to proposed enabling legislation.

Find it all here.

Filed under: Pennsylvania proposed FY 2018 budget

New Report on PA Hospital Financial Performance

The Pennsylvania Health Care Cost Containment Council has published its annual report detailing the financial health of acute-care hospitals in the state.

According to the report, hospital net patient revenue increased in FY 2016, accounts receivable are being paid faster, operating and total margins rose, and uncompensated care declined.

The report describes hospital financial performance and utilization state-wide and by region and also presents FY 2016 margin, uncompensated care, and Medicare and Medicaid share data for every acute-care hospital in the state.

Go here to find the PHC4 report Financial Analysis 2016:  General Acute Care Hospitals.

Filed under: Uncategorized

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2012 Safety-Net Association of Pennsylvania