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Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 

 

Pennsylvania Medical Assistance: 
Connections within the Commonwealth’s 

Public Health System 
 
 

Judith R. Lave, PhD and Margaret A. Potter, JD, MS 
Graduate School of Public Health, University of Pittsburgh 

 
 

Introduction 

Nationally, the Medicaid program is the underpinning of the 
country’s health care safety net. Jointly funded by the federal and state 
governments and administered by individual states, it is a source of 
health insurance for a high proportion of the most disadvantaged and 
vulnerable individuals, specifically low-income children and families. It 
provides long-term care assistance to individuals with disabilities and/or 
who are elderly, fills certain gaps in the Medicare program, and pays 
providers for treatment that would otherwise go uncompensated.  
Although the original Medicaid program acted like a traditional health 
insurance program by paying claims to providers for services given to 
individual Medicaid recipients, it has since evolved to being more 
population-oriented – like a public health system. 

In this paper, we focus on the Medicaid program in Pennsylvania, 
known as Medical Assistance (MA), and its role in the public health 
system. We begin with some background and definitions about the 
purposes and functions of public health as these concepts have evolved 
nationally over the past two decades. Next, we provide a succinct 
description of the Medical Assistance Program in Pennsylvania, followed 
by a description of how MA contributes to the public heath system by 
assuring access to personal health care services, evaluating the 
accessibility and quality of personal health services, monitoring health 
status, and developing policies that support individual health efforts. 
Then, we consider some of the ways that MA could be better connected 
to the overall public health system. 



164 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

Background and Definitions 

The 1988 Institute of Medicine landmark report, The Future of 
Public Health (Institute of Medicine 1988, 1), defined public health as 
“What we as a society do collectively to assure the conditions under 
which people can be healthy.” The report argued that there was an 
organizational mechanism for achieving population health and that 
public health encompassed the activities undertaken within the formal 
structure of government and the associated efforts of private and 
voluntary organizations and individuals. The 2001 Institute of Medicine 
report, The Future of the Public’s Health in the 21st Century, built upon 
these ideas and argued that the concept of a public health system 
describes a network of individuals and organizations that have the 
potential to play critical roles in creating the conditions for the public’s 
health. 

Subsequent reports defined the concept of a public health system in 
greater detail.  Halverson (2002, 98) defined the public health system as 
"The organizations and individuals who collectively share the benefits, 
burdens, and responsibilities for the health of a defined population or 
community.” The Centers for Disease Control and Prevention (CDC) 
(2008) has said that public health systems are the constellation of 
individuals and organizations in the public and private sectors that 
provide information and assets to promote population health, provide 
health care delivery, and prevent disease and injury (including health 
care providers, insurers, purchasers, public health agencies, community-
based organizations, and entities that operate outside the traditional 
sphere of health care).  

All of these definitions have an unstated assumption:  that the 
various parts of the system – the individuals and organizations – are 
interconnected and that they communicate with and reinforce each 
other’s functions. Assuring such interconnectedness is not necessarily 
straightforward or simple. In the following section of this paper, we 
describe features of the Pennsylvania Medical Assistance Program that 
clearly function to benefit the “health of a defined population.”  
However, we later point out that the MA program lacks an explicit 
mandate for connectedness with the Commonwealth’s governmental 
public health agencies and that this omission weakens the networks that 
support the health of all Pennsylvanians.  



Judith R. Lave and Margaret A. Potter       165 
 

 

 

Overview of the Medicaid Program in Pennsylvania 

The federal Medicaid Program was created by Congress in 1965, as 
Title XIX to the Social Security Act. Governed by federal regulations, 
states are required to cover a set of mandated services for specific groups 
of people to qualify for federal matching payments. However, states 
administer the program and set rules for eligibility, benefits, and provider 
payments. In Pennsylvania, Medicaid is called Medical Assistance or 
MA. The Department of Public Welfare (DPW) is responsible for its 
management. Within DPW, the Office of Medical Assistance Programs 
(OMAP) has the primary responsibility for the administration of MA. 
However, the Office of Mental Health and Substance Abuse (OMHSA) 
is primarily responsible for administration of behavioral health care.  

