Hawaii – The National Academy for State Health Policy

Unwinding Medicaid’s Continuous Coverage Requirement: State Communication Strategies

September 8, 2022/in Health Coverage and Access, Policy Arizona, Arkansas, California, Hawaii, Illinois, Maryland, Nevada, New Hampshire, New York, Oklahoma, Utah, Wisconsin Blogs, Featured News Home COVID-19, Eligibility and Enrollment, State Insurance Marketplaces /by NASHP Staff

Emerging State Innovations in Developing a Medicaid Community-Based Palliative Care Benefit

August 19, 2022/in Palliative Care, Policy California, Colorado, Hawaii, Maine, Oregon Blogs, Featured News Home Palliative Care /by Salom Teshale and Wendy Fox-Grage

Adding Teeth to Transparency: States Take Stronger Steps Against Drug Price Hikes

March 1, 2021/in Prescription Drug Pricing Hawaii, Maine, Washington Blogs, Featured News Home Administrative Actions, Consumer Affordability, Health System Costs, Legislative Tracker, Model Legislation, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck

Three states have proposed legislation, based on National Academy for State Health Policy’s model law, that penalizes drug manufacturers for hiking prescription drug prices without new clinical evidence to justify the increase.

More than a dozen states have enacted drug price transparency legislation to better understand the extent of and drivers behind prescription drug price hikes. Now two of those states, Washington and Maine,* along with Hawaii, have proposed legislation to take the next step: penalizing manufacturers for hiking prices on their products without new clinical evidence to support a price increase.

Learn more about NASHP’s model act penalizing “unsupported” prescription drug price increases here.

The legislation is based on a NASHP model bill that is designed to be easy to administer and a low-cost approach. The model bill enables states to utilize an annual report published by the Institute for Economic and Clinical Review (ICER) that identifies a small number of expensive drugs with large unsupported price increases. ICER’s January 2021 report, for example, revealed that US spending on unsupported price increases for just seven drugs led to increased spending of $1.2 billion in 2019.

The model bill penalizes manufacturers for 80 percent of their drug sales from unsupported price increases in a state – representing millions in potential revenue that can be used to help reduce prescription drug costs for consumers. NASHP can work with states to estimate potential revenue from this legislation.

ICER is an independent organization that conducts methodologically rigorous research into the clinical and economic value of prescription drugs. A growing number of states is looking to ICER’s annual analysis of unsupported price increases because it is thorough and transparent. The report reflects research that would be difficult for states to replicate on their own without a large investment of time and resources.

ICER actively engages drug manufacturers in its unsupported price increase report by giving them opportunities to correct the data ICER uses in its analysis and to present alternative explanations that might justify the price increases under investigation. In some cases, engagement with manufacturers has led to removal of a drug that had been identified as having an unsupported price increase from ICER’s list. While some stakeholders have expressed concern with ICER’s use of quality adjusted life years (QALYs) in its separate analyses determining the value of specific drugs, ICER’s unsupported price increase report does not use or reference QALYs in any form.

ICER’s January 2021 report on unsupported price increases identified well-known, frequently used, and high-cost drugs, such as Humira, which is used to treat autoimmune diseases. Another drug, Enbrel, also used to treat autoimmune diseases, was reviewed by ICER after being nominated by states with drug price transparency laws. States tracking drug price increases knew that Enbrel was a problem – and ICER’s exhaustive review of the clinical evidence on Enbrel confirmed that Enbrel’s price increase was not supported by new clinical evidence. Enbrel’s unsupported price increase contributed to more than $400 million in increased spending across the United States last year.

While drug price transparency laws help states detect and report on price increases, NASHP’s Unsupported Price Increase model bill enables states go further to more aggressively discourage price increases and to recoup spending lost to manufacturers that raise their prices – not because their products are in any way improved – but because they can.

NASHP has developed a template for determining potential revenue from penalizing manufacturers for unsupported price increases and can work with states that want to estimate potential total revenue from implementing unsupported drug price penalties in their states. Please contact Jennifer Reck for more information.

*Maine lawmakers have pre-filed this bill, meaning it has been proposed but has not yet been published as a legislative document by the Maine’s Revisor of Statutes.

