State Legislatures Examine Proposals to Curb Rx Drug Costs
Recent legislative committee hearings in Maryland, Florida, and Illinois provide a national snapshot of states’ diverse and innovative proposals to reign in drug costs.
Maryland’s drug affordability review board: Earlier this month, Maryland’s House Health and Government Operations Committee and Senate Finance Committee held lengthy hearings on an innovative bill that creates a state prescription drug affordability review board (see NASHP’s model legislation here.)
The board would review drugs whose price increases met or exceeded a certain threshold and set an upper payment limit if the board found the drug cost to be excessive. During the committee hearings, constituents stressed the urgency of finding a solution for increasing drug prices, and many shared their struggles of choosing between paying bills and purchasing necessary medication. There was also testimony from pharmaceutical industry representatives who voiced their concerns about the bill and said it could hamper innovation.
The committee hearings gave legislators the opportunity to hear details of the proposed bill. One Maryland state senator questioned how the upper payment limit established by the affordability board differed from the state’s anti-price-gouging law that was found to be unconstitutional last year, based on the claim that it regulated commerce beyond state borders. Supporters explained that an affordability review board would not encounter the same legal challenge because it clearly defines its jurisdiction over only drugs sold in the state. Another representative asked whether all drugs would fall under the purview of the board. The sponsor explained that only drugs that meet certain price increase thresholds would be subject to board review. As seven other states explore similar legislation, NASHP has compiled a Drug Affordability Review Board Legislation Q&A that answers many legislators’ questions.
Florida’s drug importation bill: Florida lawmakers are considering implementation of a wholesale drug importation program. Bills filed in both the Florida House and Senate would allow the state to import high-cost drugs from Canada at a lower price. Florida’s legislative process often requires that bills pass through two or three committees before a floor vote, giving lawmakers, stakeholders, and constituents ample time to consider a bill. In March, three House committees met to ask questions about the bill and learn more about importation. During hearings, the bill’s sponsor explained that more than 30 Canadian drug manufacturers are already registered by the US Food and Drug Administration to produce drugs for US markets, and that safety standards in Canada are comparable to those in the United States. Lawmakers had additional questions about cost savings and the supply chain. For more information about importation legislation, read NASHP’s importation Q&A.
Illinois’ prescription drug committee action: The Illinois House of Representatives created a Prescription Drug Affordability and Access Committee to address bills designed to curb drug costs. The committee is currently reviewing 17 bills, including legislation to create a drug affordability review board, similar to Maryland’s, and a wholesale importation program. It is also reviewing a bill that requires health insurers to ensure that at least 25 percent of their plans apply a pre-deductible, flat-dollar copayment structure to their entire drug benefit component. The committee is also considering a proposal to tax drug price increases that exceed the inflation rate. This tax would be paid by businesses that make the first sale in the state and could not be passed through to consumers. Any money collected from the tax will be deposited into a new fund dedicated to prescription drug cost fairness.
To date, the Illinois committee has met multiple times for informational sessions to learn how the drug pricing system works and to hear from consumer advocates and stakeholders. Establishing a specific committee dedicated to identifying solutions to the rising cost of prescription drugs indicates how important this issue is as the state legislature tries to help constituents afford medication and balance the state’s budget.
NASHP is tracking state legislative action across the country as lawmakers schedule more hearings on prescription drug costs. To find out the status of any state’s drug pricing legislation as they move toward enactment, explore NASHP’s Rx State Legislative Tracker. To learn more about NASHP’s prescription drug work, visit its Center for State Rx Drug Pricing.
States Jumpstart Efforts to Integrate Health and Housing Policies
As part of the National Academy for State Health Policy’s (NASHP) health and housing institute, officials from five states (IL, LA, NY, OR, and TX) met with other policymakers at #NASHPCONF18 to share how they work across agency siloes to improve health and housing for vulnerable populations, including those experiencing homelessness, struggling with behavioral health or substance use disorders, or transitioning out of institutions.
While the responsibilities of each sector often overlap, the ability to develop and maintain clear cross-agency communication allows each sector to play to its strengths and maximize resources and staff capacity.
States are working to partner across agencies to strengthen services that can help vulnerable populations become and remain successful tenants, such as helping with completing leasing forms, budgeting, interacting with landlords, or navigating personal crises that could jeopardize their living arrangements. States are also exploring ways to weave health and housing priorities into the very fabric of state health transformation initiatives, such as requiring or encouraging accountable health entities or Medicaid managed care plans to provide housing-related services and supports. States are using their policy levers to spur development of more affordable housing initiatives through public-private partnerships or increasing state fees to support affordable housing programs.
State health and housing policymakers, including those participating in the Health Resources and Services Administration-supported NASHP institute, shared their progress toward health and housing goals, discussed cross-sector data strategies, and explored federal policy priorities during #NASHPCONF18.
Cross-Sector Collaboration
The state teams participating in the discussion themselves exemplified cross-sector collaboration, with representatives from:
- Affordable housing
- Aging and adult services
- Developmental disabilities
- Health/public health
- Homes and community renewal
- Housing and community services
- Housing development
- Human services
- Medicaid
- Mental health
With both housing and health sectors represented, state teams were able to candidly discuss the responsibilities of each sector. On the housing side, state officials and partners explained they generally work to maximize available housing units, manage waiting lists, work with landlords, and administer subsidy programs. State health officials said they often oversee the housing- and health-related services that help keep people stably housed. While the responsibilities of each sector often overlap, the ability to develop and maintain clear cross-agency communication allows each sector to play to its strengths and maximize resources and staff capacity.
Harnessing the Power of Shared Data and Goals
State teams visited Ability Housing’s Village on Wiley in Jacksonville, FL, during #NASHPCONF18.
