In 2019, Pennsylvania launched an innovative, voluntary, global budget payment system for its rural hospitals. This program, known as the Rural Health Model, pays hospitals a fixed amount per month—allowing them to use funds in ways that would best serve their community for meeting financial, access, outcomes and quality targets.
Pennsylvania performs well with respect to monitoring and reporting on hospital acquired infections. In addition, Pennsylvania fares better than most of the nation when it comes to curbing healthcare-associated infections. For example, Pennsylvania had 21 percent fewer central line-associated bloodstream infections (CLABSIs) and 22 percent fewer MRSA infections compared to the national average.
Like many states, Pennsylvania has work to do on overall health system spending, consumer affordability and cost transparency. The state does have a long running Cost Containment Council, an independent state agency that collects, analyzes and reports on information about hospital costs and quality in the state. Unfortunately, limitations on ways this data can be distributed only ensure broad trends on provider quality and service effectiveness can be reported, but not detail that would permit high-priced outliers to be identified. Moreover, Pennsylvania has low per capita public health funding. The data show that state public health spending has been declining, going from $29 in 2005 to $13 per-capita in 2020. Spending wisely to address social determinants of health not only has the potential to create healthier, more productive populations, but may generate significant savings, as well.
Pennsylvania ranked 22 out of 47 states plus DC, with a score of 35.3 out of 80 possible points in the Hub's 2021 Healthcare Affordability State Policy Scorecard.
Pennsylvania survey respondents support government interventions in prescription drug pricing,
according to Families USA. The survey found that 87 percent of respondents support the
Pennsylvania state government making prescription drugs more affordable, and 83 percent of
all respondents supporting the creation of a Prescription Drug Affordability Board, including 75
percent of Republicans. 94 percent of Democrats, and 70 percent of unaffiliated respondents.
A new report from the American Economic Liberties Project details the negative impacts of the University of Pittsburgh Medical Center’s (UPMC) control of the western Pennsylvania health care market, reports Fierce Healthcare. The report highlights UPMC’s practice of using market power to acquire and shut down competing hospitals and driving patients to its other facilities, thereby increasing their ability to raise prices for patients. It also includes specific policy recommendations to reform the Pennsylvania health care industry, such as increasing scrutiny over hospital mergers.
Six of Pennsylvania’s 67 counties are now classified as “maternal health deserts,” which presents concerns about maternal mortality rates for Black women, reports the Pennsylvania Capital-Star. These insights come from a March of Dimes, Nowhere to Go: Maternity Care Deserts Across the U.S. 2022 Report, which found that six counties had no hospitals providing obstetric care, no birth centers, no OB/GYN and no certified nurse midwives, affecting more than 105,000 women age 18-44. Notably, the state’s overall maternal mortality rate is 82 deaths per 100,000 live births, but the rate for Black residents is 163 deaths per 100,000 live births.
The Pennsylvania legislature has passed a law intended to simplify how healthcare providers work with insurers, according to WSKG. The law bars prior authorization for most emergency department services. Insurers must state what they will authorize, and when insurers deny something, they must give written notice which patients can then appeal.
Pennsylvania’s state-based health insurance marketplace has added a new qualifying event that will allow low-income households to enroll in health insurance plans at any time, according to the . Rather than being restricted to regular open enrollment period in the Fall-Winter, residents with a household income at or below 150% of the federal poverty level will automatically get a qualifying event to start coverage or change their current plan. This is intended to make it easier for low-income residents to stay and get covered.
Although hospitals must publicly release their prices in response to a new federal requirement, this information is often difficult for consumers to navigate, reported AboutHealthTransparency.org. To help Philadelphia residents navigate price comparison information, the Philadelphia Inquirer compiled a database with prices for more than 70 common services for 29 hospitals and 43 insurance companies. This revealed wide cost variations for medical services that can be scheduled in advance. For example, the price of a hip or knee replacement in the Philadelphia area ranged from $12,234 to $60,666.