Program Resources in Pennsylvania 

In FY 2009, (July 1, 2008, through June 30, 2009), the state 
budgeted approximately $14.4 billion in state, federal, and other dollars 
to pay for MA. About 55% of the total cost of the MA program will be 
paid from federal funds, 35% will be drawn from the state general fund, 
and 10% will be paid for by other funds (including $134.1 million from 
the State Tobacco Settlement Fund).  After basic education, MA is the 
second largest spending category in Pennsylvania’s general fund budget 
– the state allocates approximately 18% of the state general fund to the 
program.  

Eligibility  

Individuals are eligible for MA if they meet all of the following 
eligibility requirements: 1) they fit into a specified coverage group; 2) 
they meet the income requirement for the specific coverage group; 3) 
they meet the asset requirement for the specific coverage group; 4) they 
are United States citizens or qualified legal aliens; and 5) they are 
Pennsylvania residents. There are five broad MA coverage groups in 
Pennsylvania (children, pregnant women, families with children, 
individuals with disabilities, and the elderly), and each group has its own 
income and asset standards. In general, an individual has to be very poor 
to be covered under the program. There are subcategories within the five 
stated categories (Costlow and Lave 2007).  For example, elderly and 
disabled individuals (with the exception of disabled children) are eligible 
for MA if their income is equal to or less than 100% of the Federal 



166 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

Poverty Level (FPL) and their “countable assets” are less than $2,000. 
Pregnant women are eligible with family incomes up to 185% of the FPL 
while women with breast and/or cervical cancer are eligible with family 
incomes up to 250% of the FPL. Children’s Medical Assistance 
eligibility is dependent on age; for example, children under the age of 
one are eligible if their family incomes are at or below 185% of the FPL; 
children aged one through six are eligible if their family incomes are at 
or below 133% of the FPL, while children aged six through 19 are 
eligible if their family incomes are at or below 100% of the FPL. 
Children who meet the disability criteria are eligible for MA regardless 
of their family income or assets.  

The Organization of Care 

Although MA was initially a fee-for service program, MA recipients 
in Pennsylvania could enroll voluntarily in managed care plans starting 
in 1986. The HealthChoices Program, which was implemented in 1997 
by DPW, expanded managed care considerably. This program separated 
physical health (medical services for physical health, dental care, and 
pharmaceuticals) and behavioral health (mental health and substance 
abuse) services. Physical health was to be provided through Managed 
Care Organizations (MCOs) and behavioral health was to be provided 
through Behavioral Health Managed Care Organizations (BH-MCOs). 
The HealthChoices program was phased in over time.  

Figure 1 (page 167) shows the HealthChoices regions and the date 
when managed care was introduced into each region.  Currently, MA 
recipients1 who live in three regions of the state (southeast, southwest 
and Lehigh/Capital regions) are required to enroll in MCOs to receive 
their physical and dental health and pharmaceuticals. MA recipients may 
enroll voluntarily in MCOs in other counties (if there is a MCO 
available). All MA recipients receive their behavioral health care through 
a BH-MCO. Each county (or group of counties) contracts with a BH-
MCO to provide behavioral health care services to the MA recipients in 
their counties. Currently, seven MCOs and five BH-MCOs operate in 
                                                 
1Some groups of Medical Assistance recipients such as Medical Assistance recipients 
who are also on Medicare (dual eligibles), people who have been receiving long-term 
care for more than 30 days, children in Juvenile Detention Centers (after 35 days), and 
residents of a state institution are not required to enroll in an MCO. Dual eligibles were 
required to be in a MCO prior to 2006. 



Judith R. Lave and Margaret A. Potter       167 
 

 

 

Pennsylvania. There were 1,074,230 MA recipients enrolled in MCO in 
December 2007. Of this number, 93.4% were enrolled in mandatory 
managed care.   

 

Figure 1:  HealthChoices Regions in Pennsylvania 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In 2005, Pennsylvania launched the Access Plus Program.  Access 
Plus is a primary care case management system and disease management 
system for MA recipients. The disease management aspect of Access 
Plus provides case-management for individuals who suffer from selected 
chronic illnesses. In January 2008, 293,007 MA recipients were enrolled 
in Access Plus. MA recipients who live in the regions where managed 
care is not mandated may select a primary care physician to provide 
standard medical care and to serve as a gatekeeper to other medical 
specialties.   



