By Christopher Guadagnino, Ph.D.

Published December 2007

• React to this article in the Discussion Forum.

RNG: Prescription for Pennsylvania is a set of inextricably linked, inter-dependent initiatives which when fully implemented will make quality health care accessible and more affordable for all Pennsylvanians, while driving down health care cost and containing its unsustainable rate of growth.

Some of the Governor’s health care reform proposals were introduced last year. In the Spring of 2006, the Governor proposed the Cover All Kids piece of his plan and last Fall, the General Assembly passed an expansion of Pennsylvania’s Children’s Health Insurance Program, making Pennsylvania only the second state in the country to provide affordable health care coverage to all children, regardless of their families’ household income. Also last Fall, the Governor signed into law a new Advance Directives bill that will allow Pennsylvanians to determine how they want to spend the last days of their lives and whether or not they want heroic efforts made on their behalf.

In January, the day after the Governor’s second term inauguration, he introduced the complete Prescription for Pennsylvania. Within the next two weeks all the initiatives requiring legislation were submitted in one omnibus bill, House Bill 700. The General Assembly then advised the Administration that they would deal with subsets of House Bill 700 as separate pieces of legislation. Between January and June of 2007, the Administration began its work on launching those Rx initiatives that required neither legislation nor regulation. For example, in May, by Executive Order, the Governor created the Chronic Care Management and Cost Reduction Commission to develop and implement a state-wide chronic care management model which will significantly increase the use of evidence-based protocols and pilot a new health care provider reimbursement method. The Commission and its committees have been meeting over the past two months. The Commission will release its three-year strategic plan in December. An implementation phase, in regional collaboratives, will begin early in 2008.

In addition, the Governor established the Office of Health Equity to address health care treatment disparities and placed funds in this year’s budget for start-up funding for new federally qualified health centers, nurse managed health centers and mobile wellness vans to serve areas of Pennsylvania without adequate access to primary and preventive care.

In July of this year, the Governor signed a series of bills that eliminate practice barriers for health care professionals, including certified nurse practitioners, certified nurse midwives, physician assistants, dental hygienists, and clinical nurse specialists. These bills allow these licensed health care providers to expand the services they provide, within the parameters of their education, training and clinical experience. Now, more Pennsylvanians will have greater access to quality care by qualified health care professionals. Some of these bills require the promulgation of regulations, and those regulations are well underway.

Also in July, 2007, the Governor signed legislation which will drive Pennsylvania hospitals, nursing homes, and ambulatory surgical facilities to work toward eliminating health care-acquired infections (HAIs) within their facilities. Act 52 requires hospitals, nursing homes and ambulatory surgical facilities to develop infection control plans, adopt electronic surveillance systems to detect HAIs in every unit throughout their facilities and report HAIs to the Patient Safety Authority. The Department of Health will act as a partner to these facilities and review infection control plans, develop recommendations for protocols and procedures for eliminating HAIs and promote greater public awareness of HAIs. As a result of this legislation and previous efforts, Pennsylvania is often cited as a national leader on this issue. Reducing and eventually eliminating HAIs will have a tremendous impact on the health of all Pennsylvanians and will bring down costs throughout the health care system.

This Summer, the Governor signed legislation to establish separate licensing standards for assisted living residences, which will allow persons needing long term living services to age in places with services changing as needed. Not only will this enable Pennsylvanians to maintain their independence and continue to exercise personal choice while receiving the support they need, it is a more cost-effective model for providing these services. Regulations required to establish these licensing standards are being formulated.

