Safety Net Providers and Rural Health – The National Academy for State Health Policy

Medicare’s New Rural Emergency Hospital Designation — Considerations for States

September 20, 2022/in Health Coverage and Access, Policy Blogs, Featured News Home Safety Net Providers and Rural Health /by Rebekah Falkner and Sam Mermin

How North Dakota Uses 1915(i) to Provide Supportive Services to People with Behavioral Health Conditions in Rural Areas

October 29, 2021/in Behavioral/Mental Health and SUD North Dakota Featured News Home, Reports Behavioral/Mental Health and SUD, Safety Net Providers and Rural Health /by Neva Kaye

Michigan’s Caring for Students Program Leverages Medicaid Funding to Expand School Behavioral Health Services

April 5, 2021/in Policy Michigan Blogs, Featured News Home Behavioral/Mental Health and SUD, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Safety Net Providers and Rural Health, Social Determinants of Health /by Anita Cardwell and Gia Gould

Despite a federal rule change that allows states to bill Medicaid for school-based physical and behavioral health services provided to all Medicaid-enrolled students, many states struggle to overcome the persistent and complex billing challenges associated with receiving Medicaid reimbursement for delivery of these critical services.

To access additional Medicaid funds to expand school-based behavioral health services, Michigan established the Caring 4 Students (C4S) program, which strengthens partnerships between its Medicaid agency, providers, and educational entities and streamlines Medicaid billing policies and procedures. This case study explores how Michigan overcame some of the challenges states face when seeking Medicaid reimbursement for school-based behavioral health services. It also describes how Michigan retooled the C4S program during the pandemic to ensure the services continued to reach students through telehealth.

Introduction

The majority of children who receive behavioral health care access these services in school settings. According to the School-Based Health Alliance, 70 percent of children who receive mental health services access them at school.[1] As an increasing number of children experience worsening behavioral health due to the pandemic,[2] the need for these support services is even greater. Also, with the pandemic forcing many schools to offer reduced in-person teaching or fully remote learning, they have had to adapt and provide more behavioral health services through telehealth.

While states can fund school-based behavioral health services in a variety of ways, a number of states have leveraged federal Medicaid dollars to help fund behavioral health services for students with Medicaid coverage. In federal fiscal year 2016, estimated Medicaid spending for both school-based and administrative services totaled $4.5 billion.[3]

Historically, schools were restricted in their ability to receive federal Medicaid reimbursement for physical and behavioral health services provided to Medicaid-enrolled students. The “free care rule” prohibited schools from seeking Medicaid payments for services provided to Medicaid-enrolled students if the services were provided for free to all students, such as no-cost health screenings. While the rule contained an exception for services identified in Medicaid-enrolled students’ Individuals Education Plans (IEPs), it limited schools’ ability to obtain Medicaid reimbursement for services provided to students with Medicaid coverage who did not have IEPs. However, as a result of the “free care rule” policy reversal in 2014, states have the opportunity to bill Medicaid for physical and behavioral health services delivered to all Medicaid-enrolled students, including students without IEPs.

Despite the rule change, some schools still face challenges in obtaining Medicaid reimbursement for services provided to Medicaid enrollees, either due to state-level policy barriers or other issues, such as the administrative complexity of the billing process. School staff often may not have the expertise or resources to implement Medicaid billing procedures, and often need assistance and training from state education and Medicaid agencies.[4] Also, some states with budgets impacted by the pandemic may be limited in their ability to invest in an expansion of services.

Development of C4S

To help increase students’ access to behavioral health services, in 2019 Michigan capitalized on the flexibility provided by the reversal of the free care rule by creating the C4S program through a state plan amendment (SPA) that leverages the Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) benefit. Through the C4S program, Michigan schools can now receive Medicaid reimbursement for services delivered to Medicaid-eligible students if they are covered under EPSDT, delivered within a provider’s scope of practice, and billed in accordance with state Medicaid billing procedures.[5]

In addition to federal Medicaid dollars, implementation of the C4S program was bolstered by state funding,[6] which included a $16.5 million allocation by the state legislature in the fall of 2018 to provide direct medical services to students that must be billed to Medicaid whenever possible. State officials subsequently acted quickly to submit a Medicaid SPA by December 2018, and after approval by federal officials, the state launched the C4S program in October 2019.

Interagency Coordination

Nearly all 587 school districts in Michigan fall under the authority of an intermediate school district (ISD), which conducts various administrative functions for the schools. Michigan has 56 ISDs, as well as two independent school districts, and the ISD system structure allows all schools, regardless of how small they are, to participate in the C4S program because the reimbursement claims are administered by the ISDs. The state considers the ISDs to be the main provider entities within the C4S program, as clinicians participating in the program report their services under each ISD’s provider identifier number.

State officials characterize the C4S program as a three-legged stool – consisting of Medicaid, the ISDs and the Michigan Department of Education (MDE) – all closely coordinating together to support the behavioral health needs of students. Even prior to the reversal of the free care rule, Michigan ISDs worked closely with the state Medicaid agency to provide IEP services for Medicaid-enrolled students. The strong relationship between Medicaid and the ISDs can be credited, in part, to a payment agreement that provides ISDs with 60 percent of federal Medicaid reimbursement for school-based services. To provide schools the support needed to manage the service expansion through C4S, ISDs receive 95 percent of the federal share for services covered under the program and the state Medicaid agency receives the remaining five percent to cover administrative costs.

Challenges and Solutions

Lack of behavioral health providers: In addition to expanding the scope of Medicaid reimbursable health and behavioral health services, the C4S program also expanded the type of providers who can claim reimbursement for delivering services to Medicaid-enrolled students. While funding from the legislature allowed the state to hire new mental health staff, the C4S program still needed additional providers because similar to many states, Michigan was already facing shortages within its mental health workforce.

In response, Michigan’s Medicaid officials employed a creative approach to ensure there were enough providers to support the expansion of school behavioral health services. Recognizing the potential of utilizing other categories of providers, such as physician assistants, nurse practitioners, behavior analysts, and marriage and family therapists, state officials incorporated them and others into the list of allowable providers. Including these additional provider types expanded the behavioral health workforce pool and helped the state address the lack of providers, particularly in rural areas of the state.

Overall complexity of reimbursement process: State Medicaid agency officials indicated that some school districts were initially hesitant to participate in the C4S program because they were concerned about the potential administrative burden that might be involved with implementing the Medicaid reimbursement process. These concerns have been addressed by establishing strong communication channels among the three entities (Medicaid, ISDs, and MDE) to clarify processes and procedures and provide ample opportunities for staff training sessions.

Given the complexity of the reimbursement process, the state Medicaid agency works particularly closely with the ISDs to provide them with answers to specific questions. Training on implementing the reimbursement processes occurs frequently, both at an annual conference and on a regular basis because of the frequency of staff turnover in the schools and consequently the need to train new employees about the procedures and how to account for time spent providing services.

One key aspect of the Medicaid reimbursement model is that the state uses a process that is based on paying for part of the salary of a particular staff position, rather than reimbursing for the actual services themselves. Given that providers do not spend all of their time engaging in reimbursable activities, in order to determine the amount of their salaries that can be reimbursed by Medicaid, state officials must estimate the portion of time they spent on providing medically eligible services to Medicaid-enrolled children. To do this, each month state officials ask for responses to a Random Moment Time Study (RMTS), which is a federally approved method to assess how providers spend their time. The RMTS data is incorporated into an algorithm containing a number of other factors, and this calculation forms the basis of the Medicaid reimbursement model.

State officials reported there are still some challenges associated with helping providers understand how to evaluate their time spent providing services when they respond to requests for RMTS data, due to some providers’ lack of familiarity with the RMTS process as well as the accelerated pace of implementation of the C4S program. However, state officials indicated that they expect these issues can be addressed with additional training.

Provider and general reimbursement issues: One challenge the state encountered during the initial stages of C4S implementation was due to an existing rule within MDE, which stipulated that if a provider’s salary was partially funded by general education dollars that individual was not permitted to work with special education students. State Medicaid officials worked with MDE to eliminate that rule, and this has resulted in the ability to more effectively and efficiently allocate providers’ time and allow them to serve more students.

Another key to the state’s success in increasing Medicaid reimbursement for behavioral health services provided in the schools was to address the reimbursement rate applied to school psychologists. There are four different pools of staff providers serving students — direct services staff, personal care services staff, targeted case management staff, and administrative and outreach staff. Prior to implementation of C4S, the school psychologists were categorized as part of the administrative outreach pool, resulting in a low Medicaid reimbursement rate. State officials were able to work with the Centers for Medicare & Medicaid Services (CMS) to change that designation so they were instead recognized as part of the direct service staff pool, which significantly increased their reimbursement rates.

Michigan state officials also anticipated a potential administrative challenge related to provider reimbursement. If the state used two separate Medicaid state plans to implement the program — one for special education students and another for general education students — this would create reimbursement complications because it would silo providers into serving only one student population group. By instead submitting a SPA for the C4S program that added in coverage of the general education students, this allowed providers to serve both groups of students. The state also worked closely with CMS on the overall reimbursement methodology to maximize the program’s potential for leveraging federal Medicaid funds, which included keeping the students with IEPs separate from the general education students in the state’s calculations because of their differing Medicaid eligibility rates.

Transition to online school services due to COVID-19: Michigan officials had to quickly adjust policies and processes in response to the statewide shift to online learning in the spring of 2020 due to the COVID-19 pandemic. State officials had heard anecdotally about an increased need among students for behavioral health services due to stresses associated with the pandemic, and they anticipate that this demand may continue to grow. Recognizing the need to increase access to behavioral health services for students who may be in crisis, the state waived the requirement that a plan of care must be in place, allowing schools to bill Medicaid up to 30 days without an existing plan of care.

State officials quickly broadened their telehealth policies to include an audio-only provision, and while that will most likely be discontinued when the pandemic ends, they indicated that they plan to sustain many other telehealth provisions post-pandemic.

Also, while telehealth services were implemented fairly rapidly, state officials reported that changing the billing processes was not as easy. School closures caused nearly all RMTS moments to show no reimbursable activity, because providers were not providing medical or behavioral health services during the initial stages of the closure. State officials explained that while this did result in a notable loss in reimbursement, the enhanced Federal Medical Assistance Percentage (FMAP) provided by the Families First Coronavirus Response Act would help cover much of this decrease. Also, CMS allowed the state to use an average of RMTS responses from the last two quarters for their RMTS when schools were closed, because of the significant declines in time spent providing care, and state officials indicated that federal approval to do this helped significantly.

The state is also seeking to ensure equitable access to behavioral health services by focusing on addressing issues for students who lack access to devices that can be used for telehealth services. State officials recently submitted a SPA to federal officials to obtain reimbursement for providing students in need of devices with access to iPads and computers that would be owned and managed by the schools. They indicated that if the proposal is approved, they plan to continue reimbursing for devices beyond the pandemic period.

Overall successes: The C4S program has not only achieved one of its overall goals of increasing students’ access to behavioral health services, it has also helped bring in needed additional funds to the schools. There had already been some psychologists in the schools, but it was not until implementation of C4S that Michigan was able to obtain Medicaid reimbursement for any qualifying services provided. Also, despite needing to navigate the challenges associated with the pandemic, state officials considered it a success that there has been an approximate 6 percent increase in the amount of federal Medicaid reimbursement being directed to schools through the C4S program.

The Future of C4S

State officials said they anticipate that C4S’ initial successes will continue and that the program will likely expand further, as not all ISDs were able to implement the program fully during its initial stages. As school hiring begins to increase post-pandemic and as providers and ISDs become more familiar with navigating the RMTS responses and overall reimbursement process, state officials indicated they expect the program to grow steadily in the coming months.

Notes

The National Academy for State Health Policy (NASHP) would like to thank state officials from Michigan for their time and contribution to this publication. Support for this work was provided by the David and Lucile Packard Foundation. The views expressed here do not necessarily reflect the views of the foundation.