168 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

Managed Care and Measurement of Plan Performance 

Managed care has significantly changed since it was first introduced 
in the 1960s and 1970s. While it began as a mechanism to contain costs 
through controlling the utilization of services, it has evolved into a model 
for improving the overall delivery of services and quality of care. When 
managed care was introduced into the nation’s private health care plans 
during the 1970s and 1980s, a number of policy concerns arose. First, 
many policy analysts felt that the optimal way of organizing the health 
care system was through “managed competition.” Under this system, 
health plans would compete for clients based on cost and quality; 
however, there had to be objective measures of plan quality for such 
competition to work.  Second, employers were spending a lot of money 
on health care and they began to clamor for measures to assess the results 
of their expenditures. Thirdly, many managed care plans were paid a 
fixed amount per member per month, and there was some concern that 
health plans would limit services inappropriately. Without measures on 
processes and outcomes, it would not be possible to monitor health plans.  

Plan Measurement Systems 

Over the years, researchers addressed these concerns, with the results 
that two major sets of health plan performance measures emerged:  the 
Health Plan Effectiveness Data and Information Set (HEDIS®), and the 
Consumer Assessment of Healthcare Providers and Systems (CAHPS®).   

The HEDIS® measures were developed by the National Committee 
on Quality Assurance (NCQA). These measures are derived from either 
administrative data collected by the health plans or from data kept by 
medical providers.2 NCQA specifies how each measure is to be collected 
and measured. HEDIS® measures are frequently classified into two 
groups:  Effectiveness Measures and Access and Visits Measures.   

Effectiveness Measures focus on aspects of performance such as the 
extent to which plan members receive certain types of recommended care 
(i.e., screening and prenatal care) or the extent to which selected 
                                                 
2For example, data on the number of physician visits can be obtained from the claims 
data (administrative data). However, the claims data does not have information on 
outcomes, such as the percentage of people with hypertension who have their 
hypertension under control. Thus, the health plans have to collect data from the 
providers’ medical records to measure performance on these variables. 



Judith R. Lave and Margaret A. Potter       169 
 

 

 

problems (i.e., blood pressure) are under control. Access and Visits 
Measures indicate the extent to which members make certain types of 
visits (such as “early care for pregnant women” and “well-child visits in 
the first 15 months of life”). While these measures were originally 
created for health plans that covered employed workers, they have been 
adapted for the Medicaid population. Although most of the HEDIS® 

measures relate to physical health care, some of them relate to behavioral 
healthcare.  

For the CAHPS® measures, developed by the federal Agency for 
Healthcare Research and Quality (AHRQ), data are obtained from 
surveys of plan members. CAHPS® measures are frequently classified 
into two groups:Experience Measures and Access Measures.  Experience 
Measures gauge the extent to which members are satisfied with aspects 
of the health plan. Access Measures indicate the extent to which 
members perceive they are able to access the services they need.  

As work on measurement evolved and as health care costs continued 
to increase, a growing number of employers, health plans, and 
government programs began to look for ways to link their health care 
spending to quality care. This movement has been labeled Pay for 
Performance or P4P. By 2008, it had become quite widespread.  The 
federal government had implemented a number of P4P demonstrations.  
A recent study found that more than half of a representative sample of 
commercial health maintenance organizations had incorporated pay-for-
performance in their contracts (Rosenthal et al. 2006). A 2007 survey of 
State Medicaid Programs found that 43 states had implemented one or 
more pay-for-performance programs (Kuhmerker and Hartman 2007).   

Performance Measurement in Pennsylvania  

Managed Care Organizations. When the HealthChoices Program was 
introduced in Pennsylvania, the Pennsylvania DPW mandated that 
MCOs report many of the HEDIS® and CAHPS® performance measures 
that had been developed for Medicaid plans.  In addition, the Office of 
Medical Assistance Programs (OMAP) in DPW developed another set of 
measures to evaluate aspects of MCOs’ performance that were omitted 
by the other two performance measurement systems. The Pennsylvania-
specific measures include items such as the extent to which children 
under six have been screened for lead poisoning or received dental 



170 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

sealants. OMAP publishes information on plan performance of 27 of 
these measures on its website (Pennsylvania Department of Public 
Welfare, Office of Medical Assistance Programs 2007). In 2005, OMAP 
took another step to promote overall improvement in MCOs’ 
performance by introducing a pay-for-performance system.  It set aside 
over $19 million to pay plans that improved their performances based on 
a complex formula. 