RBG: There are two critical lynchpin proposals. Legislation to enact Cover All Pennsylvanians (CAP) has been introduced in both Chambers. This would mirror Pennsylvania’s Cover All Kids model and would make affordable health care coverage available to uninsured adults with household incomes up to 300 percent of the federal poverty level. These Pennsylvanians would be eligible to receive federal and state subsidies to purchase their insurance. Depending on their income, the individual would pay a premium between $10 and $60 per month. Three of every four uninsured Pennsylvanians work and many of them are low-wage earners in small companies – 50 employees or less. In addition to being available to uninsured individuals, small low-wage employers who do not currently offer health insurance to their employees could, with a contribution of $130 per month per employee, offer CAP to their employees. Uninsured individuals with household incomes over 300 percent of the federal poverty level could purchase the CAP product at cost, which is about $280 per month.

Legislation has also been introduced to reduce the high cost of health care insurance currently being paid by small businesses and individuals. Pennsylvania is one of only two states that does not limit the rating factors insurance companies can use for small group and individual coverage. These proposals include expanded regulatory powers for the insurance commissioner, replacing medical underwriting and other unfair rating practices with standards that reduce price differences among groups and protect everyone against rate spikes, requiring minimum medical loss ratios, requiring standard benefit packages to make it easier for small businesses to compare benefit packages, and encouraging young adults to stay insured by allowing them to stay on their parents’ policies until age 30.

In addition to the CAP and small group insurance reforms not yet passed by the General Assembly, there are other pieces of legislation in process. Legislation on indoor air quality – the smoking ban – was passed by both Chambers and is awaiting consideration by a conference committee. There is also legislation to formally establish the Center for Health Careers to address health care workforce issues, which builds on the work already underway that has led the way for more nurses in Pennsylvania.

Also under consideration by the Legislature are additional reforms to enable health care professionals to practice within their full scope. These include expansion of pharmacists’ scope of practice to permit management of drug therapy under collaborative agreements with physicians, expansion of the scope for Expanded Function Dental Assistants, and insurance reforms that will require insurers to credential and include various types of health practitioners and service sites in their insurance networks – and to provide financial incentives for practitioners who offer extended primary care hours.

With regard to the regulatory process, the Department of Health has drafted regulations to reduce the unnecessary use of emergency rooms and to ensure that patients who need non-emergent, but urgent care, are able to get the care they need when they need it. The Department is developing regulations to address concerns about uniform admission to hospitals and hospital fair billing practices.

The Department of Health’s current efforts in updating the hospital regulations include many of the Governor’s quality improvement and patient safety efforts. The Department plans to update the overview chapters to the facilities regulations to include additional quality improvement and patient safety concerns expressed in the Governor’s plan.

All of these pieces are critical to expanding access to affordable health care coverage, improving the health of Pennsylvanians, improving quality and reducing health care costs.

PND: Could Pa.’s CHIP expansion be put into jeopardy by guidelines put out by the Bush Administration, and by the way that SCHIP is reauthorized at the federal level?

RBG: The Bush Administration issued guidelines on August 17, 2007 requiring states to meet new standards in order to receive Federal funding for children enrolled in CHIP in families with income above 250 percent of the Federal poverty level (about $51,000 yearly for a family of four). Although PA has one of the lowest rates of uninsured children in the country (only about four percent of children lack health insurance based upon a study completed by the Insurance Department in 2004), the standards contained in the letter are so aggressive that it is possible that no state, at least currently, will be able to meet the standards. For example, in order to receive Federal funds for children in families with income greater than 250 percent of poverty, we must demonstrate to CMS that: (1) We have enrolled 95 percent of the children in the state living in families with income below 200 percent of the Federal poverty level (we are currently at about 93 percent, based upon our survey); (2) The number of children in the target population insured through private employers is not more than two percent points less than the number five years ago; and (3) The cost sharing requirement under the state plan compared to the cost sharing requirement required by competing private plans cannot be more favorable by more than one percent of family income

Our program currently receives funding for children enrolled in CHIP in families with incomes up to 300 percent of poverty, so the Bush Administration directive could impact our program if we are unable to meet those standards. The compromise legislation passed by the Senate and the House would have abolished the requirements in the August 17th letter, but the President vetoed the legislation and there were not enough votes to override his veto in the House. So we will have to wait to see reauthorization, whenever it occurs, will affect CHIP in Pennsylvania.

