2008 Finalist
Commonwealth of Pennsylvania
Innovations in American Government Awards
Innovations in American Government Awards

Multiple health service offerings are made available to state residents through the Office of Medical Assistance Programs (OMAP) of the Pennsylvania Department of Public Welfare. One such healthcare model, fee-for-service—a program which allows patients to obtain care from doctors or hospitals of their choosing, paying a fee for each individual service such as an office visit, test, or procedure—is administered by OMAP's Bureau of Fee for Service Programs (BFFSP), an office responsible for the care of 800,000 fee-for-service (FFS) recipients.

ACCESS Plus is a reform of BFFSP offerings, initiated in 2005 to improve the quality of healthcare by providing disease management services and creating medical homes for the 280,000 nondual eligibles of the greater FFS population. The initiative is comprised of distinct efforts. The first is the provision of Certified Case Managers (CCM), tasked with the management of complex medical cases and the early identification of high-risk patients. As of 2007, ACCESS Plus's cohort of 26 CCMs were overseeing 800 complex medical cases and 1,300 high-risk obstetrical cases each month.

The second of ACCESS Plus's efforts was to couple disease management with its case management efforts. After a thorough analysis of data to determine the population that would most benefit from disease management, ACCESS Plus matched disease with case managers of recipients with diabetes, asthma, chronic obstructive pulmonary disease, coronary artery disease, and chronic heart failure, ensuring that patient health was not only managed holistically, but with expert attention to specific pathology.

A Pay-for-Performance (P4P) program, and well as a Quality Improvement Program, were also established as part of ACCESS Plus. The P4P program rewards physicians for active engagement in case and disease management programs and for providing quality healthcare. The evaluation of standards of healthcare practice, the guarantee of timely access to primary, preventative, and specialty care, and the satisfaction of both enrollee and provider fall under the purview of the Quality Improvement Program.

An independent analysis by Mercer Consulting verified $27 million in cost savings in just the first year of ACCESS Plus operation. The savings are attributed to improved care coordination and disease management, with results including a decrease in costly member hospital admissions from 9.6 to 8.6 thousand per month, and a similar decrease in emergency room utilization from 61.1 to 55.3 thousand members per month. Disease specific improvements are also evident: HgA1C numbers—reflecting the average blood sugar of a diabetic over a three-month period—decreased by 9 percent, beta blocker treatment after heart attack improved from 78.7 percent to 94.22 percent, and the appropriate use of asthma controlling medications improved from 79.4 percent to 87.5 percent. After implementing high risk maternity case management, complex births also dropped from .71 per thousand members per month to .65, and the length of hospital stay for complex newborns decreased from 19.23 to 17.57 days.

Although yet to be replicated in its entirety, Pennsylvania's BFFSP has worked with other state agencies working to duplicate aspects of the ACCESS Plus model. For example, Illinois, Washington, and Texas have implemented more rigorous monitoring of contractors, and Texas is planning to implement a P4P program for providers, all based on Pennsylvania's model. California and Montana have additionally expressed interest in implementing a care management programs similar to ACCESS Plus.