 
Table 1, below, lists the performance measures that are publicly 

reported as well as the set of measures used in the Pay-for-Performance 
program.  These measures, which are a small subset of the total number 
of measures reported to the state, illustrate the type of data collected.     

 

Table 1:  Publicly Reported Performance Measures and 
Measures Used for Pay-for-Performance: 

Pennsylvania, 2003-2006 
 
 
Performance 

Program 
Measurement

Category Performance Measures 

Experience 
 

Satisfaction with Plan* 

Satisfaction with Child’s Plan* 
Choosing a Doctor You are Happy with* 

Satisfaction with  Specialist* 

CAHPS® 
 

Access® 
 

Seeing a Specialist* 
Getting an Appointment with Your Doctor or 

Nurse* 
Getting Necessary Care* 
Waiting for Plan Approval* 



Judith R. Lave and Margaret A. Potter       171 
 

 

 

Performance 
Program 

Measurement
Category Performance Measures 

Effectiveness 
 

Cholesterol Management Screening (after CV 
Events)* 

Cholesterol  Management: LDL control <100# 
Controlling High Blood Pressure*# 
Eye Check-Ups for People with Diabetes* 
Diabetes:  HbA1C Control# 
Diabetes: Cholesterol LDL Control < 100#  
Cervical Cancer Screening*#   
Breast Cancer Screening#     
Use of Appropriate Medications for People with 

Asthma# 

HEDIS® 
 

Access and 
Visits 

 

Early Care for Pregnant Women*# 
Regular Prenatal Care* 
Regular Check-Ups for Children 3-6 Months* 
Well-Child Visits in the First 15 Months of Life* 
Doctor Visits for Children 7-11 Years Old* 
Doctor Visits for People 45-64 Years Old* 
Doctor Visits for People 65 Years and Older* 
Adolescent Well-Child Care# 

Pennsylvania-Specific 
Measures 

Finding Cervical Cancer in Women with HIV* 
Blood Lead Screening for Children under 19 

Months*# 
Blood Lead Screening: Age 3 Years# 
BMI screening at Regular Check Up* 
Satisfaction with Dental Care* 
Dental Sealants for Children* 
Regular Dental Care, Ages 3-20 Years old* 
Annual Dental Visits for those with Development 

Disabilities* 
Emergency Room Visits for Asthma*   

Key: 

*  These performance measures are posted on the DPW web site. 
#  These measures were included in the pay-for-performance program. 
 
 



172 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

Behavioral Health Managed Care Organizations. DPW requires that the 
BH-MCOs report on several measures including the few HEDIS® 
measures that have been developed for behavioral health (such as 
“patients should be followed up within specified time periods within a 
certain number of days after they were discharged from a hospital”).  
DPW also has set specific goals for selected measures (such as 
“involuntary admissions should decrease over time” and “less than 10% 
of hospitalized patients should be readmitted within 30 days”). DPW’s 
Office of Mental Health and Substance Abuse Services (OMHSAS) 
reports on the performance of the BH-MCOs through its quarterly 
monitoring reports (Pennsylvania Department of Public Welfare, Office 
of Mental Health and Substance Abuse Services 2008). These reports 
include information on individual performance improvement projects, 
adult involuntary admissions, 30-day readmissions, complaints, denials, 
grievances, and consumer satisfaction.  

Access Plus.  The reporting requirements under the Access Plus Program 
are somewhat different. The Bureau of Fee-for-Service, within OMAP, 
mines its administrative database to calculate measures of clinical quality 
of care and medical utilization measures for this program.  It models the 
development of these measures after the technical specifications for the 
HEDIS® measures (Pennsylvania Department of Public Welfare, Bureau 
of Fee-for-Service 2005). In addition, OMAP requires the disease 
management companies to report on processes of care, as well as clinical 
outcomes.  OMAP has also introduced a pay-for-performance system for 
the disease management component of that system.  

 

Medical Assistance and Essential Public Health Services 

The definition of what a public health system does is well-
established in the concept of “Ten Essential Services” (Public Health 
Functions Steering Committee 1994) shown in Table 2 (page 173). A 
brief review of the Ten Essential Services shows that MA contributes 
significantly to at least four of them.  In order of priority for discussion 
in this paper, these four essential services are: 1) assuring access to 
personal health care services; 2) evaluating the accessibility and quality 
of personal health services; 3) monitoring health status; and 4) 
developing policies that support individual health efforts.   



