Medicaid:

HealthPASS: An Evaluation of a Managed Care Program for Certain Philadelphia Recipients

HRD-93-67: Published: May 7, 1993. Publicly Released: Jun 8, 1993.

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Pursuant to a congressional request, GAO reviewed the Philadelphia Accessible Services System's (HealthPASS) medical services, focusing on whether HealthPASS members receive: (1) timely and appropriate pregnancy-related services; (2) early and periodic screening, diagnostic, and treatment (EPSDT) services; and (3) Special Supplemental Food Program for Women, Infants, and Children (WIC) benefits. GAO also reviewed: (1) whether financial incentive arrangements with primary care physicians compromise the quality of care; and (2) the program's quality assurance and credentialing processes.

GAO found that: (1) although HealthPASS providers follow established guidelines for obstetrical care, many patients do not avail themselves of the services or return for follow-up care; (2) the number of women seeking early prenatal care has not significantly increased despite the development of several outreach and education programs; (3) many children do not receive required EPSDT services, particularly immunizations and screening tests, due to a lack of documentation; (4) HealthPASS has increased its emphasis on lead-poisoning screening and sickle cell testing and is providing training for physicians and their staffs on the EPSDT program; (5) HealthPASS is attempting to educate parents and guardians about the importance of EPSDT services for children by giving parents immunization schedules and emphasizing childhood immunizations during the enrollment process; and (6) HealthPASS is not contractually required to enroll its members in WIC, but it has voluntarily worked to educate them about WIC and enroll eligible members in WIC. GAO also found that: (1) financial incentives may have affected decisions about the services patients receive; (2) HealthPASS has changed its capitation fees and physician's referral services fund assessments in response to physicians' concerns about inequitable financial burdens and assumed greater financial responsibility for specialist-care and hospitalization costs; (3) HealthPASS has developed quality assurance procedures and revised its recredentialing process for primary care physicians to identify incompetent and unethical providers; and (4) the HealthPASS quality assurance program meets federal requirements and exceeds state requirements, and is superior to traditional Medicaid fee-for-service programs.

Matter for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: HCFA took the position that the Social Security Act places responsibility for promoting optional use of WIC upon the state as opposed to Medicaid providers. In addition, federal regulations do not authorize the release of information on Medicaid recipients by providers to whom it was originally released. HCFA therefore took the position that release of names to the WIC agency should be performed by the state Medicaid agency, as opposed to any or all Medicaid providers.

    Matter: Congress may wish to consider amending title IV of the Health Care Quality Improvement Act of 1986 (P.L. 99-660) to require health insuring organizations to participate in the National Practitioner Data Bank. By doing so, health insuring organizations like HealthPASS could access information needed to identify unethical or incompetent practitioners.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HCFA supported this recommendation, in part, and stated that it is desirable for Healthcare Management Alternatives (HMA) to contact the National Practitioner Data Bank as part of its provider credentialing program. Because HMA does not have statutory eligibility, however, HCFA determined that it could not legally require such coordination in its contract.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Health Care Financing Administration (HCFA) to require the Pennsylvania Department of Public Welfare and Department of Health to make the necessary arrangements to allow Healthcare Management Alternatives, Inc., (HMA) to provide the names of HealthPASS members to the WIC program.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HMA could not get access to the National Practitioner Data Bank because HMA is a health insurance organization. HCFA did not institute a regulation to allow access. However, the HealthPASS program terminates as of December 1996.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to direct Pennsylvania to modify its contract with HMA to require HMA to query nationwide information banks to improve the identification of potentially problematic physicians in the HealthPASS program.

    Agency Affected: Department of Health and Human Services

 

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