Five Trailblazing States Consider Legislation to Capture Big Rx Savings Using Canadian Reference Rates

February 1, 2021/in Prescription Drug Pricing Hawaii, Maine, North Dakota, Oklahoma, Rhode Island Blogs, Featured News Home Model Legislation, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck and Trish Riley

Burdened by high US drug prices that average 218 percent more than in Canada, innovative states across the country are exploring a range of approaches to give their residents the same access to affordable drugs Canadians have. To date, six leading states have passed laws that enable them to import drugs from Canada pending federal approval of their programs. Now, a second set of trailblazing states are exploring an alternative approach that does not require federal approval – importing Canadian drug prices.

Lawmakers in five states (HI, ME, OK, ND, and RI) have introduced or pre-filed bills based on the National Academy for State Health Policy’s (NASHP) model legislation to establish international reference rates using Canadian pricing.

Establishing payment rates for hospitals’ and providers’ services is common to ensure access to affordable care. The NASHP model extends that practice to prescription drugs, giving states a powerful tool to limit what payers within a state will pay, without running afoul of patent law by setting prices.

What is international reference rate legislation?

International reference rate legislation authorizes a state’s department of insurance to establish international reference rates for the costliest drugs in that state. The department determines the reference rates based on those drugs’ prices in Canada’s four largest provinces. The lowest price would become the legal upper payment limit for those drugs for participating purchasers in the state.

A savings analysis NASHP facilitated for one state considering this legislative approach, showed annual savings of more than $32 million for just 35 drugs purchased by state employees alone. States are proposing setting reference rates for up to 250 drugs for all commercial payers, including Medicare advantage plans (Medicaid and traditional Medicare would be excluded), so total savings would far exceed that initial estimate.

Under the model legislation, any savings generated must be shared with consumers through mechanisms left to the discretion of a state. Options may vary by payer, ranging from reducing premiums for commercial payers, maintaining or expanding access to Medicaid services, and avoiding tax increases for public payers.

Oklahoma state Sen. Greg McCortney identified the potential for savings as key. “I do not believe that we can fix our broken health care system until we address the cost of care,” he said. “This bill, once fully implemented, should reduce insurance premiums for every person in the state by hundreds of dollars each year.”

The model law’s implementation process is designed to be easy for a state to administer and does not require costly infrastructure at a time when states are burdened by the pandemic and budgetary restraints. As a proxy for all commercial payers, the bill uses a state’s employee health plan to identify the costliest 250 drugs, determined by drug price times utilization.

The state employee health plan shares the list of 250 drugs with the Department of Insurance.
The department then establishes references rates by comparing publicly available data on drug prices in Canada’s four most populous provinces. The lowest price becomes the reference rate for payers within the state.
No commercial payer could pay more than the reference price established by the state’s department of insurance, and a manufacturer that withdrew a drug or refused to negotiate in good faith would be subject to significant penalties.

As states move forward in their legislative sessions, states are adapting NASHP’s reference rate model and making it their own. They’re exploring variations in the roles their agencies would play, as well as possibly limiting the number of referenced drugs to a smaller group that would have maximum impact.

States Include Catch-up Routine Immunization Strategies in Back-to-School Planning

July 27, 2020/in Policy Hawaii, Michigan, Oregon, Texas Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Immunization, Maternal, Child, and Adolescent Health, Population Health /by Rebecca Cooper

As states consider strategies to reopen schools safely this fall, ensuring that children receive their appropriate, on-schedule vaccines continues to be an important safety and prevention strategy. Because the COVID-19 pandemic has dramatically reduced the volume of in-person children’s preventive care visits across the country – many providers have reported a 70 to 80 percent decrease in well-child visits with fewer children receiving immunizations – catching children up on missed routine immunizations is critical, regardless of whether schools offer in-person instruction.

The American Academy of Pediatrics states that, “existing school immunization requirements should be maintained and not deferred because of the current pandemic,” and according to a 2014 study, vaccines will prevent 40,000 deaths and 20 million illnesses over the lifetimes of US children born in 2009. As a result, many school districts are implementing strategies that include immunizations along with other health priorities, like social distancing, mask wearing, and increased hygiene measures, for students in their back-to-school plans.

The Centers for Disease Control and Prevention’s (CDC) priorities for the fall include catching children up on needed routine vaccinations and ensuring that adults and children get their annual flu shots to stay healthy and reduce the risk of coinfections and the burden on the health care system. CDC also recently released guidance to assist local public health agencies in establishing satellite vaccination clinics for routine vaccinations, including back-to-school immunizations and annual flu shots. Considering the immense pressures teachers and school administrators face as policymakers grapple with school reopening decisions, continuing to provide protection from preventable diseases is critical.