Judith R. Lave and Margaret A. Potter       173 
 

 

 

Table 2:  The Ten Essential Services of Public Health 
(Public Health Functions Steering Committee, 1993)* 

 

1 MONITOR HEALTH STATUS TO IDENTIFY COMMUNITY HEALTH PROBLEMS  

2 
Diagnose and investigate health problems and health hazards in the 
community  

3 Inform, educate, and empower people about health issues  

4 Mobilize community partnerships to identify and solve health problems  

5 
DEVELOP POLICIES AND PLANS THAT SUPPORT INDIVIDUAL AND 

COMMUNITY HEALTH EFFORTS  

6 Enforce laws and regulations that protect health and ensure safety  

7 
LINK PEOPLE TO NEEDED PERSONAL HEALTH SERVICES AND ASSURE THE 

PROVISION OF HEALTH CARE WHEN OTHERWISE UNAVAILABLE  

8 Assure a competent public health and personal health care workforce 

9 
EVALUATE EFFECTIVENESS, ACCESSIBILITY, AND QUALITY OF PERSONAL 

AND POPULATIONS BASED HEALTH SERVICES 

10 Research for new insights and innovative solutions to health problems  

 
*Entries in BOLDFACE type are those addressed in this paper as contributed in 
whole or in part by the Pennsylvania Medical Assistance Program. 
 

Assuring Access to Personal Health Care Services 

Essential Service #7 calls upon a public health system to “Link 
people to needed personal health services and assure the provision of 
health care when otherwise unavailable.” The availability of health 
services depends not only on payment for services by or on behalf of 
those who need them, but also on the location of services and service 
providers even in areas of sparse population density.  MA provides a 
health care plan and coverage for a large proportion of the Pennsylvania 
population.   



174 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

Enrollment.  In December 2007, 1,893,949 individuals, or about 15% of 
the population of the Commonwealth of Pennsylvania, were covered 
under MA. Medical Assistance covered almost 33% of the children in 
Pennsylvania. In addition, MA pays for about 41% of the births in the 
State.3 It also covered 513,946 individuals with disabilities, many of 
whom are individuals with severe mental illness.4 On an average month, 
MA covers about 38,808 children with disabilities (about 10.3% of the 
disabled MA population) and 1,165 women with breast and/or cervical 
cancer. 

Since eligibility for MA is tied to income, the distribution of MA 
recipients varies across the Pennsylvania counties depending on the 
general level of income in the county. Figure 2 (page 175) shows the 
percentage of births covered by MA in 2005 and 2006, while Figure 3 
(page 176) shows the percentage of children enrolled in MA in 2006. We 
focus on these groups because of the importance of medical care 
services, particularly prenatal and preventive care services, to the birth 
outcomes and the development of children.  

As shown in Figure 2, there is wide variation across the counties in 
the percentage of births that are covered by MA – the percentage ranges 
from 18% in Montgomery County to 64% in Philadelphia County. These 
data indicate the importance for rural areas and for the poor. There were 
21 counties where the proportion of births paid for by MA exceeded 
50%. These counties were primarily rural counties – 17 were rural 
counties, two (Fayette and Pike) were fringe counties of a metro area 
with a population of million or more, and only two counties (Erie and 
Philadelphia) were metropolitan counties (U.S. Department of 
Agriculture 2003).5 Furthermore, with one exception (Pike), the median 
family income in each of these counties was well below the median 
family income for the state:  In 1999, the average median family income 
in these counties was $32,850 while the median family income in the 
state was $40,106 (Wickipedia 2008).  

                                                 
3These two percentages refer to 2006. 
4We do not report the percent of people with disabilities who are covered under Medicaid 
because we do not know the denominator.   
5All non-metropolitan counties are classified here as rural counties.    



Judith R. Lave and Margaret A. Potter       175 
 

 

 

Figure 2:  Percent of County Newborns Covered by 
Medical Assistance:  2005-2006 

 

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Figure 3 (next page) shows that, as with births, there is wide 
variation across counties in the percentage of children who are enrolled 
in MA. It ranges from 12% in Chester County to 63% in Philadelphia 
County. There are three counties where more than 50% of the children 
and nine counties where between 40% and 49% of the children, are 
enrolled in MA. Figure 4 (page 177) shows the relationship between the 
proportion of children covered by Medicaid in a county and the county 
median income. These data reinforce the importance of MA for the poor. 

