Medicaid: HealthPASS: An Evaluation of a Managed Care Program for Certain Philadelphia Recipients (Chapter Report, 05/07/93, GAO/HRD-93-67). Federal and state policymakers believe that managed care programs are less expensive than traditional fee-for-service medical care, but critics express concern that cost-control measures may harm patient access to care and the quality of care. In 1986, Pennsylvania contracted with the private sector to create HealthPASS, a managed care program available to Medicaid recipients in south and west Philadelphia. GAO found that pregnant women enrolled in HealthPASS receive appropriate obstetrical care when they seek it, but often women seek prenatal care too late or too infrequently, despite the program's outreach efforts. Many children enrolled in HealthPASS are not receiving timely and federally mandated care, such as immunizations, vision tests, hearing tests, and lead poison and sickle cell anemia screening, apparently because doctors are unaware of federal requirements or because parents and guardians are not seeking these services for children. Outreach efforts and increased reimbursement for these services have not significantly boosted the number of children receiving care. Several reviews of HealthPASS' quality assurance program show it to meet federal and state requirements; GAO found, however, that the program has unknowingly contracted with physicians whose performance is substandard or whose conduct is unprofessional. GAO suggests that the program use information from the Federation of State Medical Boards and the National Practitioner Data Bank to spot doctors with questionable histories. --------------------------- Indexing Terms ----------------------------- REPORTNUM: HRD-93-67 TITLE: Medicaid: HealthPASS: An Evaluation of a Managed Care Program for Certain Philadelphia Recipients DATE: 05/07/93 SUBJECT: Health care services Health care programs Medicaid programs Disease detection or diagnosis Health care cost control Medical services rates Quality assurance Immunization services Women Disadvantaged persons IDENTIFIER: Philadelphia Accessible Services System HealthPASS Program Special Supplemental Food Program for Women, Infants, and Children WIC Philadelphia (PA) Pennsylvania Medical Assistance Transportation Program (Philadelphia, PA) HHS National Practitioner Data Bank ************************************************************************** * This file contains an ASCII representation of the text of a GAO * * report. 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We are unable to accept electronic orders * * for printed documents at this time. * ************************************************************************** Cover ================================================================ COVER Report to the Chairman, Subcommittee on Health and the Environment, Committee on Energy and Commerce, House of Representatives May 1993 MEDICAID - HEALTHPASS: AN EVALUATION OF A MANAGED CARE PROGRAM FOR CERTAIN PHILADELPHIA RECIPIENTS GAO/HRD-93-67 HealthPASS Abbreviations =============================================================== ABBREV ACOG - American College of Obstetricians and Gynecologists AIDS - acquired immunodeficiency syndrome CEO - Chief Executive Officer C.F.R. - Code of Federal Regulations DTP - diphtheria, tetanus, and polio EPSDT - Early and Periodic Screening, Diagnostic and Treatment services HCFA - Health Care Financing Administration HealthPASS - Philadelphia Accessible Services System HMA - Healthcare Management Alternatives, Inc. HMO - health maintenance organization WIC - Special Supplemental Food Program for Women, Infants, and Children Letter =============================================================== LETTER B-252699 Letter Date Goes Here The Honorable Henry A. Waxman Chairman, Subcommittee on Health and the Environment Committee on Energy and Commerce House of Representatives Dear Mr. Chairman: In response to your request, we have reviewed certain aspects of the Philadelphia Accessible Services System (HealthPASS). We found that (1) women who avail themselves of pregnancy- related care are receiving appropriate services, (2) some providers are not furnishing preventive care services to children as federally mandated, and (3) enrollment of eligible HealthPASS members in the Special Supplemental Food Program for Women, Infants, and Children (WIC) is no greater than the enrollment of eligible Medicaid fee-for-service women and children. However, if the names of HealthPASS members were shared with the WIC contractor, enrollment could increase. We also found that the HealthPASS quality assurance program meets federal and state standards, but its physician credentialing program could be improved if additional information about physician sanctions were sought. We have made specific recommendations about sharing the names of HealthPASS members with the WIC program and improving HealthPASS's physician credentialing procedure. In response to physician concerns and competitive pressures, the HealthPASS administrator recently revised its physician incentive program. It is to early to determine the effects of these changes. However, previous incentive arrangements may have had an adverse impact on access to specialty care. Unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its issue date. At that time, we will send copies to the appropriate congressional committees; the Secretary of Health and Human Services; the Director, Office of Management and Budget; and other interested parties. We also will make copies available to others on request. This report was prepared under the direction of David P. Baine, Director, Federal Health Care Delivery Issues. Should you have any questions, please call him at (202) 512-7101. Other major contributors are listed in appendix X. Sincerely yours, EXECUTIVE SUMMARY ============================================================ Chapter 0 PURPOSE ---------------------------------------------------------- Chapter 0:1 Federal and state policymakers believe that managed care programs are a less expensive alternative to the traditional fee-for-service medical system.