[1] Mental Health webpage on the School-Based Health Alliance webpage, https://www.sbh4all.org/school-health-care/health-and-learning/mental-health/.

[2] Stephen W. Patrick et al, “Well-being of Parents and Children During the COVID-19 Pandemic: A National Survey. Pediatrics October 2020, 146(4). https://pediatrics.aappublications.org/content/146/4/e2020016824

[3] Medicaid and CHIP Payment and Access Commission (MACPAC), “Medicaid in Schools.” April 2018. https://www.macpac.gov/wp-content/uploads/2018/04/Medicaid-in-Schools.pdf

[4] Heather Clapp Padgette, Candace Webb, Phyllis Jordan, “How Medicaid and CHIP Can Support Student Success through Schools.” Georgetown University Center for Children and Families, April 2019. https://ccf.georgetown.edu/2019/04/24/how-medicaid-and-chip-can-support-student-success-through-schools/

[5] While the C4S program serves all students, the state can only receive Medicaid reimbursement for services provided to Medicaid-eligible children. Also, the C4S program also expands school nursing services, but this case study focuses on the program’s behavioral health services.

[6] Also, the non-federal share of Medicaid spending for school-based services is provided by schools through certified public expenditures.

Q&A: How Louisiana Has Retooled its Harm Reduction Services for Vulnerable Populations during COVID-19

November 23, 2020/in Policy Louisiana Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Health Equity, HIV/AIDS, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health, Social Determinants of Health /by Eliza Mette, Mia Antezzo and Jodi Manz

As drug overdose deaths accelerate during the COVID-19 pandemic, states are working to ensure that a continuum of services, including access to harm reduction programs, remain available to people with substance use disorder (SUD). The National Academy for State Health Policy (NASHP) recently spoke to Louisiana’s Viral Hepatitis Coordinator Emilia Myers and STD/HIV/Hepatitis Program Deputy Director Anthony James to learn how the state is continuing to provide harm reduction services during the pandemic.

Louisiana authorizes cities, including New Orleans, Baton Rouge, Shreveport, and Alexandria, to operate syringe services programs (SSP). The state has helped maintain these programs by targeting federal grants and through close cooperation between state and community partners.

How have the challenges posed by COVID-19 impacted the day-to day operation of harm reduction services in Louisiana?

Louisiana has six active SSPs across the state. They have stepped up to the challenges of this pandemic and have continued to provide their services, essentially without interruption. They’ve been able to do so through some very innovative approaches, such as hotlines and mail-based naloxone services, and by moving away from brick-and-mortar SSPs. The Louisiana Department of Health (LDH) has worked to improve its relationships with SSPs and link them with their respective local health departments. One result of this manifested in New Orleans where, right when COVID-19 started to ramp up, the city started providing residences for folks who were experiencing homelessness. SSPs went out to the hotels that were housing people to bring harm reduction services to them.

We are also using federal State Opioid Response (SOR) grant dollars in collaboration with the Office of Behavioral Health to fund SSP navigators and federal Opioid Overdose Data to Action (OD2A) dollars in collaboration with the Bureau of Community Preparedness to fund Linkage to Treatment Coordinators (LTCs), who prioritize people who inject drugs (PWID) who have fallen out of hepatitis C treatment. If they are also willing to talk about their drug use, the LTC will conduct a Screening, Brief Intervention and Referral to Treatment (SBIRT). We’ve also been using OD2A funds for our marketing campaign to raise awareness of integrated and co-located care for OUD (opioid use disorder), hepatitis C, HIV, and SSPs to reduce harms associated with substance use disorder, which we hope to continue.

Luckily, there is buy-in to this work. About a year ago, together with the Office of Behavioral Health and Bureau of Community Preparedness, we developed a state health department-wide, harm-reduction crosswalk, which was an environmental landscape analysis of who’s doing what in infectious disease, who’s doing what in OUD, and how we can create no-wrong-door systems of care. We’ve had some modest gains as a result, including braiding select government funds, scaling up SSP-based OEND (overdose education and naloxone delivery), increasing opt-out hepatitis C testing at select human service district agencies and cross-training OBOT (office-based opioid treatment) providers statewide to deliver both medication-assisted treatment for OUD and treatment for hepatitis C and we are looking to build on our momentum. Our state agencies have innovative leaders that make connections for more effective public health and behavioral health collaboration and care touch points, and we’re fortunate to have trailblazers that keep this work moving along.

How have people with comorbid HIV and hepatitis C diagnoses been affected by COVID-19, and how has the state responded?

We know folks who are coinfected are one of the populations most vulnerable to unemployment, poverty, lack of access to health care, and they generally have a lot of competing priorities between trying to take their medications and live their lives. Anecdotally, we are seeing more people accessing SSPs and needing supplies, and SSPs are trying to accommodate that increased demand. With an increase in utilization of SSP services, we hope there will not be an increase in overdoses and or increases in HIV and hepatitis C transmission. I think COVID-19 has really turned access into a challenge and created additional burdens for vulnerable populations, so we have to look at the issue through a health equity lens. There are a lot of systemic challenges and barriers that have been exacerbated by the pandemic, and people’s health has become a lesser priority because they’re trying to survive day to day.

Within our Hepatitis C Elimination Plan activities [featured in an April 2020 NASHP case study], we have seen decreases in testing and treatment as a result of the pandemic. Before we launched our program, 61 people per month were starting curative treatment. After implementation, we were seeing on average 478 people per month starting treatment. At the start of the COVID-19, that number dropped back down to an average of 155 people per month, but since September 2020, testing and treatment utilization has picked back up. This has forced us to learn how to get testing and treatment outside of brick and mortar treatment facilities, because people are anxious of going into health care systems. Because of funding reductions and other impacts of COVID-19, we revisited our hepatitis C strategy to ensure we were focused on realistic and achievable objectives for the second year of the plan, and reassess what Years 3 through 5 will look like. COVID-19 has forced us to pivot and continuously innovate hepatitis C service delivery. We will use this as an opportunity to leverage our response and facilitate a larger push in harm reduction.

How does Louisiana’s harm reduction approach support health equity and reduce disparities?

In both the LDH and STD/HIV/Hepatitis Program mission statements, we focus on addressing health equity and racial disparities across the board. Disparities in health care exist and are associated with worse health outcomes, for example the HIV/HCV coinfection diagnosis and prevalence rates are disproportionally higher among Black males primarily in the Baton Rouge and New Orleans areas. Looking at the mono-hepatitis C surveillance data, there hasn’t been a lot of variability in who’s being diagnosed by race. We see disparities in rates of infection by age – we have baby boomers and people who inject drugs getting infected, so we have this bimodal distribution. In an effort to address these disparities in the context of the current hepatitis C/OUD syndemic, we have to pinpoint shortcomings in hepatitis action towards people who actively use drugs and expand primary prevention through harm reduction because treating your way out of a hepatitis C epidemic isn’t feasible. PWID are increasingly researched, but their ability to tell their own stories and provide input into the programs and services they utilize has been historically limited due to stigma. Louisiana is changing that by leveraging community wisdom through community advisory boards to inform evidence-based service delivery. We move this work forward through a core set of values to help us ensure that the services that we and our community partners provide are moving in an equitable direction.

How has the pandemic necessitated or encouraged new strategies or partnerships?

One of our strategies has been offering provider training. We’ve leveraged Project ECHO to train providers how to leverage telemedicine to treat and manage hepatitis C virtually, revamping remote care. There has been a lot of engagement from clinicians.

There was also a decline in hepatitis C and HIV testing at the start of COVID-19. Our community-based partners have conducted risk mitigation strategies to safely re-engage people in testing. Now that they’ve been able to get PPE, they are able to conduct testing in community settings again.

We are also prioritizing data sharing and maximizing opportunities to form strong partnerships, because the syndemic of hepatitis C, HIV, and drug overdose is really intertwined, and COVID-19 has only made things more challenging. Reinforcing our partnerships and leveraging data sharing, in addition to amplifying the voices and wisdom of community members, is helping us make these programs work for the people who rely on them.

What would you say are your greatest lessons learned from COVID-19?

We really need to lean into interdisciplinary telemedicine for comprehensive care, especially for the hard-to-reach communities in high-burden regions of the state. COVID-19 has caused so much slow down, but also additional time to re-assess what we’re doing. In this context, developing robust telemedicine programs will be critical. The next challenge will be how to integrate offerings into clinical care beyond the COVID-19 pandemic so that a “one-stop-shop” PWID service bundle will become an increasingly ordinary part of care with movement towards the goal of reducing disparities in infectious diseases and opioid use disorder treatment access.

Tackling the Trifecta: State Approaches to Addressing Co-Occurring Substance Use Disorders, HIV, and Hepatitis C

April 17, 2020/in Policy Behavioral/Mental Health and SUD, Chronic and Complex Populations, Health Coverage and Access, Health Equity, Health IT/Data, HIV/AIDS, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Safety Net Providers and Rural Health /by Eliza Mette, Jodi Manz and Kristina Long

In response to an increase in HIV and hepatitis C virus (HCV) infections in individuals with substance use disorders (SUD), including opioid use disorders (OUD), state policymakers are employing multifaceted strategies to address this syndemic, collaborating with public and private partners to prevent the spread of infectious disease and provide access to evidence-based treatment. This report explores innovative approaches Louisiana, New York, and West Virginia have taken to address co-occurring HIV and HCV infections and SUD – providing both rural and urban perspectives – and highlights their resourceful use of funding streams, leveraging of data, and advancing community readiness.

Background

The opioid epidemic has left no state untouched. In 2017, over 70,000 people died from drug overdoses,[1] 11.4 million people improperly used opioids, and 2.1 million people suffered from an opioid use disorder.[2] In addition to the thousands of overdoses and overdose deaths attributed to opioids, another result of the nation’s substance use disorder crisis has been an increase in rates of infectious diseases in people who inject drugs (PWID), including hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infections, which can be transmitted by sharing contaminated syringes.[3]

Of particular concern is the fact that most new cases of hepatitis C are related to injection drug, and a previously consistent 25-year downward trend in rates of HIV infection among PWID is beginning to plateau.[4] The cumulative costs of treatment for these two conditions in the United States is quite high:

The total annual cost of providing treatment and services to people living with HIV was $21.5 billion in FY 2019,[5]
And the total annual health care cost for managing chronic hepatitis C in the is estimated to be $15 billion.[6]

In contrast, allocating the equivalent of the cost of treatment for a single person living with HIV ($400,000) to harm reduction[7] strategies would lead to the prevention of 30 new HIV cases – a significant cost-savings beyond the clear benefit of disease prevention for individuals and communities.[8] States at the forefront of addressing the opioid epidemic are increasingly interested in providing not only treatment, but also access to comprehensive prevention services in order to safeguard public health and make good use of limited resources.