Provider participation.  A Medical Assistance card is not of much value 
if individual providers do not accept MA recipients.  Individual providers 
can choose whether to accept MA patients. Some providers in 
Pennsylvania, primarily dentists, do not participate in the Medical 
Assistance Program at all or they only accept a small number of MA 
patients because, they argue, the payment rates are very low. 
Pennsylvania Medical Assistance payment rates are in fact low. For 
example, the Kaiser Family Foundation reports that in 2003, physician 
fees under Pennsylvania’s Medicaid Program were low relative to 



176 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

Medicare payment rates and to Medicaid rates nationally (Henry J. 
Kaiser Family Foundation 2003). Pennsylvania ranked 46th among all 
states in the level of payments for all services, primary care, and other 
services; and it ranked 30th among all states in the level of payments for 
obstetric care.   

 
Figure 3:  Percent of Children in County Covered by Medical 

Assistance:  2005 
 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

By using a managed care model for its Medicaid program, DPW 
increases the attractiveness of MA and thus improves access to care for 
enrollees. The DPW’s contract with the managed care organizations 
usually specifies that the MCOs have a large enough network to serve the 
enrolled Medicaid recipients.  There are specific provisions built into the 
contracts (factors such as time to appointment) that are meant to ensure 
that Medicaid recipients have access to the system. This means that the 
MCOs have to work hard to build their networks. One result is that MA 
MCOs in Pennsylvania usually have payment rates that are above the 
formal Medicaid payment rates but below the Medicare payment rates 
(Personal Communication 2008).   



Judith R. Lave and Margaret A. Potter       177 
 

 

 

Figure 4:  2006 Percentage of County Population on Medicaid 
by the 2003 Percentage of People in County 

Below the Poverty Income Level* 
 

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

0.00% 5.00% 10.00% 15.00% 20.00% 25.00%

 % of Population in County Below Poverty

%
 o

f 
P

o
p

u
la

ti
o

n
 in

 C
o

u
n

ty
 o

n
 M

ed
ic

ai
d

 
 
* We do not have 2006 data on the percent of the population in each county that 
falls below the poverty level. 

 

Evaluating the Accessibility and Quality of Personal Health Services 

Public Health Essential Service #9 calls for a public health system to 
“Evaluate effectiveness, accessibility, and quality of personal and 
population-based health services.” Pennsylvania’s Medical Assistance 
Program carries out this requirement – at least addressing the quality of 
personal health care services – by using a system of performance 
measures to which its MCO plan contractors are held accountable. 



178 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

OMAP and OMHSA use the reported information to monitor the 
performance of the Medical Assistance MCOs.  The general expectation 
is that the availability of this kind of information would help drive plan 
improvement.  Both the MCOs and the BH-MCOs are given information 
on the performance of other plans as well as national benchmark 
information which is available for the HEDIS® and the CAHPS® data.  
Furthermore, much of these data are provided to other stakeholders – 
particularly advocates for various groups.6 Furthermore, three MCOs 
compete for MA recipients in the three regions where managed care 
enrollment is mandatory. The data are meant to inform the choices of 
MA recipients in choosing a MCO and to spark improvements in quality.  
Finally, the implementation of Pay for Performance should be an 
additional stimulus to improvements in plan performance.  

MCOs. Lave and Riaz (2008) examined the performance of Pennsylvania 
MCOs between 2003 and 2005. With respect to general access, they 
found that in 2005, the proportion of recipients who said that seeing a 
specialist was not a problem ranged across the plans from 58% to 74%. 
Furthermore, they found that the proportion of recipients who said that 
they could always see their doctor or nurse right away when they needed 
care ranged from 46% to 74%. These data indicate that there are some 
access problems. In looking at improvement in plan performance, they 
found that five of the seven plans had improved their performance on at 
least half of the performance measures that could be compared. 
However, overall performance on the CAHPS® data deteriorated over 
this time period. They also found that there was large variation in 
performance across the MCOs. The results for the Pay-for-Performance 
Program for 2006 also indicated variation in improvement across the 
plans. One plan received payouts for improvements in nine measures, 
one received payouts for improvements in seven measures, two received 
payouts for improvements in three measures, and three received payouts 
for improvements in only one measure (Kelly undated). 

