Rural Pennsylvanians Stranded by Health Care Giants

From The American Prospect, December 27, 2022

Insurer UPMC and its new pharmacy benefit manager Express Scripts are squeezing local independent pharmacies, with residents caught in the crossfire.

In late November, at a strip mall in the rural Pennsylvania town of Bedford, Stephanie Over worked behind the Fisher’s Pharmacy counter, filling prescriptions into translucent orange pill bottles and administering shots. As strip mall pharmacies go, Fisher’s stands out. A recently restored art deco facade juts out, and the store’s name runs down vertically in Broadway font. The store is a local fixture in Bedford, population under 3,000, and has been around for almost 100 years, of which Stephanie has worked nearly 30.

Stephanie was about to check out for her lunch break when the letters flooded in. Regulars at Fisher’s began marching up to the counter, clutching notices from the University of Pittsburgh Medical Center (UPMC), a leading health insurer in Western Pennsylvania, and Express Scripts, the pharmacy benefit manager for UPMC.

The letter told them that under a new policy, UPMC’s insurance plan would not cover prescriptions at Fisher’s anymore. Instead, UPMC’s beneficiaries would be encouraged to go to other pharmacies in the health plan network for their own “convenience,” which meant national chains like Rite Aid, Walmart, or Giant Eagle, a regional grocery chain. Bedford is a remote town, 100 miles from both Harrisburg and Pittsburgh. Residents, many of whom had gone to Fisher’s for decades, would have to drive several towns over, maybe 30 or 40 minutes, just to get their prescriptions filled. Fisher’s knew them, their families, and medical history, a personal touch that would be lost at a chain.

“Why should our people have to drive through 20 signal lights to get a prescription filled when they could just call us and we’d have it ready,” said Over.

The letter offered no explanation for the policy change. Stephanie called the owner, Jennifer Leibfreid, who had not been notified by UPMC. Fisher’s tried calling other local pharmacies and associations to piece together whether other independents were receiving the same letters from customers.

Most had. In an overnight purge, UPMC, the third-largest insurer in the state and the most powerful hospital network, dropped over 1,200 pharmacies from its health plan, around half of the stores it previously carried. Most were independents. The decision impacted tens of thousands of individuals who bought their insurance on the state health insurance exchange, known as Pennie, as well as company plans for businesses with fewer than 50 employees. Patients covered by Medicare and Medicaid are not affected by the change.

The UPMC kill-off will have devastating consequences for pharmacies and patients across rural Pennsylvania. Fisher’s estimates that it might lose 20 percent of its customers, some of whom need prescriptions filled every other day. They’ll have to decide whether to drive several towns over or pay out of pocket at Fisher’s for generic drugs.

Thirty miles south of Bedford, Potomac Valley Pharmacy in Hyndman was another retailer cut out from UPMC’s plan. Pharmacist Dan Iseminger doesn’t know how much business he’ll lose because “frankly, I’ve been too scared to look.” In that area, as in many other rural parts of the state, UPMC is often the only health plan locals can afford.

Read the full article here.

Announcing $6.3M for ARC’s First-Ever ARISE Grantee!

ARC announced our first-ever Appalachian Regional Initiative for Stronger Economies (ARISE) award! Connect Humanity will help 50 underserved communities in Appalachia plan for broadband growth.

The Connect Humanity team will work with local partners across 12 Appalachian states to help communities develop tailored digital equity plans, secure funding for high-speed internet expansion, provide digital literacy and broadband job training, and more.

“Broadband access is essential for Appalachia to thrive and compete in a global economy; without this support, our most rural communities may be left further behind. I commend our states and community partners in every Appalachian subregion for coming together in order to fully participate in our digitalized world,” said ARC Federal Co-Chair Gayle Manchin.

The details on the funding are:

Appalachian communities can get involved at connecthumanity.fund/arise.

New Policy Brief and Webinar: Impacts of CAH Independence and System Ownership during the COVID-19 Pandemic

A new policy brief is available on the Flex Monitoring Team (FMT) website: Impacts of Critical Access Hospital Independence and System Ownership during the COVID-19 Pandemic. In this brief, the FMT describes findings from a survey of CAH CEOs about their response to COVID-19, with a specific focus on advantages and disadvantages of system ownership or independence as described by survey participants.

Additionally, a new webinar recording is available on the FMT website: COVID-19 Response in System-Owned and Independent CAHs. In this webinar, the FMT presents findings from their survey of CAHs including advantages and disadvantages of system ownership or independent status, support received from State Flex Programs, staff recruiting challenges, partnerships, and patient transfers.

American Academy of Pediatrics Updates Children’s Oral Health Recommendations

The American Academy of Pediatrics (AAP) has updated their recommendations on maintaining and improving children’s oral health. The AAP advises that children drink only water between meals, preferably fluoridated tap water, and avoid juice intake before age 1. Fluoride is also critically important to prevent dental caries, especially for those who do not have early or consistent ongoing dental care.

Click here for more information.

Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP)

CMS released a State Health Official (SHO) letter that provides guidance to states on policy for Medicaid and the Children’s Health Insurance Program (CHIP) to allow one provider to discuss a Medicaid or CHIP beneficiary’s case with a specialist, with or without the beneficiary present, and to pay the specialist for their services directly. The current policy only allows payment in this circumstance if the provider who is seeking the consultation is paid for the consulted provider’s services and then pays the consulted provider directly. This change more directly “links” routine care with specialty care, allowing more people to benefit from practitioners with specialized knowledge.

For more, read the full letter https://www.medicaid.gov/federal-policy-guidance/downloads/sho23001.pdf

CMS Issues an Informational Bulletin on the Provisions Included in the Consolidated Appropriations Act, 2023

CMS issued an informational bulletin on the provisions included in the Consolidated Appropriations Act, 2023 (CAA, 2023) related to the Medicaid continuous enrollment condition.

The CAA, 2023 updates various Medicaid and CHIP provisions, including significant changes to the continuous enrollment condition of the Families First Coronavirus Response Act. Under the CAA, 2023, expiration of the continuous enrollment condition will no longer be linked to the public health emergency (PHE) and instead the condition will end on March 31, 2023. Following the end of the condition, states will have up to 12 months to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, the Children’s Health Insurance Program, and the Basic Health Program. As of January 2023, the PHE is still in effect.

Read the Informational Bulletin for more detail.

CMS Promotes National Poverty in America Awareness Month Resources

During January, the Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) recognizes National Poverty in America Awareness Month. The United States measures poverty based on how income compares to a federal guide. In 2021, an individual was considered to be living in poverty if their income was lower than $12,880, $26,500 for a family of four.  The poverty rate in 2021 was 12.8%, an increase from the 11.4% rate recorded in 2020. American Indian/Alaskan Native individuals were the most impacted (25.9%), followed by Black Americans (21.7%), Hispanic Americans (17.6%), Asian/Native Hawaiian and Pacific Islanders (10.2%), and White Americans (9.5%).

Poverty in the United States is concentrated in specific regions, counties, and neighborhoods. These areas face obstacles such as poor housing and health conditions, higher crime and school dropout rates, lower employment opportunities, and lack of healthy foods, contributing to social determinants of health. Rural poverty rates continue to be higher than urban rates, with Black Americans being the most likely to live in poverty in nonmetro areas. The Southern United States had the highest rural and urban poverty rates (19.7% and 13.8) between 2015 and 2019 while the Northeast had the lowest (12.9% and 12%).

Poverty is shown to influence health outcomes, with unmet social needs, environmental factors, and barriers to accessing health care contributing to worse health outcomes for people with lower incomes. Those who qualify as impoverished may have more difficulty obtaining health insurance or paying for expensive procedures and medications. Children comprise the largest age group experiencing poverty and childhood poverty is associated with developmental delays, toxic stress, chronic illness, and nutritional deficits.

CMS OMH calls for an advancement in health equity for American’s during National Poverty in America Month. Visit the below resources for additional information on how to help during National Poverty in America Awareness Month.

Resources

Visit the ASPE’s FAQs for poverty guidelines and general poverty.

Pennsylvania Governor Highlights Substance Use Disorder Prevention, Education Tool for Restaurant and Hospitality Workers  

The Pennsylvania Department of Drug and Alcohol Programs (DDAP) and Pennsylvania Department of Community and Economic Development (DCED) joined C&J Catering employees to discuss substance use disorder (SUD) in the restaurant and hospitality industries, highlighting the importance of SUD education and prevention for employees and employers.

“Just below the construction and mining industries, the restaurant industry has a high rate of substance use disorder among its employees,” said DDAP Special Assistant to the Secretary Steve Ross. “Long, irregular hours and high-pressure, physically demanding work can all have an impact on an individual’s behavioral health. We must ensure that employers and employees know about every resource available to them to support individuals living with the disease of addiction. It is also critical to keep providing education to all employers and all Pennsylvanians to address the stigma still faced by those who are struggling with substance use disorder.”

Thomas Jefferson University Hospital reported an increase in opioid overdose deaths among restaurant-industry workers in Philadelphia in 2020. According to the U.S. Bureau of Labor and Statistics, the restaurant industry holds more than four million available positions across the country and is projected to grow faster than the average for all occupations from now until 2031.

“We need to make sure we are providing employees in the tourism industry, and their families, with the SUD resources and support they need to navigate these difficult situations,” said DCED Executive Director of Tourism Michael Chapaloney. “In the tourism industry, the restaurant industry – in all industries – we want employees to be both physically and mentally healthy.”

Pennsylvania Governor Wolf’s Administration’s Just Five initiative is a self-paced program designed to increase awareness, reduce stigma, and provide education about SUD prevention and treatment. It is displayed as six short learning modules that each take “just five” minutes to complete. The interactive lessons include:

  • The Science of Addiction
  • Are You at Risk?
  • The Dangers of Opioids
  • Signs, Symptoms and Treatment
  • How You Can Help
  • The Gift of Recovery

DDAP rolled out a version of Just Five to Pennsylvania commonwealth employees in May 2021 and an additional version of Just Five is available to all of Pennsylvania’s workforce. Since roll out, the statewide Just Five tool has had nearly 12,000 new users and users, with an average of 12 minutes of engagement per session.