The five state health and housing teams share some common goals, such as capitalizing on insights and efficiencies gained from shared or integrated data to improve health through health and housing initiatives. For example, states are working to match Medicaid claims data with data from state Homeless Management Information Systems (HMIS) to map changes in emergency department use after previously homeless people are housed, in order to make the business case for investing in housing initiatives. States are also working to match HMIS and Medicaid data to identify and help the highest utilizers of emergency departments. A number of states are working to compile and integrate data from Medicaid, public health, justice, and homelessness systems to create a more complete picture of the social conditions and unmet needs that affect the health of vulnerable groups.
While states share many health and housing goals, individual states may focus on different populations. For instance, some states focus on housing people transitioning from long-term care or other institutional settings, such as through the Money Follows the Person program, while others prioritize housing people experiencing homelessness. States may also concentrate on the housing and service needs of people with behavioral health needs or substance use disorders, rural residents, or families with children. Despite the different populations of interest, some common state goals include:
- Make more effective use of data by:
- Creating and implementing agreements to share data across mental health, intellectual/developmental disability, Medicaid, and homeless systems;
- Developing data-matching systems to help with hot-spotting and managing wait lists, such as developing a vulnerability score that prioritizes people on housing waiting lists based on their use of shelters, jails, and emergency services;
- Using data from managed care organizations to track the interaction between Medicaid, health care, and housing programs; and
- Analyzing data across systems to demonstrate the return on investment (ROI) of health and housing programs.
- Explore capital investment strategies for healthy affordable housing acquisitions and/or development;
- Develop pilot programs to leverage health systems as housing referral sources;
- Facilitate meaningful partnerships between accountable care and housing entities in local communities to support investment in housing-related services and supports; and
- Test the impact of integrated housing and tenancy support services on emergency department usage.
Over the next two years, the five state teams in the health and housing institute will continue to work toward stably housing vulnerable people and providing the services they need to live healthy lives in their communities. While individual state goals differ, they often build on progress made during past technical assistance opportunities, such as the Centers for Medicare & Medicaid Services Innovation Accelerator Program. As the health and housing institute advances, states’ successes and lessons learned will be featured at future NASHP conferences and at its health and housing resources page at NASHP.org.
The health and housing institute is supported through NASHP’s Cooperative Agreement with the Health Resources and Services Administration (HRSA), grant #UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.
State Lawmaker Will Guzzardi Plots His Next Move to Curb Generic Drug Price Gouging in Illinois
Earlier this year, Illinois state Rep. Will Guzzardi proposed an aggressive, anti-price-gouging bill that banned manufacturers from excessively hiking the costs of generic drugs sold to Illinois residents for his first foray into prescription cost control legislation. Guzzardi’s bill was one of a dozen anti-price gouging measures introduced in state legislature this year.
The bill easily passed the Illinois House, but it stalled in the Senate after a federal appeals court ruled that Maryland’s first-in-the-nation, anti-price-gouging law was unconstitutional. Like many state lawmakers working to craft innovative solutions to rein in drug costs, Guzzardi, a two-term legislator representing the Northwest Side of Chicago, is already prepping for Round 2 in the next legislative season.
Illinois’ anti-price-gouging bill:• Prohibited a pharmaceutical manufacturer or wholesaler from increasing the wholesale cost of an off-patent or generic drug 30% in one year, 50% over three years, or 75% over five years;
• Allowed the state’s Medicaid director, the director of Central Management Services, and others to notify the attorney general of excessive price hikes imposed on Illinois consumers; and
• Authorized the attorney general to request information from drug manufacturers and institute proceedings for violations.
Why did you choose anti-price-gouging legislation, which is a political heavyweight compared to transparency or regulating pharmacy benefit managers, for your first foray into curbing drug costs?
We had heard about Maryland’s law, which implemented anti-price-gouging safeguards, and we were interested in it. We also thought it had newsworthiness and timeliness to it because Martin Shkreli [former Turing Pharmaceutical CEO who raised one generic drug’s price 5,000 percent after buying the company] had been in the news as well as the price-gouging on EpiPens. We had also been talking about the need to keep drugs such as Narcan, used to counter-act opioid overdoses, affordable in the future. So, we reached out to Maryland state officials to explore their anti-price-gouging bill.
How was your bill different than Maryland’s?
I believe Maryland’s bill applied to drugs sold in Maryland. We added language that specified that our bill would only apply to drugs sold to Illinois residents. The distinction comes in the language in House Amendment 1, which inserts the words “that is ultimately sold in Illinois” into the definition of what drugs are covered. This language creates a nexus in Illinois, which we believe gives us a stronger case for the legality of regulation.
Who opposed the legislation?
Only the generic drug manufacturer’s association opposed it. They made red herring arguments, that the problem was not generics but brand-name drugs and that the state would lose jobs. While we’re happy to see lower-priced generics, there are still egregious cases where generic prices are hiked without manufacturers adding any value in terms of product development. Ultimately, it became a philosophical question for Republicans in the House and Senate, who viewed the legislation as Soviet-style price controls. They argued that a free market naturally guarantees the cheapest prices. But with generics, more than 50 percent of them have fewer than three manufacturers and a large number of generic manufacturers are monopolies or operate in a quasi-monopoly environments, which allows a huge opportunity for price increases and taking advantage of consumers. And, government regulates prices in all types of monopolies, including public utilities. It’s not unheard of for a state government to step in and prevent monopolies from extorting people.
On April 13, 2018, a federal appeals panel struck down Maryland’s anti-price-gouging law by a 2-1 decision.
Two judges ruled that Maryland could not regulate the prices charged by drug manufacturers because the sale to wholesalers occurred outside Maryland. As a result, they ruled that the anti-price-gouging law violated the Constitution’s Dormant Commerce Clause, which prevents states from interfering with interstate commerce.
A third judge dissented, arguing that Maryland’s law only addressed prices paid by Maryland consumers. He argued that manufacturers could simply price their products that were sold in Maryland to adhere to the state’s anti-price-gouging law.
Two judges ruled that Maryland could not regulate the prices charged by drug manufacturers because the sale to wholesalers occurred outside Maryland. As a result, they ruled that the anti-price-gouging law violated the Constitution’s Dormant Commerce Clause, which prevents states from interfering with interstate commerce.
A third judge dissented, arguing that Maryland’s law only addressed prices paid by Maryland consumers. He argued that manufacturers could simply price their products that were sold in Maryland to adhere to the state’s anti-price-gouging law.
Democrats were the majority party in both the House and Senate, why didn’t it pass?
It passed 65-38, mostly along party lines, in the House. Then we had a couple of things happen. The generic manufacturers’ association lobbyist had much more access and influence in the state senate, where there are fewer members. Specifically, he had very close relationships with several senators.
And then, there was the unfortunate timing of the Maryland court decision in April, just when the Senate was going to vote on it. Senators worried they would be voting on something that would end up in court.
The federal court panel in the Maryland decision ruled against the bill in ways that are indefensible. They said the Dormant Commerce Clause prevented regulation of upstream (out-of-state) transactions, but there are all kinds of regulations made at a state level that affect products sold by out-of-state manufacturers, such as state food labeling requirements or product safety and quality requirements. A lot of things we think of as normal state legislation would be considered unconstitutional under that view.
What are your plans for drug cost control legislation in the next session? [Guzzardi, a Democrat, faces no Republican opponent in the November election.]
I and my colleagues are looking into this now. This was my first year looking into prescription costs and I’ve discovered an appetite for it. I am learning that there is plenty of room for states to engage in this area, such as an insulin-for-all programs, or pharmacy benefit manager oversight laws or drug cost transparency mandates. We also need to see if it’s better to introduce several bills at once that tackle drug costs using different strategies or whether it’s better to focus on one approach. We’re also waiting to see what the federal court decides in the Maryland case, to see if we revive the anti-price-gouging bill.
I also intend to work on building a nonpartisan coalition to support this, involving AARP and other organizations. I truly believe there is a lot of pent-up demand for this.
Is outrage over drug prices gaining enough traction in Illinois that the legislation could succeed next session?
My district is a very diverse community. It’s roughly half white and half Latino, and it’s largely working-class. I think it’s hard for people to break out who the individual players are in the drug supply chain and what their responsibilities are, but they do know that drug prices are so high that they’re splitting pills, not filling prescriptions, and skipping doses. They may not know whom to blame, but they know they’re being taken advantage of.
Three-Part Series: Improving Care for People Living with HIV: Opportunities for State Medicaid-Ryan White HIV/AIDS Program Collaboration
States play critical roles in ensuring that people living with HIV (PLWH) have access to quality care through their Medicaid and Ryan White HIV/AIDS programs. PLWH can be among the most medically complex individuals covered by state health programs, and their care can cost five-times more than the average Medicaid beneficiary. Given limited resources, state policymakers are working to develop policies and strategies to ensure that care to PLWH is accessible, well-coordinated, and effective.
This three-part series explores policy levers and strategies that states are utilizing to focus limited resources and provide comprehensive and accessible care to PLWH.
- State Strategies to Improve Collaboration Between Medicaid and AIDS Drug Assistance Programs: This report explores how Illinois, Louisiana, New Jersey, New York, Oklahoma, Rhode Island, Washington, DC, and Wisconsin are using policy levers to more effectively deploy limited resources and provide better care to PLWH.
- States Strengthen Medicaid-Ryan White Collaboration to Improve Care Coordination for People Living with HIV: This report explores how Medicaid and Ryan White HIV/AIDS Programs in California, New York, Washington, and Wisconsin have partnered to improve care coordination services for people living with HIV.
- Maintaining Access: State Strategies to Coordinate Eligibility between Medicaid and Ryan White Programs: This report examines how Colorado, Illinois, Maryland, Phoenix (AZ), Texas, and Vermont have coordinated eligibility between Medicaid and Ryan White HIV/AIDS Programs in order to help ensure consistent access to care for people living with HIV.
NASHP’s State SUD Policy Institute Supports States to Address SUD in Federally Qualified Health Centers
NASHP congratulates the five states selected to participate in NASHP’s State Substance Use Disorder (SUD) Policy Institute:
- Alabama
- Illinois
- South Dakota
- Virginia
- Wisconsin
The State SUD Policy Institute, supported by a cooperative agreement with the Health Resources and Services Administration, will assist these five state teams to develop innovative strategies to increase access to and improve the quality of SUD treatment, recovery, and preventive services for Medicaid beneficiaries using federally qualified health centers (FQHCs). The institute began in September 2018.
Fast Facts:
What’s in it for states?
- Eighteen months of flexible, practical support and resources, including:
- Individualized assessments of states’ policies and regulatory barriers;
- Assistance developing a state action plan;
- State-specific supports and resources; and
- Opportunities to connect with peers and state, federal, and national experts while supported by NASHP’s in-house expertise.
Team composition: Each state team consists of a senior Medicaid official, a senior state behavioral health agency or division official; a senior representative from the state’s primary care association, and one FQHC representative. Additional team members may be included as needed.
More information: Interested states and partners can view an informational webinar, held July 12, 2018, that provided more information about the institute. To download the slides, click here. To view the webinar, click here. Email questions to Hannah Dorr (hdorr@oldsite.nashp.org).
Archived RFA and Application Questions
View or download the Request for Applications.
Download the Application Questions.
View frequently-asked-questions about the institute.
The institute is supported through the National Academy for State Health Policy’s National Organizations for State and Local Officials Cooperative Agreement with the Health Resources and Services Administration.
Toolkit: State Strategies to Improve Health Outcomes for People Living with HIV
Collaboration between state health department HIV programs and Medicaid is integral to providing quality, comprehensive care to people living with HIV (PLWH). With consistent, well-coordinated care and access to antiretroviral therapy (ART) many PLWH can achieve virologic suppression. Those who achieve sustained virologic suppression tend to have better health outcomes and a reduced risk of transmitting HIV to others. Collaboration and partnership can be challenging in many states, particularly when the Medicaid and state health departments are housed in separate agencies. There are, however, numerous strategies states can implement to improve collaboration and partnership between Medicaid and state health departments to implement policy and program changes to achieve this goal.
In 2017, NASHP completed work with 19 states to support them in identifying and implementing policy and program changes to improve rates of sustained virologic suppression among Medicaid and CHIP beneficiaries living with HIV. While working with these states, NASHP identified that state officials needed additional resources on a variety of topics, such as data sharing and use and quality improvement.
This toolkit, supported through a cooperative agreement with the Health Resources and Services Administration, is intended provide state officials with tools and resources, including issue briefs, webinars, and presentations, they need to improve rates of sustained virologic suppression. New items will be added to the toolkit on a regular basis, providing state officials with up-to-date information and timely policy resources.
Tools and Resources
Publications
One-Page Summary: HIV Health Improvement Affinity Group Evaluation Report
March 2019
This two-page summary 2019 highlights state action plans designed to increase viral suppressions and improve health outcomes for people living with HIV enrolled in Medicaid.
HIV Health Improvement Affinity Group Evaluation Report
March 2019
This full report explores the state action plans that 19 states and Medicaid agency staff developed to increase viral suppression and improve the health of people living with HIV. Federal agency partners and NASHP supported this one-year, peer-to-peer learning initiative.
States play critical roles in ensuring that people living with HIV (PLWH) have access to quality care through their Medicaid and Ryan White HIV/AIDS programs. PLWH can be among the most medically complex individuals covered by state health programs, and their care can cost five-times the average Medicaid beneficiary. Given limited resources, state policymakers are working to develop policies and strategies that are accessible, well-coordinated, and effective. This three-part series explores policy levers and strategies that states are using to focus limited resources and provide comprehensive and accessible care to PLWH.
This mini-brief highlights promising strategies for HIV Health Improvement Affinity Group states to successfully engage managed care organizations, health systems, and providers in quality improvement efforts aimed at increasing rates of virologic suppression. Louisiana, Michigan, New York, and Wisconsin are featured. This mini-brief was written as part of the HIV Health Improvement Affinity Group project.
How States Use Medicaid and State Health Department Data to Improve Health Outcomes of People Living with HIV
December 2017
This issue brief discusses key considerations and promising state strategies to share and then analyze Medicaid claims and HIV surveillance and Ryan White HIV/AIDS Program data. Analyses of these interagency data sets can help inform state and local policy and program changes aimed at increasing rates of virologic suppression for Medicaid and CHIP beneficiaries living with HIV. The brief also provides an overview of select data sets that states may be interested in sharing. This issue brief was written as part of the HIV Health Improvement Affinity Group project.
This mini-brief highlights promising strategies for HIV Health Improvement Affinity Group states to successfully engage managed care organizations, health systems, and providers in quality improvement efforts aimed at increasing rates of virologic suppression. Louisiana, Michigan, New York, and Wisconsin are featured. This mini-brief was written as part of the HIV Health Improvement Affinity Group project.
States Share Data to Improve the Health of People Living with HIV
December 2017
This blog presents lessons learned from three HIV Health Improvement Affinity Group states—Alaska, Louisiana, and Maryland—that are working toward sharing and analyzing Medicaid and state health department data to ultimately increase rates of virologic suppression among people living with HIV. This blog was written as part of the HIV Health Improvement Affinity Group project.
Better Together: How Cross-Agency Data Sharing Can Improve the Care Continuum for People Living with HIV/AIDS
October 2017
The state of Georgia leveraged a data sharing agreement between its public health and Medicaid departments in order to assess care quality for Medicaid beneficiaries living with HIV. Data use agreements are critical for agencies interested in sharing data. This blog was written as part of the HIV Health Improvement Affinity Group project.
As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates an integrated care model they call “one-stop shopping.” This issue brief showcases the CORE Center’s model and how it is partnering with the Illinois Department of Health to improve care for people living with HIV. The accompanying webinar can be accessed here. The webinar and issue brief were developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Advancing HIV Prevention Through Health Departments: Health Homes for People Living with HIV/AIDS
June 2016
This case study highlights Wisconsin’s health home program for Medicaid beneficiaries living with HIV, which is the first and only health home program exclusively for this population. Wisconsin’s experience may assist other states considering the health home state plan option as a strategy to support integrated care for Medicaid beneficiaries living with HIV. This case study was developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Advancing HIV Prevention Through Health Departments: HIV-Specific Quality Metrics for Managed Care
June 2016
This case study highlights New York’s use of HIV-related performance metrics to incentivize its Medicaid managed care plans to improve care for their members living with HIV. Their experience may assist other states considering how to incentivize quality improvement in their managed care program. This issue brief was developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Strategies for Coordination Between Medicaid and Ryan White HIV/AIDS Programs
November 2013
This policy brief discusses the importance of coordination between a state’s Medicaid agency and the Ryan White HIV/AIDS Program (RWHAP) to ensure that people living with HIV have access to comprehensive, high-quality care. NASHP interviewed Medicaid and RWHAP officials in 14 states about successful coordination efforts. This brief highlights those examples, along with additional promising practices for coordination that facilitate delivery improvements for people living with HIV. An accompanying webinar can be accessed here. The Health Resources and Services Administration (HRSA) provided support for this issue brief and webinar.
Webinars and Presentations
Overview of state and federal HIV programs
State Health Department HIV Programs: An In-Depth Look
February 23, 2017
View the webinar | Download the slides
The purpose of this webinar was to provide Medicaid and other state officials with information about the structure and components of state health department HIV programs and resources, as well as opportunities for collaboration between these programs and Medicaid. The Centers for Disease Control and Prevention discussed state HIV surveillance and prevention programs and the Health Resources and Services Administration discussed the Ryan White HIV/AIDS Program. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Housing Opportunities for Persons with AIDS: Presentation for HIV Health Improvement Affinity Group
December 7, 2016
Download the slides
This presentation described the Housing Opportunities for Persons with AIDS (HOPWA), a federal program dedicated to assisting with the housing needs of people living with HIV, and work in Alabama focused on improving health outcomes for people living with HIV/AIDS through greater access to housing. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Health Resources and Services Administration and HIV/AIDS Bureau Update
December 6, 2016
Download the slides
Laura Cheever, Associate Administrator for the HIV/AIDS Bureau within the Health Resources and Services Administration presented an overview of the Bureau’s priority areas and a preview of 2015 Ryan White HIV/AIDS Program Services Report data. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Overview of state Medicaid programs
The Medicaid Program: An In-Depth Look
February 16, 2017
View the webinar | Download the slides
While Medicaid programs vary greatly across states, the purpose of this webinar was to provide state health department and other officials with information about the structure and components of this program, as well as opportunities for collaboration between Medicaid and state health departments. The Centers for Medicare & Medicaid Services and NASHP presented about Medicaid structure, eligibility, benefits, financing, payment and delivery, as well as waivers and state plan amendments. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Interagency collaboration
Rhode Island Lessons Learned: Relocating Ryan White
December 7, 2016
Download the slides
Rhode Island presented on how Medicaid and its Ryan White HIV/AIDS Program are partnering on quality improvement projects and the implementation of Medicaid benefits, such as a targeted case management program. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination
August 29, 2013
Download the slides
This webinar highlighted strategies that California, Massachusetts, Tennessee, and Washington have used to improve interagency coordination, as well as implement policy changes to improve health outcomes for people living with HIV. An accompanying issue brief is available here. The Health Resources and Services Administration (HRSA) provided support for this webinar and issue brief.
Opportunities for state policy improvement
Webinar: Increasing Rates of Virologic Suppression: Promising Practices from HIV Health Improvement Affinity Group States
Wednesday, Dec. 6, 2017
View the webinar | Download the slides
Increasing rates of virologic suppression among people living with HIV is critically important to improving their quality of life and decreasing the risk of further HIV transmission. For the last 12 months, the HIV Health Improvement Affinity Group has worked with state health departments and Medicaid agencies from 19 states to develop and implement performance improvement projects aimed at improving rates of sustained virologic suppression among Medicaid beneficiaries living with HIV. This webinar featured leaders from the Office of HIV/AIDS and Infectious Disease Policy in the US Department of Health & Human Services, the Centers for Medicare & Medicaid Services, the Health Resources and Services Administration, and the Centers for Disease Control and Prevention. It also featured Affinity Group states, Alaska and North Carolina, that shared lessons learned and best practices from their performance improvement projects.
Improving Quality of Care for Medicaid Beneficiaries Living with HIV: Strategies to Engage Managed Care Plans and Providers
August 17, 2017
View the webinar | Download the slides
It is important for states to engage key partners, such as managed care plans and providers, in order to improve the quality of care provided to Medicaid beneficiaries living with HIV. This webinar showcased New York state’s work to incentivize managed care plans to improve rates of virologic suppression for their members living with HIV. The New England AIDS Education and Training Center also shared resources and promising strategies to engage HIV providers in quality improvement. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group: Policy and System Change
December 7, 2016
Download the slides
This presentation highlighted the role that Medicaid plays in ensuring many people living with HIV have access to comprehensive, high quality care. It also showcased policy changes that states could implement to improve access to and quality of care for beneficiaries living with HIV, including increased access to HIV testing, benefit design changes, and network adequacy standards. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Rhode Island Lessons Learned: Relocating Ryan White
December 7, 2016
Download the slides
Rhode Island presented on how Medicaid and its Ryan White HIV/AIDS Program are partnering on quality improvement projects and the implementation of Medicaid benefits, such as a targeted case management program. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Recent HIV Data to Care (D2C) Experiences in Maryland
December 6, 2016
Download the slides
Maryland presented on how it is using analyses of HIV surveillance and Medicaid claims data to identify people living with HIV who are not engaged in regular HIV care, and then developing policy and program changes to address these gaps in care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
View the webinar | Download the slides
This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Better Together: State Strategies for Medicaid-Ryan White HIV/AIDS Program Coordination
August 29, 2013
Download the slides
This webinar highlighted strategies that California, Massachusetts, Tennessee, and Washington have used to improve interagency coordination, as well as implement policy changes to improve health outcomes for people living with HIV. An accompanying issue brief is available here. The Health Resources and Services Administration (HRSA) provided support for this webinar and issue brief.
Data sharing and use
Data Sharing and Use: Creating Platforms for Exchange, Insight, and Action
May 24, 2017
View the webinar | Download the slides
This webinar highlighted the importance of building technological infrastructure to link and use data sets across state agencies, programs, and provider groups, as well as provided details about available 90/10 match funding to support infrastructure development. Louisiana and the District of Columbia both shared their experiences with developing information technology infrastructure to share data among agencies and programs. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Data Transfer and Use: Navigating Federal and State Laws and Regulations
March 28, 2017
View the webinar | Download the slides
This webinar discussed various data sharing regulations at the state and federal level, such as HIPAA and 42 CFR Part 2, and how these regulations may impact the sharing and use of HIV-related data across state agencies. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
North Carolina’s Engagement in Care Database for HIV Outreach (NC Echo): A Collaborative Effort
December 7, 2016
Download the slides
North Carolina presented on its Engagement in Care Database, which analyzes data from Medicaid claims and health department surveillance and Ryan White HIV/AIDS Program to identify people living with HIV that are not engaged in HIV care. State program staff then use this information to target outreach to these individuals to get them re-engaged in HIV care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Public Health Innovation: Emerging Opportunities for Leveraging Health Systems Data
December 6, 2016
Download the slides
This presentation explained why data sharing between Medicaid and state health departments is critical to better understanding utilization patterns and health outcomes for people living with HIV. It also identified key considerations for states interested in advancing this work. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Data analysis and presentation
How Data Visualization Efforts Impact Care and Decision Making
July 20, 2017
View the webinar | Download the slides | Presentation handout
The way in which data is presented is important when trying to increase stakeholder understanding and engagement on a particular issue. This webinar discussed strategies states can use to tailor their communication of data to specific audiences. The Massachusetts Department of Public Health shared how it designed a new website about the impact of the state’s opioid epidemic to be a rich, user-friendly resource for policymakers and community members. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Recent HIV Data to Care (D2C) Experiences in Maryland
December 6, 2016
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Maryland presented on how it is using analyses of HIV surveillance and Medicaid claims data to identify people living with HIV who are not engaged in regular HIV care, and then developing policy and program changes to address these gaps in care. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
HIV Health Improvement Affinity Group Kickoff Webinar
October 12, 2016
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This webinar was intended to provide context to HIV Health Improvement Affinity Group states about the importance of improving care and health outcomes for people living with HIV. Following presentations and remarks from senior federal agency officials, two Affinity Group states presented about their work. Louisiana shared their work to date using data to determine the proportion of Medicaid beneficiaries that are engaged in care and virally suppressed, and implementing a HIV-related metric into its MCO incentive-based performance metric set. Wisconsin shared its progress analyzing Medicaid claims and HIV-related clinical data to better evaluate health outcomes for Medicaid beneficiaries living with HIV.
Provider- and system-level quality improvement
Improving Quality of Care for Medicaid Beneficiaries Living with HIV: Strategies to Engage Managed Care Plans and Providers
August 17, 2017
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It is important for states to engage key partners, such as managed care plans and providers, in order to improve the quality of care provided to Medicaid beneficiaries living with HIV. This webinar showcased New York state’s work to incentivize managed care plans to improve rates of virologic suppression for their members living with HIV. The New England AIDS Education and Training Center also shared resources and promising strategies to engage HIV providers in quality improvement. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Data, Delivery, and Decisions as Levers for Enhancing Whole-Person Care for People Living with HIV: Lessons from the Ruth M. Rothstein CORE Center
January 26, 2017
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As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates an integrated care model it calls “one-stop shopping.” This webinar featured speakers from the CORE Center and the Illinois Department of Health who shared lessons learned from their partnership to improve care for PLWH. The accompanying issue brief can be accessed here. The webinar and issue brief were developed as part of HealthHIV’s Three D HIV Prevention Program, supported by the Centers for Disease Control and Prevention.
Process Improvement Methods and Tools
November 18, 2016
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Dr. Kevin Larsen from the Centers for Medicare & Medicaid Services shared methods and tools that states can use to design quality improvement initiatives. This webinar was originally produced for participants in the HIV Health Improvement Affinity Group.
Addressing social determinants of health
Housing Opportunities for Persons with AIDS: Presentation for HIV Health Improvement Affinity Group
December 7, 2016
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This presentation described the Housing Opportunities for Persons with AIDS (HOPWA), a federal program dedicated to assisting with the housing needs of people living with HIV, and work in Alabama focused on improving health outcomes for people living with HIV/AIDS through greater access to housing. This presentation was originally developed for participants in the HIV Health Improvement Affinity Group.
Data, Delivery, and Decisions as Levers for Enhancing Whole-Person Care for People Living with HIV: Lessons From the Ruth M. Rothstein CORE Center
Thursday, January 26, 2017
3:00 – 4:00PM
As states continue to focus on integrated care and delivery system reform, meaningful opportunities exist to improve care for people living with HIV (PLWH). In particular, states can use existing centers of care to promote “one-stop shopping” utilization of multidisciplinary services for PLWH and linkages to Ryan White and Medicaid. The Ruth M. Rothstein CORE Center in Chicago, Illinois – part of the Cook County Health & Hospitals System – operates just such a model. By emphasizing integrated and coordinated service delivery, using a unified data system, and making programmatic decisions that directly support the client as they navigate the integrated care system, the CORE Center and its partnerships at the state level offer multiple strategies for health systems and state agencies alike in the pursuit of improved care for PLWH.
View the brief here.
Medicaid Funding Opportunities in Support of Perinatal Regionalization Systems
Preterm birth, which accounts for approximately 11.5 percent of all births and 50 percent of pregnancy-related costs, is the largest cause of infant morbidity and mortality. This creates a significant burden on the U.S. healthcare system. A leading strategy for decreasing infant morbidity and mortality related to preterm birth is for states to use perinatal regionalization, a designation system where infants are born in or transferred to specific facilities based on the amount of care needed.
Regionalization of perinatal care is characterized by a tiered system of risk-appropriate care delivery whereby hospitals choose or are given specific designations based on the level of care they can provide. The system’s purpose is to ensure that high-risk mothers and infants are cared for at appropriate level facilities. For example, evidence suggests that an infant born at less than 32 weeks gestation or weighs less than 1500g should be cared for at a Level III facility with a neonatal intensive care unit. Perinatal regionalization has been shown to improve maternal and neonatal outcomes, and to be cost effective.[1]
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization.
Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system.
A new joint issue brief by the National Academy for State Health Policy (NASHP) and NICHQ explores Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered.
For more information, download and read the new issue brief.
State Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
For example, California has identified transportation as a critical element to its perinatal regionalization system and, more broadly, the health of high-risk mothers and infants. The provision of transportation can be challenging due to both the structure of their perinatal regionalization system and the different modalities used for providing transportation under the Medi-Cal Benefit (e.g. Local County Agreements and/or Fee-for-service and Medicaid managed care systems). In regards to transportation services, Medi-Cal currently serves as the payer of last resort. However, when Medi-Cal eligible individuals need coverage for transportation services, Medi-Cal will cover the cost from either fee-for-service or managed care delivery systems. Transportation to a hospital as well as transfer between hospitals is also a common benefit in health plans available under the California Medi-Cal Access Program. Medi-Cal’s Comprehensive Perinatal Services Program also partners with the California Perinatal Transport Systems and Regional Perinatal Programs of California to promote and cover services integral to perinatal regionalization. These two programs are supported by the state Title V Maternal and Child Health Services Block grant.
The Georgia Medicaid Program plays a key role in funding the Georgia Regional Perinatal Care Network (GRPCN) along with state general revenue funds appropriated to the Georgia Department of Public Health (DPH). GRPCN is managed under the DPH. GRPCN is made of up six regional care centers for the treatment of high-risk mothers and infants. These six centers are designated based on regional need and available funding. The GRPCN’s funding comes from Medicaid, state funds appropriated to the DPH and state matched funds. Available funding is intended to support costs associated with cost of care, and regional center administrative costs for outreach, education and transportation services. Georgia also uses the state Title V Maternal and Child Health Services Block grant to support a range of programs and initiatives focused on preventing infant mortality, including perinatal regionalization.
[1] Anne Rossier Markus, Elie Andres, Kristina D. West, Nicole Garro, and Cynthia Pellegrini, “Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform,” Journal of Women’s Health Issues 23, no.5 (2013): e273, doi:10.1016/j.whi.2013.06.006
Additional Resources
New issue brief
California Case Study
Georgia Case Study
Interactive Chart
Selected State Initiatives on Medicaid Financing of Perinatal Regionalization
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization. Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system. This chart includes selected state initiatives and highlights Medicaid as a key partner in financing perinatal regionalization systems.
For more information on Medicaid funding opportunities in support of perinatal regionalization systems, read the blog post and issue brief that further explore Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered. Case studies of California and Georgia demonstrate how state Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
This resource was developed by NASHP in partnership with the National Institute for Children’s Health Quality (NICHQ) as part of the Health Resources and Services Administration’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).
| California | The Regional Perinatal Programs of California (RPPC) were established in 1979 due to the need for a more comprehensive network of healthcare providers within specific geographic areas to promote access to high quality levels of maternal and infant care.[ii] Today, the RPPC has divided California into 9 separate regions, each of which include between 18-38 hospitals each.[iii]The California Perinatal Transport Systems (CPeTS) act of 1976 appropriated funds for the development of a dispatch service to facilitate transportation of mother and infants to NICUs.[iv] It also provides collection and analysis of perinatal and neonatal transportation data. |
| Florida | Developed in the 1970’s, Florida’s eleven Regional Perinatal Intensive Care Centers (RPICCs) provide access to high-risk perinatal care and are managed by FL’s Department of Health. Each facility provides community outreach education, and consultative support to other obstetricians and Level II and III NICUs in their areas, in addition to inpatient and outpatient services.[x] |
| Georgia | The Georgia Regional Perinatal Care Network Project (GRPCN) is a statewide initiative funded by the state Medicaid agency and state general funds appropriated to the Georgia Department of Public Health. Georgia’s six regional care centers are designated based on regional need and available funding.[xiii] |
| Illinois[xv] | First adopted in 1976, Title 77 created a perinatal regionalization system through Illinois Administrative code. [xvi] The Illinois Department of Public Health oversees the system and works with a Perinatal Advisory Committee (PAC) that offers recommendations relating to perinatal care. Today, Illinois’ perinatal regionalization system includes 10 administration Perinatal Centers that supervise 122 obstetric hospitals. In additional to a supervisory role, each Regional Perinatal Center has both clinical and administrative responsibilities.[xvii] |
| South Carolina | Established in the 1970’s, South Carolina’s regionalized perinatal system of care, is now made up of five perinatal centers in four regions that contract with the SC Department of Health. Key elements of the system include early risk assessment and referral to appropriate care; coordination and communication between hospitals and community providers; monitoring systems through data; and ensuring access to services from preconception through the first year of life.[xx] |
| California | Medi-Cal works with a variety of different partner programs to ensure coverage and access to services for pregnant women and neonates. These programs include the California Children’s Services Program (CCS),[v] The California Medi-cal Access Program (CMAP),[vi] and the Comprehensive Perinatal Services Program (CPSP).[vii] Through these programs, Medi-cal provides a variety of benefits, but the most notable is reimbursement for transportation services.[viii] |
| Florida | All RPICC Program patients are potential Medicaid Recipients. RPICC Medicaid reimbursement is inclusive for all services provided by the neonatology or obstetrical groups. [xi] The Agency for HealthCare Administration pays claims for inpatient-only services provided to Medicaid recipients by neonatologists and obstetricians enrolled in RPICC with Medicaid funds. |
| Georgia | Georgia Department of Public Health services for Medicaid members include: Perinatal Health Partners (PHP), Perinatal Case management, and Presumptive Eligibility Determination. [xiv] |
| Illinois[xv] | Two main programs offering coverage are available for pregnant women: Medicaid Presumptive Eligibility (MPE) which offers immediate temporary coverage for pregnant women who meet income requirements (outpatient care) and Moms & Babies, which covers healthcare during pregnancy and 60 days post-partum (inpatient, outpatient, and transportation).[xviii] Illinois’ Medicaid managed care plans are required to pay for and ensure the same level of care for pregnant women as in the fee-for-service benefit package. |
| South Carolina | Overall, the ability to link and contract with Medicaid providers has been difficult due to variations in policies and services of the Medicaid managed care plans. [xxi] |
| California | Funding for the RPPC and CPeTS is provided via Federal Title V Maternal and Child Health (MCH) Block Grant Funds.[ix] |
| Florida | The RPICC program is funded through a combination of Federal Title V MCH Block Grant Funds and Medicaid dollars. [xii] |
| Georgia | GRPCN is jointly funded by Georgia Medicaid and the Georgia Department of Public Health. |
| Illinois[xv] | IDPH allocates state funds to target preventative services, and provide grants to designated APCs responsible for the administration and implementation of the perinatal program.[xix] |
| South Carolina | Majority of the funding is through SC Department of Health and Hospitals. Additional funds are provided by the Title V MCH Block Grant.[xxii] |
| California | There is a neonatal transportation policy and it includes maternal transportation. Medicaid reimbursement policy exists for neonatal transportation. |
| Florida | There is a neonatal transportation policy and it includes maternal transportation and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation. |
| Georgia | There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants, and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation. |
| Illinois[xv] | There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants and mothers, and inter-hospital transportation. |
| South Carolina | There is a neonatal transportation policy and it includes maternal transportation, back-transportation for infants, and inter-hospital transportation. |
[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[ii] “Regional Perinatal Programs of California Fact Sheet,” California Department of Public Health, Accessed August 24, 2016, https://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/RPPC.aspx[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[iii] California Department of Public Health- Maternal, Child, and Adolescent Health Program – Epidemiology, Assessment, and Program Development Branch, “Regional Perinatal Programs of California (RPPC),” October 2015, https://www.cdph.ca.gov/programs/rppc/Documents/RPPC_Regions_Oct2015.pdf
[iv] California Perinatal Transport System, “California Perinatal Transport System,” Accessed August 24, 2016, https://www.perinatal.org/
[v] California Department of Health Care Services, “Program Overview – California Children’s Services,” Accessed August, 29, 2016, https://www.dhcs.ca.gov/services/ccs/Pages/ProgramOverview.aspx
[vi] California Department of Health Care Services, Medi-Cal Access Program, “What Services are Covered in MCAP?,” Accessed August 24, 2016, https://mcap.dhcs.ca.gov/Services/?lang=en
[vii] County of Los Angeles Public Health, “Comprehensive Perinatal Services Program,” Accessed August 24, 2016, https://publichealth.lacounty.gov/mch/cpsp/CPSPwebpages/cpsp_rev.htm
[viii] “Medical Transportation – Ground,” in: California Code of Regulations, 2015, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwi7_PmV7trOAhXDHx4KHScUBtkQFggeMAA&url=https%3A%2F%2Ffiles.medi-cal.ca.gov%2Fpubsdoco%2Fpublications%2Fmasters-mtp%2Fpart2%2Fmctrangndcd_a05.doc&usg=AFQjCNFzBYxIjWfYOw5gAKxm32BkzRkHug&sig2=QFlVSnGrnpIL6_Y7Sjbd2Q
[ix] California Department of Public Health, “Maternal and Child Health Services Title V Block Grant – California,” 2015, https://www.cdph.ca.gov/programs/mcah/Documents/Title%20V%202016%20Application%202014%20Report%20final.pdf
[x] Children’s Medical Services (CMS), “Regional Perinatal Intensive Care Centers,” Accessed August 29, 2016, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/rpicc.html
[xi]Florida Department of Health, Regional Perinatal Intensive Care Centers Handbook, August 2010, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/documents/rpicc_handbook.pdf
[xii] Ibid.
[xiii] National Perinatal Information Center, “Medicaid Funding – The Georgia Regional Perinatal Care Network, Accessed August 24, 2016, https://www.npic.org/projects/MedicaidFunding.php
[xiv] Georgia Department of Community Health, “Georgia Public Health Services Available for Medicaid Members,” Accessed August 29, 2016, https://dch.georgia.gov/sites/dch.georgia.gov/files/Georgia_Public_Health_Services_for_Medicaid_Members.pdf
[xv] Bruce Rauner, Felicia F. Noorwood, and Teresa Hursey, Report to the General Assembly, January 2016 – Public Act 93-0536, (2016), https://www.illinois.gov/hfs/SiteCollectionDocuments/perinatalreport2016.pdf
[xvi] Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640: Regionalized Perinatal Health Care Code, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/07700640sections.html
[xvii] Illinois Department of Public Health, “Perinatal Regionalization,” Accessed August 29, 2016, https://www.dph.illinois.gov/topics-services/life-stages-populations/infant-mortality/perinatal-regionalization
[xviii] Illinois Department of Healthcare and Family Services, “Moms and Babies,” Accessed August 29, 2016, https://www.illinois.gov/hfs/MedicalPrograms/AllKids/Pages/MomsAndBabies.aspx#momsbabies
[xix]Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640, Section 640.80: Regional Perinatal Networks – Composition and Funding, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/077006400000800R.html
[xx] Association of State and Territorial Health Officials, “South Carolina’s Perinatal Regionalized System of Care: Reducing Premature Births and Infant Mortality,” (2013), https://www.astho.org/Presidents-Challenge-2013/SouthCarolina/
[xxi] South Carolina Department of health and Environmental Control, Healthy Mothers, Healthy Babies: South Carolina’s Plan to Reduce Infant Mortality & Premature Births, (October 2013), https://www.scdhec.gov/library/cr-010842.pdf
[xxii] The Title V Maternal and Child Health Block Grant funded components include: obstetric and neonatal outreach education, transport coordination, and physician consult and follow-up.
Association of Maternal and Child Health Programs, “South Carolina – Maternal and Child Health Block Grant 2016 State Profile,” Accessed August 29, 2016, https://www.amchp.org/Policy-Advocacy/MCHAdvocacy/Documents/South%20Carolina%202016.pdf
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
