Pennsylvania Uses AHRQ Resources in Medicaid Program

Comparative Effectiveness
July 2010

As a result of participating in the Medicaid Medical Directors' Learning Network—an AHRQ Knowledge Transfer project—the Pennsylvania Department of Public Welfare used several AHRQ resources to develop and enhance its Medicaid programming. Among the AHRQ products used were the Prevention Quality Indicators (PQIs), Technology Assessments, and Effective Health Care Program guides.

David Kelley, MD, Chief Medical Officer in the Office of Medical Assistance Programs (OMAP), Pennsylvania Department of Public Welfare, has been a member of the Learning Network since 2004. For several years, Kelley and OMAP managed care staff have been using AHRQ's PQIs to examine the quality and efficiency of care being coordinated by the managed care organizations and to adjust their payment rates based on shortcomings in care coordination to prevent hospitalizations.

AHRQ's PQIs are screening tools that assess the quality of care for 14 conditions, 12 of which are used by the State of Pennsylvania. The PQIs use hospital discharge data to identify conditions affected by the quality of care outside the hospital or ambulatory care-sensitive conditions among adults. These are medical conditions that can potentially be prevented with good outpatient care. These conditions are those for which early intervention can prevent complications for more severe disease and which do not require hospitalization.

During the first year of the program, Pennsylvania Medicaid officials realized more than $40 million in savings based on their payment adjustments, called efficiency adjustments. That year, the program spent $107 million on PQI-related encounters and $815 million on inpatient care, with an overall program budget of $3 billion. Kelley notes that the savings were "not a huge percentage of our total inpatient spending," but that the PQIs were useful in calculating a modest reduction in what Pennsylvania Medicaid pays to the managed care organizations.

In 2008, Pennsylvania Medicaid staff also began pursuing efficiency adjustments for payments to managed care organizations for cesarean deliveries. Kelley drew on research from the AHRQ Evidence Report/Technology Assessment, Cesarean Delivery on Maternal Request, as well as the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set, both of which indicate that Pennsylvania's cesarean delivery rates are high. Kelley found the AHRQ report useful when considering appropriate and inappropriate reasons for cesarean deliveries and used the evidence to compare national trends in cesarean delivery rates.

Pennsylvania Medicaid is also encouraging its managed care organizations to educate providers on guidelines regarding appropriate use of cesarean delivery. Given that its cesarean delivery rate seems high, Pennsylvania Medicaid adjusted its payment rates to managed care organizations. It now pays a percentage of cesarean deliveries at the vaginal delivery rate which is lower than the cesarean delivery rate in an effort to discourage unnecessary cesarean deliveries.

Another Evidence-based Practice Center report that has been useful to the State is "Integration of Mental Health/Substance Abuse and Primary Care." This report describes models of integrated care used in the United States, assesses how integration of mental health care and primary or specialty care affects patient outcomes, and outlines barriers to sustainable programs. Kelley and his colleagues reviewed the report's descriptions of both successful and unsuccessful approaches. They found the lessons learned to be useful in conducting a pilot initiative on improving care coordination between physical and behavioral health care for patients with severe mental illness and/or substance abuse. This "Innovations" pilot involves more than 6,000 consumers.

One of the pillars of the Innovations pilot includes collaboration between behavioral and physical health providers to define a medical home for patients by using a co-location model. Pilot studies examining high-volume primary care practice and mental health centers began in June 2009 in the Philadelphia and Pittsburgh areas.

The Effective Health Care Program guide, Registries for Evaluating Patient Outcomes: A User's Guide, was also helpful to Pennsylvania Medicaid. The State is implementing an electronic registry aimed to reduce disparities in health care for patients with diabetes. The program is being conducted in Philadelphia medical practices that have a high prevalence of Latino and African American populations. The User's Guide highlights issues for consideration in the design, implementation, and evaluation of effective registries to understand patient outcomes.

The disparities-reduction program addresses diabetes care in very small medical practices (those with fewer than five providers) that treat a high volume of Medicaid patients. The program provides a practice coach/care manager for each patient, and providers have free access to the registry. Kelley notes that when they've had "to convince medical practices of the value of a patient registry, we point to the User's Guide."

Kelley and his colleagues have drawn upon a number of AHRQ resources, noting, "We've been able to develop cutting-edge programs and processes in Pennsylvania using AHRQ products to help design our innovations. It's valuable to have an unbiased resource that reflects expert consensus to create the evidence-based foundation for our work. I call AHRQ 'the little engine that can.' They produce wonderful resources."

Impact Case Study Identifier: 
AHRQ Product(s): Effective Health Care Program, HCUP-Prevention Quality Indicators, Healthcare Cost and Utilization Project (HCUP), Medicaid Medical Directors Learning Network
Topics(s): Women's Health, Mental Health
Geographic Location: Pennsylvania
Implementer: Pennsylvania Department of Public Welfare
Date: 07/01/2010

Cesarean Delivery on Maternal Request, March 2006. Evidence Report/Technology Assessment No. 133. AHRQ Publication No. 06-E009. Agency for Healthcare Research and Quality, Rockville, MD.

Integration of Mental Health/Substance Abuse and Primary Care, December 2008. Evidence Report/Technology Assessment No. 173. AHRQ Publication No. 09-E003. Agency for Healthcare Research and Quality, Rockville, MD.

Registries for Evaluating Patient Outcomes: A User's Guide, April 2007. AHRQ Publication No. 07-EHC001-1. Agency for Healthcare Research and Quality, Rockville, MD.

Page last reviewed October 2014