RBG: Many of the new initiatives proposed by the Governor in Prescription for Pennsylvania require legislation, but there are some that can be implemented without legislation. For example, the Governor appointed prominent health care professionals from across the state to the Chronic Care Management and Cost Reduction Commission through an Executive Order signed in May. The result of their work, and that of their committees, will be completed and presented to both the Governor and leaders of the General Assembly in early January. Their charter is to redesign the delivery system from one that is reactive when the patient’s chronic condition is life threatening to a proactive system to make sure needed care is obtained to avoid preventable hospitalizations. It will be based on using a health care provider team that uses consistent evidence-based care and is appropriately reimbursed for quality outcomes.

The Governor as CEO of the Commonwealth, the largest purchaser of health care in the state, will meet with business CEOs, as well as health care insurers and providers to determine how to best leverage their purchasing power to institute value-based health care purchasing throughout Pennsylvania – it doesn’t take legislation to do that. Another group is working on designing a technological strategy for creating a shared health care information management structure for Pennsylvania. That doesn’t take legislation either.

RBG: The Governor has reiterated his commitment publicly for all of these proposals, and has consistently and clearly urged the Legislature to take immediate action on Cover All Pennsylvanians, small group and individual insurance reforms before the end of this calendar year. Coalitions of insured, uninsured and the underinsured, wellness and health care advocates and organizations, and other concerned citizen groups have rallied and made their support known for the Governor’s proposals. Small business owners and employees from across the state have long recognized the need for insurance reform and have expressed the need for affordable health care coverage for their employees. Pennsylvanians have been facing steep increases in the cost of health care coverage and are supportive of proposals that reduce costs and ensure access to affordable health care coverage.

RBG: Health care and its costs is a socio-economic issue that affects everyone, individually and collectively. The stakeholders and interest groups are diverse and they have strong, and often conflicting, views on how to reform our current health care system and drive down costs. Everyone recognizes and seemingly agrees that too many Pennsylvanians lack coverage, that there are costly inefficiencies in the way health care is delivered, that we pay for both bad and good quality, and that the increasing costs are unsustainable.

The Legislature hears mostly from persuasive lobbyists who are representing and protecting the interests of their powerful clients. The lobbyists have lined up where you would expect – protecting the interests of the groups and organizations that employ them. For example, the for-profit insurance lobbyists have opposed the insurance reforms and the CAP proposal. The business lobbyists have fought the fair share assessment which would be paid by businesses that don’t offer insurance to their employees. The hospital and physician groups have issues with certain Rx initiatives as well. However, the hospitals and physicians engaged with the administration in a redesign of certain Rx for Pennsylvania proposals and then solicited support for those proposals with legislators. The result of that collaboration was legislation that passed and was signed by the Governor in July. For example, the Pennsylvania Medical Society worked with us on the scope of practice bills and HAP worked on the HAI bill. On a positive note, the CRNPs, PAs, midwives, clinical nurse specialists and dental hygienists have been very helpful in supporting and gaining legislative support of the scope bills.

The Governor’s Prescription for Pennsylvania requires every stakeholder group, including insurers, hospitals, health care providers, employers and consumers to come to the table of common good and change some aspect of their business or professional practices in order to achieve accessible, affordable, quality health care for all Pennsylvanians while driving down and containing the rate of growth of health care costs. Doing the right thing often puts the Legislature between a rock and a hard place, between and among diverse stakeholders. The Governor and this Administration are very hopeful that the General Assembly will take two critical legislative actions before they go home for the holidays. They are: grant the Insurance Commissioner the power to regulate health care insurance rates; and approve other insurance reforms which will contain the growth and spikes of ever increasing premiums; and approve the funding which will enable Pennsylvania to obtain the federal matching funds to subsidize the purchase of basic health insurance – CAP – for low income wage earners and the small businesses that employ them.