Highlight on Pennsylvania: Healthy PA is going away, ACA expansion gets its day

Pennsylvania’s Medicaid program will make the transition to traditional Medicaid expansion by September 30, 2015, according to the Pennsylvania Department of Human Services (DHS). The state Medicaid program is in the process of moving from the alternative Medicaid expansion program known as Healthy PA to an expansion of traditional Medicaid as intended by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148).

Power Struggle

The outline for the Healthy PA plan came from Pennsylvania’s former governor, Tom Corbett (R). Healthy PA took ACA dollars and used them to subsidize private plans for Pennsylvania’s working poor. According to the Pittsburgh Post-Gazette, the plan received approval from federal regulators in August 2014. Although the approval was received three months before the election and Corbett eventually lost his reelection campaign, the former governor went ahead with Healthy PA’s implementation despite the fact that the Democratic Gov. Tom Wolf indicated his plan to undo Healthy PA when he took office.


Now that Governor Wolf is in office, Pennsylvania plans to transition out of Healthy PA and into an ACA expansion of Pennsylvania’s existing Medicaid program—HealthChoices.  The Pennsylvania DHS will implement the transition through two phases. The first phase will operate between April 2015 and June 1, 2015. In the first phase, individuals will begin to be transferred from the private coverage option (PCO) into the new adult benefit package under HealthChoices. During the first phase, new applicants will no longer be enrolled in the private coverage option. In the second phase, which is set to take place between July 2015 and September 30, 2015, Pennsylvania will transition all remaining PCO enrollees into HealthChoices. At the end of the transition, Pennsylvania estimates that Wolf’s plan will provide access to health care coverage for hundreds of thousands of Pennsylvanians. The Pennsylvania DHS was clear in its announcement that no gaps in coverage will occur during the transition and that enrollees will be informed by mail prior to the change.

Other Changes

In addition to the move towards a more traditional expansion, Governor Wolf has pushed for other changes to the Medicaid program.  Specifically, the new governor pushed for reforms to allow the state’s elderly poor to receive home and community-based services in place of nursing home based services. The reform is intended to lower the $27.6 billion that Pennsylvania annually spends on Medicaid.

Kusserow on Compliance: CMS changes five star quality rating for nursing homes

CMS has made changes to the Five Star Quality Rating System for nursing homes on the Nursing Home Compare (NHC) website. CMS rates nursing homes based on three categories: (1) onsite inspection results from trained surveyors; (2) performance on quality measures; and (3) levels of staffing. The changes to the nursing home star rating system include:

  • Inclusion of two new quality measures related to the use of antipsychotic medication since these drugs are often employed for diagnoses that do not warrant their use;
  • Improved calculations of nursing home staffing levels by adjusting staffing algorithms;
  • Recalibration of quality standards requiring nursing homes to achieve a higher standard for a higher rating on the quality measure dimension; and
  • Expansion of targeted state surveys to conduct specialized, onsite surveys of a sample of nursing homes to assess adequacy of resident assessments and accuracy of information reported to CMS used in calculating quality measures for the rating system.

In its press release on the subject, CMS predicts that approximately two-thirds of nursing homes will experience a decline in their quality measures star rating and approximately one-third of nursing homes will experience a decline in their overall five star rating. It is expected that this will be the result of new increased standards for performance on quality measures. Currently, about half of nursing homes will receive a 4 or 5 star rating as their quality measure rating, versus 80 percent of nursing homes in the previous period. CMS’ changes to the NHC website include more meaningful distinctions in performance and aim to incentivize nursing homes to continuously improve care.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Nurse Practitioners to the Primary Care Shortage Rescue?

As the U.S. population grows and health insurance coverage expands, the demand for primary care is steadily increasing, giving rise to a shortage in primary care physicians (PCPs). In answer to this shortage, Kaiser Family Foundation (KFF) suggests filling the gap with increased use of nurse practitioners (NPs).

ACA Provisions

The Patient Protection and Affordable Care Act (P.L.111-148) (ACA) contributes to health coverage growth across the country and provides incentives to PCPs to address Health Professional Shortage Areas (HPSAs). Not only does the ACA offer a 10 percent Medicare payment bonus for five years to physicians and general surgeons practicing in HPSAs, the ACA also allows the HHS Secretary to award three-year grants to eligible entities to operate NP programs as part of a training demonstration program. Grant awardees will enroll and employ graduates of NP programs and provide one-year training for careers as PCPs in HPSAs. In 2012, HHS awarded $15 million in such grants to support 10 clinics.


KFF notes that at least 58 million Americans reside in geographic areas or belong to population groups that are considered HPSAs, in which the supply of PCPs relative to the population falls below federally defined standards. The proportion of Americans living in HPSAs varies from state-to-state, with a little over 1 percent in Nebraska to 57 percent in Mississippi. In 19 states, the proportion is at least 20 percent and in six states, it exceeds 30 percent (Alabama, Arizona, the District of Columbia, Louisiana, Mississippi, and New Mexico). It is estimated that by 2020, there will be a shortage of 20,400 PCPs.

