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Healthcare for Pennsylvanians when it's needed

A Look At the Numbers provides information on how managed care organizations (MCOs) partner with Pennsylvania to serve the healthcare needs of the clinically and most economically challenged Pennsylvanians.

Medicaid managed care enables Pennsylvania to deliver a higher standard of healthcare, improve health outcomes of Medicaid recipients, and manage healthcare costs.

The care people need, when they need it. That is the model of managed care.

Medicaid in Pennsylvania

HealthChoices is the name of Pennsylvania’s managed care program, which serves the healthcare needs of the clinically and most economically challenged Pennsylvanians.

Program history

Serving Pennsylvania since 1972

MCOs have worked with the commonwealth of Pennsylvania for decades, helping to deliver a higher standard of healthcare to millions of Pennsylvanians.

  • 1972

    Voluntary managed care program introduced1

  • 1997

    HealthChoices launched for Medicaid1

  • 2015

    Pennsylvania expands Medicaid to more individuals experiencing low incomes2

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Program population

Helping 2.2 million in Pennsylvania

In Pennsylvania, MCOs are responsible for program administration, including network management, claims payment, care coordination, and utilization management.

HealthChoices covers approximately 2.2 million people in the commonwealth and utilizes MCOs to provide coverage for its members.3

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2-in-3

nursing home residents covered by HealthChoices4

Reduced costs

Billions saved through managed care since 2016

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Our healthcare system requires the innovation, expertise, and capital of the private sector.

MCOs are uniquely positioned to combine these resources with public funding, accountability, and oversight.

With the costs of healthcare rising, states need a way to plan and manage their budgets while ensuring that Medicaid recipients get the high-quality healthcare they deserve.

Between 2016 and 2020, HealthChoices is projected to save as much as $4.4 billion in state funds through the use of managed care.5

MCOs use a range of strategies to run cost-effective programs, including helping patients receive preventive services, providing supportive care for members with complex conditions, and managing the provider network.

In 2017, thousands of Pennsylvanians accessed preventive screenings and checkups through Medicaid, including: 104,000 breast cancer screenings, 68,000 colon cancer screenings and 153,000 cervical cancer screenings.6

Improved population health

Better health outcomes

4.5%

increase in adults controlling high blood pressure7

MCOs in Pennsylvania integrate behavioral and physical health services to address the holistic needs of a person to ensure they are healthy.

In Pennsylvania, MCOs are addressing the opioid crisis by coordinating care and working with providers on prescribing practices as well as introducing safety measures to curb the abuse of opioids among Medicaid enrollees.8

Patient experience

Coordinated care for Pennsylvanians

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MCOs coordinate care and provide a single point of contact for Pennsylvanians.

MCOs serve as the glue that binds community resources with a unified health strategy, integrating physical and mental health services.

In 2018, 79% of HealthChoices members said they were satisfied with their health plan, and 87% of enrollees said that they were satisfied with their child’s health plan.9

Provider experience

Under Medicaid managed care, MCOs provide a cohesive service platform that helps to efficiently process payments and offer provider training.

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MCOs use value-based payment models that incentivize, empower, and reward providers for the quality of care they deliver, not the quantity. The focus is on keeping individuals healthy and delivering better outcomes; over time, this improves overall population health and reduces the total cost of care.