BH-MCOs. The OMHSAS Quarterly Monitoring Reports provide 
information on the plan performance in the southeast, southwest and 
Lehigh/Capital region (Department of Public Welfare, Office of Mental 
Health and Substance Abuse Services 2008).  The data suggest that there 
                                                 
6The data on outcomes for the BH-MCOs have been available to the advocates for the 
mentally ill.   



Judith R. Lave and Margaret A. Potter       179 
 

 

 

is considerable variation in performance across the regions and within 
the regions across the counties.  Furthermore, there were few significant 
trends in the data across all of the plans.  General readmission rates did 
decrease somewhat between 2005 and 2007. The number of readmissions 
for the severely mentally ill (which was a focus of specific performance 
improvement plans) also fell.  

Access Plus.  OMAP has examined change over time in performance on 
several measures. Of the 18 measures where they could compare 
performance between 2005 and 2006, OMAP found that performance on 
13 measures improved (four statistically significantly) and on five 
performance measures deteriorated (one statistically significantly).  Only 
one formal quality report, which looks at performance in 2005, has been 
prepared.7  

Monitoring Health Status  

Essential Service #1 is to “monitor health status.”  This requires a 
public health system to collect and analyze data affecting the 
population’s health across several threat categories including infectious 
diseases, chronic diseases, injuries, and environmental hazards.  
Pennsylvania, like most other states, allocates responsibility for 
mitigating these threats across numerous state agencies; and, for the MA 
enrollees, several aspects of program services yield information that 
could fulfill the need to monitor health status. 

We noted above that Pennsylvania monitors the performance of the 
MCOs, the performance of BH-MCOs, the performance of care 
managers in Access Plus for individuals who suffer from selected 
conditions, and the health utilization data for individuals enrolled in 
Access Plus. Some of these measures are indirectly related to health 
(such as prenatal care) whereas others are directly related to health (the 
extent to which blood pressure and LDL are controlled). The number of 
measures monitored by these various systems is very large.  Furthermore, 
MA complies with the requirements of the federal Early, Periodic 
Screening, Diagnosis and Treatment Program (EPSTD), which requires 

                                                 
7Access Plus – HEDIS® 2006-2007 rates were provided to the authors from the Deputy 
Secretary’s Office of the Bureau of Fee for Service, Pennsylvania Department of Public 
Welfare.   



180 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

that all enrolled children are tested for specified environmental toxins 
such as lead exposure.   

Developing Policies that Support Individual Health Efforts   

Essential Service #5 requires the public health system to “Develop 
policies that support health efforts.” At the state level, this includes 
health planning based on data that tracks measurable health objectives 
and establishes how to guide health improvement efforts. Pennsylvania 
has developed a number of programs within MA that support individual 
health efforts. One policy is pay-for-performance, which incentivizes the 
MCOs and the care managers in the fee-for-service sectors to exceed 
certain performance targets.  A second policy is the implementation of 
smoking cessation programs for pregnant women.  A third policy is the 
development of a set of fees that will enable the program to pay 
physicians for many services provided to manage the weight of their 
overweight patients. 

 

Medical Assistance and the Pennsylvania Public Health System 

A major function of the public health system is to assure access to 
health care services throughout the population.  The foregoing discussion 
demonstrates that Pennsylvania Medical Assistance or MA, functioning 
as a managed care program through Access Plus, carries out at least four 
of the Ten Essential Services of Public Health as they relate to the health 
care needs of the most disadvantaged and vulnerable residents in the 
state.  MA monitors health status by tracking measures of performance 
on processes of care that are highly correlated with health outcomes 
(such as whether a pregnant woman had early prenatal care and whether 
children are receiving well-child visits) and by assessing certain types of 
outcomes such as whether the blood pressure of people with 
hypertension is controlled and whether the cholesterol levels of people 
who have had a cardiovascular event are within clinical guidelines.  
Pennsylvania MA has developed policies and plans to improve health 
care, implement a pay-for-performance system, and contract with the 
BH-MCOs to initiate plan improvement projects.  MA links people to 
needed personal health services:  it pays for about 40% of the births in 
the state, covers about 33% of the children in the state, and provides for 
the health care of individuals with physical or mental disabilities and for 



Judith R. Lave and Margaret A. Potter       181 
 

 

 

the elderly. MA evaluates effectiveness, accessibility, and quality of 
health services by building and maintaining the technical capacity to 
assess the type of care that is being provided through the fee-for-service 
system and thereby assessing the managed care organizations through 
which it contracts.   

Nevertheless, a comprehensive approach requires that we consider 
also those essential public health services that MA does not carry out or 
does not carry out alone.  MA serves only a portion – albeit a large and 
particularly vulnerable portion – of the Commonwealth’s entire 
population.  Although MA provides some public health services to many, 
the majority of Pennsylvanians are served by other health care plans or 
by no plans at all.  If there is to be effective linkage of all Pennsylvanians 
to needed health care as Essential Service #7 requires, then sharing 
information about counties where needed services are unavailable can 
help other public health agencies to prioritize direct-service programs 
and to supplement the delivery of needed care to underserved 
populations.  The same kind of interagency cooperation is necessary also 
to monitor the health of all residents (Essential Service #1), to support 
statewide health policy development (Essential Service #5), and to 
evaluate how well statewide health plans are performing (Essential 
Service #9).   

 MA’s public health services should be integrated with those 
provided throughout the public health system.  For example, if the 
incidence of lead exposure detected among children in the MA program 
is never reported to an agency with authority to “diagnose and 
investigate … health hazards in the community” (Essential Service #2), 
then ever more children will suffer the consequences of lead exposure.  If 
the MA program functions only as a way to pay health care providers, 
then its recipient population is not benefiting from disease prevention 
approaches that “inform, educate, and empower people about health 
issues” (Essential Service #3) or that “mobilize community partnerships 
to identify and solve health problems” (Essential Service #4).  The MA 
program lacks authority to enforce public health laws to protect health 
and safety (Essential Service #6), so its health-care contractors do not 
conduct the “contact-tracing” needed to prevent the spread of certain 
dangerous infections such as HIV. Although the MA program contributes 
to assuring a competent health workforce (Essential Service #8) and to 



182 PENNSYLVANIA MEDICAL ASSISTANCE:  CONNECTIONS WITHIN 
THE COMMONWEALTH’S PUBLIC HEALTH SYSTEM 

 
 

 

researching for new insights and solutions for health problems (Essential 
Service #9), those contributions are uncoordinated with other health and 
human service agencies in the Commonwealth.   

State government holds the responsibility to coordinate among all 
public agencies and private organizations contributing public health 
services, and coordination requires communication through joint 
planning and data sharing.  As stated by the Institute of Medicine, “States 
are and must be the central force in public health. They bear primary 
public sector responsibility for health” (1988, 143). Among the 
numerous public health duties of state government, those particularly 
important for inclusion of a Medicaid program are “assessment of health 
needs within the state based on statewide data collection” and “assurance 
of an adequate statutory base for health activities in the state” (Institute 
of Medicine 1988, 143). 

 

Conclusions 

In Pennsylvania, the responsibility for all Ten Essential Public 
Health Services is distributed among several agencies of state 
government, local health departments, and non-governmental entities.  
Nevertheless, the Commonwealth retains the obligation and the powers 
to assure that all Ten Essential Services are being carried out and to 
maintain coordination and communication among the responsible 
agencies and organizations. The Medical Assistance Program performs 
some of the essential public health services, but only for its enrolled 
population and without formal coordination with those agencies and 
organizations responsible for other essential services and other 
population groups.   

Pennsylvania’s legislative policymakers should consider ways to 
explicitly link the public health aspects of the MA Program with the 
larger public health system. Two approaches to consider, both of which 
are currently used by other states, include: 

 Making the MA Program accountable to a statewide public health 
policy board: Such accountability would take advantage of the 
excellent systems of MA quality oversight already in place and could 



Judith R. Lave and Margaret A. Potter       183 
 

 

 

contribute to more robust public health programs elsewhere in state 
government. 

 Sharing aggregated public health data: MA performance data can 
inform the public health system about the incidence of toxin-induced 
diseases in children, the sources of air-borne and water-borne toxic 
substances, and the geographic location of potential disease clusters.  
MA disease incidence data could help to inform the state’s allocation 
of federal dollars from categorical and block grants.  

 

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