Half of Pennsylvania residents struggled with healthcare costs in the past year and nearly two thirds were worried about affording healthcare in the future, reports The Philadelphia Inquirer. In addition, Altarum Healthcare Value Hub’s 2020 Consumer Healthcare Experience State Survey (CHESS) found that to reduce healthcare costs, 20 percent of Pennsylvania adults skipped going to the doctor, a procedure or a recommended test and 22 percent skipped medication doses, cut pills in half or avoided filling a prescription. The COVID-19 pandemic has only exacerbated concerns about healthcare costs, with 60 percent of Pennsylvania residents worried about being able to afford COVID-19 treatment if they need it
Although the State Health Department directed providers months ago to report COVID-19 vaccine race and ethnicity data, 36 percent of race and 40.9 percent of ethnicity data are missing, according to the Pittsburgh Post-Gazette. Many providers, including Pennsylvania’s largest health system, are still not collecting and reporting this data. Based on available data, Black people make up 3 percent of the state’s population but only 0.4 percent of vaccine recipients, while Latino people make up 8 percent of the population but 3 percent of vaccine recipients. Incomplete race and ethnicity data make it difficult to comprehensively track and address disparities in vaccine distribution.
Lehigh County could have saved roughly $1.4 million for prescription drugs in 2019, reports Stat+. The Office of the Controller’s report found that rebates negotiated by pharmacy benefit managers were frequently pocketed by the insurance company as profit, rather than credited to the county. In addition, the office identified 200 prescription drugs that were available at lower prices from competitors. The office recommended pursuing comparative prescription drug pricing for the 200 drugs and receiving the full value of prescription drug and medical claim rebates from the insurance company to save the county money.
The Pennsylvania Interagency Health Reform Council (IHRC) released recommendations to reduce costs, decrease disparities and improve healthcare delivery, reports the Pennsylvania Pressroom. The IHRC’s recommendations include creating a health value commission to institute healthcare cost benchmarking, developing regional accountable health councils to address health equity, integrating social services into healthcare delivery, making data dashboards public to drive quality improvement and leveraging state purchasing power. The IHRC will support legislative action related to these recommendations, continue to facilitate inter-agency coordination and track progress on the recommendations.
The Department of Health released results on social determinants of health, health equity and health factors from the 2020 State Health Assessment, according to SHADAC. The report showed that among adults under 65,10 percent did not see a doctor in the past year due to cost. In addition, Black and Hispanic adults were less likely to have health insurance and more likely to not be able to see a doctor due to cost compared to non-Hispanic white adults.
The Department of Health announced that four additional hospitals will join the 13 hospitals and six payers participating in the Pennsylvania Rural Health Model (PARHM), reports the Pennsylvania Pressroom. The PARHM will test a more sustainable financial model for hospitals serving rural areas to help ensure that they stay open, are financially stable and improve population health in rural communities. It is projected to serve more than one million Pennsylvanians living in rural areas and have $725 million in net patient revenue in the global budget model.
The Governor of Pennsylvania announced the passage of two laws meant to increase coverage for mental health services. These laws require health insurers to verify that they conducted analyses to ensure that their plans offer mental health and substance use disorder coverage that has similar cost sharing and in- and out-of-network coverage compared to physical health services. In addition, insurers must be able to make this documentation available to the state insurance department, policyholders and providers upon request. These laws will help strengthen and enforce mental health parity among insurance plans.
The Governor of Pennsylvania signed an executive order to set up new councils in an effort to control healthcare costs, improve access to medical care and address treatment disparities, reports the Pittsburg Post-Gazette. The Governor also plans to create five Regional Accountable Health Councils to develop ways to reduce disparities in the healthcare system and promote the purchase of healthcare services based on the highest value to the consumer. The Governor will also work with the state legislature to create a Health Value Commission, charged with keeping healthcare payers and providers accountable for spending growth and ensuring the long-term affordability and sustainability of the healthcare system by setting spending benchmarks.
Proposed legislation in Pennsylvania would allow the state to set payment rates for high-cost prescription drugs equivalent to prices in Canada, where prescription drugs can cost as much as 80 percent less than in the U.S., reports NASHP. This model would reduce prices for 250 high-cost drugs identified by the state, hold drug manufacturers more accountable and result in significant savings for both patients and states. If a drug manufacturer refuses to comply or withdraws their drugs from the market, they will have to pay significant penalties to the state.
Black patients in Pennsylvania are more than twice as likely to die prematurely of treatable health conditions compared to white patients, reports the Philadelphia Inquirer. Black patients had a mortality of 162.1 deaths per 100,000 people due to treatable health conditions, compared to 74.2 deaths per 100,000 people among white patients and 70.8 deaths per 100,000 among Hispanic patients.
