Oregon – Page 2 – The National Academy for State Health Policy

Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives

December 17, 2020/in Medicaid Managed Care Illinois, Louisiana, New York, Oregon, Texas Featured News Home, Reports Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Population Health, Social Determinants of Health, Special Populations and Services /by Allie Atkeson, Ariella Levisohn and Jill Rosenthal

Webinar: How NASHP’s Model Legislation Increases Health System Financial Transparency and Provides a First Step to Address High Hospital Costs

October 26, 2020/in Policy Connecticut, Oregon Webinars Consumer Affordability, Health System Costs, Hospital/Health System Oversight, Making the Case for Action /by NASHP Staff

Hospitals account for the largest expenditure of US health care dollars, followed by physician and clinical services, half of which are owned by a hospital or health system. To address rising health care costs, policymakers and the public need detailed financial information to understand a hospital’s assets as well as its expenses and liabilities.

The recording and accompanying slides from this webinar offer an opportunity to learn about NASHP’s recently released model legislation and reporting template directly from state leaders with expertise in hospital finances. Listen to this webinar to learn:

Why hospital and health system financial transparency is an important first step, particularly with federal financial COVID-19 relief dollars allocated to health care systems and decreased utilization of non-emergency services.

2:30-3:30 p.m. (ET) Thursday, Nov. 12, 2020

DOWNLOAD SLIDES

How NASHP’s model legislation and reporting template increases transparency.
What critical information the model provides to state policymakers.
What state entity should be tasked with oversight and review of the data received.

Moderator: Trish Riley, Executive Director, National Academy for State Health Policy

Speakers:

Nancy Kane, DBA, Adjunct Professor of Management in the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health
Jeremey Vandehy, JD, Director of the Health Policy and Analytics Division, Oregon Health Authority
Vicki Veltri, JD, LLM, Executive Director, State of Connecticut Office of Health Strategy

How Oregon Uses Medicaid Incentive Payments and Quality Measures to Improve Contraceptive Use and Timely Postpartum Care

October 12, 2020/in Policy Oregon Blogs, Featured News Home Health Equity, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health, Quality and Measurement /by Eddy Fernandez

To improve effective contraceptive use and timely postpartum care statewide, Oregon’s Medicaid program successfully used incentive payments and quality measures to increase the rates of effective contraceptive use from 35.4 to 46.8 percent between 2015 and 2018, and timely postpartum care from 61.3 to 68.2 percent between 2018 to 2019.

Oregon implemented the quality incentive measures and incentive payments made to its Coordinated Care Organizations (CCC) to improve uptake of effective contraceptive use (which have failure rates under 13 percent) and timely postpartum care to reduce unplanned pregnancies and improve health outcomes following childbirth among Medicaid enrollees.

Background

In 2010, approximately 46 percent of all pregnancies in Oregon were unintended, similar to the national average rate of 45 percent, and almost 70 percent of Oregon’s unplanned pregnancies were publicly funded. Long-acting reversible contraception (LARCs), a contraceptive method with less than 1 percent failure rates, are highly effective and have the highest continuation rates of reversible contraceptive methods, as additional adherence to an ongoing medication regimen or regular follow-up are not required. Additionally, there are cost savings associated with increased access to contraception, as unintended pregnancies in 2010 cost states more than $6 million. It remains essential for states and providers to honor individual choice when determining if a LARC or other contraceptive option is appropriate.

In 2017, Oregon’s CCOs, networks of various health care providers serving Medicaid enrollees, reported that about 50 percent of enrolled women received a postpartum care visit 21 to 56 days after delivery. The American College of Obstetrics and Gynecologists (ACOG) recommends that all postpartum women contact a maternal care provider within the first three weeks postpartum and as needed for ongoing care. According to ACOG, a comprehensive postpartum visit that includes a full assessment of physical, social, and psychological well-being, should occur no later than 12 weeks after birth.

As part of Oregon’s commitment to pay for better quality care and health outcomes, CCOs can qualify for incentive payments if they meet a pre-established state benchmark or reach their individual improvement targets. The individual target is at least a 10 percent reduction in the gap between the baseline and the benchmark. These initiatives were design to encourage CCOs to focus more on prevention and care management.

Federal Efforts to Improve Postpartum and Contraceptive Care

Improving access to postpartum care and contraception is also a priority for the Maternal and Child Health Bureau (MCHB) and the Centers for Medicare & Medicaid Services (CMS). MCHB has funded the creation of two patient safety bundles, one focusing on a comprehensive postpartum visit and the other on transitioning from maternity to well-woman care. Additionally, CMS’ Adult and Child Core Measure Sets include postpartum care and contraceptive care.

Oregon’s Reproductive Health Incentive Measure

The Effective Contraceptive Use (ECU) measure, created by the Oregon Health Authority (OHA) in 2014, focuses on women ages 15 to 50 who are not currently pregnant and who adopted or continue to use one of the most effective or moderately effective contraceptives. The OHA decided to continue using this measure when CMS formally adopted a contraceptive measure, called the CCW Measure, under the Medicaid Adult Core Set of Health Care Quality Measures.

When developing this measure, the OHA carefully considered the history and risk of reproductive coercion in the United States. The OHA also recommended CCOs use particular strategies to increase voluntary contraceptive use. Those strategies include, but are not limited to:

Removing barriers to contraception (e.g., providing contraception supplies for longer than three months);
Improving availability and uptake of LARCs by partnering with local Title X family planning clinics;
Offering clinician training, such as how to provide effective contraceptive counseling that includes discussing the efficacy and benefits of the chosen method, employing a “teach-back” method, and providing time for the client to review and sign the informed consent form for LARC procedures;
Adjusting workflows to support and implement the One Key Question initiative, which screens for pregnancy intentions; and
Creating quality improvement processes.

The OHA relied on administrative claims data to determine if CCOs qualified for incentive payments. Through claims data, the OHA was able to determine the number of CCO enrollees using intrauterine devices (IUDs), implants, contraception injections, contraceptive pills, sterilization, patches, rings, or diaphragms. The OHA also uses claims data to measure surveillance of a contraceptive method. Additionally, the ECU measure stratified enrollees by age group – adolescents ages 15 – 17 and adults 18 – 50. In order to qualify for the incentive payment, CCOs must meet benchmarks or pre-established improvement targets. Meeting the benchmarks or targets applied to all ages (15 to 50), not stratified results. In 2019, the OHA established a 53.9 percent benchmark, which was in the 90th percentile for CCOs in 2017.

Statewide performance on the ECU measure increased from 35.4 percent in 2015 to 46.8 percent in 2018. CCOs have also documented improvements among various racial and ethnic groups. In 2017, effective contraceptive use rates among Latinx was 46.8 percent compared to 37.2 percent in 2015. Effective contraceptive use rates among Black women were at 43.1 percent in 2017 compared to 35.4 percent in 2015. In the Journal of the American Medical Association report, Association of Implementing an Incentive Metric in the Oregon Medicaid Program with Effective Contraceptive Use, researchers found a significant increase in contraceptive use every year among Medicaid enrollees, compared to the control group. As of 2020, the OHA no longer uses this metric as a result of improvements in contraceptive use.

Postpartum Care Incentive Measure

Timeliness of postpartum care is a measure outlined in Oregon’s 1115 demonstration waiver and is reported as a CMS Adult Core Measure. To address decreasing timely postpartum care rates, Oregon replaced an incentive associated with timely prenatal care, which had shown drastic improvements in prior years, with one focused on improving timely postpartum care. This incentive measure pulls data from the Medicaid Management Information System (MMIS), Decision Support/Surveillance and Utilization Review System (DSSURS), and medical records to determine the percentage of live birth deliveries for which there is a subsequent, timely postpartum visit. Timely postpartum visits are defined as postpartum care on or between 21 and 56 days after delivery.

The OHA published a resource with strategies for improving timely postpartum care designed specifically for CCOs, clinics, and the community. These strategies include:

Delivery changes, such as offering patient education, peer support, and enhanced maternity care models (e.g., maternal medical homes);
Using email, texts, or apps to remind women to schedule postpartum follow-up; and
Leveraging payment strategies, such as reimbursement to support dyadic care (e.g., visits where both mother and baby receive care).

These strategies, along with incentive payments to CCOs that reach benchmarks or improvement targets, worked to address the decreasing postpartum care rates. As a result of implementing this measure, the OHA was able to increase timely postpartum care visit rates from 61.3 percent in 2018 to 68.2 percent in 2019.

In addition to increasing postpartum care visits, OHA officials indicated they plan to develop a measure to determine the quality of a postpartum visit. This measure, which may be released as soon as early 2021, will include breastfeeding evaluation and education, postpartum depression screening, postpartum glucose screening for patients with gestational diabetes, and family planning and contraception.

Conclusion

In order to improve effective contraception use and timely postpartum care, Oregon successfully leveraged Medicaid incentive payments and quality measures. These examples can inform other states’ efforts to address unplanned and unintended pregnancies and improve maternal and infant outcomes.

For more information about state Medicaid quality measurement activities for women’s health, explore NASHP’s interactive map State Medicaid Quality Measurement Activities for Women’s Health.

For more information about increasing access to LARCs under Medicaid, read a joint report by NASHP and the National Institute for Children’s Health Quality, Strategies to Increase Access to Long-Acting Reversible Contraception (LARC) in Medicaid.

Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ 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.

Stand by Me: Supporting Long-Term Services and Supports Workers

October 2, 2020/in The RAISE Act Family Caregiver Resource and Dissemination Center Oregon, Tennessee Chronic and Complex Populations, Health Coverage and Access, Health Equity, Long-Term Care, Population Health, Social Determinants of Health, State Resources, The RAISE Family Caregiver Resource and Dissemination Center, Workforce Capacity /by Wendy Fox-Grage

Direct care workers play a critical role in the success of states’ long-term services and supports (LTSS) systems, but faced with COVID-19, low wages, and few advancement opportunities, states struggle to retain this workforce. Recently, state leaders came together virtually at National Academy for State Health Policy’s annual conference to share strategies to improve recruitment and retention of these workers.

Today, personal care attendants, home health aides, and nursing assistants are on the frontlines, providing care to older adults and people with disabilities. COVID-19 has made direct care work one of the most dangerous professions, while putting an enormous strain on family caregivers and state budgets.

Even prior to the pandemic, states faced a significant direct care workforce shortage due to the low wages and limited advancement, which has contributed to high turnover. The pandemic has exposed other vulnerabilities – nearly six out of ten direct care workers are people of color and almost half live in low-income households.

Tennessee Promotes Workforce Retention

In 2013, the TennCare (Tennessee Medicaid) Long-Term Services and Supports (LTSS) division held listening sessions throughout the state and found that Medicaid enrollees’ quality of life hinged on the quality and consistency of their LTSS workers. That insight led state officials to create a value-based workforce strategy for direct care workers. Using a State Innovations Model (SIM) grant from the Centers for Medicare & Medicaid Services (CMS), the state incorporated workforce recruitment and retention into its value-based payment strategy, and worked across state agencies to implement and incentivize career and educational opportunities for direct care staff.

In consultations with national experts, the state developed a competency-based training program using evidence-based best practices in adult learning. Corresponding with CMS Direct Support Workforce Core Competencies released in 2014, the training uses an online format combined with work-based learning to provide an opportunity to acquire shorter-term credentials with clear labor market value.

Officials from TennCare worked with the Tennessee Board of Regents to award college credit and a post-secondary credential (certificate) for completion of the training. This curriculum is embedded within a variety of existing (and potential new) degree paths through the Tennessee Community Colleges and Colleges of Applied Technology. The state was also able to leverage Tennessee Promise and Tennessee Reconnect funds to defray tuition costs for adult learners, and plans to provide incremental raises to direct care staff who complete the training once the state weathers COVID-19-related budget shortfalls.

At the same time, TennCare has begun to transition its LTSS system to a value-based payment model. Staff training, retention, and job satisfaction are key measures in the state’s quality framework and tied to LTSS provider reimbursement. By aligning Medicaid payment, investments in workforce training, and the state’s higher education goals and resources, Tenncare has established a clear education and career pathway that will help it grow and retain its direct care workforce.

Oregon’s Home Care Workforce Unionized

Because of the relationship between direct care workers and quality of care, the state created the Oregon Home Care Commission, a semi-independent state commission that supports home care workers, personal support workers, and consumers/employers by:

Defining qualifications of home care and personal support workers;
Providing a statewide registry of these worker that matches individuals needing in-home care with home care workers;
Providing training opportunities; and
Serving as the “employer of record” for collective bargaining for home care and personal support workers who receive service payments that are from public funds.

The Service Employees International Union (SEIU), represents Oregon’s in-home workforce. Full-time equivalent in-home workers must earn an income above the poverty level for a family of four in Oregon. They have health benefits (for 40 hours of work per month) as well as leave time for vacation, sick time, and COVID-19. They also receive training and personal protective equipment (PPE).

The state funds Oregon Care Partners, an education resource that provides in-person and online classes to help family and professional caregivers build the knowledge and skills needed to improve the quality of life of older adults and people living with Alzheimer’s in Oregon. These classes are available to anyone living or working in Oregon and are offered free of charge. Classes include COVID-19 infection control, supporting individuals with Alzheimer’s/dementia, supporting individuals with challenging behaviors, cultural competency, and more.

Oregon’s support of its direct care workers through living wages, sick and vacation benefits, training, and a registry that matches these workers with individuals needing home care helps not only this important workforce but also care recipients and their families. This support has been an important strategy in this state’s longtime effort to successfully rebalance its LTSS system toward home and community-based services.

Looking Forward

Both Tennessee and Oregon have had to respond quickly and with enormous flexibility to the challenges presented by the pandemic, maintaining LTSS services through strategies such as provider rate increases and retainer payments, new infection control protocols, and additional protections and benefits for LTSS staff.

While cascading effects of both COVID-19 and state budgets make ongoing investments in the direct care workforce incredibly challenging, the experience of the past few months has also opened up new opportunities: Medicaid waiver flexibilities and the Coronavirus Aid, Relief, and Economic Security (CARES) Act and state funding allowed states to increase payments to stabilize and incentivize the LTSS workforce to maintain care to some of the most vulnerable populations during the pandemic. Telehealth has been transformational. Certain services, such as therapies, care management, and adult day health, moved from face-to-face to virtual encounters. Some states used additional pandemic-related money to provide childcare for essential workers.

As a result of these unprecedented changes, state officials are rethinking how LTSS is delivered, where, and by whom. The future direct care workforce will likely need additional training on managing the spread of infectious disease, delivering care through telehealth and other virtual modalities, and engaging families as critical partners on the care team. State health policymakers may also want to invest in the LTSS workforce as another opportunity to address racial equity within state-funded healthcare systems. While it is too soon to tell which of the many changes wrought by the pandemic in state LTSS systems will be sustained, one thing is certain, as noted by a state health official during the NASHP conference: “Medicaid will never look the same after COVID.”

This conference session and blog is one component of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, which is funded by The John A. Hartford Foundation in collaboration with the Administration for Community Living.

Three States’ Efforts to Use Accountable Care to Improve Oral Health Services in Medicaid

August 24, 2020/in Policy Colorado, Maine, Oregon Blogs, Featured News Home Accountable Health, Child Oral Health, CHIP, CHIP, Cost, Payment, and Delivery Reform, Health Coverage and Access, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Oral Health, Population Health, Quality and Measurement /by Neva Kaye

Recognizing that improving oral health significantly affects overall health, Medicaid agencies in Colorado, Maine, and Oregon have begun to leverage their primary care-based accountable care programs to improve the delivery of oral health care to adults and children.

Introduction

What’s an accountable care program?In an accountable care program, groups of providers (called accountable care organizations or ACOs) share responsibility for the quality of care, health outcomes, and cost for a defined population. These programs emphasize primary care, care coordination and integration, and value-based payment. Payment to an ACO and its affiliated providers depends, at least partially, on the ACO’s performance on defined metrics.

For almost a decade, state Medicaid agencies and the federal government have worked to reform the health care system to produce better quality health care at a lower cost by implementing accountable care programs. States recognize that Medicaid enrollees often have difficulty accessing oral health services, even in states whose Medicaid programs cover dental services for adults. There has also been a growing consensus that integration of primary care and oral health services would help improve oral health.

The Medicaid programs in Colorado, Maine, and Oregon cover dental services provided to both adults and children. Although results are not yet available in Maine, Colorado and Oregon’s accountable care programs have generated promising results.

Oregon’s program produced increases in the number of children receiving dental sealants on permanent molars and the number who received an oral health assessment upon entering foster care.
Colorado’s program produced an increase in the percent of Medicaid members who had at least one dental visit.
The accountable care programs in Colorado, Oregon, and Maine have also all produced savings. It is, however, not known how much of the savings was due to including dental services in the model.

Policymakers seeking to improve the delivery of oral health services will benefit from an understanding of these states approaches and outcomes. In addition, as states face significant COVID-19 pandemic-related revenue declines, most will need to find ways to contain costs. As an optional Medicaid benefit, adult dental services could be targeted for cost cutting. As policymakers face difficult choices, the experience of these three states can inform those deliberations.

Each of these states established policies that address oral health in the areas of ACO payment and performance. Beyond this shared, high-level approach, the states have little in common. There is a some overlap in the measures the states chose to assess ACO performance. Both Colorado and Oregon assess ACO performance by measuring the percent of enrollees receiving preventive dental visits and factor that metric into ACO payments. Also, both Maine and Oregon assess ACOs’ performance in their rate of topical fluoride applications, but only Maine chose to factor that performance into its ACO payment. The following explains the policies developed by each state.

Colorado’s Regional Accountable Entities

Colorado:
• Considers oral health in three performance areas;
• Factors performance on one oral health measure into ACO payment; and
• Increased the percent of Medicaid enrollees with at least one dental visit.

In Colorado, most Medicaid services are delivered to program enrollees through seven regional accountable entities (RAEs). RAEs support a local network of primary care medical providers (PCMPs) that deliver behavioral health services, coordinate members’ care across systems, and are accountable for the cost and quality of care delivered to Medicaid members. RAEs are paid through a combination of per member per month (PMPM) payments, capitation (for behavioral health services), and incentive payments. PCMPs receive fee-for-service payments from the Medicaid agency and administrative and incentive payments from the RAEs.) The total administrative PMPM available to the RAEs is $15.50. RAEs receive $11.50 of the administrative PMPM as a monthly payment and Colorado Medicaid withholds the remaining $4 to fund Key Performance Indicator (KPI) payments. There are seven KPI metrics, including one oral health measure. The Medicaid agency assigns each KPI a specific PMPM amount and, if a RAE produces sufficient improvement in the measure, it receives a payment based on the PMPM amount assigned to the measure. KPI payments are calculated and distributed each quarter. Unearned incentive payments are used to fund a challenge pool that is also distributed to the RAEs based on performance.

Although dental health services in Colorado are delivered under a separate contract and not through the RAEs, Colorado’s RAE contract requires RAEs to consider oral health services in several areas of operation. Examples include:

Care coordination: RAEs must establish a relationship and communications with the Medicaid agency’s dental contractor to foster the RAEs’ members’ access to oral health services.
ACO payment: One of the seven KPI measures is an oral health measure called “dental visit,” which is defined as the “percent of members who received professional dental services.” This measure is worth up to $0.571 PMPM.
Provider payment: Each RAE is required to share incentive payments with providers that are in its “health neighborhood,” which consists of the providers (including dentists) and facilities that work with an enrollee’s PCMP to meet all of the person’s health needs.

During the RAEs’ first year of operation, they increased the percent of Medicaid enrollees who had at least one dental visit from 33.83 percent during the baseline period (from July 1, 2017 to June 30, 2018) to 37.63 percent for the 12-month period from July 1, 2018 to June 30, 2019.

Oregon’s Coordinated Care Organizations

Oregon:
• Considers oral health in six performance areas;
• Factors performance on four oral health measures into its ACO payments;
• Increased the percent of children receiving dental sealants; and
• Increased the percent of children entering foster care system who received an oral health assessment.

In Oregon, almost all Medicaid services are delivered through regional coordinated care organizations (CCOs). Oregon’s CCOs are community-governed organizations that bring together physical, behavioral, and oral health providers to deliver coordinated physical, behavioral, and oral health care for their members. CCOs are funded through a global budget. CCOs also earn retroactive quality pool payments based on their performance on selected “incentive metrics” during the contract year. In 2018, the quality pool was $188 million, which represented 4.25 percent of the total amount all CCOs were paid in 2018. The slate of quality measures, which are selected by the Metrics and Scoring Committee, changes each year. In 2019, there were 19 incentive measures and in 2020 there are 13. CCOs must pay for all Medicaid-covered services (including dental services) provided to CCO members. CCOs may also use their funding to test new models of care and to provide services in addition to those covered by Medicaid. Finally, Oregon encourages CCOs to distribute quality pool payments to network providers, including oral health providers. Oregon’s CCO contract requires CCOs to consider oral health services in several areas of operation. Examples include:

Network and covered services: CCOs must contract with sufficient dental providers to deliver oral health services to their Medicaid enrollees, including those who may have difficulty accessing dental care, such as children in foster care or adults in nursing facilities.
Care coordination: CCOs must coordinate physical and dental providers to ensure that enrollees who need to receive dental care in an outpatient hospital or ambulatory surgical center can do so.
Quality: Each CCO must develop a transformation and quality strategy (TQS) that addresses oral health integration as one strategy for improving quality. CCOs must regularly report progress on implementing the TQS.
Population health: Each CCO must develop a community health improvement plan that addresses oral health needs, among others. CCOs may also invest in health-related services, which are cost-effective, evidence-based non-covered services or community benefit initiatives that improve “care delivery and overall member and community health and well-being.” One CCO invested in a community-based dental program which, among other things, delivered oral health supplies to participants’ homes.
ACO payment: Four of the incentive measures used in either 2019 or 2020 measured oral health performance:
- Assessments for children entering foster care including oral health assessment;
- Dental sealants on permanent molars for children;
- Oral evaluation for adults with diabetes; and
- Preventive dental visits for children ages 1-5 and 6-14. (Oregon also measured the number of children and adults who had access to dental services and received any dental service and topical fluoride varnish use, but does not include these measures in its pay-for-performance program.)
Provider payment: CCOs must have value-based payment (VBP) for oral health in place by 2024. The state has committed to helping both CCOs and oral health providers develop and implement the VBP models.

Since Oregon began incentivizing performance on these measures, CCOs have increased the percent of children receiving dental sealants on permanent molars from 18.5 in 2015 to 24.8 in 2018. The increase was greatest for younger children — that number increased from 20.7 to 27.8 percent for children ages 6 to 9. The CCOs also increased the percent of children who received an oral health assessment (along with physical and behavioral health assessments) upon entering foster care from 27.9 in 2014 to 86.7 in 2018. (The other measures of oral health performance described above had not been in place long enough to produce documented trends.) An evaluation of Oregon’s program found that CCOs were more likely to produce improvements in measures that were part of the incentive program than those that were not—emphasizing the importance of tying ACO payment to performance.

Maine’s Accountable Community Partnerships

Maine:
• Considers oral health in two performance areas, and
• At ACO’s option, will factor performance on one oral health measure into ACO payments.
• No performance data has been published to date.

In Maine, primary care practices can voluntarily form networks, identify a lead entity to administer the network, and contract with the Medicaid agency to become Medicaid ACOs, called Accountable Community Partnerships (ACs). Between Aug. 1, 2018 and July 31, 2019, the four ACs that were participating in the program included 90 practices that served 59,443 patients. Primary care providers that participate in an AC receive fee-for-service payment for the services they provide and those that qualify as a health home or behavioral health home receive PMPM care management fees.

ACs are paid through one of two payment models.

Model 1 is open to ACs that serve at least 1,000 patients and features shared savings but not losses.
Model 2 is only open to ACs that serve more than 2,000 members, and it features both shared savings and losses.

Model 2 pays ACs a greater share of the savings they produce than does Model 1. Savings and losses are calculated by comparing the total cost of care (TCOC) for providing a defined package of services to the members assigned to the AC with their projected TCOC absent the AC. Each AC decides whether it will include dental services in the defined package of services. If actual TCOC is less than projected, the difference is savings – if actual TCOC is more than projected, the difference is a loss. In order to receive any portion of the savings it produces, an AC must achieve a specified level of performance on a set of quality measures (fifteen core measures, four elective measures, and one monitoring-only measure). Then, the exact portion of the savings an AC receives depends on its performance on these same measures. Maine’s AC contract requires ACs that choose to include dental services in their TCOC calculations to consider oral health services in two areas of operation:

Network and covered services: ACs that are responsible for oral health services must contract with a sufficient number of dentists to serve their assigned population.
ACO payment: The cost of dental services is factored into shared savings and loss calculation of those ACs that choose to be responsible for dental services. Also, effective August 2018, Maine began allowing ACs to choose to factor an oral health measure into the calculation of their shared savings/losses calculation: “primary caries prevention intervention as offered by primary care providers, Including dentists.” This measure is defined as, “Percentage of members ages 1-20, who receive a fluoride varnish application during the measurement period.”

Although no AC has yet chosen to factor the cost of dental services into its TCOC calculations, one did choose to use the oral health measure in the 2018-2019 performance year.

Conclusion

Although accountable care programs focus on primary care, Colorado, Maine, and Oregon are all leveraging these programs to improve the delivery of dental care. Although it is still too early to assess Maine’s results, Colorado’s RAEs and Oregon’s CCOs have shown improved performance on measures of oral health care performance. It is important to note that even states such as Colorado that do not deliver dental services through Medicaid ACOs can still use the ACO structure to improve oral health care. Colorado, for example, incorporated a measure of oral health access (the percent of members who received oral health services) to reinforce the contract requirement that the ACOs foster connections between primary care and oral health providers. Importantly, however, the measure was also one that the RAEs’ contracted primary care providers could impact. States that seek to improve oral health services through Medicaid ACOs should consider taking the following steps.

Measure and publicly report ACO performance on oral health measures that an ACO can impact. Even if the performance is not factored into ACO payment, knowing that its performance will become public could cause the ACO to devote resources to improve performance in that area.
Articulate oral health requirements in contractor performance standards to establish clear expectations for ACO performance in the area. Some of these performance standards will be chosen based on program structure. Others are likely to be chosen because they are areas the state would like to see improvements in and believes the ACO can produce.
Factor the cost of oral health services into ACO payments. Factoring oral health services into TCOC calculations and/or incentive payments is the most direct way to incent an ACO to change its delivery of oral health services. In addition, Oregon found that its CCOs were more likely to improve performance on incentivized measures. However, factoring oral health into payment is best done in conjunction with performance measurements and performance standards to ensure that the changes result in the desired improvements.

Acknowledgements: The author thanks state officials in Colorado, Maine, and Oregon who graciously reviewed a draft of this publication. Trish Riley, Carrie Hanlon, and Ariella Levisohn of the National Academy for State Health Policy provided helpful guidance or assistance. Finally, we thank the Health Resources and Services Administration (HRSA) officials who provided thoughtful input. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UD3OA22891, National Organizations of State and Local Officials. This information, content, or conclusions are those of the author’s 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.

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

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

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

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

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

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

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

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

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

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

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

Four State Strategies to Employ Doulas to Improve Maternal Health and Birth Outcomes in Medicaid

July 13, 2020/in Policy Indiana, Minnesota, Nebraska, Oregon Featured News Home, Reports Health Equity, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health /by Taylor Platt and Neva Kaye

Oregon CHIP Fact Sheet

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

What We’ve Learned from Early Adopters of Drug Price Transparency, and What We’ll Learn from the Next Wave

December 2, 2019/in Policy California, Maine, Nevada, Oregon, Vermont Blogs, Featured News Home Administrative Actions, Cost, Payment, and Delivery Reform, Health System Costs, Model Legislation, Newly-Enacted Laws, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck

As prescription drug price increases greatly outpace inflation and new specialty drugs priced in the millions of dollars enter the market, several states have led the way as early adopters of drug price transparency legislation and are taking the first steps to curb costs with the help of transparent drug pricing information.

Read NASHP’s new report, What Are We Learning from State Reporting on Drug Pricing?, to discover what early reports from California, Maine, Nevada, Oregon, and Vermont’s drug price transparency laws reveal.

A new National Academy for State Health Policy (NASHP) report, What Are We Learning from State Reporting on Drug Pricing?, offers a cross-state analysis of drug price transparency findings through August 2019, based on reports from California, Maine, Nevada, Oregon, and Vermont. States are:

Learning which drugs cost the most – and are the best targets for focused strategies;
Tracking the percentage of health premiums attributed to drug spending – and identifying opportunities to leverage reporting on drug spending, such as implementing spending caps; and
Beginning to capture information on net price – and profit – along the supply chain to inform fair and balanced policy approaches to ensure affordability.

Honing in on the Costliest Drugs to Take Action Where It Matters Most

States with transparency laws are identifying the drugs creating the greatest affordability challenges for both payers and consumers. State transparency laws require gathering data from a variety of sources, including through required reporting by public and private health plans (California, Oregon, Vermont), or through all-payer claims databases (Maine), or proprietary databases (Nevada), in order to report lists of:

The costliest drugs in the state based on price and utilization;
The drugs with the highest year-over-year cost growth; and
The most commonly prescribed drugs.

A cross-state analysis of these reports identified 30 drugs that appear in common across drugs reported in three of five states. Many of the drugs reported are used for the treatment of diabetes, including Humalog, Lantus Solar, Novolog, Januvia, Metformin, and Victoza. Multiple drugs for the treatment of arthritis were also identified across states: Stelara, Cosentyx, Enbrel, and Humira.

Identifying the classes of drugs – and specific drugs within those categories – that are creating the greatest affordability challenges can help states hone in on strategies to address drug costs. For example, states working to leverage their purchasing power across agencies are seeking this type of information to guide potential approaches such as bulk purchasing or establishing single preferred drug list. State officials from Nevada have credited their transparency law, initially limited to diabetes medications and since expanded to include asthma medications, with bringing payers to the table to leverage their purchasing power through Nevada’s Silver State Scripts program.

Illuminating the Link between Rising Drug and Insurance Premium Costs

Several states (California, Vermont, and Oregon) require commercial health plans subject to state regulation to submit information on the impact of prescription drug spending on premiums rates. Results shared publicly to date include a range of prescription drug spending accounting for, on average, 13 percent in California, 15.67 percent in Vermont, and up to 18 percent of premiums in Oregon. Tracking prescription drug spending, as part of rate review or other initiatives, represents an important leverage point for states to take action on drug spending. Doing so can enable, for example, monitoring and enforcement of prescription drug spending caps. Several states, including New York, Massachusetts, and Maine, have established caps for drug spending – New York and Massachusetts have the authority to negotiate supplemental rebates to meet their caps while Maine tasks its Drug Affordability Review Board with identifying strategies to meet its voluntary cap on drug spending for public plans.

Uncovering the Factors Driving Up Prices along the Drug Supply Chain

One of the questions at the heart of drug price transparency laws is: What factors are driving high price increases and high launch prices? The only way for a state to determine the actual causes of high drug prices – and the relative profit accrued by players in the supply chain – is by requiring reporting across the entire supply chain, including manufacturers, pharmacy benefit managers (PBMs), wholesalers, and health plans. In order to be meaningful, this information must shed light on the net cost of drugs – an otherwise closely guarded secret behind a black box of secret rebate negotiations between manufacturers and PBMs.

Some of the early adopter states, while laying the foundation for future transparency efforts, enacted laws with limitations in terms of their ability to shine a light on net prices or to uncover the interplay between players in the drug supply chain. California, for example, limits manufacturer reporting to information that is already in the public domain. While Nevada did require reporting of some information considered to be trade secrets, and required reporting by both manufacturers and PBMs, the lack of alignment in reporting requirements (e.g., state versus national level) makes it difficult to “follow the money” across the supply chain.

A new wave of tougher state transparency measures, including a 2019 Maine law, An Act To Further Expand Drug Price Transparency, will have the ability to shine a light on net drug prices – and profits – in order to guide fair and effective state policy solutions. The Maine law, based on NASHP’s model legislation, requires reporting by entities across the entire drug supply chain, including manufacturers, PBMs, wholesalers, and health plans.

Enforcement

In addition to establishing reporting requirements with the ability to produce meaningful, actionable data, states must also have the ability to enforce reporting their new requirements. Early efforts at collecting data from manufacturers have yielded imperfect compliance at best. California received data justifying price increase from only one-third of manufacturers required to report, and Nevada recently levied $17.4 million in fines on manufacturers for failure to report in that state. While non-reporters in Nevada face fines up to $5,000 a day, Maine’s new law increases that penalty to up to $30,000 a day.

Taking Action on What Transparency Reveals

As actionable information on net drug prices and profits across the supply chain becomes available, states will use the data to make informed, impactful policy decisions. Though state policymakers are challenged by a number of limits on their authority to regulate drug prices, and meaningful action at the federal level currently remains pending, states are advancing a number of policy options to address drug prices building on what transparency laws are revealing. One model is a state Drug Affordability Review Board (DARB) with the authority to review data on drugs deemed unaffordable, and if warranted, set an upper payment limit for that drug within the state. Transparency data is essential to DARBs and related efforts. Such approaches do not seek to prohibit profit along the supply chain, but to ensure that those profits are reasonably balanced with the need to preserve access to essential drugs by ensuring their affordability.

What Are We Learning from State Reporting on Drug Pricing?

December 2, 2019/in Policy California, Maine, Nevada, Oregon, Vermont Featured News Home, Reports Administrative Actions, Cost, Payment, and Delivery Reform, Health System Costs, Legal Resources, Model Legislation, Newly-Enacted Laws, Prescription Drug Pricing, State Rx Legislative Action /by Deborah Chollet, PhD, William Mulhern, JD and Jia Pu, MA, PhD, Mathematica

This report summarizes what states are learning from reporting required by prescription drug price transparency laws, which include reports on data submitted by health insurers, manufacturers, and pharmacy benefit managers (PBMs). The review period includes reports published by states through August 2019. The National Academy for State Health Policy’s Center for State Rx Drug Pricing, with support from Arnold Ventures, commissioned this analysis from experts affiliated with Mathematica.

Executive Summary

This report summarizes what states are learning from reporting required by prescription drug price transparency laws, including reports on data submitted by health insurers, manufacturers, and pharmacy benefit managers (PBMs). The review period includes reports published by states through August 2019.

Costliest Drugs across States

Five states — California, Nevada, Maine, Oregon and Vermont — have published reports identifying specific drugs that are high cost, for which costs are rising fastest, and/or that are most frequently prescribed. In Nevada, these drugs include only those related to the treatment of diabetes. California, Maine, Oregon, and Vermont reported up to 126 prescription drugs across therapeutic uses. These states reported many of the same drugs—including five drugs used for treatment of diabetes and four drugs used for treatment of psoriasis, psoriatic arthritis, or rheumatoid arthritis.

Impact on Premiums

California, Vermont, and Oregon have reported impacts of retail prescription drug costs on insurance premiums, averaging 13 percent in California (before accounting for manufacturer rebates, which averaged 10.1 percent of insurers’ retail drug costs) in 2017, 15.67 percent of premiums in Vermont in 2018 (before accounting for rebates), and up to 18 percent of premiums in Oregon (after accounting for rebates) in 2018.

Manufacturer and PBM Reporting

Requiring both manufacturers and PBMs to report allows states to track drug pricing along the supply chain. As of August 2019, only Nevada had publicly reported information about manufacturer and PBM costs, focused on essential diabetes drugs. Nevada’s report indicates that:

Production costs accounted for 29 percent of manufacturers’ estimated average revenue in 2018 for essential diabetes drugs after rebates. Administrative costs and profit each accounted for 25 percent. On average, manufacturers earned $42 in profits for every $100 spent on production and administrative cost for these drugs.
Financial assistance to consumers accounted for 14 percent of the manufacturers’ estimated total revenues after rebates, although most manufacturers reported offering no financial assistance.
Most of the rebates that PBMs in Nevada negotiated nationally for essential diabetes drugs were on behalf of private insurers and self-insured employer plans. PBMs retained 6.6 percent of all rebates, whether negotiated on behalf of private third parties or Medicaid.

Early Lessons

The information these states have made public suggests some early lessons:

States share concerns about the affordability of many of the same drugs. There may be substantial value in sharing information across states with similar confidentiality protections while reducing the burden of redundant reporting to multiple states.
Understanding pricing across the entire supply chain, from the manufacturer to the consumer, is critical. Reporting that uses consistent concepts and measures can foster mutual understanding of facts among policymakers and stakeholders in a complex system.
The agency responsible for obtaining data must have the authority and resources to follow up when the data are not complete or credible, if drug transparency laws are to help states develop a fair approach to ensuring that prescription drugs are affordable.

Introduction

This report summarizes what states are learning from reporting required by prescription drug price transparency laws, including data reported by health insurers, manufacturers, and pharmacy benefit managers (PBMs). Since 2017, nine states have enacted drug price transparency legislation that requires such reporting.[1]

Five of these states — California, Nevada, Maine, Oregon, and Vermont — have published reports identifying specific drugs that are high cost (defined by total spending), for which costs are rising fastest (defined as year over year increase), and/or that are most frequently prescribed (so represent high consumer exposure).[2] In Nevada, these drugs include only those related to treatment of diabetes. California, Maine, Oregon, and Vermont included prescription drugs across all therapeutic classes. In Section 1, we present the drugs of interest that these states reported and look, in particular, at the 30 drugs of interest reported by at least three of these states.

In Section 2, we describe the impact of drug prices on health insurance premiums, as reported by three states, California, Oregon, and Vermont. These states have published the dollar amounts and/or the percentage of premiums attributed to retail prescription drugs — in California and Vermont, before manufacturer and other rebates and price discounts to insurers; and in Oregon, after rebates and price discounts.

In Section 3, we describe what Nevada is learning from the reporting required of manufacturers and PBMs. Currently, eight states have enacted laws requiring PBMs to report rebate amounts either for specific drugs or in the aggregate. These laws have taken effect in four states (Connecticut, Nevada, Texas, and Washington) as part of each state’s drug pricing transparency effort, but as of August 2019, only Nevada (for specified essential diabetes drugs) had made summary information public.

Reporting of High-Cost, High Cost-Growth, and Most Prescribed Drugs

California, Maine, Nevada, Oregon, and Vermont have reported drugs that account for high total cost or high cost growth, or because they are frequently prescribed, represent high consumer exposure. Maine derived its lists from analysis of the state’s all-payer claims database (APCD) system; California and Oregon relied on insurer reporting under special statutory authority; and Vermont relied on both insurer and Medicaid reporting. Nevada derived it list of drugs from analysis of a purchased database.

Table 1 lists the number of unique drug names reported in each state. California and Vermont reported the most extensive list of drugs: each reported on more than 120 unique drug names; Nevada, Maine, and Oregon each reported on approximately 50 unique drug names.

Table 1. Number of drugs listed in state public reports, by state

Reporting state	Reference period	Number of unique drug names reported*
CA	CY2017	126
ME	FY2018	51
NV	CY2018	53
OR	CY2018	56
VT	CY2018	121

*The number of unique drugs was developed by merging separate lists of drugs, if the state reported separate lists by reason for reporting and/or by insurer.

Source: Mathematica analysis of data reported in these reports: California Department of Managed Health Care (2018); Maine Health Data Organization (2018); Nevada Department of Health and Human Services (2018b); Oregon Department of Consumer and Business Services (2019); and State of Vermont Green Mountain Care Board (2019). See full references at the end of this report.

We matched drugs reported across these states by National Drug Code (NDC) and identified 128 unique NDCs that at least two states selected in common (shown in Appendix 1). The 30 drugs that at least three states selected in common are shown in Table 2.

These 30 drugs span multiple therapeutic classes, but several have similar therapeutic uses. Eight of the drugs are used for treatment of diabetes myelitis — including five drugs, Lantus Solostar, Novolog, Januvia, Metformin, and Victoza, which four of the five states reported in common.

At least three of the four states that did not focus only on essential diabetes drugs — California, Maine, Oregon, and Vermont — selected in common a number of additional drugs that clustered around treatment for asthma (Fluticasone Prop, Ventolin, Proair, and Symbicort); depression (Bupropion Hcl and Sertraline); hepatitis C (Harvoni and Epclusa); multiple sclerosis (Copaxone and Tecfidera); psoriasis, psoriatic arthritis, and/or rheumatoid arthritis (Stelara, Cosentyx, Enbrel, Humira Syringe, and Humira Pen); and a range of cardiovascular concerns (Eliquis, Xarelto, Hydrochlorothiazide, Atorvastatin).

Table 2. Drugs reported by three or more states, 2017-2018 (in alphabetic order of primary therapeutic use)

NDC	Drug name	States	Therapeutic class	Primary therapeutic use	Reasons for reporting
00054327099	Fluticasone Prop	CA, ME, VT	Respiratory tract agents	Treatment of allergic and non-allergic nasal symptoms; long term management of asthma, COPD	Most frequently prescribed (CA, ME, VT)
00173068220	Ventolin	CA, ME, OR, VT	Autonomic drugs; respiratory tract agents	Treatment of asthma, acute bronchitis	Most costly (CA); highest cost increase (CA); most frequently prescribed (CA, ME, OR, VT)
59310057922	Proair	CA, ME, OR, VT	Beta-Adrenergic agents	Treatment of asthma, acute bronchitis	Most frequently prescribed (CA, ME, OR, VT)
00186037020	Symbicort	CA, ME, VT	Antiasthmatic and bronchodilator agents	Treatment of asthma, chronic obstructive pulmonary disease (COPD)	Most frequently prescribed (ME); most costly (ME, CA); highest price (VT)
00003089421	Eliquis	CA, ME, OR	Blood formation, coagulation, and thrombosis agents	Prevention of blood clots/stroke in people with atrial fibrillation.	Most frequently prescribed (ME); highest price increase (CA, ME); most costly (CA, ME)
50458057930	Xarelto	CA, ME, VT	Anticoagulants, coumarin type	Treatment/prevention of blood clots	Most costly (CA, ME); highest cost increase (CA, ME, VT)
50111078751	Azithromycin	CA, ME, OR	Antibacterials	Treatment of bronchitis; pneumonia, sexually transmitted diseases, and infections of the ears, lungs, sinuses, skin, throat, and reproductive organs.	Most frequently prescribed (CA, ME, VT)
45963014205	Bupropion Hcl	CA, VT, OR	Antidepressants	Treatment of depression	Most frequently prescribed (VT); most costly (CA); highest price increase (CA)
68180035302	Sertraline	CA, ME, OR, VT	Antidepressants	Treatment of depression, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD), social anxiety disorder, panic disorder	Most frequently prescribed (CA, ME, OR, VT)
00002771559	Basaglar (Kwikpen)	ME, NV, OR	Hormones and synthetic substitutes	Treatment of diabetes myelitis type 1 and 2	Highest price increase (ME, NV)
00002879959	Humalog (Kwikpen)	ME, NV, OR	Hormones and synthetic substitutes	Treatment of diabetes myelitis type 1	Most costly (CA, ME); highest price increase (CA, ME, NV); most frequently prescribed (CA)
00002751001	Humalog	CA, ME, NV, OR	Hormones and synthetic substitutes	Treatment of diabetes myelitis type 1	Most costly (CA, ME, OR); most frequently prescribed (CA); highest price increase (CA, ME, NV)
00088221905	Lantus Solostar	CA, ME, NV, VT	Hormones and synthetic substitutes	Treatment of diabetes myelitis type 1 and 2	Most costly (CA, ME); highest price (VT); Most commonly prescribed (ME, VT); highest cost increase (NV)
00169633910	Novolog	NV, ME, OR, VT	Hormones and synthetic substitutes	Treatment of diabetes myelitis type 1 and 2	Most costly (ME); highest price (OR, VT); highest cost increase (NV); most frequently prescribed (CA)
00006027731	Januvia	CA, ME, NV, VT	Blood glucose regulators	Treatment of diabetes myelitis type 2	Most costly (CA, ME); highest cost increase (CA, ME, VT); most commonly prescribed (CA)
Multiple NDCs	Metformin	CA, NV, OR, VT	Blood glucose regulators	Treatment of diabetes myelitis type 2	Most frequently prescribed (CA, OR); highest cost increase (NV, VT); most costly (CA)
00169406013	Victoza	CA. ME, NV, VT	Hormones and synthetic substitutes	Treatment of diabetes myelitis type 2	Most costly (CA, ME); highest cost increase (CA, NV); most frequently prescribed (CA); highest price (VT)
61958180101	Harvoni	CA, ME, VT	Anti-infective agents	Treatment of hepatitis C	Most costly (CA, ME); highest cost increase (CA); highest price (VT)
61958220101	Epclusa	CA, ME, OR, VT	Antivirals	Treatment of hepatitis C	Most costly (CA, ME); highest price (OR, VT); highest cost increase (CA)
16729018317	Hydrochlorothiazide	CA, ME, OR, VT	Diuretics	Treatment of high blood pressure, edema, kidney stones	Most frequently prescribed (CA, ME, OR, VT)
60505258009	Atorvastatin	CA, ME, OR, VT	Antihyperlipidemics	Treatment of high cholesterol and triglyceride levels	Most frequently prescribed (CA, ME, OR, VT); most costly (CA); highest cost increase (CA)
61958200201	Descovy	CA, ME, VT	Antivirals	Treatment of HIV-1	Most costly (CA); highest cost increase (CA, ME, VT); most frequently prescribed (CA)
68546032512	Copaxone	CA, ME, OR, VT	Miscellaneous therapeutic agents	Treatment of multiple sclerosis	Most costly (CA, ME); highest cost increase (CA); highest price (OR, VT)
64406000602	Tecfidera	CA, ME, OR, VT	Psychotherapeutic and neurological agents – misc.	Treatment of multiple sclerosis	Most costly (CA, ME, OR); highest cost increase (CA); highest price (VT)
57894006103	Stelara	CA, ME, VT	Immunological agents	Treatment of plaque psoriasis, psoriatic arthritis	Most costly (CA, ME); highest cost increase (CA, ME, VT); highest price (VT); most frequently prescribed (OR)
Multiple NDCs	Cosentyx	CA, ME, OR, VT	Immunological agents	Treatment of plaque psoriasis, psoriatic arthritis, ankylosing spondylitis	Highest price (VT); most costly (CA); highest cost increase (CA, ME, OR); most frequently prescribed (OR)
58406044504	Enbrel	CA, ME, OR, VT	Miscellaneous therapeutic agents	Treatment of plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis	Most costly (ME, CA); highest cost increase (CA, OR, VT); most frequently prescribed (CA, OR); highest cost (VT)
00074379902	Humira (Syringe)	CA, ME, OR, VT	Gastrointestinal drugs; miscellaneous therapeutic agents	Treatment of rheumatoid arthritis, plaque psoriasis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis	Most costly (CA, ME, OR); highest price (VT); highest cost increase (CA, OR, VT); most frequently prescribed (CA)
00074433902	Humira (Pen)	CA, ME, OR, VT	Gastrointestinal drugs; miscellaneous therapeutic agents	Treatment of rheumatoid arthritis, plaque psoriasis, ankylosing spondylitis, Crohn’s disease, ulcerative colitis	Most costly (CA, ME, OR); highest price (VT); highest cost increase (CA, OR, VT); most frequently prescribed (CA)
69097081412	Gabapentin	CA, ME, OR, VT	Anticonvulsants	Treatment/prevention of seizures, pain	Most frequently prescribed (CA, ME, OR, VT); highest expenditure (CA)

Source: Mathematica analysis of drug website data and data reported in: California Department of Managed Health Care (2018); Maine Health Data Organization (2018); Nevada Department of Health and Human Services (2018b); Oregon Department of Consumer and Business Services (2019); and State of Vermont Green Mountain Care Board (2019).

Impact on Insurance Premiums

Three states — California, Oregon, and Vermont — have reported impacts of rising drug prices on insurance premiums. California[3] reported that insurer payments for retail prescription drugs totaled $8.7 billion in 2017, accounting for 13.1 percent of health plan premiums that year. Specialty drugs accounted for a small minority of prescriptions (1.6 percent), but more than half (51.5 percent) of all insurer spending on retail prescription drugs.

Manufacturer rebates and consumer cost sharing lessened the impact of retail prescription drugs on premiums in California, compared to what it might otherwise have been. Manufacturer rebates to insurers equaled about 10.5 percent ($915 million) of the $8.7 billion insurers spent on retail prescription drugs. Among the 25 most frequently prescribed drugs (representing 42.8 percent of total spending on retail prescription drugs), health plan enrollees paid approximately 3 percent of the cost overall — ranging from 2.9 percent of the cost of specialty drugs to 56.6 percent of the cost of generics. Enrollees paid about 8.8 percent of the cost of the 25 most costly drugs (91.2 percent of total spending on retail prescription drugs) reported by insurers.

Vermont [4] reported that prescription drugs accounted for 15.67 percent of premium rates in 2018 (before accounting for manufacturer rebates and other price concessions). Expressed as a per member per month (PMPM) amount, that averaged $81.65 PMPM in 2018. Vermont also identified the three drugs contributing the most to premiums: Humira Pen, Harvoni, and Enbrel Sureclick. Specialty drugs as a category contributed most to premium increases, compared with generic or brand name drugs.

Oregon[5] reported the impact of prescription drugs on premium rates PMPM in 2018 after accounting for manufacturer rebates or other price concessions to insurers. Insurers reported impacts that ranged from a low of 2.5 percent of premiums ($13 PMPM, or about $154 per member annually, for one insurer’s small-group plans) to 18 percent of premiums (about $85 PMPM, or more than or $1,000 per member annually, for two insurers’ small group plans, respectively. At the median, prescription drugs accounted for 11.9 percent of the premiums — nearly $53 PMPM in 2018, or about $635 annually.

Manufacturer and PBM Reporting

At present, five states — Nevada, Connecticut, Maine, Texas, and Washington — have enacted laws that require both manufacturers and PBMs to report annually. Manufacturers are required to report information on specified drugs. PBMs are required to report information about the rebates they have obtained from manufacturers — either in the aggregate (for all drugs) or for specified drugs. Requiring both manufacturers and PBMs to report offers the potential for states to track pricing along the supply chain for drugs of interest, if the state aligns the level of information that each must report.

The drug cost transparency reporting requirements in these states are shown in Table 3. Washington will require PBMs to report information for each covered drug—a provision that will enable the Washington Health Care Authority to track prices across the supply chain for each drug.[6] Nevada requests PBM reporting on essential diabetes drugs (collectively), as specifically identified by the Nevada Department of Health and Human Services. Connecticut and Texas will require PBMs to report aggregate rebates obtained across all drugs from pharmaceutical manufacturers. In Maine, the Maine Health Data Organization will adopt rules specifying the data elements to be reported.

Table 3. States that require reporting by both manufacturers and PBMs^*

State	Manufacturers must report:**	PBMs must report:
Connecticut	· Total company level research and development costs for the most recent year	· The aggregate dollar amount for all rebates concerning drug formularies that PBM collected from pharmaceutical manufacturers, Including those that manufactured outpatient prescription drugs covered by the health carriers and are attributable to patient utilization of such drugs under the health care plan · The aggregate dollar amount of all rebates excluding rebates received by health carriers
Nevada	· Total administrative expenditures (including marketing and advertising costs) · Profit earned and percentage of total profit attributable to the drug · Total amount of financial assistance provided through patient assistance · Cost associated with coupons · Wholesale acquisition cost · History of any increase over the 5 years including percentage increase, date of increase, and explanation · Aggregate amount of all rebates provided to PBM’s	· Total (aggregate) amount of rebates negotiated with manufacturers during the previous year · Total amount of rebates retained by the PBM · Total amount of rebates negotiated for purchases of drugs for use by Medicare and Medicaid recipients, and persons covered by third parties that are or are not governmental entities
Texas	· Total company level research and development costs for the previous calendar year	· Aggregated rebates, fees, price concessions, and other payments from manufacturers · Aggregated dollar amount of rebates, fees, price concessions from manufacturers that were (a) passed to insurers, (b) passed to enrollees at point of sale; and (c) retained by the PBM
Washington	· Annual manufacturing costs · Annual marketing and advertising costs · Total research and development costs · Total costs of clinical trials and regulation · Total costs for acquisition of the drug · Total financial assistance given by the manufacturer through assistance programs, rebates, and coupons	· All discounts (total dollar amount and percentage discount) and all rebates received from manufacturers for each drug on the PBM’s formularies · Total dollar amount of discounts and rebates that are retained by the PBM for each drug · Actual total reimbursement amounts for each drug the PBM pays retail pharmacies after all fees · Negotiated price health plan pays PBM for each drug · Amount, terms, and conditions relating to copayments, reimbursement policies, etc. · Disclosure of any ownership interest the PBM has in a pharmacy or health plan with which it conducts business

Sources: Connecticut HB 5384/Public Act 18-41(2018); Nevada Department of Health and Human Services (2018a); Texas HB 2536 (2019); and Washington HB 1224, Chapter 334 (2019).

^*Maine also requires reporting from manufacturers and PBMs. The Maine Health Data Organization will adopt rules specifying the data elements to be reported.

^** In addition to the items indicated, each state requires manufacturers to report reasons for price increases, if any.

As of August 2019, Nevada was the only state that had publicly reported information about manufacturer costs and the role of PBMs in the final cost of drugs to consumers that are privately insured or enrolled in Medicare or Medicare.[7] Together with manufacturer reporting, reporting by PBMs offers a reasonably complete (if aggregated) picture of factors that contribute to essential diabetes drug costs in Nevada.

Nevada asks both manufacturers and PBMs to report pricing information for essential diabetes drugs in the aggregate and, in general, at the national level. Manufacturers report only one item specific to Nevada: rebates paid to PBMs for essential diabetes drugs in Nevada.

A summary of the information reported by manufacturers and PBMs, as shown in Nevada’s public report, is shown in Table 4. Because Nevada reported PBM-negotiated rebates for essential diabetes drugs ($1.9 billion) at the aggregate national level and manufacturer rebates only in Nevada and as the average aggregated across manufacturers, they cannot be compared. Such discrepancies make it impossible to track the supply chain for these drugs nationally or in Nevada. Nevertheless, some insights can be drawn within the information reported by manufacturers and PBMs, respectively.

Table 4. Summary of data reported by manufacturers and PBMs in Nevada for essential diabetes drugs

	Average amount per manufacturer (simple averages)	Percent of estimated average manufacturer revenue after rebates
*Manufacturer-reported data for essential diabetes drugs*
Estimated total revenue after rebates (national)^*	$204,353,658	100.0 percent
Production cost	$58,934,388	28.8 percent
Administrative expenses	$65,548,748	32.1 percent
Profit	$51,979,630	25.4 percent
Cost of consumer financial assistance	$27,890,892	13.6 percent
Total provided through any patient prescription assistance program	$12,874,326	6.3 percent
Consumer coupons and consumer copayment assistance programs	$14,036,828	6.9 percent
Manufacturer cost of redeeming coupons and use of consumer copayment assistance programs	$979,738	0.5 percent
Aggregate rebates to PBMs in Nevada	$3,039,646	1.5 percent
	Total amount (all PBMs)	Percent of PBMs’ total negotiated rebates
*PBM-reported data for essential diabetes drugs (Nevada only):*
Total rebates negotiated with manufacturers	$1,922,857,158	100.0 percent
Total rebates negotiated for persons covered by
Medicaid	$31,648,939	1.6 percent
3rd party governmental entities, not Medicare or Medicaid	$597,759,023	31.1 percent
3rd parties that are not governmental entities (potentially including self-insured employer plans)	$1,293,449,196	67.3 percent
Total rebates retained by the PBM	$126,754,864	6.6 percent

Source: S. Jones, et al. (2019), Tables 4, 5 and 6.

*Calculated as the sum of all shown manufacturer-reported amounts excluding aggregate rebates to PBMs in Nevada.

Manufacturer cost, profit, and consumer assistance

In 2018, average manufacturer costs and profits for essential diabetes drugs, reported at the national level, totaled nearly $204.4 million (Figure 1). Drug production costs accounted for just 29 percent of the total ($58.9 million).

Figure 1. Reported profits and production and administrative costs for essential diabetes drugs (Nevada)

Source: S. Jones, et al. (2019), Tables 4 and 5.

Manufacturers’ administrative expenditures, which may include executive compensation, accounting and legal fees, marketing, advertising, and other administrative expenses as each manufacturer deems reasonable, accounted for $65.5 million. This amount exceeded their reported average production costs (although the Nevada report indicates multiple drug manufacturers reported $0 for total administrative expenditures, and likely included all their costs for manufacturing the drug in the drug production costs).

Manufacturers reported average profits (nearly $52.0 million) — equal to 25.4 percent of the sum of production cost, administrative cost, consumer assistance, and profit — or 41.8 percent of total production and administrative cost. That is, aggregated across reporting manufacturers, manufacturers of essential diabetes drugs earned $42 in profits for every $100 they spent on production and administrative cost.[8]

Nationally, financial assistance to consumers accounted for an estimated 13.6 percent ($27.9 million) of manufacturers’ estimated average total revenues after rebates for essential diabetes drugs. This financial assistance included patient prescription programs, coupons, or copayment assistance programs. However, more than half of the reporting manufacturers indicated that they provided no financial assistance through patient prescription assistance programs (58 percent), and also provided no rebates to PBMs or pharmacies (55 percent). By inference, the average dollar amount of financial assistance among manufacturers that provided any financial assistance (presumably the larger manufacturers) was more than twice the average across all manufacturers (including those that provided none).

PBM negotiated and retained rebates

PBMs reported negotiating more than $1.9 billion in rebates for essential diabetes drugs for Nevadans (Table 4). Nearly this entire amount was negotiated on behalf of private third parties—predominantly private insurers and self-insured employer plans ($1.3 billion) or other nongovernmental third parties ($598 million). PBMs reported retaining 6.6 percent of all rebates that they negotiated, whether on behalf of private third parties or Medicaid.

Differences in how Nevada’s public report summarized the data obtained from manufacturers and PBMs make it impossible to develop a picture of the supply chain from the information offered—although it seems likely that Nevada has the information necessary to do this. Nevada’s report demonstrates the crucial importance of requiring manufacturers and PBMs to report information at the same level of aggregation—at the state level or nationally (but not either/or), and for the same individual drugs or narrowly specified groups of drugs—in order to build a coherent picture of the factors that contribute to high consumer cost.

Summary

This report summarizes information that five states—California, Maine, Nevada, Oregon, and Vermont—have obtained from insurers, manufacturers, and/or PBMs to achieve greater drug price transparency. Each of these states is in a relatively early stage of obtaining and understanding their data. Nevertheless, the information they have made public suggests some early lessons for states interested in obtaining meaningful reporting for drug price transparency.

States share concerns regarding the affordability of many of the same drugs. We identified 120 drugs that concern at least two of the five states—due to high cost, fast-rising cost, and/or the frequency with which the drug is prescribed. The large number of drugs that are of concern across states indicates that there might be substantial value in sharing information across states. State efforts such as Maryland’s recently enacted Drug Affordability Review Board might initially focus on many of these same drugs.[9] States that are developing statutory authority to require manufacturer reporting for these drugs might consider explicitly authorizing data sharing with other states that have compatible confidentiality protections—or else explore other options available in current law or regulation to reduce manufacturers’ burden of redundant reporting to multiple states.
There is substantial value in understanding pricing across the entire supply chain, from the manufacturer to the consumer, for drugs that drive increases in health insurance premiums and consumer costs. States that design reporting templates using consistent and compatible concepts and measures, and report those measures publicly, can foster mutual understanding of facts among policymakers and stakeholders in a complex system. However, if rebates and other information are reported collectively for all drugs, it frustrates the ability of policymakers to understand impacts on costs for specific drugs. PBM reporting by manufacturer/product code (if not by NDC) is critical to understanding the supply chain for the specific drugs of interest to the states. Nevada’s PBM reporting requirement — for a list of specified NDCs—demonstrates that PBMs are able to report on specific drugs, not only on their aggregate business.[10]
When requiring manufacturers, PBMs, or other entities to report drug price data, it is critical that the responsible agency be given the authority and resources necessary to follow up when reported data are not complete or credible. Especially in the first years of implementation, the reporting entities may be learning how to report, and they may be reluctant to invest in getting the data right. Accurate reporting is essential for drug transparency laws to help states develop a fair approach to ensuring that prescription drugs are affordable.

References and Appendix

Arkansas

Arkansas SB 520/Act No. 994, 2019. Available at: http://www.arkleg.state.ar.us/assembly/2019/2019R/Acts/Act994.pdf. Accessed August 1, 2019.

California:

California Department of Managed Health Care. “Prescription Drug Cost Transparency Report (SB 17): Measurement Year 2017.” Sacramento, CA: Department of Managed Health Care, December 2018. Available at https://www.dmhc.ca.gov/Portals/0/Docs/DO/sb17.pdf. Accessed July 31, 2019.

California Office of Statewide Health Planning and Development. “Cost Transparency: Prescription Drugs (CTRx),” 2019. Available at https://oshpd.ca.gov/data-and-reports/cost-transparency/rx/. Accessed July 31, 2019.

Connecticut:

State of Connecticut, Substitute House Bill No. 5384/Public Act No. 18-41. Available at https://www.cga.ct.gov/2018/ACT/pa/pdf/2018PA-00041-R00HB-05384-PA.pdf. Accessed July 31, 2019.

Iowa:

Iowa SF 563, 2019. Available at: https://www.legis.iowa.gov/legislation/BillBook?ga= 88&ba=SF percent20563. Accessed August 1, 2019.

Louisiana:

Louisiana SB 283/Act No. 371, 2018. Available at: https://legiscan.com/LA/text/SB283/id/1799999/Louisiana-2018-SB283-Chaptered.pdf. Accessed August 1, 2019.

Maine:

Maine Health Data Organization. “MHDO Prescription Drug Reports,” June 2018. Available at https://mhdo.maine.gov/tableau/prescriptionReports.cshtml. Accessed July 31, 2019.

Minnesota:

Minnesota SF 278, 2019. Available at: https://www.revisor.mn.gov/bills/bill.php?b=senate&f=SF0278&ssn=0&y=2019. Accessed August 1, 2019.

Nevada:

Nevada Department of Health and Human Services, SB539 Reporting Timeline v08.10.2018, August 10, 2018a. Available at: http://dhhs.nv.gov/uploadedFiles/dhhsnvgov/content/HCPWD/SB539 percent20Drug percent20Transparency percent20Reporting percent20Timeline_v08.10.2018_website.pdf. Accessed July 31, 2019.

Nevada Department of Health and Human Services. “Essential Diabetes Drugs Price Increase Report.” Carson City, NV: Division of Public and Behavioral Health, Primary Care Office. September 2018. Available at http://dhhs.nv.gov/uploadedFiles/dhhsnvgov/content/HCPWD/09.11.2018 percent20Nevada percent20Essential percent20Diabetes percent20Drugs percent20Price percent20Increase percent20Report_Final.pdf. Accessed July 31. 2019.

Jones, S., P. Thompson, J. Tucker, H. Mitchell, T. McKnight, H. Wallace, and K. Devine. “Drug Transparency Report 2019 Essential Diabetes Drugs” Carson City, NV: Nevada Department of Health and Human Services, Division of Public and Behavioral Health, May 2019. Available at http://dhhs.nv.gov/uploadedFiles/dhhsnvgov/content/HCPWD/DHHS percent202019 percent20Drug percent20Transparency percent20Report percent205-31-2019(1).pdf. Accessed July 31, 2019.

Oregon:

Oregon Department of Consumer and Business Services. “Insurer Reports on Prescription Drugs Drug Price Transparency Program,” 2019. Available at https://dfr.oregon.gov/drugtransparency/data/Documents/insurer-reports-rx-drugs-2019.pdf. Accessed October 16, 2019.

Texas:

Texas HB 2536, 86th Legislature, 2019-2020. Available at: https://legiscan.com/TX/text/HB2536/id/2027782/Texas-2019-HB2536-Enrolled.html. Accessed July 31, 2019.

Vermont:

Office of the Vermont Attorney General. “Prescription Drug Cost Transparency-Manufacturer and Health Insurer Annual Reporting” (undated). https://ago.vermont.gov/drug-price-transparency-manufacturer-and-health-insurer-annual-reporting/. Accessed July 31, 2019.

State of Vermont Green Mountain Care Board. “Impact of Prescription Drug Costs on Health Insurance Premiums.” Montpelier, VT: State of Vermont Green Mountain Care Board, January 2019. Available at https://legislature.vermont.gov/assets/Legislative-Reports/Act-193-Report-Impact-of-Prescription-Drug-Costs-on-Health-Insurance-Premiums.pdf. Accessed July 31, 2019.

Washington:

Washington HB 1224/Chapter 334, 2019. Available at: http://lawfilesext.leg.wa.gov/biennium/2019-20/Pdf/Bills/House percent20Passed percent20Legislature/1224-S2.PL.pdf

Appendix 1: Drugs reported by two or more states: California, Maine, Nevada, Oregon, and Vermont

NDC	Drug	States	Therapy Class
00173069600	Advair (Diskus)	CA, ME	Respiratory Tract Agents
Multiple NDCs	Amlodipine Besylate	CA, OR	Antihypertensives
Multiple NDCs	Amoxicillin	CA, OR	Antibacterials
60505258009	Atorvastatin	CA, ME, OR, VT,	Antihyperlipidemics
60505257909	Atorvastatin	CA, OR, VT,	Antihyperlipidemics
50111078766	Azithromycin	CA, VT	Antibacterials
50111078751	Azithromycin	CA, ME, OR	Antibacterials
00002771559	Basaglar (Kwikpen)	ME, NV, OR	Hormones and Synthetic Substitutes
00173085910	Breo Ellipta	CA, ME	Respiratory Tract Agents
45963014205	Bupropion Hcl	CA, OR, VT,	Antidepressants
10370010150	Bupropion Hcl	CA, OR, VT,	Antidepressants
00069046903	Chantix	CA, VT	Antidotes, Deterrents, and Toxicological Agents
00069047103	Chantix	CA, VT	Antidotes, Deterrents, and Toxicological Agents
68546032512	Copaxone	CA, ME, OR, VT,	Miscellaneous Therapeutic Agents; Miscellaneous Therapeutic Agents (Platelet-Aggregation Inhibitors)
	Cosentyx	CA, ME, OR, VT,	Immunological Agents
61958200201	Descovy	CA, ME, VT	Antivirals
00024591401	Dupixent	ME, OR	Immunological Agents
00003089421	Eliquis	CA, ME, OR	Blood Formation, Coagulation, and Thrombosis Agents
58406044504	Enbrel	CA, ,ME, ,OR, VT	Miscellaneous Therapeutic Agents; Miscellaneous Therapeutic Agents (Platelet-Aggregation Inhibitors)
61958220101	Epclusa	CA, ME, OR, VT,	Antivirals
00173071920	Flovent	CA, VT	Corticosteroids
Multiple NDCs	Fluoxetine	CA, OR	Antidepressants
00054327099	Fluticasone Prop	CA, ME, VT	Respiratory Tract Agents
60505082901	Fluticasone Prop	CA, VT	Respiratory Tract Agents
69097081412	Gabapentin	CA, ME, OR, VT,	Anticonvulsants
61958190101	Genvoya	CA, OR	Antivirals
00078060715	Gilenya	CA, VT	Immunological Agents
68084011201	Glipizide ER	CA, NV	Blood Glucose Regulators
68084029521	Glipizide ER	CA, NV	Blood Glucose Regulators
68084011101	Glipizide ER	CA, NV	Blood Glucose Regulators
61958180101	Harvoni	CA, ME, VT	Anti-infective Agents
00002879959	Humalog (Kwikpen)	ME, NV, OR	Hormones and Synthetic Substitutes
00002751001	Humalog	CA, ME, OR	Hormones and Synthetic Substitutes
00074433902	Humira (Pen)	CA, ME, OR, VT,	Gastrointestinal Drugs; Miscellaneous Therapeutic Agents; Miscellaneous Therapeutic Agents (Platelet-Aggregation Inhibitors)
00074379902	Humira (Syringe)	CA, ME, OR, VT,	Gastrointestinal Drugs; Miscellaneous Therapeutic Agents; Miscellaneous Therapeutic Agents (Platelet-Aggregation Inhibitors)
00002880559	Humulin N	CA, NV	Blood Glucose Regulators
00002831501	Humulin N	CA, NV	Blood Glucose Regulators
00002831517	Humulin N	CA, NV	Blood Glucose Regulators
00002821501	Humulin R	CA, NV	Blood Glucose Regulators
00002821517	Humulin R	CA, NV	Blood Glucose Regulators
00002882427	Humulin R U-500 KwikPen	CA, NV	Blood Glucose Regulators
00002850101	Humulin R U-500	CA, NV	Blood Glucose Regulators
16729018317	Hydrochlorothiazide	CA, ME, OR, VT,	Diuretics
00406012301	Hydrocodone/Acetaminophen	ME, OR, VT,	Analgesics – Opioid
00069018921	Ibrance	CA, VT	Antineoplastics
50458014030	Invokana	CA, NV	Blood Glucose Regulators
50458014090	Invokana	CA, NV	Blood Glucose Regulators
50458014130	Invokana	CA, NV	Blood Glucose Regulators
50458014190	Invokana	CA, NV	Blood Glucose Regulators
00006057761	Janumet	CA, NV	Blood Glucose Regulators
00006057762	Janumet	CA, NV	Blood Glucose Regulators
00006057782	Janumet	CA, NV	Blood Glucose Regulators
00006057561	Janumet	CA, NV	Blood Glucose Regulators
00006057562	Janumet	CA, NV	Blood Glucose Regulators
00006057582	Janumet	CA, NV	Blood Glucose Regulators
00006027731	Januvia	CA, ME, NV, VT	Blood Glucose Regulators
00006011254	Januvia	CA, NV	Blood Glucose Regulators
00006027733	Januvia	CA, NV	Blood Glucose Regulators
00006027754	Januvia	CA, NV	Blood Glucose Regulators
00006027782	Januvia	CA, NV	Blood Glucose Regulators
00006022128	Januvia	CA, NV	Blood Glucose Regulators
00006022131	Januvia	CA, NV	Blood Glucose Regulators
00006022154	Januvia	CA, NV	Blood Glucose Regulators
00006011228	Januvia	CA, NV	Blood Glucose Regulators
00006011231	Januvia	CA, NV	Blood Glucose Regulators
00006027702	Januvia	CA, NV	Blood Glucose Regulators
00006027728	Januvia	CA, NV	Blood Glucose Regulators
00597015230	Jardiance	CA, NV	Blood Glucose Regulators
00597015237	Jardiance	CA, NV	Blood Glucose Regulators
00597015290	Jardiance	CA, NV	Blood Glucose Regulators
00597015330	Jardiance	CA, NV	Blood Glucose Regulators
00597015337	Jardiance	CA, NV	Blood Glucose Regulators
00597015390	Jardiance	CA, NV	Blood Glucose Regulators
00088222033	Lantus	ME, NV	Hormones and Synthetic Substitutes
00088221905	Lantus Solostar	CA, ME, NV, VT	Hormones and Synthetic Substitutes
00169643810	Levemir	ME, NV	Hormones and Synthetic Substitutes
00378180310	Levothyroxine Sodium	,CA, OR, VT	Hormonal Agents – Thyroid
00185060501	Lisinopril	CA, ,OR, VT	Antihypertensives
68180098103	Lisinopril	CA, ME, OR	Antihypertensives
65862020390	Losartan Potassium	CA, ,OR, VT	Antihypertensives
00071101668	Lyrica	CA, VT	Neuropathic Pain
60687014301	Metformin HCL	CA, NV	Blood Glucose Regulators
49483062350	Metformin Hcl Er	CA, VT	Blood Glucose Regulators
62037083101	Metoprolol Succinate Er	CA, ,OR, VT	Beta Blockers
Multiple NDCs	Montelukast Sodium	CA, OR	Respiratory Tract Agents, Asthma
55513019001	Neulasta	OR, VT	Blood products and modifiers (Anti-infective for chemotherapy)
00169633910	Novolog	ME, NV, OR, VT,	Hormones and Synthetic Substitutes
00052027303	Nuvaring	CA, VT	Contraceptives, Intravaginal, Systemic
61958210101	Odefsey	CA, OR	Antivirals (HIV Treatment)
55111015810	Omeprazole	ME, ,OR, VT	Gastrointestinal Drugs
00378773293	Ondansetron	CA, OR	Antiemetics
53885024510	Onetouch Ultra Test Strip	CA, VT	Blood Sugar Diagnostics
Non-matching NDCs	Orkambi	ME, VT	Respiratory Agents – Misc.
59310057922	Proair	CA, ME, OR, VT,	Beta-Adrenergic Agents
00023530105	Restasis (Multidose)	CA, ME	Eye, Ear, Nose, and Throat (EENT) Preparations
59572041028	Revlimid	CA, ME, OR	Antineoplastics
59572041000	Revlimid	CA, ME, OR	Antineoplastics
68180035302	Sertraline	CA, ME, OR, VT,	Antidepressants
69097083502	Sertraline	CA, VT, OR	Antidepressants
65862001305	Sertraline	CA, VT, OR	Antidepressants
16729000517	Simvastatin	CA, VT	Antihyperlipidemics
16714068202	Simvastatin	CA, VT	Antihyperlipidemics
16714068101	Simvastatin	CA, VT	Antihyperlipidemics
16714068201	Simvastatin	CA, VT	Antihyperlipidemics
00093715498	Simvastatin	CA, VT	Antihyperlipidemics
00093715598	Simvastatin	CA, VT	Antihyperlipidemics
16729000617	Simvastatin	CA, VT	Antihyperlipidemics
Non-matching NDCs	Spiriva (Respimat/Handihaler)	ME, VT	Autonomic Drugs; Respiratory Tract Agents
12496120803	Suboxone	ME, VT	Central Nervous System Agents; Miscellaneous Therapeutic Agents; Miscellaneous Therapeutic Agents (Platelet-Aggregation Inhibitors)
52268001201	Suprep Bowel Prep Kit	CA, OR	Gastrointestinal Agents (Colonoscopy prep)
57894006103	Stelara	CA, ME, OR, VT,	Immunological Agents
00186037020	Symbicort	CA, ME, VT	Antiasthmatic And Bronchodilator Agents
64406000602	Tecfidera	CA, ME, OR, VT,	Psychotherapeutic And Neurological Agents – Misc.
49702022813	Tivicay	CA, VT	Antivirals, Hiv-Spec, Non-Peptidic Protease Inhib
00597014030	Tradjenta	CA, NV	Blood Glucose Regulators
00597014061	Tradjenta	CA, NV	Blood Glucose Regulators
00597014090	Tradjenta	CA, NV	Blood Glucose Regulators
50111043301	Trazodone	ME, OR, VT,	Antidepressants
00169255013	Tresiba (Flextouch)	ME, NV	Hormones and Synthetic Substitutes
49702023113	Triumeq	CA, OR, VT,	Antivirals
Non-matching NDCs	Trulicity	ME, NV	Hormones and Synthetic Substitutes
61958070101	Truvada	CA, OR	HIV Treatment
61958070301	Truvada	CA, OR	HIV Treatment
00173068220	Ventolin	CA, ME, OR, VT,	Autonomic Drugs; Respiratory Tract Agents
00169406013	Victoza (3-Pak)	ME, NV, VT	Hormones and Synthetic Substitutes
50458057930	Xarelto	CA, ME, VT	Anticoagulants,Coumarin Type
54092060601	Xiidra	CA, VT	Opthalmic Agents
Non-matching NDCs	Metformin	CA, NV, OR, VT,	Blood Glucose Regulators
57894019506	Zytiga	ME, OR	Antineoplastics

Source: Mathematica analysis of data reported in: California Department of Managed Health Care (2018); Maine Health Data Organization (2018); Nevada Department of Health and Human Services (2018b); Oregon Department of Consumer and Business Services (2019); and State of Vermont Green Mountain Care Board (2019).

Notes

[1] These states are California, Connecticut, Maine, New Hampshire, Nevada, Oregon, Washington, Texas, and Vermont. See: National Academy for State Health Policy Center for State Rx Pricing, Newly Enacted Laws at https://www.oldsite.nashp.org/new-laws/, accessed August 8, 2019.

[2] See: California Office of Statewide Health Planning and Development (2018), Nevada Department of Health and Human Services (2018b), Maine Health Data Organization (2018), and State of Vermont Green Mountain Care Board (2019).

[3] See: California Department of Managed Health Care (December 2019).

[4] See: Vermont Green Mountain Care Board (January 2019).

[5] See: Oregon Department of Consumer and Business Services (2019).

[6] Washington defines a covered drug as one that “is currently on the market, is manufactured by a covered manufacturer, and has a wholesale acquisition cost of more than one hundred dollars for a course of treatment lasting less than one month or a thirty-day supply, and … the manufacturer increases the wholesale acquisition cost at least … [20] percent, including the proposed increase and the cumulative increase over one calendar year prior to the date of the proposed increase [or] [50] percent, including the proposed increase and the cumulative increase over three calendar years prior to the date of the proposed increase.” See: Washington HB 1224/Chapter 334 (2019), Section 2.

[7] A number of other states recently passed (but have not yet enacted) legislation that would require PBM reporting. Such states include Arkansas, Iowa, Louisiana, and Minnesota. These states variously would require PBM reporting of total rebates (all states); rebates retained by the PBM (Minnesota—like Nevada, Texas, and Washington); rebates the PBM did (or did not) pass through to insurers (Arkansas, Iowa, Louisiana, and Minnesota—like Connecticut and Texas); rebates passed through to enrollees at point of sale (Arkansas—like Texas); the amount paid for pharmacy services (Arkansas—like Washington); administrative fees received by the PBM (Iowa and Louisiana); and the highest, lowest, and mean aggregate retained rebate percentage (Iowa, Louisiana, and Minnesota). See: Arkansas SB 520/Act No. 994 (2019); Iowa SF 563 (2019), Louisiana SB 283/Act No. 371 (2018); and Minnesota SF 278/Session Law Chapter 39 (2019).

[8] Nevada’s report notes that the variation among manufacturers (and potentially among drugs produced by the same manufacturer) is significant: a simple unweighted average per manufacturer, then calculated across manufacturers, produced an average profit of 152 percent of the sum of production and administrative cost—that is, for every dollar spent on combined production and administrative costs, the manufacturers earned, on average, $1.52 in profit. The report states that larger manufacturers (with lower profit rates) tend to reduce the aggregate profit ratio, as calculated in Figure 1.

[9] Built on the National Academy for State Health Policy’s model legislation, Maryland’s Prescription Drug Affordability Board is an independent body with the authority to review high-cost prescription drugs and identify fair, appropriate rates for Marylanders to pay.

[10] To obtain consistent information from all reporting entities, NASHP’s model legislation and reporting templates call for reporting at the NDC level, and they align national and state-level reporting to support a coherent picture of pricing along the supply chain for each drug. See: https://www.oldsite.nashp.org/policy/prescription-drug-pricing/model-legislation/#toggle-id-1, accessed August 9, 2019.

Acknowledgements: The National Academy for State Healthy Policy’s Center for State Rx Drug Pricing, with support from Arnold Ventures, commissioned this analysis from experts affiliated with Mathematica Policy Research.