Six States Join NASHP and AcademyHealth’s Community of Practice to Boost Immunization Rates in Medicaid-Enrolled Pregnant Women and Children
The National Academy for State Health Policy (NASHP) and AcademyHealth, with support from Immunize Colorado, are facilitating a new community of practice (CoP) comprised of state health officials from six states interested in improving their immunization rates.
Funded by a US Centers for Disease Control and Prevention (CDC) cooperative agreement, the Immunization Barriers in the United States: Targeting Medicaid Partnerships program is engaging six state Medicaid agencies (LA, MI, TX, WA, WI, WY) in collaboration with their public health and immunization information system partners. Through this CoP, states are working to improve Medicaid policies and outreach to increase immunization rates among low-income children and pregnant women. The project will build on the work and lessons learned from the previous CoP of five states, which ended in late 2020.
Despite coverage of vaccines through Medicaid, immunization rates among children and pregnant women enrolled in Medicaid remain lower than those who are privately insured and have higher incomes. Disparities in vaccine coverage exist for Black women and people living in poverty. Additionally, CDC data shows a significant reduction in routine vaccines administered to children during the COVID-19 pandemic. While vaccination rates are slowly returning to pre-pandemic rates, national experts are concerned that the missed vaccine doses may have future health implications and lead to outbreaks of vaccine-preventable diseases.
Through virtual and in-person meetings over the course of the three-year project, AcademyHealth and NASHP will provide technical assistance to states, identify barriers, and share promising practices for increasing immunization rates.
States Use Appendix Ks to Provide Innovative Flexibilities for Medicaid Enrollees and Caregivers during COVID-19
During the COVID-19 pandemic, states have used the Appendix K Emergency Preparedness and Response authority to amend Medicaid 1915(c) home- and community-based services (HCBS) waivers and quickly provide more flexible services and supports to Medicaid enrollees and, indirectly, their caregivers.
The Appendix K amendment was developed to reduce states’ administrative burdens during a crisis by enabling states to rapidly modify or add services provided through Medicaid waivers. States can specify proposed effective dates and anticipated end dates for Appendix Ks, which are generally tied to the period of the public health emergency.
During the emergency period, states can temporarily modify waiver features, such as the types of services and providers included under the waiver, reporting requirements, payment rates and retainer payments, and modes of service delivery such as telehealth. States can also temporarily increase the unduplicated number of participants (Factor C) and make a host of other temporary changes. Appendix K provides flexibility without providing new funding to states, and states cannot use Appendix K to make changes not allowed under statute.
This report highlights examples of innovative modifications incorporated through Appendix K amendments by Connecticut, Georgia, Utah, and Washington to support older people, adults with physical disabilities, and their caregivers during the pandemic. Additional information about states’ use of Appendix K, including more information on other approaches taken by the four states highlighted below, can be found on NASHP’s interactive map of state Appendix K amendments. This map is part of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living.
Connecticut: Maintaining Key Services while Limiting COVID-19 Exposure
Connecticut submitted multiple Appendix K amendments for multiple home- and community-based services waivers, including the Personal Care Assistance (PCA) and Home Care Program for Elders waivers, in order to leverage federal flexibility to sustain services while maintaining social distancing for especially vulnerable older adults and people with disabilities.
Through its Appendix K amendments, Connecticut is supporting remote delivery for a range of services such as adult day programs, counseling, evaluation and assessment. The state has permitted family members to receive payment for providing certain personal care-related services in the home, added home-delivered meals to the PCA waiver, and allowed additional or non-traditional home-delivered meal providers for both waivers. These changes have allowed participants to maintain connections and receive support while reducing the risk of exposure to the virus.
Connecticut’s Department of Social Services reports positive feedback on the changes, noting that modifications have effectively supported continuity of care for waiver enrollees. For the Home Care Program for Elders and PCA waivers, other important changes in Connecticut included temporarily allowing emergency increases in individual cost limits for current enrollees, and, within the Home Care Program for Elders waiver, allowing substitution of lower- level staff in the service plan when necessary.
Georgia: Paying for Services in Temporary Living Situations
Georgia drafted multiple combined Appendix K amendments for two of its waivers, the Elderly and Disabled waiver and the Independent Care waiver. During the emergency, among other changes, Georgia now allows family caregivers in neighboring states to receive reimbursement for providing care when the Georgia Medicaid waiver beneficiary is temporarily living with and relying on care from them during the pandemic. The state also permits family caregivers or legally responsible individuals to receive payment for providing certain personal support services and out-of-home respite. Georgia allows certain specified waiver services, including respite, to be delivered in temporary living situations, including hotels and other accommodations both in and out of state.
Utah: Allowing Payment to Nontraditional Meal and Transportation Providers
Utah used a combined Appendix K amendment to make emergency changes across seven of its waivers. Among these waivers, the Aging, Physical Disabilities, and New Choices waivers cover older adults and people with physical disabilities. Among a range of changes and flexibilities, Utah’s combined Appendix K amendments expand provider types to permit service delivery by nontraditional providers and in alternate settings. For home-delivered meal services, Utah added the ability to use delivery services such as DoorDash and UberEats in a community meal option. For non-medical transportation, the state currently allows reimbursement for non-enrolled providers, such as Lyft or Uber drivers.
Utah also expanded provider types for environmental adaptations, specialized medical equipment, and assistive technology to include the use of a purchase card to buy items from nontraditional vendors on a case-by-case basis. The state now permits direct care services, respite, day supports, and supported employment to be provided in nontraditional settings, such as churches, hotels, shelters, or the home of a direct care worker for participants who are displaced from their home due to COVID-19, or when providers are unavailable due to COVID-19. Day supports may also be allowed in an enrollee’s home. Utah also temporarily increased the unduplicated number of participants by 250 for its New Choices waiver.
Washington State: Providing a Lifeline to Adult Day Centers
To support Medicaid enrollees who rely on long-term services and supports, their family caregivers, and long-term care workers, Washington State instituted multiple Appendix K amendments to multiple waivers, including three of its home- and community-based services waivers: the Residential Support, Community Options Program Entry System (COPES), and New Freedom waivers.
Noting that key HCBS providers – such as adult day centers – that rely on face-to-face contact were at risk of shutting down, the state used Appendix K amendments to implement retainer payments during the pandemic. One official noted that the state’s ability to offer these retainer payments, and to permit day support services to be delivered both remotely and outside the adult day care setting, have been critical to maintaining care and keeping adult day centers open during the pandemic. Washington also used Appendix K amendments to, among other changes, allow up to two daily home delivered meals (in COPES and New Freedom waivers), and support the cost of Personal Protective Equipment (PPE) as part of specialized medical equipment and supplies for beneficiaries (in COPES and Residential Support waivers).
What’s Next?
While these policies are temporary, understanding the impact of these changes on the cost and quality of care for Medicaid enrollees and their family caregivers will be important in determining whether some or all of these innovations should continue after the pandemic.
States may want to consider which flexibilities provide long-term value by reviewing how reimbursement to alternative providers (such as family caregivers) and in alternate settings impacts their costs, quality, utilization, and/or waiver capacity. States may also consider how or whether newly developed infrastructure, such as telehealth, alternative providers, and service delivery mechanisms, can improve care options post-pandemic. States can also apply for a Section 1115 Demonstration opportunity to evaluate how flexibilities undertaken during the COVID-19 emergency affected the provision of care for Medicaid enrollees. States can engage Medicaid enrollees and their family caregivers to better understand impact, identify other potential innovations, and to prepare for future emergencies.
The National Academy for State Health Policy will continue to update its interactive map of state Appendix K amendments to cover policy changes that emerge as a result of the ongoing pandemic.
States Work to Improve Long-Term Care in the Age of COVID-19
Nursing home residents account for at least one-third of COVID-19 deaths, and this disparity reveals numerous problems with infection control in institutional settings. As a result, many states are rethinking and restructuring their long-term services and supports (LTSS) programs.
A recent National Academy for State Health Policy (NASHP) annual conference session explored what states have learned during the current health crisis that could improve LTSS during and beyond the pandemic. State officials from Washington State, Wisconsin, and Ohio highlighted their states’ responses to the current crisis, emerging innovations, and prospects for restructuring LTSS in a post-COVID-19 era.
Maximizing the Flexibility of Home- and Community-Based Waiver Services
Washington State, home to the first nursing home to be ravaged by COVID-19 in the United States, immediately worked with federal partners to maximize the flexibility of home- and community-based waiver services following its first reported case. The state was among the first to receive approval from the Centers for Medicare & Medicaid Services (CMS) for its 1135 and 1115 Medicaid waivers, which provided enrollees with increased access to services during the COVID-19 pandemic and additional supports to LTSS workers. State officials noted that the presumptive eligibility measures incorporated into these new waivers ensured that individuals were able to access the LTSS they need without having to wait for their applications to be fully processed. This flexibility has helped minimize administrative burdens on eligibility workers as states face increased demands on their Medicaid programs.
Like Washington State, Wisconsin utilized waivers to implement much-needed flexibility within its home- and community-based services (HCBS) provided through the state’s 1915(c) Medicaid waiver. Importantly, the state expanded the ability of its HCBS agencies to provide waiver services remotely, including care coordination and day services. The state also modified service delivery for Medicaid acute primary services, allowing these to be delivered through telehealth and other technologies to comply with social distancing.
Leveraging State Resources to Prevent and Contain Outbreaks for High-Risk Individuals
To contain and prevent outbreaks, Ohio relied on the following guiding principles to support its nursing facilities throughout the pandemic:
- Leverage regional and local leadership to coordinate a unified response; and
- Provide resources to support nursing facilities, including additional health services and technical assistance. These efforts were supported by $314 million from the US Department of Health and Human Services (HHS), some of which was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, that was specifically dedicated to Ohio skilled nursing facilities (SNFs). Each SNF in Ohio with six or more certified beds was eligible to receive a fixed distribution of $50,000 plus an additional $2,500 per bed.
To coordinate a unified state COVID-19 response, Gov. Mike DeWine and leaders from a major hospital chain created three health care zones divided among the state’s large metro areas to manage hospital capacity and maintain patient level of care during an anticipated surge in hospitalization services. State officials in the three health care zones paired nursing facilities with local hospitals to manage distribution of personal protective equipment (PPE) and to ensure that staff were well-equipped to treat patients.
Additionally, the state developed the following resources to support nursing facilities, staff, and patients throughout the pandemic:
- A toolkit developed by the Ohio Department of Aging, Department of Health, Department of Developmental Disabilities, and Department of Medicaid to assist nursing facilities with assessing residents and determining their care needs during a COVID-related surge in service utilization;
- Increased testing services for nursing facility staff as mandated by a Public Health Order signed by the director of the Ohio Department of Health and conducted by the Ohio National Guard over a period of two months; and
- Congregate Care Unified Response Team (CCURT) Bridge Team, composed of staff from the Ohio Department of Health and Ohio Department of Medicaid, to assist nursing home staff with decision making in emergency situations and coordinating facility communication with relevant state agencies, the Emergency Operations Center, health care zones, and hospitals in the area.
Many of the steps taken by Ohio state officials track with the principal recommendations issued by the CMS-appointed Coronavirus Commission Report for Safety and Quality in Nursing Homes, including establishing a statewide strategy for testing in nursing homes, coordinating with state and local leadership, leveraging resources to support the nursing home workforce, and assembling a long-term care emergency response team to evaluate and guide emergency care coordination. With these strategies and systems in place, Ohio and other states now have the infrastructure to better manage infection control in institutional settings for future public health emergencies.
Post-COVID-19 Planning
While many of the policy changes highlighted here are temporary and in effect only during the pandemic, it is important to understand the impact of these changes on cost and quality of life to determine which, if any, should be retained after the pandemic. State officials from Washington State, Ohio, and Wisconsin reported they found the following flexibilities especially helpful:
- Presumptive eligibility for LTSS, so the state can initiate home- and community-based services as quickly as possible;
- Waiving plan signatures and self-attestation in favor of post-enrollment verification to ensure that enrollees receive timely supports; and
- Flexibilities for respite care for family caregivers, particularly those supporting individuals with intellectual and developmental disabilities, to reduce stress and burnout.
State officials noted it would be helpful to receive support from CMS in retaining these flexibilities. State officials also suggested that broader legislative changes to Medicaid, such as streamlining Medicaid authorities that support HCBS and making HCBS mandatory state plan services on par with nursing home care, would help reduce administrative complexity and facilitate rebalancing efforts.
Six States’ Strategies to Providing Home Health Services to Children Enrolled in Medicaid
To improve the quality of services for children and youth with special health care needs (CYSHCN) and reduce health care costs, states are implementing strategies to improve access to home health services. Of particular importance as states confront COVID-19-related budget challenges, home health services can help to avoid costly emergency department use, hospitalizations, and institutional care.
The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit mandates coverage of all medically necessary services for children under age 21 who are enrolled in Medicaid. However, states vary in their definitions of medical necessity, prior authorization processes, and approaches to home health service delivery.
Prior to National Academy for State Health Policy’s (NASHP) analysis, there was limited information available on home health services for CYSHCN, and few studies had analyzed states’ approaches to delivering these services.
In its new report, State Approaches to Providing Home Health Services to Children with Medical Complexity Enrolled in Medicaid, NASHP examines six states’ (WA, OH, IA, MD, DL, CT) strategies to support access to home health services for CYSHCN. These include addressing provider capacity, advancing the person-centered medical home model, streamlining prior authorization processes, collaborating with Title V Maternal and Child Health Services Block Grant Programs for CYSHCN, and promoting stakeholder collaboration.
Through analysis of these states’ home health service delivery systems, NASHP identified several key insights that other state health policymakers can leverage in their own systems to improve service delivery and reduce costs. A shortage of home health providers was the primary challenge that states faced in delivering these services to CYSHCN, which states have addressed through training programs and by increasing or modifying reimbursement policies.
Partnerships across agencies and families were recognized as key to developing informed strategies to improve home health services for CYSHCN. States have leveraged these partnerships, as well as implemented technologies and streamlined processes, to deliver more coordinated, cost-effective home health services.
- Prioritize efforts to address provider shortages. To address the lack of home health provider capacity, several states have focused on developing, enhancing, and raising awareness of training programs to increase the supply of home health agency staff. States have also modified their reimbursement policies, including increasing their reimbursement rates for home health providers, and proposing a structured fee schedule to streamline the reimbursement process for home health agencies. Ohio, for example, allows for reimbursement of family caregivers for providing services for children enrolled in its Medicaid waivers in an effort to increase home health service provider capacity.
- Leverage the benefits of cross-sector and stakeholder collaboration. Partnering with a variety of state agencies, including Title V CYSHCN programs, provider groups, families, and other key stakeholders helps build the infrastructure necessary to deliver comprehensive home health services to CYSHCN. Stakeholder groups in Ohio, Maryland, and Delaware were crucial to developing strategies to improve access to home health services for CYSHCN. Two of these states also referenced the importance of family engagement to inform the work of the stakeholder group. In Ohio and Iowa, Medicaid agencies, providers, and Title V CYSHCN programs have formed collaborations to improve care coordination and access to home health services for CYSHCN.
- Adjust service delivery models to increase capacity. The medical home is a primary care service delivery model that emphasizes coordinated care through a team-based approach. Connecticut and Delaware, have looked to this model to encourage providers to improve care coordination for CYSHCN, including home health services. States have also looked to streamline their prior authorization processes to reduce administrative challenges for CYSHCN to access home health services. Delaware and Iowa are implementing changes to simplify this process through a “flag” in their data system and by developing a standardized prior authorization form for all managed care plans, respectively.
Other key insights from this analysis include seeking regular feedback from families, strengthening oversight, and customizing fee-for-services and managed care approaches. States interested in improving children’s access to home health services through Medicaid may benefit from the approaches implemented by the six states highlighted in this issue brief. For a list of NASHP’s reports, blogs, and other resources related to improving care for CYSHCN, please click here.
Washington Official Details her State’s Response Plan to COVID-19 in Nursing Homes
In early March, Washington State experienced the nation’s first COVID-19 nursing home* outbreak, and the state quickly developed a response plan to address outbreaks at other nursing homes. Candace Goehring is director of Residential Care Services in Washington State’s Department of Social and Health Services (DSHS), the agency that regulates and performs complaint investigations into nursing facilities. She took time to answer questions from the National Academy for State Health Policy about the state’s COVID-19 nursing home response plan.
What COVID-19 response protocol has Washington State developed?
The first week after the first reported nursing home cases, Residential Care Services (RCS) immediately began developing a response to COVID-19 in our long-term care facilities and agencies. We began working collaboratively with local health jurisdictions, the state Department of Health (DOH), and state Incident Commands to mobilize resources to facilities impacted by COVID-19.
Our RCS centralized intake unit established a nightly virus report that is distributed to our regions and shared with key partners in other DSHS divisions and the DOH. This alerts them to facilities with COVID-19-positive or suspected cases where the state is providing services to Medicaid beneficiaries as well as alerting the public health system. In alignment with direction from the Centers for Medicare & Medicaid Services (CMS), RCS has reprioritized our regulatory responses. We are responding to all COVID-19 reports with immediate investigations, immediate jeopardy intakes for abuse and neglect allegations, and on-site infection control focused inspections and surveys.
DSHS has been able to secure adequate supplies of personal protective equipment (PPE) to allow our regulatory staff to do on-site inspections and investigations at nearly 2,000 facilities in the past six-weeks and will continue. DOH has also provided support to our long-term care (LTC) facilities by deploying infection preventionist nurses to facilities to support local health jurisdictions when needed.
Finally, CMS and Washington State have issued multiple waivers that have enhanced the availability of alternate care locations, increased access to caregivers available to work, and allowed the transfer and discharge of residents for the purpose of care of COVID-19 residents needing discharge from the hospital. Waivers have also expanded and expedited hospital discharge and options for patients needing long-term care residential care at discharge.
How does the state now respond when it gets a report of COVID-19 in a nursing home?
RCS responds within 48 hours with an on-site visit to the nursing home reporting COVID-19. A complaint investigator completes an investigation following CMS critical pathways and if needed uses the CMS Focused Infection Control Assessment tool. This tool is also provided to nursing homes for them to complete a self-assessment of their infection control practices and pandemic emergency response systems. Our primary purpose for these inspections and investigations is to identify areas of care needing consultation and technical assistance, and when necessary due to harm or imminent risk of harm is a facility cited. RCS will evaluate need for PPE, testing and cohorting and make referrals to DOH and local health jurisdictions as needed for additional consultation and testing recommendations. As needed, RCS will plan for revisits to determine facility compliance with standard infection control practices to reduce the transmission of COVID-19 to residents and staff.
When you receive a report, do you automatically test ALL residents and staff for COVID-19 at a facility to identify those who are asymptomatic yet capable of transmitting infection?
The DOH and local health jurisdictions have established COVID-19 testing standards. Nursing homes are working with their medical directors and local and state health authorities to determine testing of residents.
[Editor’s note: Testing protocols in nursing homes vary from state to state, depending greatly on their access to test kits. Maine, for example, currently tests all nursing home residents and staff only after there are three confirmed COVID-19 cases in a facility. State officials expect these standards to evolve as test kits become more available, especially in rural states.]
Any lessons learned that you’d like to share with states?
I think the measures our state took to:
- Rapidly reduce the number of visitors going into facilities;
- Approve waivers through the governor’s proclamations;
- Develop a specialized Long-Term Care Incident Command; and
- Quickly mobilize and support regulatory and public health staff with resources to go on-site to support a facility were all important in helping us to slow the spread of COVID 19.
There has also been great value in partnering with state agencies and local jurisdictions for a combined effort to support our most vulnerable residents.
*Note: A reported 27 people died at the Life Care Center in Kirkland from the COVID-19 outbreak since early March. The facility now faces a $600,000 fine and other sanctions after federal and state inspectors found a range of problems in how the facility handled the outbreak. Federal officials report Life Care had failed to:
- Notify state officials about the increasing rate of respiratory infections among residents;
- Rapidly identify and manage ill residents; and
- Have a backup plan after the facility’s primary clinician fell ill.
CMS said the urgent issues have since been resolved, but that Life Care also needs to demonstrate compliance on other issues, including record-keeping and its handling of safety and quality strategies.
Hospital Transparency: Lessons from 12 States’ Hospital Financial Reporting Laws
States’ hospital financial reporting laws, often referred to as “hospital transparency,” are diverse and typically seek to provide information to the public rather than to inform state health system cost-containment policies. But to address and stem rising health costs, states need specific information from hospitals and providers. States’ laws offer important lessons for policymakers who want to change reporting laws or develop new hospital financial transparency requirements.
The National Academy for State Health Policy (NASHP) analyzed 12 state hospital transparency laws to better understand the current landscape of states’ reporting requirements. This slideshow breaks the information into charts to highlight the 12 states laws in more detail. NASHP’s analysis shows that state requirements vary not only in purpose, but also in identifying:
- What type of hospital must report;
- What information must be disclosed;
- Which state agency or entity collects the data; and
- What penalties are imposed for noncompliance.
Most states require financial reports from acute-care hospitals – those that provide inpatient medical care and services for surgery and treat acute medical conditions or injuries. According to the 12-state analysis, only a few states require five or more types of facilities to submit financial transparency reports, which shows the wide range of states’ reporting requirements. For example, Georgia requires only nonprofit, acute-care hospitals to report while Florida requires acute, non-acute, and psychiatric hospitals, nursing homes, and hospice and intermediate care facilities to report financial data. Whether a state requires one facility type or multiple types to report financial data affects policymakers’ ability to understand the financial state of the entire health care system. Collecting information from acute-care facilities is important but provides only a partial picture of a state’s health care system.
The type of data states collect varies, with many states requiring hospitals to report some combination of audited financial statements, Medicare cost reports, and Internal Revenue Services tax Form 990 filings. Others, such as Missouri, do not require any “standard” reports that hospitals develop as a routine part of their business. Instead, Missouri, determines its own hospital financial reporting requirements through statute and agency rule making.
Given these varied approaches, what data elements should states be collecting? NASHP is currently analyzing data collected by the 12 states in the comparison chart. NASHP’s goal is to determine which required data elements yield the best information to support cost containment initiatives and what data is missing as policymakers seek to understand specific cost drivers within their health systems. NASHP is currently developing a reporting tool that states can use to ensure they are receiving meaningful and potentially actionable information from health care systems.
Beyond the data elements required, reporting style varies from state to state. Some states have their own accounting manuals to collect hospital financial data in a uniform manner across facilities (CA, FL, MD, MA and WA). Others don’t, which can result in inconsistencies across different facilities reporting information within a single state. By requiring facilities to adhere to specific accounting principles or follow a reporting manual applied statewide, policymakers are better able to analyze data and learn about the state’s health care system as a whole, rather than using a hospital-by-hospital lens.
In many states, the responsibility for hospital financial data collection is spread across different offices or agencies and there may be varying levels of collaboration across these collecting entities. The agency or office responsible for collecting data can affect whether reporting and analysis is focused on cost containment goals or more targeted objectives. For example, some states require nursing homes to report data to an office of aging where the focus is on quality of care and overall expenditures. While ensuring targeted objectives like quality of care is critical, identifying cost trend data reported by nursing homes could be missed if the agency responsible for its collection is not looking for that information.
Additionally, some states place data collection in an office focused on general health care data and financial analysis, while others place it in offices that are also tasked with certificate of need processes or facility licensure. These different offices will have different strengths and capacities to build on current data collection and analysis efforts. However, without a coordinating infrastructure to assess data from all reporting facilities, the goal of informing health system cost containment efforts may not be achieved.
All in all, states that have already implemented hospital financial reporting are providing critical information and lessons to NASHP as we seek inform future state financial reporting requirements and new transparency policies. Having meaningful data to better understand the health system’s cost drivers is an important foundation to build on and refine cost containment efforts.
Transforming Systems to Improve Health Upstream: Lessons from Washington’s Accountable Communities of Health
Five years ago, Washington State launched a collaborative regional Accountable Communities of Health (ACH) model to improve the health of communities across the state. These ACHs have evolved into independent organizations that are integral to the state’s health system transformation efforts. A 2019 evaluation by the Center for Community Health and Evaluation found this ACH model has largely succeeded in building robust regional coalitions to improve the health of their communities.
Washington’s ACHs take diverse approaches to improving health through projects such as:
- The Pierce County ACH’s Community HUB, which coordinates community health worker services for at-risk pregnant women throughout the county, and
- The Olympic Community of Health’s establishment of a regional opiate treatment network.
The ACH projects have aligned with the state’s broader Medicaid transformation effort, which was catalyzed through funding from a four-year State Innovation Models (SIM) test grant.
In their early stages, ACHs prioritized projects designed to improve health-related social and economic conditions. The goals of Washington’s Medicaid transformation demonstration include integrating physical and behavioral health, rewarding outcomes instead of volume in most Medicaid provider payments, addressing the needs of aging populations, and improving health equity.
“A great deal of success locally has been because of the convening role ACHs were able to play. I can’t emphasize enough how important that is in transformation.” – Washington State Medicaid Director MaryAnne Lindeblad
ACH Projects Move Transformation Forward
When Washington’s five-year Section 1115 Medicaid Transformation Project (MTP) was approved in 2017, ACHs designed regional MTP projects that sought to improve clinical care and preventive services while leveraging collaboration across clinical and community organizations to account for social determinants of health. In order to carry out these Delivery System Reform Incentive Payment (DSRIP) projects, ACHs had to build up their organizational infrastructure to the point where they could both develop project plans and distribute the funds to regional partners needed to get the projects off the ground. Given the time-limited nature of these funding sources, sustainability is emerging as a priority for ACHs.
ACHs conduct DSRIP projects on such topics as:
- Improving transitional care – when a patient moves from one health care setting to another. The Cascade Pacific Action Alliance is working to coordinate services when patients leave the hospital, in order to improve patient health and reduce preventable hospital utilization.
- Improving the integration of physical and behavioral health care. The Spokane region’s ACH, Better Health Together, is working to help patients move between the physical, behavioral, and oral health care systems to receive more integrated care. The evaluation also highlighted the work of the Cascade Pacific Action Alliance, which brings together school districts, physical health clinicians, and behavioral health providers to improve behavioral health coordination for children in the region.
- Increasing access to oral health services. North Sound ACH is working to integrate oral health and primary care in community-based settings.
While DSRIP performance accountability focuses primarily on clinical care, the state also encourages ACHs to address health equity, the social determinants of health, and the health of the whole community:
- The Greater Columbia ACH created a Community Health Fund with DSRIP dollars to address health-related needs, such as nutrition, transportation, and housing, in its region.
- The North Sound ACH requires each MTP partner to participate in an equity and Tribal learning series, and they rotate their meeting locations so that location does not bar any one partner from participating. They also begin each meeting by acknowledging the original inhabitants of the land, according to the evaluation.
- The evaluation reported that the HealthierHere ACH established a Community and Consumer Voice Committee, which developed an equity tool to “assess impact and consumer voice.”
Balancing State and Local Roles
As states develop accountable health models that tackle a variety of regional priorities, state agencies often assume the role of key convener for accountable health entities and their local or regional partners. This convening role can help regional entities learn from each other and can inform state approaches so states can balance local or regional goals with broader statewide initiatives.
Just as states convene regional entities, Washington’s ACHs are taking on a critical role in convening their own local partners and supporting efforts to align regional strategies and priorities for much of the state’s health transformation work. The state required ACHs to develop into autonomous nonprofits with the ability to allocate funds and sustain organizational infrastructure. In the process, ACHs have built trusting and collaborative relationships with their regional partners. That successful relationship-building has led to ACHs themselves emerging as key regional players, which effectively positions them to take the lead on other statewide initiatives and activities, according to the evaluation.
As ACHs take the stage regionally, state policymakers are working to balance local expertise with statewide leadership. To allow ACHs to fully capitalize on local and regional knowledge, the state built some flexibility into their structure, such as allowing the ACHs to determine who to include in their governance structures, within state guidelines.
At the same time, the state is responsible for efficiently advancing statewide goals, and certain overarching issues may require a common statewide approach. For example, efficient technology infrastructure or workforce development may call for a statewide solution rather than multiple local approaches. “Consider what would be best served by a statewide coordinated approach to reduce fragmentation, versus a regional approach,” suggested Washington State Health Care Authority Medicaid Transformation Manager Chase Napier.
Conclusion
The recent evaluation of Washington’s ACH model shows the promise of ACHs in moving the state toward health system transformation. While other states’ accountable health models seek to balance local innovation and state coordination, the recent evaluation found that Washington’s ACH model may give states a helpful roadmap for incorporating local and regional voices to improve the health of individuals and communities statewide.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
States Assert their Drug Purchasing Power to Capture Savings for Medicaid
In the face of rapidly rising prices, state Medicaid programs are asserting their prescription drug purchasing power through more active oversight of the administration of prescription drug benefits. As major drug purchasers, state Medicaid programs have leverage to lower costs without action from state legislatures. Ohio, Washington, and West Virginia have recently deployed a range of strategies to curb drug costs:
- Ohio requires Medicaid managed care plans to adopt transparent, pass-through payment models with their pharmacy benefit mangers (PBMs).
- To maximize rebate potential and reduce administrative burden, Washington State is implementing a single preferred drug list (PDL) across Medicaid fee-for-service and managed care plans.
- West Virginia carved out the prescription drug benefit from its managed care contracts and now acts as its own PBM to increase oversight of drug purchasing and reduce costs.
Below is a detailed explanation of how these three states have implemented innovative purchasing strategies for their Medicaid pharmacy purchases.
Ohio Requires a Transparent, Pass-Through PBM Payment Model
A 2018 report found that PBMs retained profits of $224 million by creating a “spread” between what Medicaid paid PBMs for pharmacy claims versus what PBMs paid pharmacies. In response, Ohio mandated that managed care plans switch to contracts with transparent, pass-through payment models with the PBMs. With a transparent, pass-through model, states can ensure PBMs do not profit off this spread-pricing practice and pass through drug discounts and rebates to managed care plans. PBMs are instead reimbursed more directly through fees. Wisconsin’s state employee health plan requires a similar, fully transparent, pass-through payment model. Through this change in contract terms, Wisconsin’s per member, per month drug costs were more than 10 percent below industry averages from 2016 to 2018.
Ohio state officials report making significant changes to managed care contracts to increase transparency, reporting, and accountability pertaining to their PBM contracts and drug payments. Through enhanced reporting from managed care plans, officials have been able to confirm the successful implementation of the pass-through model. Ohio’s 2020 budget goes a step farther, requiring all managed care plans to contract with a single PBM, which will be selected by Ohio’s Medicaid department, giving the state more authority over drug purchasing.
Washington State: Implementing a Single, Standard Medicaid PDL Across MCOs
In January 2018, the Washington Healthcare Authority implemented a single PDL – a list that indicates which drugs are “preferred” by the state and do not require prior authorization. Washington’s Medicaid program transitioned from six different PDLs across managed care organizations (MCO) to one. A single PDL provides a number of advantages, including:
- Administrative ease for providers, patients, and pharmacies;
- Rebate maximization by selecting drugs with the lowest cost or maximum rebate potential;
- Rebate transparency for more accurate cost management; and
- Fewer disruptions for patients who may switch between managed care plans.
To transition to a single PDL, Washington submitted two State Plan Amendments – one for the single PDL and one to include managed care plans in its supplemental rebate contracts through a multi-state purchasing pool for drugs on the PDL. Washington also added and amended contracts with a number of vendors to ensure the Medicaid agency and managed care plans had access to the same drug data sources to allow seamless collaboration – an important detail for ensuring care coordination. Officials met with managed care plans weekly to plan and roll out the three phases of implementation, ensuring that drugs added to the PDL were clinically appropriate and cost-effective for the state and the plans. Implementation began with 27 drug classes and is expected to be complete by April 2020 with almost 400 different drug classes included in the PDL.
West Virginia: Carving Prescription Drugs Out of Managed Care
In 2017, West Virginia Medicaid began acting as its own pharmacy benefit administrator under a fee-for-service model, after carving out prescription drug benefits from its managed care contracts. To accomplish the prescription drug carve-out, West Virginia:
- Added an additional pharmacist to its staff;
- Stress-tested its existing claims processing system;
- Increased its capacity for prior authorizations; and
- Educated the public and its help desk staff about the program change.
West Virginia’s Medicaid program now covers over 550,000 enrollees through a fee-for-service model. State officials report they are able to effectively manage the pharmacy benefit and maintain care coordination across MCOs, while obtaining savings for the state. The prescription drug carve-out led to a savings of $54.5 million in 2018. Additionally, changes to the state’s reimbursement methodology during the carve-out process led to an infusion of $122 million in dispensing fees to the state’s pharmacy community.
While West Virginia is acting as its own PBM, California is carving out the prescription drug benefit from its managed care contracts and contracting with a single PBM to leverage the state’s immense purchasing power. California will use strict contracting terms to ensure greater transparency and cost savings with the contracted PBM. Michigan is currently considering a drug carve-out and legislatures in Louisiana and Nevada prompted their Medicaid programs to explore a potential carve-out of prescription drugs from managed care.
As states strengthen their oversight of drug purchasing, the National Academy for State Health Policy (NASHP) has created and will soon release a model PBM contract for states. Informed by Ohio and Minnesota’s contracts, NASHP’s model contract is designed to help states ban spread pricing and better understand rebate arrangements with their PBMs. To learn more about other administrative actions to curb rising drug costs, read the Administrative Action section of NASHP’s Prescription Drug Pricing website.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