Louisiana

In Louisiana, the number of opioid-related overdose deaths nearly tripled between 2012 and 2018 and exceeded 450 in 2018 – a 13.5 percent increase from the previous year.[9] Louisiana is experiencing a concurrent hepatitis C and HIV crisis:

Between 2007 and 2017, 40,263 people received a hepatitis C diagnosis,[10] and the Louisiana Office of Public Health estimates that injection drug use is currently putting 112,424 more Louisianans at “very high risk” of infection.[11]
There is significant co-morbidity within this population – in 2017, the state recorded at least 1,290 Louisianans who were co-infected with HIV and HCV.[12]

To address these challenges, Louisiana developed a statewide Hepatitis C Elimination Plan. The plan was created by the Louisiana Office of Public Health (OPH) in collaboration with the Louisiana Department of Health, the state Department of Public Safety and Corrections (DPS&C), the US Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the Centers for Medicaid & Medicare Services (CMS), and state and national experts.[13] This comprehensive plan acknowledges the role of SUD in the state’s hepatitis C epidemic and the risks associated with intravenous drug use, and it aims to diagnose 90 percent and treat 80 percent of Louisianans living with hepatitis C within five years.[14] It also details a range of cross-cutting strategies that engage the private and public sectors, the health care industry, and community-level partners.[15]

Key features of Louisiana’s hepatitis C elimination strategy and related efforts to address SUD and its co-morbidities include:

Restructuring reimbursement for hepatitis C treatment: Historically, Louisiana has paid for hepatitis C medications by the dose, incurring significant costs in its effort to pay for treatment for Medicaid enrollees or who are corrections-involved.[16] In response, the state’s HCV Elimination Plan features an innovative purchasing agreement between Louisiana and Asegua Therapeutics, a wholly owned subsidiary of Gilead Sciences Inc., a biopharmaceutical company.[17] Referred to as a “modified subscription model,” this agreement sets a capped cost for all HCV medication administered to the state’s Medicaid and corrections-involved populations.[18] The methodology incentivizes the state to identify and treat as many people as possible, as the marginal cost of each additional patient is essentially zero.[19]

Louisiana estimates that approximately 34,000 Medicaid enrollees and 5,000 incarcerated individuals in state corrections facilities have chronic hepatitis C; however, fewer than 3 percent of those 34,000 Medicaid enrollees were treated in 2018.[20] Under its agreement with Asegua, Louisiana aims to treat 10,000 Medicaid-enrolled and corrections-involved individuals by the end of 2020, and 30,000 individuals by 2024.[21] Preliminary claims data indicate that 2,900 people have initiated treatment since the July 15 start date, considerably more than the number of people treated in all of 2018.[22]

Leveraging data to track and address co-morbid conditions: The Louisiana Public Health Information Exchange (LaPHIE)[23] was first implemented in 2008 as a partnership between OPH and Louisiana State University Health Care Services Division.[24] OPH maintains comprehensive HIV surveillance data that is updated daily through lab reporting. If a patient enters a participating hospital and a provider opens that patient’s electronic medical record to provide services, the provider will be notified if the patient has not received timely HIV care and prompted to take appropriate action.[25] LaPHIE is also bi-directional: any action taken by the provider with respect to the patient, whether it be a referral or a link back into care, is incorporated into the patient’s electronic medical record (EMR) and returned to OPH, which then updates the state’s HIV surveillance data.[26] This system is designed to strengthen care retention and improve disease management for patients living with HIV by engaging them at different care sites across the region. Improved HIV care management, with the aim of making a patient’s viral load undetectable, has the potential to not only improve an individual’s health status but also reduce the likelihood of HIV transmission to others.

Louisiana recently received funding to expand LaPHIE’s innovative functionality to include hepatitis C surveillance data and is now in the process of building out this new capacity.[27] State officials view the Hepatitis C Elimination Plan as a call to action to Louisiana hospital systems, whose participation in the LaPHIE surveillance system has dropped in recent years.[28]

Focusing on high-risk populations: Louisiana has been successful by targeting limited state resources on particularly high-need populations:

HIV Prevalence and Diagnoses Attributed to Injecting Drug Use

Source: National Institute on Drug Abuse, Louisiana Opioid Summary, 2016.

Individuals with SUD: In conjunction with its Hepatitis C Elimination Plan, Louisiana’s STD/HIV/Hepatitis Program updated its contracts with community-based organizations to require combined HIV, syphilis, and HCV screening and linkages to treatment for individuals with new diagnoses.[29]
Individuals who are corrections-involved: OPH has worked closely with the Louisiana DPS&C to develop a treatment model for HCV and HIV, including linkage to care.[30] The DPS&C has offered opt-out HCV screening for all new individuals as they enter the state correctional system since 2008 and opt-out HIV screening for individuals upon release since 2014. OPH provides supplies and training for both of these initiatives.[31] Starting in October 2019, OPH launched a population-level screening project with DPS&C through which OPH offers screening for hepatitis A, B, and C, HIV, and syphilis in every state-run facility, and plans to complete screening all current state inmates by mid-2020.[32] OPH also supports a corrections-based, pre-release program leveraging Ryan White HIV/AIDS Part B funding from HRSA – specialists work with inmates living with HIV prior to their release and connect them with case management and support services in the communities to which they are discharged.[33] Louisiana is exploring the possibility of building a similar system for people with hepatitis C as part of its elimination plan.
Individuals with HIV: Recognizing that people with SUD and related comorbidities often have insufficient dental care that can contribute to poor health outcomes, the Louisiana Health Access Program (LA HAP)[34] leveraged Ryan White Part B resources and worked with Guardian Dental to increase access to comprehensive oral health care for people with HIV.[35] Prior to this collaboration, people with HIV regularly encountered barriers to adequate dental care, including low annual caps, unexpected bills, and limitations on covered services.[36] The state was supported by the Health Services and Research Administration (HRSA) to structure a self-insured plan that would reduce unmet oral health care needs of people infected with HIV.[37] As a result, more than 2,000 individuals have been able to access a comprehensive set of services that address oral health care issues related to HIV infection.

West Virginia

West Virginia has one of the highest rates of drug overdose and mortality in the country. Compounding this crisis, injection drug use in West Virginia has contributed to the quintupling in new HIV diagnoses from 2014 to 2019.[38] Injection drug use is the second-leading cause of transmission for new HIV diagnoses for men and women in the state, according to most recent data from the National Institute on Drug Abuse (NIDA).[39] In 2018, Cabell County, on the state’s western edge, reported 81 new cases of HIV, which qualified it as an active HIV cluster – all 81 new HIV infections were tied to injection drug use.[40] As a very rural state that has been highly affected by the opioid crisis and its comorbidities, West Virginia has taken a decentralized approach in its harm reduction efforts, providing guidance and certification standards to communities to assist them in developing and administering programs at the local level.[41] Since 2011, when the state’s first harm reduction program opened,[42] West Virginia has navigated the challenges of operating syringe exchange programs, which is an evidenced-based, albeit sometimes controversial, approach.

HIV Prevalence and HIV Diagnoses Attributed to Injecting Drug Use

Source: West Virginia Opioid Summary, National Institute on Drug Abuse, 2016

Rural areas can face particular challenges in developing and sustaining harm reduction programs. Transportation is limited, confidentiality can be elusive in small towns, and the stigma associated with drug use can be heightened in rural, conservative communities.[43] In West Virginia, Kanawha County started the Kanawha-Charleston harm reduction program through its

department of health, offering syringe exchange in addition to comprehensive harm reduction services.[44] At its height, the program provided services to over 400 individuals weekly, effectively maximizing access to sterile syringes, preventing new HIV cases, and screening for HCV.[45] However, highly publicized public opposition, which was attributed to an uptick in crime and increase in discarded syringes in the area where the organization worked, ultimately led to the closure of the program in early 2019.[46]

West Virginia’s experience with the site in Kanawha County suggests that state support for community-level harm reduction programs can be most successful when they are community-specific.[47] Noted one West Virginia state official, “At the state level, you can’t just say, this program will work everywhere, or look at what other states have done and assume that it will work everywhere – state policymakers and public health officials have to tailor [the program] to the individual, unique communities that they serve.”[48] Those states in which syringe exchange (as a component of harm reduction) is more controversial are faced with the added challenge of finding the balance between the need for a comprehensive, evidence-based approach and implementing more limited models that are acceptable to local communities.[49] Providing messaging that helps to educate communities about the benefits of harm reduction services, including syringe exchange, may also be important in building community support.

Standardizing processes, engaging communities: In an effort to support implementation of harm reduction programs, West Virginia created Harm Reduction Program Guidelines and Procedures, which establish core certification requirements that these programs must meet in order to receive Department of Health and Human Resources’ funding.[50] To be certified, the program must outline all services provided, demonstrate compliance with state laws, rules, and local ordinances, and provide documentation of the involvement of the local health department.[51] The organization must also coordinate with local law enforcement and document any concerns they may have.[52] An integral step outlined in the guidelines is assessing the community’s readiness and building the community’s support prior to implementation.[53] The guidelines also offer several strategies to engage community stakeholders and encourage community buy-in prior to implementing harm reduction programs.[54] Although these programs do not need to be certified in order to operate in West Virginia, sites that complete the certification process are more likely to programmatically align with the state’s eight core strategies for successful harm reduction programs:

Build community support prior to implementation of a harm reduction program and maintain support for the duration of the program;
Conduct routine program and process evaluation;
Have a detailed community syringe retrieval in place for non-sterile syringes found in the community;
Emphasize harm reduction as a Pathway to Care;
Emphasize increasing stability and reducing risk among harm reduction participants and fostering supportive relationships with harm reduction program personnel;
Train caring and supportive staff to provide consistent messaging of safe injection practices, overdose prevention, and infectious disease screening;
Recommend dispensing syringes in person, not via proxy; and
Have a mechanism to get patients in treatment when they are ready.[55]

Incremental changes: Despite the programmatic and public relations challenges that harm reduction programs have sometimes faced in West Virginia, communities are gradually embracing these programs. New sites are opening, existing programs are experiencing higher client engagement,[56] and the state has allocated State Treatment Response and State Opioid Response federal grant funding to support harm reduction programs in recent years.[57] This community-by-community approach has allowed the state to increase access to treatment for SUD and prevent the spread of infectious diseases.[58] In its work with local communities, West Virginia has also leveraged CDC’s and HRSA’s HIV/AIDS Bureau’s HIV cluster detection and response service in order to identify at-risk communities, assist local health departments as they identify prevention and service system gaps, and allocate resources accordingly to be responsive to new outbreaks.[59]

New York

New York has a long history of innovation in preventing the spread of infectious disease associated with injection drug use. In particular, the state invested early in its Syringe Exchange Program,[60] creating the foundation for a comprehensive harm reduction approach. Through these efforts, only 2 percent of new HIV infections per year are reported among PWID.[61] Gov. Andrew Cuomo’s Ending the Epidemic plan includes achieving zero new HIV infections among PWID and a plan for the first-ever decrease in HIV prevalence in New York by the end of 2020.[62]

HIV Prevalence and HIV Diagnoses Attributed to Injection Drug Use

A lasting result of this early investment is New York’s Harm Reduction Initiative, a program funded by the state’s Department of Health, AIDS Institute.[63] This program funds comprehensive harm reduction programs for individuals living with SUD and the people and communities that support them, including New York’s innovative Drug User Health Hubs.[64]

*New York Opioid Summary, National Institute on Drug Abuse, 2016

Supporting integrated models of care: Drug User Health Hubs are enhanced syringe exchange programs that offer a broad range of services, driven by the particular needs of the population in the surrounding community.[65] Hubs are intended to increase access to physical and behavioral health services, including medication-assisted treatment (MAT) for people with opioid use disorder (OUD).[66] Services are offered at hub sites and through referral.[67] Hubs provide services and support with an emphasis on prevention and responding to opioid overdose.[68] Services can include:

Medical services: Includes accessible buprenorphine; wound care; HCV testing, diagnosis, and treatment; and rapid assessment of a client’s needs.
Opioid overdose prevention/aftercare for an overdose: Includes training and provision of naloxone overdose reversal kits; training on safer injection practices and provision of syringes; facilitation of appropriate referrals from Emergency Departments and first responders, etc.
Law enforcement diversion: Includes the law enforcement diversion of PWID who have committed low-level infractions to Drug User Health Hubs.
Anti-stigma activities: Features hub employees who engage with local providers to encourage a harm reduction focus in their provision of care to PWID, and with local communities to destigmatize injection drug use and create a welcoming environment for all community members.[69]

The goal of New York’s hubs is to transform the state’s syringe exchange programs into locations that can provide comprehensive, easily accessible medical services to PWID.[70] In many health care settings, patients are required to receive psychosocial counseling in order to be prescribed medications to treat OUD.[71] Recognizing that this can be a substantial disincentive to getting treatment, New York’s Department of Health (NYSDOH) began a buprenorphine-first approach, providing medications for treating OUD as a first step, without initially requiring other services.[72] Individuals can receive buprenorphine only, or opt to concurrently access services that can include counseling and other medical treatments as needed, such as those for soft tissue infections, hepatitis C, HIV, and diabetes.[73] As part of the state’s Strategy to Eliminate Hepatitis C, the NYSDOH Bureau of Hepatitis Health Care funds patient navigator positions in seven different hubs in upstate New York.[74] These individuals provide guidance to people living with hepatitis C as they navigate the health care system, and help link them to care and treatment.[75]

Leveraging Medicaid for prevention: In 2018, New York implemented a Medicaid state plan amendment (SPA) that allows the state’s harm reduction programs to deliver certain Medicaid reimbursable services, including medication management and treatment adherence counseling for MAT, HIV and HCV infections, mental health conditions, and pre-exposure prophylaxis (PrEP) to prevent HIV infection.[76]

A product of a partnership among the NYSDOH AIDS Institute’s Office of Drug User Health, the Office of Health Insurance Programs, and community partners, the SPA came to fruition after extensive negotiation and revision.[77] Initially, it was required to have a physician perform the harm reduction services covered under the SPA, but the state was able to modify staffing requirements, recognizing that many harm reduction programs in the state do not have medical providers on staff.[78] The approved SPA permits licensed clinical social workers, certified peers, and direct service providers with relevant experience to provide Medicaid-reimbursable harm reduction services under the SPA.[79]

The NYSDOH also recently amended the requirements that community-based organizations must satisfy in order to become licensed health care facilities, allowing organizations such as syringe exchange programs, to provide and bill Medicaid for primary care services.[80] Syringe exchange programs have historically been unable to directly deliver primary health care services and have been required to contract out these services in order to deliver them on-site – a model that was not financially sustainable for most.[81] The change permits these organizations to fully integrate Medicaid-reimbursable primary care, including HCV and HIV screening, assessment, and treatment within the harm reduction setting.[82] State officials see the ability to deliver primary care in these nontraditional settings as necessary to achieve the goal of disease elimination.[83]

Considerations for States and Conclusion

While states have taken different approaches to addressing the opioid crisis and its related increase in infectious disease incidence, these three states’ approaches provide some common themes that can be implemented elsewhere:

Robust data is critical to address the complex co-morbidities associated with SUD. Unlike HIV surveillance, which remains relatively well-funded and robust, hepatitis C surveillance typically does not have consistent funding nor a robust infrastructure across states. However, some states are taking steps to improve their infrastructure and leverage new technology. For example, Louisiana is adapting its HIV surveillance strategy and standards to include hepatitis C surveillance, and in so doing has turned a passive registry into an “active and rigorous system of care,” according to one state public health official. Similarly, New York is in the process of improving its hepatitis C surveillance infrastructure as part of its statewide elimination plan. In West Virginia, the CDC’s HIV cluster detection and response team has been an important resource to help the state accurately track HIV outbreaks and appropriately allocate resources.
Medicaid plays an important role in prevention and treatment. One Louisiana state official observed, “Our plan to eliminate hepatitis C hinged on the increased insurance coverage that Medicaid expansion has provided our residents.” Medicaid expansion in Louisiana was critical in expanding access to comprehensive HIV prevention and treatment, as newly eligible Medicaid beneficiaries were able to transition away from reliance solely on the Ryan White HIV/AIDS program. Louisiana used Medicaid funding to shift and alleviate costs and was able to provide expanded services to people with HIV. New York, similarly, has been able to leverage Medicaid to create a harm reduction benefit, which has expanded the ability of the state’s syringe exchange sites to engage in prevention activities.
Solutions must be tailored to local needs. Because the OUD crisis looks very different in different places, policymakers must be responsive to specific drivers and factors that shape a community’s experience. In response to the challenges it experienced in implementing sustainable harm reduction programs in West Virginia, the state developed certification guidelines that it ties to state funding. In so doing, the state ensures that the majority of harm reduction programs in West Virginia assess and engage with their local communities prior to implementation. Similarly, one of the mandates of New York’s Drug User Health Hubs is to work with the communities in which they operate to reduce the stigma associated with substance use, and better involve community members who inject drugs.

Conclusion

The concurrent increase in the incidence of blood-borne infectious diseases is just one consequence of an OUD crisis that has had a far-reaching impact on the nation. By implementing evidence-based, community-tailored prevention and treatment policies, states can prevent new infections, better address co-morbid SUD and infectious diseases, and reduce state costs. Through coordination and targeted resources, states are developing sustainable prevention and treatment policies that can address the complexity of factors at the intersection of SUD and infectious disease.

Notes

[1] “Opioid Overdose,” Centers for Disease Control and Prevention, October 18, 2019, https://www.cdc.gov/drugoverdose/index.html.

[2] “The opioid epidemic and emerging public health policy priorities,” American Medical Association, October 31, 2019, https://www.ama-assn.org/delivering-care/opioids/opioid-epidemic-and-emerging-public-health-policy-priorities.

[3] “Persons Who Inject Drugs (PWID)s,” Centers for Disease Control and Prevention, July 19, 2018, https://www.cdc.gov/pwid/index.html.

[4] “Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, May 23, 2019, https://www.cdc.gov/ssp/syringe-services-programs-summary.html.

[5] “U.S. Federal Funding for HIV/AIDS: Trends Over Time,” Kaiser Family Foundation, March 2019, https://www.kff.org/hivaids/fact-sheet/u-s-federal-funding-for-hivaids-trends-over-time/.

[6] “Syringe Services Programs (SSPs),” Centers for Disease Control and Prevention, May 23, 2019, https://www.cdc.gov/ssp/syringe-services-programs-summary.html.

[7] “Department of Health and Human Services Implementation Guidance to Support Certain Components of Syringe Services Programs, 2016,” Department of Health and Human Services, 2016, https://www.hiv.gov/sites/default/files/hhs-ssp-guidance.pdf.

[8] “Harm Reduction for HIV Prevention,” Avert, March 2019 https://www.avert.org/professionals/hiv-programming/prevention/harm-reduction.

[9] Louisiana Department of Health Opioid Steering Committee, “Louisiana’s Opioid Response Plan,” Louisiana Department of Public Health, 2019, http://ldh.la.gov/assets/opioid/LaOpioidResponsePlan2019.pdf.

[10] Sam Burgess, “Louisiana’s Hepatitis C Elimination Plan,” Louisiana Department of Health, 2019, https://www.nastad.org/sites/default/files/Uploads/2019/2019-am-burgess.pdf.

[11] Ibid.

[12] “Louisiana Hepatitis C Elimination Plan: 2019-2024,” Louisiana Department of Health, August 2019, https://www.louisianahealthhub.org/wp-content/uploads/2019/08/HepCFreeLA.pdf.

[13] Ibid.

[14] Ibid.

[15] Ibid.

[16] Ted Alcorn, “Hepatitis C Drugs may Serve as Model,” The Wall Street Journal, September 13, 2019, https://www.wsj.com/articles/louisianas-deal-for-hepatitis-c-drugs-may-serve-as-model-11568347621.

[17] Ibid.

[18] Ibid.

[19] Gretchen A. Meier, “Using the Drug Pricing Netflix Model to Help States Tackle the Hep C Crisis,” USC Leonard D. Schaeffer Center for Health Policy and Economics, August 16, 2019, https://healthpolicy.usc.edu/article/using-the-drug-pricing-netflix-model-to-help-states-tackle-the-hep-c-crisis/.

[20] “Solicitation for Offers for Pharmaceutical Manufacturers to Enter Into Contract Negotiations to Implement Hepatitis C Subscription Model,” Louisiana Department of Health, http://ldh.la.gov/assets/oph/SFO/SFOWrittenAnswersManufacturers.pdf.

[21] Gretchen A. Meier, “Using the Drug Pricing Netflix Model to Help States Tackle the Hep C Crisis,” USC Leonard D. Schaeffer Center for Health Policy and Economics, August 16, 2019, https://healthpolicy.usc.edu/article/using-the-drug-pricing-netflix-model-to-help-states-tackle-the-hep-c-crisis/.

[22] Interview with Louisiana.

[23] The Louisiana Public Health Information Exchange was originally funded by HRSA.

[24] Interview with Louisiana.

[25] Ibid.

[26] Ibid.

[27] Ibid.

[28] Ibid.

[29] “Louisiana Hepatitis C Elimination Plan: 2019-2024,” Louisiana Department of Health, August 2019, https://www.louisianahealthhub.org/wp-content/uploads/2019/08/HepCFreeLA.pdf.

[30] Interview with Louisiana.

[31] Ibid.

[32] Ibid.

[33] Ibid.

[34] Louisiana Health Access Program, 2018, https://www.lahap.org/dental/.

[35] Interview with Louisiana.

[36] Ibid.

[37] Ibid.

[38] Catherine Slemp, “Health Advisory # 162,” West Virginia Department of Health and Human Services, October 2019, https://oeps.wv.gov/healthalerts/documents/wv/WVHAN_162.pdf.

[39] “West Virginia Opioid Summary,” National Institute on Drug Abuse, March 2019 https://www.drugabuse.gov/opioid-summaries-by-state/west-virginia-opioid-summary.

[40] Kyle Swenson, “Unraveling an HIV cluster,” The Washington Post, November 3, 2019, https://www.washingtonpost.com/national/unraveling-an-hiv-cluster/2019/11/03/66cf4526-f5af-11e9-8cf0-4cc99f74d127_story.html.

[41] “Harm Reduction Program (HRP) Guidelines and Certification Procedures,” West Virginia Bureau for Public Health, 2018, https://oeps.wv.gov/harm_reduction/Documents/hcp/HRP_Guidelines_2018.pdf.

[42] “West Virginia Harm Reduction Programs At-A-Glance,” West Virginia Office of Epidemiology and Prevention Services, 2018, https://oeps.wv.gov/harm_reduction/documents/about/wv_hrp.pdf.

[43] Sean T. Allen et al., “Understanding the public health consequences of suspending a rural syringe services program: a qualitative study of the experiences of people who inject drugs,” Harm Reduction Journal, May 21, 2019, https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-019-0305-7.

[44] Kara Leigh Lofton, “Diving Deep into Harm Reduction Part 1: Why W.Va’s Largest Needle Exchange Closed,” West Virginia Public Broadcasting, November 26, 2018, https://www.wvpublic.org/post/diving-deep-harm-reduction-part-1-why-wva-s-largest-needle-exchange-closed#stream/0.

[45] Ibid.

[46] Ibid.

[47] Interview with West Virginia.

[48] Ibid.

[49] HHS resources for Syringe Services Programs may be accessed here: https://www.hiv.gov/federal-response/policies-issues/syringe-services-programs.

[50] West Virginia Harm Reduction Programs At-A-Glance,” West Virginia Office of Epidemiology and Prevention Services, 2018, https://oeps.wv.gov/harm_reduction/documents/about/wv_hrp.pdf.

[51] “Harm Reduction Program (HRP) Guidelines and Certification Procedures,” West Virginia Bureau for Public Health, February 1, 2018, https://dhhr.wv.gov/oeps/harm-reduction/Documents/HRP_Guidelines_2018.pdf.

[52] Ibid.

[53] Ibid.

[54] Ibid.

[55] Ibid.

[56] Bureau for Public Health, “White Paper: The Need for Harm Reduction Programs in West Virginia,” West Virginia Department of Health and Human Resources, November 6, 2017, https://oeps.wv.gov/harm_reduction/documents/training/hrp_white_paper.pdf.

[57] “Announcement of Funding Availability – Harm Reduction,” West Virginia Department of Health and Human Resources, Bureau for Public Health, May 17, 2019, https://dhhr.wv.gov/bhhf/AFA/Documents/AFA%20FY%2019/Harm%20Reduction%20AFA%20FINAL.pdf.