Keeping children protected from vaccine-preventable diseases is not contingent on in-person learning. States need to continue to plan for catch-up vaccinations even if states and school districts have not yet solidified their reopening plans amid rising national COVID-19 case counts, and children should have all necessary protections from vaccine-preventable diseases. However, because some states are requiring all schools to open, it is especially important to ensure there is a process for appropriate back-to-school vaccinations to be administered to keep children healthy. Several states and counties have already released back-to-school immunization plans:

Hawaii: Effective July 1, 2020, additional immunizations will be required for students entering childcare facilities or schools. By the first day of school, all students entering childcare or school in Hawaii must have either a completed health record form or an appointment already scheduled with a health care provider, as well as a completed tuberculosis (TB) clearance form. Students who have not completed the requirements will not be allowed to attend school until the requirements are met. The updated immunization requirements were enacted prior to the pandemic to conform with national recommendations and reflect what already existed as standard medical care in Hawaii. State officials chose to maintain this guidance despite uncertainty from COVID-19.
Michigan: Its Department of Health and Human Services (DHHS) is urging families to catch their children up on needed vaccines that were postponed during the COVID-19 pandemic. Michigan providers are implementing new procedures to ensure patients can come in for well-child visits and get caught up on immunizations, including the flu vaccine, in the fall. Additionally, bipartisan legislation was introduced that requires proof of vaccination before entering 12th grade to ensure an accurate immunization status for high school students, and directs the DHHS to adopt the CDC-recommended immunization schedule.
Texas: The state announced that school vaccination rules are in effect for the 2020-2021 school year that students should be up-to-date, or in the process of receiving their vaccinations, or have a valid exemption when school starts. Texas’ school vaccination rules are in effect regardless of where the education is received (on campus or via virtual learning).
Oregon County: Oregon county health Departments began scheduling 2020-2021 school year catch-up immunizations during the summer to help limit the number of individuals in provider offices receiving vaccines at any one time, and to help prevent running out of supplies, because the department is only able to place new vaccine orders once a month.

In the midst of an uncertain infectious disease climate, states continue to prioritize maintaining immunization rates, and states can use back-to-school immunization requirements as a tool to ensure timely vaccine catch-up. However, vaccine requirements are a contentious issue and state legislatures across the nation continue to debate this topic. Prior to the start of the COVID-19 pandemic, Colorado and Maine, for example, enacted new school entry immunization laws that created more stringent procedures for obtaining immunization exemptions. These states are working to prevent future outbreaks, considering the evidence that unvaccinated populations can lead to community outbreaks.

States will also need to consider strategies to ensure school-aged children will have equitable access to the COVID-19 vaccine when it becomes available. In Wisconsin, for example, both the state legislature and the Department of Health Services can add new vaccines, such as a potential new COVID-19 vaccine, to Wisconsin’s list of required vaccines for school children and children in childcare settings. Other states are taking preventive action to ensure they have a system in place for vaccine distribution when it is available. For example, New York amended a law authorizing licensed pharmacists to administer any approved vaccine for COVID-19 to include children between the ages of 2 and 18.

Schools are often under local jurisdictions and while considering federal guidance and local public health risk, most decisions will be made at the state and local levels. But, regardless of the variation, states have to make challenging decisions about reopening schools in the midst of the COVID-19 pandemic. One critical step they can take to ensure student’s health is prioritizing immunizations to ensure children are protected from preventable disease regardless of whether schools reopen in-person. The National Academy for State Health Policy will continue to monitor state back-to-school immunization policies, state efforts to keep children protected from vaccine-preventable diseases, and their implications for children.

This blog was written with support from the Centers for Disease Control and Prevention.

Hawaii CHIP Fact Sheet

December 5, 2019/in Policy Hawaii /by NASHP Staff

Ten States Selected to Attend Palliative Care Summit in Chicago

June 18, 2019/in Policy Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, Texas Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Long-Term Care, Medicaid Managed Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.

