Medicaid

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.

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.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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