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PA Unveils Proposed Medicaid Contracts for 2021

February 21, 2020

For 2021, the Pennsylvania Department of Human Services (DHS) unveiled a proposed contract with important provisions for those on Medicaid. These changes can easily be grouped into several key points: increased value, better care, and a patient-centered workforce.

Increased Value

For several years now, the state has increased the amount a plan must spend in value-based arrangements. From 2017, when plans needed to spend 7.5 percent of the dollars it spends on medical care in a value-based arrangement, it climbs to 50 percent this year (2020), and the draft 2021 contract shows it going as high as 70 percent in 2021. This is important because it marks a commitment to move away from doctors and healthcare providers being paid for the volume – or quantity of “stuff” they provided or ordered – to focus more on quality of outcomes or medical care that accomplishes agreed upon results. For patients, this is important because it signifies that these large providers are watching closely whether or not the medical care the patient receives accomplishes better outcomes, particularly in risky or challenging situations. Operating in this manner also ensures that the commonwealth is a good steward of public funds.

In 2021, plans may be required to better integrate Patient Centered Medical Homes into their operations and examine how in past years they have used these “supercharged” doctor’s practices and what steps they will take to further improve their efforts here. Patient Centered Medical Homes are primary care practices – often health centers – that see a lot of Medicaid patients. They are required to offer supports to their patients that make things like scheduling an appointment or getting an appointment easier. They also have care managers who follow up with patients and help them with follow up, such as seeing a specialist or getting a test done. PHAN and other advocates have pushed the state on ensuring that these practices are responsive to their community, listen to their patients, inclusive, and educate their patients on their benefits.

Better Care

Overall, in 2021, plans will need to elevate their attention on addressing the needs patients experience outside the doctor’s office, needs related to food security, housing stability, education, transportation, and other environmental and neighborhood factors that might impact the patient’s ability to live healthy lives. Whether through Patient Centered Medical Homes, or specialized programs that address these items, plans will need to be clear about how they will engage with community programs and measure whether or not the programs they engage with are effective and producing results for patients. Patients need this additional support and it is important that the state is focused on it.

Another important aspect of better care is closer coordination between physical health and behavioral health. Each Pennsylvania Medicaid beneficiary has a separate health plan for her or his physical health, and a different one for her or his behavioral health. This year, the state requiring physical health plans to develop plans for how they will manage patients with persistent serious mental illness and better interact with the plans that provide behavioral health benefits for those patients.

Lastly, data often drives more effective patient care. Plans as of 2021 will have to describe how they will share data with specific providers in value-based contracting relationships. Plans need to talk about whether they use predictive analytics to identify patients who might be at risk of medical issues.

Patient-Centered Workforce

Patients in Medicaid need the highest level of quality possible from those they interact with and need to ensure that providers are there when they need them. The 2021 contract helps deliver on these goals in two important ways.

First, it continues to increase wages for individuals working for managed care plans and their subcontractors, increasing that wage by $0.50 per hour until July 1, 2024 when it should reach $15.00 per hour. This helps ensure that the plans and subcontractors have workers who are knowledgeable and patient-focused. Care coordination and providing support to vulnerable populations requires extensive training and skills, and this step mitigates churn that could lower the quality and experience of patients.

It also ensures that patients have care when they need it. Work stoppages in healthcare can be challenging for patients including those enrolled in Medicaid. The 2021 contract would include a provision to ensure that providers in a plan’s network have conflict resolution agreements in place to prevent a disruption of care due to a work stoppage with a five-year lookback period. This promotes stability for patients while balancing the needs of employers and employees.