[58] Bureau for Public Health, “White Paper: The Need for Harm Reduction Programs in West Virginia,” West Virginia Department of Health and Human Resources, November 6, 2017, https://oeps.wv.gov/harm_reduction/documents/training/hrp_white_paper.pdf.

[59] Interview with West Virginia.

[60] “Policies and Procedures: Syringe Exchange Programs,” New York State Department of Health Aids Institute, September 2016, https://www.health.ny.gov/diseases/aids/consumers/prevention/needles_syringes/syringe_exchange/docs/policies_and_procedures.pdf.

[61] Interview with New York.

[62] “Ending the AIDS Epidemic in New York State,” New York State Department of Health, January 2020, https://www.health.ny.gov/diseases/aids/ending_the_epidemic/.

[63] “Drug User Health,” New York State Department of Health, August 2017, https://www.health.ny.gov/diseases/aids/general/about/substance_user_health.htm.

[64] Ibid.

[65] Ibid.

[66] Ibid.

[67] Ibid.

[68] “Drug User Health – Drug User Health Hubs,” New York State Department of Health, October 2019, https://www.health.ny.gov/diseases/aids/consumers/prevention/.

[69] “Drug User Health,” New York State Department of Health, August 2017, https://www.health.ny.gov/diseases/aids/general/about/substance_user_health.htm.

[70] Interview with New York.

[71] Ibid.

[72] Ibid.

[73] Ibid.

[74] Interview with New York.

[75] “New York State Hepatitis C Elimination Task Force,” New York State Department of Health, April 2019, https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/elimination.htm.

[76] “New York State Plan Amendment,” Centers for Medicare and Medicaid Services, August 10, 2017, https://www.health.ny.gov/regulations/state_plans/status/non-inst/approved/docs/app_2017-08-10_spa_13-19.pdf.

[77] Interview with New York.

[78] Ibid.

[79] “Harm Reduction Services,” New York State Department of Health, May 2018, https://www.health.ny.gov/health_care/medicaid/redesign/2018/docs/harm_reduction.pdf.

[80] Interview with New York.

[81] Ibid.

[82] Ibid.

[83] Ibid.

Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Louisiana, New York, and West Virginia state officials who generously shared their time and insight during the preparation of this report. The authors also thank Trish Riley and Kitty Purington of NASHP, as well as Carolyn Robbins and her colleagues at the Health Resources and Services Administration for their guidance and helpful feedback.

This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. The information or 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.

How the President’s Proposed FFY 2021 Budget Would Impact Critical State Health Programs

February 20, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health System Costs, HIV/AIDS, Housing and Health, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Medicaid Managed Care, Medicaid Managed Care, Population Health, Safety Net Providers and Rural Health /by NASHP Staff

The President’s budget request for federal fiscal year (FFY) 2021 proposes a 10 percent reduction in the Department of Health and Human Services’ (HHS) budget. A signature piece of the budget features the President’s Health Reform Vision, which includes $844 billion in cuts over 10 years to implement the Administration’s efforts to provide “better care at lower costs.”

While the proposed budget is subject to Congressional review and expected to change, it is important for states to consider how the Administration’s priorities could affect public health programs. The following highlights some of the key budget proposals that impact state health programs.

Prescription Drugs

Increases oversight of the 340B Program. The proposal gives explicit oversight authority to the Health Resources and Services Administration (HRSA) with the goal of creating enforceable standards for participation and ensuring 340B benefits low-income and uninsured patients. Part of the increased funding for oversight ($34 million) will come from a new user fee on covered entities based on 340B sales.

Bipartisan drug pricing proposals. The budget includes an allowance of $135 billion in savings for bipartisan Congressional drug pricing proposals. The Administration specifically supports efforts to improve the Medicare Part D benefit by establishing an out-of-pocket maximum and lowering out-of-pocket costs for seniors, as well as reforms to US Food and Drug Administration (FDA) approval and regulatory measures to bring lower-cost generics and biosimilars to market.

Health Insurance Markets

Encourages expansion of coverage in the small-group market through Multiple Employer Welfare Arrangements (MEWAs). Provides additional funding to the Employee Benefits Security Administration to encourage adoption of policies to boost insurance coverage for small businesses. Specifically, the budget suggests promotion of MEWAs – an arrangement made when multiple employers coordinate to offer benefits to their employees – for example, association health plans are a type of MEWA. State regulation of MEWAs varies, though largely they are exempt from many requirements imposed on other health plans, including consumer protections codified under the Affordable Care Act (ACA). This investment follows prior action taken by this Administration to promote association health plans.

Medicaid

Reductions in overall program funding. Proposes to cut $920 billion over 10 years from Medicaid.

Eligibility and Enrollment

Requires work and community engagement initiatives. To receive Medicaid benefits, the budget proposes requiring all able-bodied, working-age, Medicaid-eligible individuals to find employment, participate in job training, or volunteer. It estimates this will generate $152.4 billion in savings over 10 years.

Gives states the ability to change certain program elements and eligibility determination processes. Proposes to allow states to implement certain changes to Medicaid benefits and cost sharing, including making non-emergency medical transportation optional and allowing states to use state plan authority rather than a waiver to increase copayments for nonemergency use of emergency departments. Proposes to permit states to apply asset tests for individuals who are financially eligible for the program through the Modified Adjusted Gross Income (MAGI) standard. States would also be permitted to conduct eligibility redeterminations for MAGI-eligible individuals more frequently, to align with the soon-to-be released proposed rule on Medicaid eligibility determination processes.

Requires documentation of immigration status prior to receipt of Medicaid. Proposes that before they receive Medicaid coverage, individuals must provide evidence of citizenship or satisfactory immigration status. While states will still be allowed to provide coverage during a reasonable opportunity period, they will not be able to receive federal match for these individuals during this time. This is estimated to save $2.6 billion over 10 years.
Reduces maximum allowable home equity for Medicaid eligibility. Eliminates states’ ability to set a higher home equity limit for individuals seeking long-term care coverage through Medicaid, which is estimated to save $34.3 billion over 10 years.

Payments and Financing

Changes the ACA’s financing for the expansion population. Indicates that it will end the “…financial bias that currently favors able-bodied working adults over the truly vulnerable.” While no specific details were provided about how precisely this would be accomplished, language in the budget brief references allowing states with expansion populations to elect a block grant or per capita cap to finance their coverage. No details were provided as to whether the existing federal match rate for expansion adults would be reduced, to what base rate that reduction would be, or when this change would be enacted by Congress.
Reduces the federal match rate for Medicaid-eligible workers. Reduces the federal match rate for Medicaid-eligible workers from 75 percent to 50 percent by FFY 2024.

Prohibits Medicaid payments to public providers in excess of costs. Proposes to limit Medicaid reimbursement for health care providers operated by a governmental entity to no more than the actual cost of providing services to Medicaid beneficiaries.
Increases transparency of Medicaid financing and supplemental payments. Supports the finalization of a recently proposed rule that would require more data on states’ financing of Medicaid supplemental payments.
Gives the Centers for Medicare & Medicaid Services (CMS) increased ability to recoup Medicaid improper payments and recover Medicaid and Children’s Health Insurance Program (CHIP) overpayments. Permits CMS to issue disallowances for payments made due to noncompliance with provider screening and enrollment requirements and collect overpayments made to states for ineligible or misclassified Medicaid beneficiaries.
Continues Medicaid Disproportionate Share Hospital (DSH) reductions. Current law reduces Medicaid DSH allotments between FFY 2020 and FFY 2025. The budget proposes to continue DSH allotment reductions through FFY 2030 and estimates this will save $32.4 billion over 10 years.

Modifies Institutions for Mental Diseases (IMD) payment exclusions. Allows states that meet certain criteria and requirements to receive federal Medicaid reimbursement for covered services provided to adults with serious mental illness living in IMDs, which is estimated to cost $5.4 billion over 10 years. Also, if a group foster home is considered a qualified residential treatment program (QRTP) and qualifies as an IMD, these QRTPs would be exempted from the IMD payment exclusion.

Other Proposed Medicaid Changes

Eliminates Money Follows the Person (MFP) evaluation and reduces financing for the program, which provides funding to states to help transition people to home and community-based settings from institutions.

Creates new MFP state plan option. Provides states the ability to establish an MFP program with an enhanced federal match for the first five years of services if they spend less than 50 percent of their long-term service and supports funding on home- and community-based services in the previous year.
Extends Medicaid managed care waivers. Permits states to grandfather managed care authorities in waivers and demonstration programs if a waiver has been renewed once before and there are no substantive changes.

Proposals Affecting Individuals Dually Eligible for Medicare and Medicaid

Coordinates review of Dual Eligible Special Needs Plans marketing materials. Allows for joint state and CMS review of marketing materials for Dual Eligible Special Needs Plans.

Revisits Part D special enrollment period for dually eligible individuals. Clarifies the special enrollment period (SEP) for Medicare Part D to allow CMS to apply the same annual election process for all eligible individuals, but maintains the ability for dually eligible beneficiaries to opt into integrated care programs or to change plans following auto-assignment.

Children’s Health Insurance Program

Creates a shortfall fund to replace Child Enrollment Contingency Fund. Calls for creation of a shortfall fund containing unused annual appropriations that could be distributed to states that need additional CHIP funding. This fund serves to replace the Child Enrollment Contingency Fund as of FFY 2022; the Performance Bonus fund would also be eliminated that year.
Aligns Medicaid and CHIP policies on suspending and reinstating coverage for enrollees under age 21 who are incarcerated and released from custody. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act contains a policy requiring states to suspend coverage for youth under age 21 enrolled in Medicaid who are incarcerated instead of terminating coverage. The budget proposes extending this requirement to CHIP programs with the goal of providing access to health coverage upon release.

Children’s Health

Increase in Maternal and Child Health Services (MCH) Block Grant funding to offset reduction in other HRSA-funded programs to support children. Proposes a $60 million increase over FFY 2020 levels for the Title V MCH Block Grant, however this increase is combined with $97 million in reductions in other HRSA-funded programs for children, including: Sickle Cell Disease Treatment Demonstration, Autism and Other Developmental Disabilities, Heritable Disorders in Newborns and Children, and Emergency Medical Services for Children. This assumes states will fund the types of activities these programs previously funded through their MCH Block Grant programs.
Continue funding and disseminating research into neonatal abstinence syndrome. Proposes $2.25 million to continue the Centers for Disease Control and Prevention’s (CDC) work to investigate neonatal abstinence syndrome and share findings to improve care and outcomes for children and families.
Maintains Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. Maintains MIECHV program at current levels.
Level funding proposed for Children’s Mental Health Services grants. The budget proposes $150 million to the Substance Abuse and Mental Health Services Administration (SAMHSA) – consistent with FFY2019 funding – for Children’s Mental Health Services for state, tribes, and communities through competitive grant awards that promote collaboration between juvenile justice, child welfare, and education systems. Up to 10 percent of these funds are proposed for a new demonstration initiative that will target those at risk for developing serious mental illnesses.

Maternal Health

The overall budget proposes $116 million for the President’s Improving Maternal Health in America Initiative. The initiative focuses on health outcomes for all women of reproductive age by improving prevention and treatment, healthy pregnancies and births by prioritizing quality improvement, health futures by optimizing post-partum health, and improved data and bolster research to inform interventions.

Promotes state innovations to improve maternal health outcomes. Expands the State Maternal Health Innovation Grant Programby $30 million, the Alliance for Innovation on Maternal Health (AIM) by $10 million, and the Rural Maternity and Obstetrics Management Strategies (RMOMS) program by $10 million. There is a $50 million increase ($80 million total for FY 2021) to HRSA to improve the overall quality of maternal health services.
Advances state efforts to combat maternal mortality and morbidity. The proposed budget invests $24 million in the CDC to expand maternal mortality review committees to all 50 states and DC.

Women’s Health

Allows states to provide postpartum coverage for pregnant women with substance use disorders (SUDs). Proposes to make it easier for states to offer pregnant women diagnosed with SUD full Medicaid benefits for one year postpartum, which would cost $205 million over 10 years.
Maintains funding for family planning and health related services. Provides $286 million for the Title X family planning program but prohibits certain entities that provide abortion services from using the funding.

Prevention and Public Health

Substance use disorder and the opioid epidemic

Increases grant funds to states for SUD prevention, treatment, and recovery:Adds $85 million over the FY20 budget for State Opioid Response (SOR) grants, bringing the total to $1.6 billion, and includes language to emphasize opportunities to expand activities to address methamphetamine and other stimulants. This increase, however, is coupled with decreases or total elimination of other SUD-related grants, which may lead to states re-aligning their existing activities into this grant.
Reduces substance use prevention funding to states:Strategic Prevention Framework (SPF) grants to states have been reduced by over $109 million, eliminating all by SPF prescription drug funds, which were maintained at $10 million. This appears to assume that state prevention activities can be picked up in the increased SOR grant funds.
Eliminates Medication-Assisted Treatment for Prescription Drug and Opioid Addiction (MAT-PDOA) grantsas part of the Targeted Capacity for Expansion (TEC) program that is designed to fill gaps in treatment capacity for communities. This $89 million reduction appears to assume that these treatment activities can be picked up in the increased SOR funding. Other funding within the program for peer-to-peer grants and special projects will be maintained at $11.2 million.
Eliminates $30 million in federal funding for Screening, Brief Intervention, and Referral to Treatment (SBIRT)program grants, shifting payment for these services to states and third-party payers.
Maintains funding for the Recovery Community Services Programs (RCSP)that will continue and enhance efforts to develop recovery networks and collaboration with peer organizations.
Maintains level funding to states through the Substance Abuse Prevention and Treatment Block Grantat a total of $1.9 billion.
Maintains level funding of $8.7 million for Opioid Treatment Programs (OTP) that provide methadone– funding also supports training and technical assistance for providers.
Continues grants to nonprofitComprehensive Opioid Recovery Centers: Maintains $2 million in grants to nonprofit SUD treatment organizations as part of a four-year project that provides a continuum of treatment services.
Supports State and Tribal Youth Implementation grants: Maintains nearly $30 million to fund 11 new grants and continue 35 existing grants that support states and tribes to address gaps in SUD treatment for youth and caregivers.
Maintains level funding for justice-involved populations with SUD: Provides $89 million for 54 new and 92 existing drug courts and also supports 11 new and five existing Offender Reentry Program grants.
Maintains Building Communities of Recovery programswith $8 million for 20 new and eight continuing grants that support recovery services.
Maintains level funding to prevent and reverse overdoses:
- Provides a continued $41 million in funding to the First Responder Training program through $41.0 million in grants to states, localities, and tribes for purchasing and training of overdose-reversal drugs.
- Provides a continued $12 million through grants to states to purchase and distribute naloxone kits and provide overdose reversal training.
Funding for Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act activities
- $5 million to fund hospitals and emergency departments for alternative pain management treatments intended to decrease opioid prescribing;
- $4 million to train emerging prescribers via 117 grants to medical schools and teaching hospitals to develop curricula to educate students on MAT and providing SUD treatment;
- $4 million to implement post-overdose bridges to SUD treatment; and
- $4.5 million project to 15 select states, to provide an enhanced FMAP (80 percent) for five of those states for some SUD services.
Supports a tool that warns about emerging issues:Adds $10 million for the Drug Abuse Warning Network (DAWN), a surveillance system that can warn about emerging SUD and behavioral health crises.
Increase of $18 million, for a total of $25 million, for the Assertive Community Treatment for Individuals with Serious Mental Illness program to help 33 communities establish, maintain, or expand efforts to engage patients with serious mental illness through emergency and inpatient settings.
$25 million for Assisted Outpatient Treatment to expand SAMHSA’s existing grant program. The program has achieved favorable outcomes in reductions in hospitalization, emergency department visits, and substance use, and increases in mental health functioning.
$35 million increase, including a new 5 percent set-aside, in all states and territories to build crisis systems for individuals in mental health crisis. States will continue to spend at least 10 percent of the funds on early interventions for those experiencing a first episode of psychosis.
$225 million ($25 million increase) for certified community behavioral healthcenters –clinics certified by SAMHSA and funded through a prospective payment model, similar to federally qualified health centers (FQHC).

Provides direct support for rural communities to address SUD needs:Maintains level funding for the Rural Communities Opioid Response Program (RCORP), providing a total of $110 million in grant funds to communities to address prevention, treatment, and recovery while building infrastructure and capacity. Adds new pilot programs to address the unique and emerging needs of rural communities responding to the opioid and SUD crises.
Supports infectious disease prevention and surveillance in high-risk regions:Increases existing funding by $48 million for activities that reduce the transmission of infectious disease and the incidence of potentially fatal cardiac and skin infections as a consequence of the opioid epidemic.
Maintains $475 million and builds on existing support for data capacity in states and other jurisdictions: Through Opioid Abuse and Overdose Prevention funding, CDC will continue to support states in tracking both fatal and non-fatal drug overdoses and prescribing patterns.
Shifts Drug-Free Communities funding to CDC: Moves $100 million from the Office of National Drug Control Policy (ONDCP) that was previously administered by SAMHSA as prevention grants, into the CDC budget.
Proposes a $350 million block grant program for states to address chronic disease priorities, including tobacco control and prevention, nutrition and physical activity, heart disease and stroke, diabetes, and arthritis.

Chronic disease prevention and management

Supports training for behavioral health workforce:Maintains $139 million within Behavioral Health Workforce Development (BHWD) Programs that train professionals in under-served communities (including at health centers) and supports an addiction medicine fellowship.
Expanded support for the Ending the HIV Epidemic initiative:
- $137 million (an increase of $87 million) for HIV prevention services in FQHCs, including pre-exposure prophylaxis (PrEP), outreach efforts, and care coordination in approximately 500 community health centers.
- Additional $95 million allocated for the Ryan White HIV/AIDS program.
Cuts CDC’s total discretionary budget authority by $1.289 billion, compared to 2020 funding levels.Program-level cuts would be $175 million. Other changes include:
- A cut of $427 million for chronic disease prevention and health;
- An increase of $40 million for influenza monitoring and prevention; and
- The creation of the America’s Health Block Grant as a means of reforming state-based chronic disease programs.
Proposes a new user fee on e-cigarettes. The budgetcontains $812 million in user fees to support FDA’s anti-tobacco programs, which includes a new $100 million fee to be collected from e-cigarette manufacturers. It also proposes to move the FDA’s Center for Tobacco Products to a newly created agency within HHS.

Programs Addressing Social Determinants of Health

Some components of the HHS and Department of Housing and Urban Development (HUD) budgets could affect states’ abilities to address health through housing and other social determinants of health initiatives.

Cuts HUD funding by $8.6 billion — a 15.2 percent decrease from the 2020 enacted budget.
Proposes changes to federal investment in rental assistance.The budget request would increase rental assistance to $41.3 billion, which would maintain services for all currently enrolled HUD-assisted households. Uniform work requirements would be placed on “work-able” households.
Adds funds to the Rental Assistance Demonstration program, which supports transitioning public housing to housing voucher and project-based rental assistance units.
Increases funding for lead-safe healthy homesby $69 million to $240 million.
Supports reductions to existing programs:
- Cuts $80 million from Housing Opportunities for People with AIDS, and
- Would eliminate the Community Development Block Grant.
Proposes policy and financial changes for safety net programs.The budget cuts $15.3 billion from the Supplemental Nutrition Assistance Program (SNAP) and cuts approximately $1.1 billion from the Temporary Assistance for Needy Families (TANF) block grant. Would apply consistent work requirements for federally funded public assistance programs, including SNAP, Medicaid, and TANF.

Long-term services and support

Cuts family caregiver services by $35 million, which provides grants to states and territories to fund various supports that help family caregivers care for older adults in their homes.
Cuts state councils on developmental disabilities by $22 million, which are charged with identifying the most pressing needs of people with developmental disabilities.
Reduces National Institute on Disability, Independent Living, and Rehabilitation Research by $21.6 million.
Cuts state health insurance assistance programs by $16 million, which are state programs that receive federal funding to provide free, local health coverage counseling to people with Medicare.

Health Care Infrastructure and IT

Supports rural health care infrastructure. Authorizes up to $2.5 billion for loans to assist communities with developing or improving public services in rural areas, including rural health clinics. Allows critical access hospitals to voluntarily convert to rural stand-alone emergency hospitals, which would enable those facilities to draw in Medicare payments at emergency department rates without the additional burden of maintaining in-patient beds.
Promotes price transparency and health IT interoperability. Finances several agencies to enable implementation of policies related to the President’s Executive Order to encourage price transparency. This includes $51 million to the Office of the National Coordinator for Health Information Technology for efforts to advance interoperability, electronic information sharing, and to align patient health and cost information.

Other Programs

Enforces conscience protection laws. Makes permanent the Weldon Amendment, which prohibits government agencies — including state agencies that receive federal money — from discriminating against entities or individuals who refuse to provide or refer for abortions. Expands the authority of the Office of Civil Rights enforce the Weldon Amendment.

Other proposals addressed in the Administration’s budget include:

Access to better care at lower costs;
Personalized care;
Protection for pre-existing conditions;
Policies to encourage choice and affordability of coverage; and
Policies to address surprise medical bills.

Governors Tackle Health Care Costs, Coverage, and Quality in their State of the State Addresses

February 18, 2020/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Health Equity, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Medicaid Expansion, Population Health, Prescription Drug Pricing, Safety Net Providers and Rural Health, Social Determinants of Health, State Insurance Marketplaces, State Rx Legislative Action, Work Requirements /by Sarah Lanford and Anita Cardwell

In their 2020 state of the state speeches, governors identified new health policy initiatives on a wide range of issues. As of mid-February, 42 governors had delivered speeches or outlined key budget priorities, and all addressed health issues – most commonly strategies to tackle health care costs and behavioral health issues. Below are highlights of the key health themes that governors raised.

Behavioral Health Issues

Mental health and/or substance use disorder issues were the most frequently mentioned by governors, with 33 commenting on these topics. Governors often cited efforts to increase access to behavioral health care services and initiatives to redesign and better coordinate care systems across agencies and providers.

The speeches recognized the significant challenges of addressing the needs of individuals with mental health issues. Gov. Kim Reynolds of Iowa asked legislators to provide sufficient funding to support the state’s strengthened mental health systems for adults and children. Others focused on children’s behavioral health with four governors specifically identifying the need to ensure that schools have an adequate number of mental health professionals. Others called for comprehensive insurance coverage and better integration of behavioral and physical health care that focus on the “whole child.”

View an interactive chart to discover how 42 governors’ addressed health care in their 2020 state of the state addresses.

Gov. Tony Evers of Wisconsin proposed specifically targeting the mental health needs of farmers by creating a new program that will help them access one-on-one counseling and connect them to peer support initiatives. In Colorado, Gov. Jared Polis highlighted a task force, created in 2019, that is assessing the state’s behavioral health system and developing recommendations for reforms. Another theme, raised by at least five governors, is the importance of better addressing the behavioral health needs of justice-involved individuals either prior to incarceration or as they transition back into community settings.

Combating the opioid epidemic continues to be a top priority, with 19 governors commenting on progress made in addressing the crisis. Gov. Brad Little of Idaho praised his state’s prescription drug monitoring program and noted a proposal to provide $30 million to help physicians and pharmacists identify and prevent opioid abuse. Multiple governors cited a number of successful strategies used to reduce overdose deaths, including increasing access to naloxone and outpatient treatment, medication-assisted treatment, and other targeted, data-driven and evidence-based efforts. Kentucky’s governor, Andy Beshear, pledged that any dollar received from the state’s ongoing lawsuit against opioid manufacturers and distributors would be used to end the epidemic.