\1 However, critics have warned that managed care's use of capitation rates\2 and financial incentives to control costs could impede patients' access to necessary treatment and diminish the quality of health care. In 1986, the state of Pennsylvania contracted with several private companies to offer managed care to all Medicaid recipients,\3 approximately 115,000, living in south and west Philadelphia. The largest program is called the Philadelphia Accessible Services System--HealthPASS. the result of other risk factors, such as the use of tobacco, alcohol, or drugs. GAO's findings were similar for women who delivered under the traditional Medicaid fee-for-service system in Philadelphia, which does not feature an extensive outreach program. (See ch. 2.) June 2, 1993 June 2, 1993 June 2, 1993 June 2, 1993 June 3, 1993 June 3, 1993 June 3, 1993 June 3, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 5, 1993 June 5, 1993 June 5, 1993 June 5, 1993 June 6, 1993 June 6, 1993 June 6, 1993 June 6, 1993 June 7, 1993 June 7, 1993 June 7, 1993 June 7, 1993 June 8, 1993 June 8, 1993 June 8, 1993 June 8, 1993 June 9, 1993 June 9, 1993 June 9, 1993 June 9, 1993 June 10, 1993 June 10, 1993 June 10, 1993 June 10, 1993 June 11, 1993 June 11, 1993 June 11, 1993 June 11, 1993 June 12, 1993 June 12, 1993 June 12, 1993 June 12, 1993 June 13, 1993 June 13, 1993 June 13, 1993 June 13, 1993 June 14, 1993 June 14, 1993 June 14, 1993 June 14, 1993 June 15, 1993 June 15, 1993 June 15, 1993 June 15, 1993 June 16, 1993 June 16, 1993 June 16, 1993 June 16, 1993 June 17, 1993 June 17, 1993 June 17, 1993 June 17, 1993 June 18, 1993 June 18, 1993 June 18, 1993 June 18, 1993 June 19, 1993 June 19, 1993 June 19, 1993 June 19, 1993 June 20, 1993 June 20, 1993 June 20, 1993 June 20, 1993 June 21, 1993 June 21, 1993 June 21, 1993 June 21, 1993 June 22, 1993 June 22, 1993 June 22, 1993 June 22, 1993 June 23, 1993 June 23, 1993 June 23, 1993 June 23, 1993 June 24, 1993 June 24, 1993 June 24, 1993 June 24, 1993 June 25, 1993 June 25, 1993 June 25, 1993 June 25, 1993 June 26, 1993 June 26, 1993 June 26, 1993 June 26, 1993 June 27, 1993 June 27, 1993 June 27, 1993 June 27, 1993 June 28, 1993 June 28, 1993 June 28, 1993 June 28, 1993 June 29, 1993 June 29, 1993 June 29, 1993 June 29, 1993 June 30, 1993 June 30, 1993 June 30, 1993 June 30, 1993 June 31, 1993 June 31, 1993 June 31, 1993 June 31, 1993 June 2, 1993 June 2, 1993 June 2, 1993 June 2, 1993 June 3, 1993 June 3, 1993 June 3, 1993 June 3, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 4, 1993 June 5, 1993 June 5, 1993 June 5, 1993 June 5, 1993 June 6, 1993 June 6, 1993 June 6, 1993 June 6, 1993 June 7, 1993 June 7, 1993 June 7, 1993 June 7, 1993 June 8, 1993 June 8, 1993 June 8, 1993 June 8, 1993 June 9, 1993 June 9, 1993 June 9, 1993 June 9, 1993 June 10, 1993 June 10, 1993 June 10, 1993 June 10, 1993 June 11, 1993 June 11, 1993 June 11, 1993 June 11, 1993 June 12, 1993 June 12, 1993 June 12, 1993 June 12, 1993 June 13, 1993 June 13, 1993 June 13, 1993 June 13, 1993 June 14, 1993 June 14, 1993 June 14, 1993 June 14, 1993 June 15, 1993 June 15, 1993 June 15, 1993 June 15, 1993 June 16, 1993 June 16, 1993 June 16, 1993 June 16, 1993 June 17, 1993 June 17, 1993 June 17, 1993 June 17, 1993 June 18, 1993 June 18, 1993 June 18, 1993 June 18, 1993 June 19, 1993 June 19, 1993 June 19, 1993 June 19, 1993 June 20, 1993 June 20, 1993 June 20, 1993 June 20, 1993 June 21, 1993 June 21, 1993 June 21, 1993 June 21, 1993 June 22, 1993 June 22, 1993 June 22, 1993 June 22, 1993 June 23, 1993 June 23, 1993 June 23, 1993 June 23, 1993 June 24, 1993 June 24, 1993 June 24, 1993 June 24, 1993 June 25, 1993 June 25, 1993 June 25, 1993 June 25, 1993 June 26, 1993 June 26, 1993 June 26, 1993 June 26, 1993 June 27, 1993 June 27, 1993 June 27, 1993 June 27, 1993 June 28, 1993 June 28, 1993 June 28, 1993 June 28, 1993 June 29, 1993 June 29, 1993 June 29, 1993 June 29, 1993 June 30, 1993 June 30, 1993 June 30, 1993 June 30, 1993 June 31, 1993 June 31, 1993 June 31, 1993 June 31, 1993 -------------------- \1 Managed care programs are designed to reduce the number of unnecessary medical services provided to patients. \2 A capitation rate is a fixed, prepaid, monthly payment based on the number of patients enrolled in a program or assigned to a provider. The rate often takes into consideration the age and sex of the patient as well. Frequency of visits and services provided have no effect on the reimbursement received. \3 Approximately 76,000 Medicaid recipients are enrolled in the HealthPASS program. As of December 1, 1992, about 43,800 of these recipients were women and about 31,200 were children under the age of 21.