In mid-April, Pennsylvania state officials announced the creation of a COVID-19 Response Task Force for Health Disparity to help communicate issues about how the pandemic is affecting the state’s minority and marginalized populations. After months of weekly meetings and outreach from task force members to marginalized community members, the task force completed a report that includes six recommendations focused on these policy topics related to health disparity, ranked in order of urgency: housing, criminal justice, food insecurity, health disparity, education and economic opportunities. According to the report, each area either directly or indirectly affects the health of Pennsylvanians and must be addressed to appropriately remove the disparities that have existed for generations and have been exacerbated by the pandemic.
The Pennsylvania Insurance Commissioner released the 2021 requested rate filings for health insurance plans under the ACA, highlighting that the average rate requests would result in an average decrease in premiums in the individual market, allowing consumers greater flexibility and increased access to affordable, comprehensive coverage, reports the Pennsylvania Pressroom. Key initiatives, like establishing a state-based health insurance exchange and reinsurance fund, have driven down premium rates for 2021 and are the reason that premiums are, on average, going down in the individual market.
The Governor of Pennsylvania announced that Pennsylvania’s Section 1332 Waiver application for a reinsurance program has been approved. Pennsylvania’s Reinsurance Program is authorized to operate under section 1332 of the Affordable Care Act (ACA) from 2021 through 2025. “By having a reinsurance fund that will directly pay some of the healthcare costs for high-cost individuals, we can lower premiums for other insured Pennsylvanians on the individual market and reduce the cost for subsidies to help low-income individuals,” the governor said.
Compared with Baltimore (an untaxed control city), Philadelphia experienced significantly larger declines in the amount of sugar-sweetened beverages sold in small independent stores after implementing a 1.5 cent per ounce tax, according to a study published in Health Affairs. The study also found that 120 percent of the Philadelphia beverage tax was passed on to purchasers of taxed beverages via price increases at small independent stores one year after the tax was implemented. Researchers concluded that excise taxes may be an effective policy tool for decreasing the purchase of sweetened drinks in small independent stores, particularly among populations at higher risk for sugar-sweetened beverage consumption.
Pennsylvania state legislators submitted a 1332 State Innovation Waiver application to the Center for Medicare and Medicaid Services to create a state reinsurance program, according to GANT News. By reimbursing carriers for a portion of their higher-cost claims and spreading that risk across the broader marketplace, a reinsurance program could lower the premiums for individual health insurance plans. Lower premiums would be especially beneficial for Pennsylvanians who are not eligible for financial assistance.
Pennsylvania ranks 45th in the nation for per-capita public health spending, slightly ahead of Ohio, Kansas and Mississippi. The state spends $12 per capita on public health, according to data from the State Health Access Data Assistance Center (SHADAC). The data also show that state healthcare spending has been declining, going from $29 in 2005 to $13 per-capita in 2017. Though the state has made strides in fighting opioid and heroin abuse, funding for the public health component has remained flat. Other programs that enable people to live healthy and productive lives, such as General Assistance, were eliminated entirely, reports the Pennsylvania Capital-Star.
Pennsylvania is moving to take over the online health insurance exchange that has been operated by the federal government since 2014, saying it can cut health insurance costs for the hundreds of thousands who buy individual Affordable Care Act policies, according to the Lexington Herald Leader. State leaders assert that this move will reduce premiums for residents. Currently, the federal government takes 3.5 percent of the premium paid on plans sold through the exchange, or an estimated $94 million this year, though state can operate the exchange for $30 million to $35 million and use the difference to draw down extra federal dollars for a reinsurance program that reimburses insurers for certain high-cost claims. The state's share would be about one-quarter of the reinsurance program cost, according to estimates. Those reimbursements allow insurers to lower premiums across the board within the state's insurance marketplace. Evidence from seven states that already have reinsurance program shows that they reduced insurance premiums paid by consumers.
The Medical Society of Delaware has announced a new partnership with Pennsylvania’s medical society, PAMED, reports Delaware Public Media. The goal of the partnership is for the two medical societies to negotiate with medical providers to achieve value-based contracts that will also financially benefit physicians. The medical societies are also partnering with Health EC, a data mining company, to track patient data as well as monitor for unmet need and/or duplication of effort.