Curbing Health Care Costs

Twenty-one governors addressed health care affordability. California Gov. Gavin Newsom and New Jersey Gov. Phil Murphy proposed creating offices within their executive branches dedicated to reducing consumers’ health care costs and increasing price transparency. Gov. Eric Holcomb of Indiana is proposing the establishment of an all-payer claims database to increase cost transparency and improve information about hospital pricing and insurance reimbursement.

Connecticut Gov. Ted Lamont is proposing to curb the state’s annual health care cost increases to reduce the outsized impact of medical expenses on residents. Prior to his state of the state speech, Lamont signed an executive order establishing health care cost growth benchmarks and a primary care spending target.

New York’s Gov. Andrew Cuomo proposed expanding the state’s out-of-network surprise medical billing law to require hospitals and emergency room doctors to participate in the independent dispute resolution process to resolve surprise balance bills. Additionally, five other governors urged lawmakers to pass legislation to address surprise billing.

Two governors highlighted money-saving programs that could be expanded to larger populations. Gov. Ron DeSantis in Florida noted a patient savings plan for state employees that increases price transparency that has reportedly saved the state millions of dollars, and he argued that making a similar plan available throughout the state could result in similar savings for more individuals. Polis spotlighted a community purchasing alliance in a Colorado county that pools individuals and employers together and uses their combined purchasing power to negotiate prices with hospitals and doctors directly to save money. He wants to replicate the purchasing alliance model in other parts of his state.

Polis and other governors also recognized reinsurance programs that have reduced premium costs on their exchanges by about 20 percent. Virginia’s governor, Ralph Northam, asked state lawmakers to create a similar program.

Medicaid Reforms and Expansion

This year, 13 governors addressed Medicaid and/or Medicaid expansion. Eight governors commented on recent program improvements, the growth of overall program costs, or cost savings achieved through program reforms. Gov. Charlie Baker of Massachusetts commented that his state “cleaned up” the MassHealth program while achieving the state’s goal to limit increases in total health care expenditures. In New York, Cuomo said the state’s $6 billion financial deficit is primarily due to Medicaid costs and noted that the state will need to restructure financing arrangements with local governments. Gov. Jim Justice in West Virginia proposed creating a Medicaid Families First Reserve Fund of $150 million to ensure services are available to those most in need. In his speech, the Gov. Tony Evers of Wisconsin praised policymakers for extending access to care in rural areas by ensuring that Medicaid covered telehealth services.

Six governors spoke about the value of implementing Medicaid expansion in their states. Idaho’s governor, Brad Little, said that his proposed budget funds a full year of Medicaid expansion with a net-zero impact on the general fund by using the state’s Millennium Fund and county contributions to cover the state’s share. Both Gov. Laura Kelly in Kansas and Evers in Wisconsin advocated for passage of Medicaid expansion bills. Evers noted expansion would bring $1.6 billion in new federal investment to the state’s health care system and Kelly highlighted evidence that expanding Medicaid coverage reduces mortality rates, improves infant and maternal health, helps address opioid abuse, and strengthens rural hospitals.

Health Care Coverage and Access

Nineteen governors mentioned their efforts to ensure that individuals have health care coverage and access to care. They often mentioned state initiatives and proposals to increase coverage options, ensure protections for pre-existing conditions, and broaden access to services. Three governors proposed codifying certain Affordable Care Act (ACA) protections in state law.

Bill Lee, Tennessee’s governor, mentioned the state’s Health Care Modernization Task Force is looking for ways to provide access to high-quality, affordable health care plans, and spoke of plans to increase funding for rural health clinics to improve access to dental care and make investments in the health care safety net. Newsom highlighted plans to strengthen coverage both through Medi-Cal and Covered California. Polis in Colorado explained how the state’s public option proposal will help to both reduce costs and provide greater choices for consumers. Three governors lauded their state-based exchanges’ successes, while Murphy of New Jersey shared plans to establish a state-based exchange. Similarly, Govs. Janet Mills of Maine and Northam of Virginia noted legislation to establish state-based marketplaces to better meet the needs of their residents and address increasing premiums and decreasing enrollment.

In Oklahoma, Gov. Kevin Stitt shared plans to use the Trump Administration’s Healthy Adult Opportunity Medicaid demonstration to expand coverage through a block grant for certain adult populations. The plan – SoonerCare 2.0 – would include work or community engagement requirements and premiums while also providing treatment for substance use disorders.

Prescription Drug Costs

Twelve governors addressed rising drug costs – an increase from last year when seven governors spoke about the topic. The most comprehensive proposal came from California’s governor, whose budget proposes:

Expanding the state’s authority to consider drug prices in other countries when negotiating for state supplemental rebates;
Leveraging the purchasing power of the Medicaid program to negotiate rebates on behalf of targeted populations outside the program; and
Increasing the state’s purchasing program by expanding partnerships with local pharmaceutical purchasers.

The governor’s budget also includes a single market for drug pricing that would combine state purchasing power and create the state’s own generic drug label through partnerships with generic drug manufacturers.

Michigan Gov. Gretchen Whitmer, Polis of Colorado, and New Hampshire Gov. Chris Sununu all supported drug pricing transparency. Illinois Gov. J.B. Pritzker noted his state capped out-of-pocket insulin costs at $100 for a 30-day supply, and three other governors urged lawmakers to pass similar legislation.

Polis and DeSantis of Florida also mentioned their states’ efforts to implement wholesale drug importation programs, while Cuomo, Sununu, and Gov. Lujan Grisham of New Mexico urged their lawmakers to enact a similar program. In addition to a wholesale drug importation program, Cuomo also wants to grant the New York Department of Financial Services additional enforcement authority over spikes in drug costs and to register and regulate pharmacy benefit managers.

Health Care Workforce

Ten governors raised the issue of the health care workforce, with most proposing ways to address provider shortages. Four governors highlighted plans to invest state general funds or to create loan repayment and scholarship programs to help attract providers to underserved areas. To help develop and sustain rural practices, Alabama Gov. Kay Ivey recommended creating a pilot program to incentivize primary care physicians and nurse practitioners to establish services in medically underserved areas and asked legislators to support other rural health initiatives to increase care access. Gov. Kim Reynolds of Iowa shared plans to increase the state’s capacity to provide obstetric services through a fellowship and tele-mentoring program that will train family practice physicians to specialize in this type of care. Mills of Maine noted that the state is providing $75 million over two years to nursing homes, in part to help fulfill their workforce needs. In Washington State, Gov. Jay Inslee highlighted the state’s multi-employer, multi-union health care apprenticeship program.

Other Health-Related Issues

Most governors mentioned other health-related accomplishments and proposals. These included reducing tobacco and vaping use among youth, family and medical leave, and maternal health. Governors in seven states expressed concerns about the rate of tobacco use by youth. California’s Newsom supports a tax of $2 per 40 milligrams of nicotine in vaping products that will go into effect in 2021, while New York and Rhode Island governors applauded lawmakers for banning flavored e-cigarette products last year.

Five governors praised their states’ paid family and medical leave policies, and others expressed support for implementing these types of initiatives. Sununu of New Hampshire urged legislators to pass a bill to establish a voluntary paid family leave program, Lee of Tennessee proposed 12 weeks of paid family leave to eligible state employees, and Gov. Phil Scott of Vermont indicated he would soon be introducing a voluntary paid family leave plan. Gov. Lujan Grisham of New Mexico highlighted her proposed Senior Dignity Fund to provide seniors and their caregivers with support.

Four governors expressed support for maternal health programs. Whitmer of Michigan plans to expand access to home visiting programs, particularly for women of color, and Virginia’s Northam urged lawmakers to pass a health equity budget that would give new mothers access to care for a year after their baby is born. Lee of Tennessee proposed expanded prenatal and postpartum coverage, including a pilot program to extend postpartum coverage to 12 months for mothers covered by Medicaid.

Many governors also mentioned the importance of social determinants of health and public health initiatives. Next week, the National Academy for State Health Policy (NASHP) will release a chart and blog that highlight how governors plan to address health-related social and economic factors in 2020, including education, housing, jobs, and the environment, among other topics.

Given the wide range of health initiatives proposed by governors, it is clear states will continue to pursue innovative health policies and programs in 2020. NASHP will track many of these proposals as they take shape.

Transforming Systems to Improve Health Upstream: Lessons from Washington’s Accountable Communities of Health

January 17, 2020/in Policy Washington Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Equity, Health System Costs, Healthy Child Development, Maternal, Child, and Adolescent Health, Oral Health, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Safety Net Providers and Rural Health, Social Determinants of Health /by Amy Clary

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.

Idaho Develops a Medicaid Value-Based Payment Model for its FQHCs, Based on Cost and Quality

December 9, 2019/in Policy Idaho Blogs, Featured News Home Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Eligibility and Enrollment, Health Coverage and Access, Health IT/Data, Health System Costs, Medicaid Managed Care, Medicaid Managed Care, Population Health, Quality and Measurement, Safety Net Providers and Rural Health, Social Determinants of Health, Value-Based Purchasing /by Neva Kaye

Starting in early 2020, Idaho will launch a new value-based payment model that will compensate federally qualified health centers (FQHCs) and other providers based on how much they improve the cost and quality of care delivered to Medicaid enrollees. The agency plans to sign contracts to implement the model in January, with implementation beginning July 1, 2020.

Both FQHCs and other types of providers have expressed interest in participating in this value-based model.

Background

Idaho has operated a Medicaid Primary Care Case Management (PCCM) program since 1993 and has worked to advance patient-centered medical homes (PCMHs) since 2008, when the Governor’s Select Committee on Health Care recommended PCMH implementation as a priority. In 2016, Idaho Medicaid launched its Healthy Connections program, which blended the two initiatives. In 2017, the Medicaid agency began working to incorporate value-based payment into Healthy Connections. The agency submitted a State Plan Amendment (SPA) in October 2019 to secure Centers for Medicare & Medicaid Services (CMS) approval of its new payment model, which awards payment to FQHCs and other providers based on how much they improve costs and quality of care provided to Medicaid enrollees.

How Healthy Connections Value Care Operates

In the Healthy Connections program, primary care providers (PCPs) are paid on a fee-for-service basis, plus a per member per month (PMPM) care management fee. Care management fees range from $2.50 to $10 and vary based on the characteristics of the PCP’s practice and the patients attributed to the PCP. Specifically, PCPs qualify for one of four reimbursement tiers based on their capabilities – those who qualify for higher tiers receive higher care management fees. The types of capabilities considered in tier assignment include being able to both send and receive data from the state health data exchange or offering extended hours of service to patients. Also, the PMPM care management fee is higher for beneficiaries with disabilities or special needs.

The Healthy Connections Value Care (HCVC) program will operate under Section 1905(t) of the Social Security Act and builds on the structure of the Healthy Connections program. Participating PCPs will continue to receive both fee-for-service payments and care management fees. Participating PCPs, including FQHCs and rural health centers (RHCs), will participate as one of two types of organizations:

Accountable primary care organizations are primary care clinics (or groups of clinics) that serve at least 1,000 Medicaid enrollees. Clinics that wish to participate as a group must create a legal entity and sign a joint operating agreement. (Hospitals may not participate in this type of organization.)
Accountable hospital care organizations are integrated networks of providers that include an acute care hospital and serve at least 10,000 Medicaid enrollees.

Both types of organizations (referred to collectively as value care organizations or VCOs) are expected to contain Medicaid’s total cost of care (TCOC) and improve quality for their Medicaid patients. Both types of VCOs will share in any savings or losses they generate. The specific amounts will be determined through an annual settlement process. Each VCO’s share of savings will depend on the VCO’s performance. A VCO’s share of losses will not be adjusted for performance. However, an accountable primary care organization’s liability for losses is limited to the total amount paid to the organization in care management fees. Importantly, because the model builds on the fee-for-service payment structure and limits accountable primary care organizations’ risk to the amount paid in care management fees, the model enables FQHCs to participate without placing their federally-mandated per visit payments at risk.