How Hawaii Fights the Flu: Pop-up Vaccination Clinics and State Agency Collaboration

February 5, 2019/in Policy Hawaii Blogs Chronic Disease Prevention and Management, Immunization, Maternal, Child, and Adolescent Health, Population Health /by Megan Lent and Jill Rosenthal

States are using creative and collaborative methods to increase flu immunization rates after 185 children died from influenza during the 2017-2018 season — the highest toll reported since the 2009 flu pandemic. The health and economic toll of last season’s flu outbreak in children nationwide included more than 48,000 hospitalizations and 6.5 million medical visits.
Increasing flu vaccination rates, especially early in the season, can help reduce flu-related illness and complications, yet nearly 80 percent of children who died from the flu last season had not received the flu vaccine. Compared to this time last year, estimated flu vaccination rates for children are up, but a recent poll found that one-third of parents said their child was unlikely to receive the flu vaccination this year.

“School-located vaccination programs are evidence-based, best-practice strategies that reduce out-of-pocket costs, increase vaccination rates, and increase access to immunizations that reduce morbidity and mortality related to vaccine-preventable diseases.”
—Community Preventive Services Task Force

Hawaii has been fighting the flu and improving childhood vaccinations in innovative ways for nearly a decade, relying on close collaboration between state education and health agencies to operate “pop-up,” school-based vaccination clinics to protect children’s health.
Removing barriers to vaccine access can help increase vaccination rates. Medicaid covers the flu vaccine for all enrolled children, as recommended by the Advisory Committee on Immunization Practices, which removes a financial barrier. However, removing non-financial barriers to accessing the flu vaccine – such as inconvenience – can also help increase vaccination rates. The Community Preventive Services Task Force recommends providing vaccinations in schools and childcare settings to address this barrier.

Watch Hawaii’s Department of Health YouTube informational promotion of its Stop Flu at School here.

Despite having very few school-located health clinics, Hawaii operates a yearly “pop-up” influenza program called Stop Flu at School. The program provides free flu vaccinations to all elementary and middle-school children in participating schools and is the result of a partnership between its state departments of health and education and the private health insurance association. The voluntary program improves accessibility to the vaccination by providing it during the school day. The Stop Flu at School program is made possible by a blend of private insurer in-kind and monetary donations, state support, and several federal funding sources. Federal support comes from funds for pandemic flu preparedness, the Vaccines for Children program (VFC), which provides immunizations at no charge to physicians’ offices and public health clinics that are registered as VFC providers, and the Section 317 Immunization Program immunization program funds. The state health department serves as the VFC provider for the pop-up clinics which allows VFC eligible children to receive influenza vaccine through the Stop Flu at School program. Insurance status is tracked for program participants and documented on consent forms. Insurance status is used as a proxy for VFC program eligibility.
An evaluation of the program from 2007 to 2011 found that close to 50 percent of the target age group received the flu vaccine as a result of the program, and nearly one-third of students vaccinated were covered by Medicaid. Data that tracked influenza-like illness in Hawaii suggests there was less flu activity during the program’s first years (2007-2010), compared to previous years. State health officials also credit their experience operating the Stop Flu at School program with enabling them to effectively conduct emergency mass vaccinations during the H1N1 pandemic, which occurred in 2009.
Mobile or pop-up school-based vaccination clinics provide an effective vehicle to increase access to vaccinations and protect the health of children, and have the potential to reduce overall disease burden and costs.
As Hawaii demonstrates, these clinics require leadership and collaboration between state agencies and the private sector. Alabama provides another example of state leadership in this area – the governor recently issued a resolution urging all schools to participate in school-based immunization programs.
In addition to leadership and cross-agency partnerships, implementing mobile vaccination clinics also requires planning and resources. State officials will find videos, checklists, and other resources in this Mobile Immunizations Toolkit developed by Spokane Regional Health District, which shows how Spokane County in Washington State worked with health departments, schools, and health care providers to create school- and community-based mobile immunization clinics.

How Governors Addressed Health Care in Their 2018 State of the State Addresses

February 26, 2018/in Policy Georgia, Hawaii, Idaho, Iowa, Massachusetts, New Hampshire, New Jersey, New Mexico, Rhode Island, South Dakota, Utah, Washington, Wisconsin, Wyoming Charts Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Housing and Health, Integrated Care for Children, Integrated for Pregnant/Parenting Women, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Social Determinants of Health, Value-Based Purchasing, Workforce Capacity /by NASHP Staff

Toolkit: State Strategies to Develop Value-Based Alternative Payment Methodologies for FQHCs

December 12, 2017/in Policy Colorado, Hawaii, Michigan, Minnesota, Nevada, Oklahoma, Oregon, Washington Toolkits Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement, Safety Net Providers and Rural Health, Social Determinants of Health, Value-Based Purchasing /by NASHP Writers