A survey conducted by the Healthcare Value Hub found that one in two Pennsylvania adults struggled to afford healthcare, according to the Philadelphia Inquirer. Alarmingly, Pennsylvanians are coping with their affordability burdens by making decisions that may jeopardize their health such as: delaying care, avoiding getting care, skipping a test or treatment, failing to fill prescriptions or skipping doses. Pennsylvania adults pointed to, in particular, the rising cost of prescription drugs as a “major reason” for high healthcare costs. This is supported by other data that show that prescription drugs are one of the key drivers of high healthcare costs in the U.S. Other data show that certain populations – including medically vulnerable and older Pennsylvanians – are particularly hard hit by soaring drug prices. The survey revealed that there is support across party lines for government actions to curtail unfair prescription drug pricing and unreasonable price hikes.
A new study released by the Pennsylvania Health Care Cost Containment Council (PHC4) to look at heroin and pain medication overdose patients by age, ethnicity/race and socio-economic status found that pain medication overdose admission rates had the highest increases among Hispanic residents, followed by low income residents, according to the Philadelphia Business Journal. Male residents had a higher rate of hospitalization for heroin overdose last year at 24.1 per 100,000 residents, compared to 9.4 per 100,000 for females. In a comparison by county, Philadelphia had the state’s highest heroin overdose hospitalization rate at 54.7 per 100,000 residents. PHC4 is an independent state agency based in Harrisburg that collects, analyzes and reports information that can be used to improve the quality and restrain the cost of healthcare in Pennsylvania.
Manufacturers, distributors and retailers in Philadelphia are passing the full amount of the city’s newly implemented sugar-sweetened beverage tax on to consumers, according to Mathematica Policy Research. Although the data revealed some variation across stores, the tax of 1.5 cents per ounce typically raised retail prices by roughly 1.5 cents per ounce. As a result of the tax, sweetened drinks are more expensive and less available in stores. These findings come at a time when a growing number of communities are considering beverage taxes as a solution to rising rates of obesity and diet-related chronic diseases, such as Type 2 Diabetes.
According to the Observer-Reporter, a Pennsylvania Health Care Cost Containment Council report found that acute care hospitals statewide experienced a decrease in the amount they spent on uncompensated care in fiscal year 2017. However, the four hospitals in Washington and Greene counties had mixed marks on uncompensated care, which is uncollected debt and charity care. That was the fourth consecutive year, PHC4 noted, the percentage fell.
More than a third of Pennsylvania hospitals lost money running their facilities in Fiscal Year 2017, a 30 percent increase from the previous year, according to The Morning Call. But statewide hospitals are doing relatively well--with combined profits of $2.4 billion. Hospitals are under pressure to cut costs and implement programs that manage the health of their local communities, which can mean decreased payments and increased costs. These demands are particularly hard on smaller and rural hospitals, according to the Hospital and Healthsystem Association of Pennsylvania.
The shroud of mystery around healthcare costs has hidden from many consumers the fact that prices vary widely, even for relatively straightforward services such as an MRI. According a Philadelphia Inquirer analysis of cash prices — the amount charged to patients without insurance — for more than 30 procedures by dozens of local providers, prices vary by thousands of dollars.
One of the American healthcare system’s most stubborn challenges is the vicious circle of poor health and poverty which continues to snare high-risk patients. According to Penn Today, the Penn Center for Community Health Workers designed a new program based on patient feedback that deploys skilled and caring health workers into the community. This approach improves quality of life for Philadelphia patients and has a direct impact on their health and well-being, while saving money on avoidable hospitalizations.
A recent report by the Pennsylvania Health Care Cost Containment Council, known as PHC4, focused attention on patients with complex health and social needs (described as “super utilizers”). These patients often use a disproportionate amount of hospital services. While these patients accounted for just 3 percent of all hospital admissions last year, they accounted for 10 percent of hospital costs (about $1.25 billion). According to Lancaster Online, hospitals and health systems across the commonwealth have developed innovative programs to address the often-complex and multifaceted needs of these patients.
A bill introduced in the Pennsylvania Senate aims to make telemedicine reimbursement equivalent to in-person care services, according to mHealth Intelligence. The bill would also set reimbursement for telehealth services under "ancillary service plans."