Use of the Just Five website is completely confidential and voluntary, and no personal information regarding utilization of the program is shared. It can be accessed virtually from anywhere at any time with no registration required. The program is also available in English and Spanish and accessible for individuals with visual and/or hearing impairments.

DDAP operates the Get Help Now hotline at 1-800-662-HELP (4357). The hotline is a trusted resource for individuals and/or their loved ones if SUD treatment or resources are needed. The hotline is confidential, available 24 hours a day, 365 days a year and staffed by trained professionals who will connect callers to resources in their community. Callers can also be connected with funding if they need help paying for treatment.

To learn more about the Wolf Administration’s efforts in combating the addiction crisis, visit ddap.pa.gov.

 

Thriving PA Report Highlights WIC Program Community Feedback

Thriving PA’s newest report, WIC Participants Encourage Improvements to Remove Barriers to Access, highlights community feedback about the Special Supplemental Nutrition Program for Women, Infants, and Children, commonly referred to as WIC. Over the summer, Thriving PA partnered with several community organizations across the state to hold seven focus sessions with current and former WIC clients to hear directly from their experiences on the strengths and barriers of the WIC program.

The WIC program provides eligible pregnant and postpartum women and infants and children up to age 5 with access to nutritious foods, breastfeeding supports, nutritional education, and health referrals. Unfortunately, participation in PA’s WIC program has been declining in recent years, a trend that is happening nationally. From 2018-2022, the PA program saw nearly a 25% decline in participation. The pandemic also impacted these numbers, with Pennsylvania seeing the third largest decrease in participation from February 2020 to February 2022.

To address the declining participation, which impacts the federal funding Pennsylvania receives to administer the program, Thriving PA sought out direct feedback from participants to identify solutions to the WIC program’s challenges. Many of the recommendations in the report highlight opportunities to modernize the program and provide greater flexibility for participants. Some recommendations include technology improvements like moving to an online EBT card system and simplifying the application process through system integration with other state application systems like COMPASS. Others include allowing virtual visits to continue and coordinate care between health professionals, so participants do not need to provide the same information to multiple providers.

Thriving PA hopes the incoming administration and WIC Advisory, a stakeholder group formed earlier this year, will consider the recommendations from WIC clients to help improve the WIC program and increase participation statewide.

Pennsylvania Partnerships for Children Releases Annual Health Care Report

Pennsylvania’s child uninsured rate improved slightly to 4.4% from 4.6% during the COVID-19 pandemic thanks to the federal continuous coverage provision that prevents states from disenrolling children and families from Medicaid during the public health emergency, according to our recently released 2022 State of Children’s Health report.

Even more families turned to Medicaid during the pandemic when child enrollment increased by 20%. More than 1.4 million Pennsylvania children currently have Medicaid as their health insurance.

We are cautiously optimistic about the improvement in our child uninsured rate in Pennsylvania. While we have made progress, Pennsylvania has the 8th highest number of uninsured children in the nation, with 126,000 children who do not have health insurance and don’t have regular access to preventive and primary health care.

And hundreds of thousands of children are at risk of losing Medicaid coverage when the public health emergency ends and the state begins to unwind the disenrollment freeze and resume pre-pandemic operations. According to the latest estimates from DHS, 1 in 4 children enrolled in Medicaid could lose coverage when the public health emergency ends and the process to redetermine eligibility begins.

It will be imperative for DHS to implement an unwinding process that does not disconnect the children most at risk of losing coverage, particularly when Pennsylvania’s uninsured rate is starting to improve.

We recommend DHS:

  • Reaffirm its commitment to using a 12-month unwinding period as recommended by the Centers for Medicare and Medicaid, which most other states plan to use. Using the full 12 months permitted will give Pennsylvania the best chance to minimize inappropriate terminations and disruptions in coverage (churn) that often impact children more than the adult population.
  • Immediately expand the 12-month continuous eligibility policy to children ages 4 through 21 in Medicaid when the public health emergency ends to make it more equitable—Pennsylvania already provides 12-month continuous eligibility (regardless of changes in circumstances) in Medicaid for children up to age 4. All Pennsylvania children in CHIP have continuous eligibility for a full year.

According to the report, factors such as race and ethnicity, poverty level and geographic region impact children’s access to health insurance. Some additional key findings include the following:

  • Hispanic or Latino children, children who identified as Some Other Race, and children who identified as Two or More Races have worse rates now than in 2019, showing they are more likely to be uninsured.
  • 5% of children in PA who qualify for no-cost or reduced-cost health insurance through Medicaid, CHIP, or Pennie™ do not have health insurance.
  • The uninsured rates improved in 38 counties and worsened in 29 counties over the last two years.

New to this year’s report are fact sheets for each of the 67 counties that show the local uninsured rate, race and ethnicity profiles, and public health insurance enrollment data.

Read the latest coverage: