Three More States Enact Reverse Auction Laws to Reduce Prescription Drug Spending
Colorado, Louisiana, and Minnesota enacted laws this session enabling reverse auctions to procure a pharmacy benefit manager (PBM) for their state employee health plans (SEHPs).
This approach to PBM procurement, first used by New Jersey, aims to achieve savings by encouraging PBMs to be more competitive on pricing in their bidding for contracts without reducing drug benefits for the state’s public employees.
In the reverse auction procurement model, states design their own drug formulary for their SEHP, and a PBM’s participation in the auction is contingent on agreeing to the terms of the proposed state drug benefit plan. This eliminates the need for states to compare bids based on specific services provided and instead allows states to focus solely on price.
To conduct a reverse auction, states must first procure a third-party technology vendor through a request for proposal (RFP). PBM procurement is then initiated through a second RFP and managed through the vendor’s technology platform. The reverse auction platform allows each PBM to see how its bid compares against the highest bid in an anonymous fashion, giving bidders the opportunity to improve their offers over several rounds of bidding. This process forces vendors to compete more aggressively on price alone while still offering the same services and benefits to SEHP beneficiaries.
Colorado, Louisiana, and Minnesota enacted legislation in June 2021 to authorize reverse auction procurement of PBM services for their SEHPs and are in the early stages of implementation. Minnesota released an RFP for a technology platform with bids due in early August. Colorado is in the process of developing their technology vendor RFP, while Louisiana’s law went into effect on August 1.
New Jersey became the first state in the nation to authorize and implement reverse auction procurement of PBM services in 2016 – the state reports a savings of $2 billion over five years without cutting drug benefits for State Health Benefits Program and School Employees’ Health Benefits Program enrollees. Maryland followed in 2019, tasking the state’s Prescription Drug Affordability Board (PDAB) with evaluating whether to pursue this model of procurement. In the meantime, Maryland moved forward with an RFP for a technology platform to support the reverse auction with bids due early July. New Hampshire’s Employee Benefits Plan secured a contract with a technology platform in January. Initial responses to their RFP for PBM services were due in June, and bidders are being evaluated on price and a point system based on the technical questionnaire. Their proposed PBM contract terms contain few major changes from their existing PBM contract, though the state is switching to a pass-through model.
Other states continue to express interest in this approach to achieving prescription drug savings. Looking ahead, NASHP will continue to monitor reverse auction proposals and compile resources useful to states considering and implementing reverse auctions such as enacted laws, RFPs, and contracts. On July 28, 2020, NASHP hosted a webinar featuring New Jersey’s experience implementing a reverse auction model. State officials interested in viewing the webinar recording or learning more about reverse auctions should contact Amanda Attiya.
Eight States Join NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy to Address Maternal Mortality
The National Academy for State Health Policy (NASHP) has announced a new, two-year policy academy kicking off in April for state health officials interested in building state capacity to address maternal mortality for Medicaid-eligible pregnant and parenting women, with the goal of improving access to quality care.
Through the Maternal and Child Health Policy Innovation Program (MCH PIP), funded by the Maternal and Child Health Bureau within the Health Resources and Services Administration, NASHP’s Maternal and Child Health Policy Innovation Program Policy Academy will engage eight state teams (GA, ID, IL, IA, LA, PA, SD, and VA). The teams include representatives from state Medicaid agencies, public health agencies, and other state stakeholders (e.g., mental health/substance use agencies, child welfare agencies, provider groups, Medicaid managed care plans, and others.)
Through this policy academy, states will identify, develop, and implement policy changes or develop specific plans for policy changes to improve maternal health outcomes, with a specific focus on improving racial disparities in maternal mortality.
The United States has seen a steady rise in maternal mortality over the past few years and has the worst maternal mortality rate among developed nations. Additionally, there are stark racial disparities in pregnancy-related deaths. American Indian/Alaska Native and Black women are two- to three- times more likely to die from pregnancy-related causes than non-Latinx (non-Hispanic) White women. States are grappling with a number of factors in their efforts to improve access to quality care for this population and strengthen the systems serving them.
Over the course of the two-year project, NASHP will provide technical assistance to states, identify barriers, and share promising practices for improving maternal health outcomes to help states achieve their policy goals.
Six States Join NASHP and AcademyHealth’s Community of Practice to Boost Immunization Rates in Medicaid-Enrolled Pregnant Women and Children
The National Academy for State Health Policy (NASHP) and AcademyHealth, with support from Immunize Colorado, are facilitating a new community of practice (CoP) comprised of state health officials from six states interested in improving their immunization rates.
Funded by a US Centers for Disease Control and Prevention (CDC) cooperative agreement, the Immunization Barriers in the United States: Targeting Medicaid Partnerships program is engaging six state Medicaid agencies (LA, MI, TX, WA, WI, WY) in collaboration with their public health and immunization information system partners. Through this CoP, states are working to improve Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. The project will build on the work and lessons learned from the previous CoP of five states, which ended in late 2020.
Despite coverage of vaccines through Medicaid, immunization rates among children and pregnant women enrolled in Medicaid remain lower than those who are privately insured and have higher incomes. Disparities in vaccine coverage exist for Black women and people living in poverty. Additionally, CDC data shows a significant reduction in routine vaccines administered to children during the COVID-19 pandemic. While vaccination rates are slowly returning to pre-pandemic rates, national experts are concerned that the missed vaccine doses may have future health implications and lead to outbreaks of vaccine-preventable diseases.
Through virtual and in-person meetings over the course of the three-year project, AcademyHealth and NASHP will provide technical assistance to states, identify barriers, and share promising practices for increasing immunization rates.
Q&A: How Louisiana Has Retooled its Harm Reduction Services for Vulnerable Populations during COVID-19
As drug overdose deaths accelerate during the COVID-19 pandemic, states are working to ensure that a continuum of services, including access to harm reduction programs, remain available to people with substance use disorder (SUD). The National Academy for State Health Policy (NASHP) recently spoke to Louisiana’s Viral Hepatitis Coordinator Emilia Myers and STD/HIV/Hepatitis Program Deputy Director Anthony James to learn how the state is continuing to provide harm reduction services during the pandemic.
Louisiana authorizes cities, including New Orleans, Baton Rouge, Shreveport, and Alexandria, to operate syringe services programs (SSP). The state has helped maintain these programs by targeting federal grants and through close cooperation between state and community partners.
How have the challenges posed by COVID-19 impacted the day-to day operation of harm reduction services in Louisiana?
Louisiana has six active SSPs across the state. They have stepped up to the challenges of this pandemic and have continued to provide their services, essentially without interruption. They’ve been able to do so through some very innovative approaches, such as hotlines and mail-based naloxone services, and by moving away from brick-and-mortar SSPs. The Louisiana Department of Health (LDH) has worked to improve its relationships with SSPs and link them with their respective local health departments. One result of this manifested in New Orleans where, right when COVID-19 started to ramp up, the city started providing residences for folks who were experiencing homelessness. SSPs went out to the hotels that were housing people to bring harm reduction services to them.
We are also using federal State Opioid Response (SOR) grant dollars in collaboration with the Office of Behavioral Health to fund SSP navigators and federal Opioid Overdose Data to Action (OD2A) dollars in collaboration with the Bureau of Community Preparedness to fund Linkage to Treatment Coordinators (LTCs), who prioritize people who inject drugs (PWID) who have fallen out of hepatitis C treatment. If they are also willing to talk about their drug use, the LTC will conduct a Screening, Brief Intervention and Referral to Treatment (SBIRT). We’ve also been using OD2A funds for our marketing campaign to raise awareness of integrated and co-located care for OUD (opioid use disorder), hepatitis C, HIV, and SSPs to reduce harms associated with substance use disorder, which we hope to continue.
Luckily, there is buy-in to this work. About a year ago, together with the Office of Behavioral Health and Bureau of Community Preparedness, we developed a state health department-wide, harm-reduction crosswalk, which was an environmental landscape analysis of who’s doing what in infectious disease, who’s doing what in OUD, and how we can create no-wrong-door systems of care. We’ve had some modest gains as a result, including braiding select government funds, scaling up SSP-based OEND (overdose education and naloxone delivery), increasing opt-out hepatitis C testing at select human service district agencies and cross-training OBOT (office-based opioid treatment) providers statewide to deliver both medication-assisted treatment for OUD and treatment for hepatitis C and we are looking to build on our momentum. Our state agencies have innovative leaders that make connections for more effective public health and behavioral health collaboration and care touch points, and we’re fortunate to have trailblazers that keep this work moving along.
How have people with comorbid HIV and hepatitis C diagnoses been affected by COVID-19, and how has the state responded?
We know folks who are coinfected are one of the populations most vulnerable to unemployment, poverty, lack of access to health care, and they generally have a lot of competing priorities between trying to take their medications and live their lives. Anecdotally, we are seeing more people accessing SSPs and needing supplies, and SSPs are trying to accommodate that increased demand. With an increase in utilization of SSP services, we hope there will not be an increase in overdoses and or increases in HIV and hepatitis C transmission. I think COVID-19 has really turned access into a challenge and created additional burdens for vulnerable populations, so we have to look at the issue through a health equity lens. There are a lot of systemic challenges and barriers that have been exacerbated by the pandemic, and people’s health has become a lesser priority because they’re trying to survive day to day.
Within our Hepatitis C Elimination Plan activities [featured in an April 2020 NASHP case study], we have seen decreases in testing and treatment as a result of the pandemic. Before we launched our program, 61 people per month were starting curative treatment. After implementation, we were seeing on average 478 people per month starting treatment. At the start of the COVID-19, that number dropped back down to an average of 155 people per month, but since September 2020, testing and treatment utilization has picked back up. This has forced us to learn how to get testing and treatment outside of brick and mortar treatment facilities, because people are anxious of going into health care systems. Because of funding reductions and other impacts of COVID-19, we revisited our hepatitis C strategy to ensure we were focused on realistic and achievable objectives for the second year of the plan, and reassess what Years 3 through 5 will look like. COVID-19 has forced us to pivot and continuously innovate hepatitis C service delivery. We will use this as an opportunity to leverage our response and facilitate a larger push in harm reduction.
How does Louisiana’s harm reduction approach support health equity and reduce disparities?
In both the LDH and STD/HIV/Hepatitis Program mission statements, we focus on addressing health equity and racial disparities across the board. Disparities in health care exist and are associated with worse health outcomes, for example the HIV/HCV coinfection diagnosis and prevalence rates are disproportionally higher among Black males primarily in the Baton Rouge and New Orleans areas. Looking at the mono-hepatitis C surveillance data, there hasn’t been a lot of variability in who’s being diagnosed by race. We see disparities in rates of infection by age – we have baby boomers and people who inject drugs getting infected, so we have this bimodal distribution. In an effort to address these disparities in the context of the current hepatitis C/OUD syndemic, we have to pinpoint shortcomings in hepatitis action towards people who actively use drugs and expand primary prevention through harm reduction because treating your way out of a hepatitis C epidemic isn’t feasible. PWID are increasingly researched, but their ability to tell their own stories and provide input into the programs and services they utilize has been historically limited due to stigma. Louisiana is changing that by leveraging community wisdom through community advisory boards to inform evidence-based service delivery. We move this work forward through a core set of values to help us ensure that the services that we and our community partners provide are moving in an equitable direction.
How has the pandemic necessitated or encouraged new strategies or partnerships?
One of our strategies has been offering provider training. We’ve leveraged Project ECHO to train providers how to leverage telemedicine to treat and manage hepatitis C virtually, revamping remote care. There has been a lot of engagement from clinicians.
There was also a decline in hepatitis C and HIV testing at the start of COVID-19. Our community-based partners have conducted risk mitigation strategies to safely re-engage people in testing. Now that they’ve been able to get PPE, they are able to conduct testing in community settings again.
We are also prioritizing data sharing and maximizing opportunities to form strong partnerships, because the syndemic of hepatitis C, HIV, and drug overdose is really intertwined, and COVID-19 has only made things more challenging. Reinforcing our partnerships and leveraging data sharing, in addition to amplifying the voices and wisdom of community members, is helping us make these programs work for the people who rely on them.
What would you say are your greatest lessons learned from COVID-19?
We really need to lean into interdisciplinary telemedicine for comprehensive care, especially for the hard-to-reach communities in high-burden regions of the state. COVID-19 has caused so much slow down, but also additional time to re-assess what we’re doing. In this context, developing robust telemedicine programs will be critical. The next challenge will be how to integrate offerings into clinical care beyond the COVID-19 pandemic so that a “one-stop-shop” PWID service bundle will become an increasingly ordinary part of care with movement towards the goal of reducing disparities in infectious diseases and opioid use disorder treatment access.
Eliminating Hepatitis C: New State Payment Models for Treatment and Emerging Evidence
With hepatitis C infections on the rise and curative, but expensive, prescription drugs now available, state leaders across the country are compelled to address this public health crisis, and Louisiana and Washington are developing innovative drug-purchasing strategies within their efforts. At the same time, the Patient-Centered Outcomes Research Institute (PCORI) is investing in patient-focused studies into hepatitis C treatment to help fill gaps in our knowledge with a patient focus to help guide future state efforts to combating this deadly liver disease.
During this National Academy for State Health Policy (NASHP) webinar, officials from Louisiana and Washington share their approaches to using negotiated fixed price payments to ensure unlimited access to hepatitis C drugs for individuals with public health coverage.
Since 2010, the number of new infections has tripled, which experts attribute to the opioid crisis and an increase of people who inject drugs. A growing number of states are committing to eliminating hepatitis C as the World Health Organization, the US Centers for Disease Control and Prevention, and others are advocating. Such a commitment is possible due to drugs introduced in 2011 that can achieve cure rates above 95 percent when the 12-week treatment regimen is followed. However, the costs of these drugs in the United States remains high even though prices have dropped since their introduction. Although prescription drugs are just one component of states’ comprehensive public health hepatitis C elimination campaigns, the high cost of these drugs is the one of the biggest challenges facing states as they address this growing public health crisis.
Although their payment strategies are slightly different, Louisiana and Washington are exploring agreements with drug manufacturers to pay a flat fee over a contracted time period to gain unlimited access to hepatitis C drugs, rather than pay on a per unit basis, which is how most drugs are purchased. In Louisiana, corrections system populations and individuals enrolled in Medicaid and will have access to the drugs. In Washington , incarcerated individuals, Medicaid enrollees, public and school employees, individuals covered by workers compensation, and those in state hospitals will have access to the drugs as needed.
During this National Academy for State Health Policy (NASHP) webinar, officials from Louisiana and Washington share their approaches to using negotiated fixed price payments to ensure unlimited access to hepatitis C drugs for individuals with public health coverage.
As states forge ahead to design and implement strategies to eliminate hepatitis C and find ways to ensure access to treatment while working to contain costs, PCORI research is seeking to learn more about:
- Effective screening to identify more cases;
- What harm results, compared to no treatment;
- Direct comparison of treatments in the real world; and
- Effectiveness of care delivery models.
As results from these ongoing patient-centered research studies become available, they will help inform evolving state efforts to address the hepatitis C crisis. The introduction of the effective drug treatment has changed states’ public health approaches and incentivized Louisiana and Washington’s innovative purchasing strategies.
According to an overview of PCORI’s hepatitis C research highlighted during the webinar, researchers are hoping to learn how to most effectively engage people living with hepatitis C who use injection drugs to provide treatment that works. Patient-centered research is also seeking to learn more about the prevalence of re-infection. The evidence from these studies will help with clinical interventions, but could also be taken into consideration as states design, implement, and review their public health campaigns and treatment payment strategies.
Emerging issues, such as public health crises, require immediate attention and innovative cost-effective solutions from state officials. States’ call to action to address the rise in hepatitis C infections is an example of how they must react quickly using the information, appropriate lessons learned, and resources they have to address current crises. State officials are designing their drug contracts and plans to be as flexible as possible so they are able to adjust their approaches as new information becomes available, such as new PCOR evidence. As Louisiana and Washington learn from their prescription payment model and evidence becomes available from PCORI about treatment outcomes and approaches, state efforts will continue to evolve.
Webinar: How States Pay for Hep C Drugs Using a “Netflix-style” Subscription Model
Wednesday, May 15, 2019
3 p.m. (ET)
Faced with costly and effective treatment for hepatitis C, states are exploring innovative alternative payment methodologies (APMs) to expand access to treatment and generate savings. Using a “Netflix-style” subscription model, Louisiana and Washington are negotiating agreements with drug manufacturers to get unlimited access to hepatitis C drugs for a fixed, predetermined cost. Join this NASHP webinar to hear about Louisiana and Washington’s innovative APMs as well as related research into hepatitis C from the Patient-Centered Outcomes Research Institute (PCORI).
Moderator: Trish Riley, Executive Director, National Academy for State Health Policy
Speakers:
- Pete Croughan, Health Policy Advisor, Louisiana Department of Public Health
- Donna Sullivan, MS, PharmD, Chief Pharmacy Officer, Washington Health Care Authority
- Robyn Liu, MD, MPH, Assistant Professor of Family Medicine, School of Medicine, Oregon Health and Science University
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.
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. 