Healthcare system mergers and consolidation have led to a number of mega systems, some of which now reach across vast geographic areas, according to PA Penn Live. The Pennsylvania Healthcare Cost Containment Council has produced an interactive map that provides viewers a breakdown of the systems with the highest market share in some counties.
Building on all-payer models in Maryland and Vermont, the Centers for Medicare and Medicaid Services this week announced a new global capitation model for rural hospitals in Pennsylvania. According to Healthcare Finance, participating critical access and acute care hospitals will receive a fixed amount of money that is funded by all participating payers.
According to a study published in Health Affairs that looked at access to primary care providers across neighborhoods in Philadelphia, the odds of being in a area with low access to primary care providers was twenty-eight times greater in neighborhoods that had a high proportion of African Americans. This study highlights that even in densely populated cities primary care provider supply can vary greatly.
According to the Philly Voice, the massive healthcare system merger of Jefferson and Aria Health is complete. With the merger of the two systems, the combined organizations now consists of 23,000 employees, including more than 10,000 doctors and nurses.
Philadelphia has become the first major city in the U.S. to approve a 1.5 cent per ounce tax on sugary and diet beverages, according to the Philadelphia Inquirer. Exempt products include baby formula and beverages that are more than 50 percent fruit, vegetables, or milk. The tax is slated to begin Jan. 1, 2017, and is expected to raise $91 million dollars that would help support programs such as citywide pre-K education.
In Pennsylvania, Geisinger Health Plan has requested a rate increase of 40 percent for 2017, according to The New York Times. Geisinger has been lauded as a model that provided high quality care at low costs but, David Feinberg, president of Geisinger, has said that the health plan was losing $30 million a year with coverage being sold on the federal exchange. The article addresses the rising health plan costs that are occurring throughout the country.
Six different Pennsylvania health insurance companies proposed rate hikes of more than 25 percent for 2016. In October these rates were approved at a much lower rates, reported LancasterOnline, and the companies were asked to phase in these rate adjustments over the next few years as they are generally financially strong enough to accommodate the lower rates. The state insurance commissioner encouraged state residents to shop the market for the plans that best fit their needs.
Starting in 2016, Capital BlueCross will offer telehealth services to their members. This offering through American Well will cost members $39 per visit and is touted to make routine care more convenient. The plan joins UnitedHealthcare and MultiCare Health Systems, which currently offer their members and patients telehealth visits for under $50.
Pennsylvania’s healthcare system is below average in the value of care provided reports Philly.com. Healthcare spending per person in the state is at least $900 more than the national average. The article suggests that the state look to successful reform programs in states like Arkansas, Maryland and Massachusetts in order to improve healthcare value.
A report from Duke University Law School found that around 35 percent of people in Pennsylvania have inadequate access to primary care. The report finds that Pennsylvania could save between $6.4 billion and $12.7 billion dollars each year if greater practice autonomy was allowed. The research concludes that Pennsylvania should follow the lead of the 21 other states and the District of Columbia in authorizing full practice autonomy for nurse practitioners.
Recent evaluations of two regional medical home pilots (i.e., efforts to improve the capabilities and performance of primary care practices) within the Pennsylvania Chronic Care Initiative (PACCI) have produced differing results. According to the RAND blog, data from the southeast region revealed that the intervention was associated with improvements in diabetes care, but no changes in other measures of quality and costs were observed. By contrast, the northeast region saw reductions in rate of hospital admissions, emergency department visits, and ambulatory visits to specialists. These differences may be due to variation in practice size and culture, EHR adoption, and socioeconomic status of the patient population.
Patients are spending fewer days than ever in the hospital, with the total number of days sliding by 14 percent during the past five years, according to a report by the Pennsylvania Healthcare Cost Containment Council.
Tandigm Health, Innovative Wellness Alliance and Holy Redeemer Health System entered an agreement that aims to bring the organizations closer to a population health model reports Modern Healthcare. The agreement will allow the organizations to share the risk of managing patients without entering a formal merger while allowing them to further implement value-based care. Furthermore, it allows the systems to take advantage of each other’s strengths further expanding the services they can offer without drastically increasing costs.
This report from the Pennsylvania Healthcare Cost Containment Council reported the cost impact that so-called “super-utilizers”—patients who are admitted to the hospital 5+ times in a year—have on the healthcare system.