Power of NPs

NPs are registered nurses who have completed Master’s degrees or higher-level nursing degrees. Nearly 90 percent of all NPs are trained in primary care and able to prescribe medications. NPs are more likely to practice in urban and rural areas and serve a high proportion of uninsured patients and other vulnerable populations. Research shows that NPs can manage 80 to 90 percent of the same care provided by PCPs, although NPs achieve training in fewer years than PCPs (an average of six years of education and training versus 11 or 12 years, respectively).


Unfortunately, there are some barriers to the extended use of NPs. Some states require NPs to have a regulated collaborative agreement with a PCP in order to provide patient care and limit NPs’ engagement in at least one element of NP practice, according to KFF. Only 20 states allow NPs to have full-practice authority.

In its 2011 report, “The Future of Nursing: Leading Change, Advancing Health,” the Institute of Medicine (IOM) specifically noted, “Remove scope-of-practice barriers” as one of its first recommendations to solve the PCP shortage. The IOM report called for a Federal Trade Commission (FTC) review of state regulations and for the Department of Justice (DOJ) to identify states with unjustified anticompetitive effects.

Highlight on Washington, DC: Prescription Drug Reporting, Licensing, and Exchange Laws Adopted in 2014

Pharmacists and other dispensers of controlled substances in the District of Columbia will have to provide specific information  to a new database on the substance prescribed and the person to whom the medication was prescribed under legislation adopted in 2014.  Another piece of legislation adopted by the City Council would regulate an additional nine professions including home health and assisted living administrators.  The Omnibus Health Regulation Amendment Act of 2013 would also require additional certification for dentists and dental facilities where anesthesia is administered.  Finally the City Council adopted legislation that provides definitions of key  phrases in the Health Benefit Exchange Authority Act of 2011.   Upcoming proposals having to do with health care will be treated differently in 2015, as the City Council is combining the Health Committee and the Human Services Committee.

Prescription Drug Monitoring Program

Effective February 22, 2014 dispensers of medications licensed by the District of Columbia will have to report information within 24 hours on each prescription  dispensed for a schedule II, III, IV or V controlled substance to the Prescription Drug Monitoring Program.  The patient’s name, address, date of birth, and gender as well as the dispenser’s and prescriber’s identification number, the date the prescription was written, the date the prescription was dispensed, the prescription number, the quantity dispensed, the source of payment and other information needs to be reported.  Hospitals, nursing facilities, hospices, and drug wholesalers are exempt from the act as are prescriptions provided by a licensed narcotic maintenance programs.

The report of the City Council’s Health Committee stated that this legislation is designed to “reduce the diversion of prescription drugs in an efficient and cost effective manner.” The committee reported that prescription drug abuse has become a nationwide problem with nearly one-third of people 12 years of age or older began abusing drugs by using a prescription drug for a non-medical purpose. Typically it will be pharmacists who will be checking the database and reporting data to the database and not physicians.  Pharmacists have the power to deny a request to fill a prescription, but without this database pharmacist have a difficult time obtaining information to make that decision.

Licensed Professionals

Dentists and dental facilities that administer anesthesia in the District of Columbia will have to obtain an additional certification under the provisions of the Omnibus Health Regulation Amendment Act of 2013, adopted on January 7, 2014 and effective on March 26, 2014.  In addition teachers of dentistry hygiene and dentistry will also have to be licensed in the District of Columbia.

While home health care agencies in the District  of Columbia have been licensed for a number of years they will now be required to provide both a skilled nursing services and a therapeutic services that includes physical, speech, or occupation therapy, medical social services, or personal care services. This definition will be in conformance with federal law and will minimize inconsistencies among oversight agencies, according to a report prepared by the City Council’s Health Committee on this legislation.

Home healthcare administrators, assisted living administrators, assistants in the practice of speech language pathology and audiology, as well as speech language pathology clinical fellows will need to be licensed. Prior to this legislation health professionals were regulated by 18 health occupation boards and four registration programs.

Health Insurance Exchange

The Better Prices, Better Quality, Better Choices for Health Care Coverage Amendment Act of 2014 provided key definitions for the regulation and operation of the District of Columbia’s health insurance exchange.  The Act would require insurers to offer plans at the bronze, silver and gold level on their exchange and require standardization of at least one plan at each metal level. The District of Columbia’s exchange acts more as a clearinghouse and contracts will all qualified health plans who want to offer insurance on their exchange instead of only offering pre-selected health plans with negotiated premiums prices, according to a Health Committee report.  The Act defines terms such as metal level, navigator, standardized plan, accurate attestation, prescription drug formularies, and essential health benefits.  The District of Columbia established its exchange with the Health Benefit Exchange Establishment Act of 2011.

Future Activity

The District of Columbia’s City Council may be more active in 2015 than it was in 2014.  It begins a new two year legislative session  on January 2, 2015, and the City Council will  be reducing the number of committees it has from ten to eight, according to a recent press release.  Most notably the Health and Human Services Committees will be combined into one committee which will be chaired by the former Chair of the Health Committee, Councilmember Yvette Alexander.  This combination could have a significant impact on how and what types of legislation will be adopted by the District of Columbia’s City Council on health care related issues in 2015 and 2016.