How Performance Determines Savings

Shared savings will be distributed to VCOs based on their performance on reducing growth in total cost of care and achieving specified quality measures goals. Idaho Medicaid chooses the measure set in conjunction with VCOs and updates the set each year. For the first year of the program, the set will include hospital re-admissions, emergency department visits, breast cancer screening, diabetes HbA1c test, well-child visits during the first 15 months, well-child visits during ages 3 to 6 years, and well-care visits for adolescents. Idaho publishes the measure specifications in its Healthy Connections website. If a measure does not apply to a practice, that measure is excluded from consideration when calculating share of savings (e.g., pediatric measures are only considered if the practice serves children). However, hospital-related measures apply to all VCOs as PCP performance affects those outcomes.

The Medicaid agency will retain 20 percent of savings produced by a VCO for administration. The VCO can earn the remaining 80 percent. The VCO will earn half of the available savings (40 percent of total savings) if it maintains quality of care, which is defined as maintaining baseline performance – the individual clinic’s performance on the measure in the previous year – on at least half of the measures in the quality measure set. This half is referred to as the efficiency pool. The other half of the available savings, referred to as the quality pool, can be earned by showing acceptable improvement on the measures in the set — improvement on more measures secures a greater share of savings. Acceptable improvements are either:

Performing at 90 percent of the state or national benchmark established for the measure (aspirational goal); or
Producing a 3 percent reduction in the gap between the VCO’s performance and the aspirational goal (individualized annual improvement target).

Supporting Participating Providers

Healthy Connections staff provide support to practices seeking to qualify for a higher tier. Idaho Medicaid plans to continue this support and to offer new types of support to help VCOs succeed. The state has structured other features of the program to encourage provider engagement:

Enrollment policies: On July 1, 2019, Idaho Medicaid implemented an annual fixed enrollment policy (enrollment lock-in). Previously Medicaid enrollees could change their PCCM provider at any time. Under the new policy, enrollee will have 90 days from enrollment with a PCCM provider to change providers. If an enrollee does not change providers within the 90 days, the individual will not be able to do so until that next annual enrollment period, which occurs from May 1 to June 30 of each year. Enrollees can request a change outside of the enrollment period due to special circumstances, such as moving out of the provider’s service area or poor quality of care. This new enrollment policy supports VCOs by creating a more defined and stable panel of patients for the VCOs to manage.

Information on provider performance: Once an FQHC indicates an interest in participating in the HCVC program, Idaho Medicaid generates a cost/quality dashboard showing the clinic’s current performance on both cost and quality. Idaho Medicaid also plans to establish an automated claims data portal for VCOs that will enable them to view their performance on selected qualify measures on an ongoing basis.

Community-level investments in patient health, including addressing the social determinants of health (SDOH). Idaho Medicaid plans to form and support two regional advisory groups to support the work of the VCOs in the region. Regional care collaboratives will consist of physicians who participate in the HCVC program and are responsible for identifying the health care needs in the region and seeking collaborations to improve cost and quality by addressing those needs. Community health outcomes improvement councils will be composed of community stakeholders and are responsible for identifying opportunities to improve health and wellness, including addressing SDOH in their communities.

A Medicaid Perspective

The Idaho Medicaid agency pursued VBP because it wanted to foster cost control, but not at the expense of quality. After reviewing their options, the agency chose to pursue the HCVC model because it allowed it to “begin where they are” by building on the existing PCCM payment structure. The existing Healthy Connections payment model is also well known to – and has the strong support of – PCPs. The agency developed the HCVC model with the input of both hospitals and PCPs, including FQHCs. As the agency sought feedback on successive iterations of the model, the model evolved. Early versions of the model proposed that accountable hospital care organizations would share both savings and losses, but accountable primary care organizations would share only savings. In early 2019, the agency added shared loss for the accountable primary care organizations at the suggestion of hospitals and after consultation with primary care providers.

Agency representatives report they have encountered two major challenges. The first was determining which federal authority to use to implement the model. It could have been implemented as managed care under Section 1932(a) of the act or as fee-for-service under 1905(t).* Idaho ultimately decided that 1905(t) would better support the HCVC model for a number of reasons. Implementing the model under 1905(t) enabled Idaho to avoid the need to require primary care organizations to secure agreements with the hospitals, specialists and other providers whose costs are included in calculations of savings/losses when using a TCOC approach. Idaho found the State Medicaid Director Letter on Policy Considerations for Integrated Care Models, as well as consultation with CMS staff, to be very helpful in guiding the decision. Reflecting on their experience, agency staff advise other states to consult with CMS early in the development of new VBP models. The agency also found it valuable to engage outside experts to help staff evaluate policy options and determine how each option would affect operation.

The second challenge was data. Idaho Medicaid is seeking to build a transparent model — one where participating providers can easily track their performance on cost and quality and have the information they need to improve on both. Idaho Medicaid has a small data team and has found it challenging to implement their data plans. For example, agency staff had hoped to have an automated claims data portal operating at program launch, but now anticipates that the portal will need to launch after January 2020. Similarly, the agency plans to give VCOs the information they need to make referral decisions on both quality and cost, but will not be able offer cost information at program launch.

FQHCs have already expressed interest in participating in the HCVC model as accountable primary care organizations. State officials believe the new model plays to FQHCs’ strengths in panel management and the efforts they have already made to become effective, efficient PCMHs for their patients. Officials, note, however, that in order to produce savings, FQHCs may need to change some aspects of their practice. For example, FQHCs may need to identify which providers in a group (e.g., labs or specialists) produce equally good health outcomes, but at less cost to the Medicaid program and then shift their referral patterns to increase referrals to the less-costly providers within the group.

The FQHC Perspective

FQHC representatives report they believe the new model is a move in the right direction. They expressed concerns about some specific aspects of the model, but overall, believe it will be good for their patients and that FQHCs will succeed under the new model. Idaho’s 16 FQHCs serve more than 50,000 Medicaid enrollees living in 54 communities throughout the state. In 2012, 14 FQHCs formed the Community Health Center Network of Idaho. This FQHC-owned network has engaged in VBP contracts with commercial payers since 2014 and also operates a Medicare accountable care organization. This experience and support give Idaho’s FQHCs several advantages that should help them thrive under the HCVC model. Because the network is statewide and HCVC was originally conceived as a purely regional model, initial FQHC interest in participating as a statewide network presented some challenges. But the Medicaid agency adapted the approach and the FQHCs are now interested in joining the program as accountable primary care organizations when the final VCO contract and data are available.

FQHCs also see gaining access to the Medicaid data they need to manage cost and quality as one of the greatest advantages of participation — but they also identified data as a challenge. Although the dashboards the FQHCs received from Medicaid were helpful, they did not provide sufficient detail to enable FQHCs to manage their population as they will need to under the HCVC model. The network anticipates that the Medicaid agency will soon share claims level data, and the network plans to use the data to produce patient registries, identify gaps in patient care, and inform participation decisions.

The FQHCs also identify sharing losses from the program’s inception as a challenge. They would prefer to have one to two years of shared savings-only before they had to also share losses with the Medicaid agency. Officials are confident that their strategy of increasing primary care expenditures to reduce TCOC will produce savings. However, it has been the FQHCs’ experience with other payers that it takes time to fully understand any VBP model and identify what they need to do to succeed under it. For example, because the individual FQHCs serve tend to be more high-risk than those served by other providers, FQHC representatives would prefer to test the Medicaid agency’s approach to risk-adjustment in TCOC for a year or two before being asked to live with the results of the approach. Limiting accountable primary care organizations’ risk just to the care management fee could make sharing in losses from the start of the program more palatable. However, FQHC officials remain concerned that any loss of the income from care management fees will endanger the care management programs that FQHCs have developed with that funding.

Conclusion

The HCVC payment model is Idaho’s next step on its path to:

Ensure that Medicaid enrollees are served by effective PCMHs; and
Reward practices that produce savings while maintaining or improving quality with increased payments.

Some challenges, particularly in ensuring that primary care providers have the data they need to manage their patients’ care, remain. However, stakeholders who were interviewed indicated that Idaho was on the right path and were optimistic about the new model’s success.

*A July 2012 letter from CMS indicates that states can also operate integrated programs under other federal authorities, including waivers, but Idaho eliminated these options early in program development

Acknowledgements: The National Academy for State Health Policy wishes to thank Matt Wimmer and Meg Hall of Idaho’s Division of Medicaid and Yvonne Ketchum-Ward of the Idaho Primary Care Association for their contributions. The author also wishes to thank Trish Riley and Kitty Purington of NASHP, as well as NASHP’s Health Resources and Services Administration project officer, Lynnette Araki, and her colleagues for their review and guidance. Finally, the author thanks Kristina Long of NASHP for her assistance in the preparation of this case study.

State Officials Consider Patient Preferences when Evaluating Telehealth Evidence

December 2, 2019/in Policy Alaska, California Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Population Health, Safety Net Providers and Rural Health /by Johanna Butler

When exploring new evidence about the effectiveness of telehealth, state policymakers want to know which interventions consumers prefer and are scalable for a range of populations. In addition to working to ensure that new telehealth tools are evidence-based and effective, officials want to make sure both patients and providers are interested in utilizing them.

The National Academy for State Health Policy’s (NASHP) Telehealth Affinity Group recently convened to discuss two studies funded by the Patient-Centered Outcomes Research Institute (PCORI):

One ongoing study in rural Alaska is testing how well a new school-based screening and referral process – combined with a telemedicine consultation – can expedite the diagnosis of hearing loss in children. In the 15 participating communities, children are screened for hearing loss at school. Under the usual model, parents of children identified as needing a follow-up consultation are sent a letter with a request to take their child to a clinic. Under the intervention, the school and clinic work together to schedule a telemedicine appointment, during which a community health aide who is on-site at the local clinic works with specialists at a remote location to do follow-up testing. While the study does not yet have full results, the region saved $18 million in 2016 and 91 percent of patient travel to specialists was avoided. Data will be collected until February 2020.
Another study investigated the use of patient portals – secure websites where patients can view health records and electronically communicate with doctors – among adults with chronic diseases in the Kaiser Permanente Northern California health system. Researchers wanted to understand how portal use impacted patients’ utilization of health care services. Among the eligible participants, 68 percent of patients created a patient portal. Portal use was associated with more office visits, fewer emergency department visits, and fewer preventable hospitalizations. Although portal use was connected to better outcomes, the results were somewhat limited as the study focused on a closed health care system. It is also difficult to discern if patients’ portal engagement impacted their behavior. For instance, it is unclear if these patients may have been proactive participants in their care even without the portal.

In response to these telehealth studies, affinity group members expressed their interest in understanding:

How can an intervention be scaled to diverse populations? Would the rural, school-based intervention also work in urban areas? Could a similar telehealth invention be successful for adults who need follow-up care?
How do patient preferences impact the adoption of telehealth? To what extent does the evidence support the success of a specific intervention itself, versus a specific population’s interest in utilizing it?
What is the appropriate role of state officials in promoting evidence-based telehealth?

Scaling Interventions to Broad Populations

As affinity group members explore new evidence about telehealth, they expressed the desire to better understand how an intervention can be scaled to meet the needs of the populations they serve. The Alaska hearing loss study is of particular interest to officials because it offers a promising approach that could be adapted to connect a range of rural or underserved communities to specialists. The affinity group was very interested in the projected savings and how the community-focused design could be applied to their own states.

Members expressed skepticism about the applicability of the patient portal tool for the populations they serve. State officials questioned how this intervention might be scaled beyond a closed, integrated health system like Kaiser Permanente. For example, would an investment into an online portal for a state’s Medicaid population – some of whom may not have the same access to the internet as other higher-income populations – yield the same improved health outcomes?

Patient Preferences Impact Telehealth Adoption

A prominent theme from the discussions of both of the studies was the importance of patient preferences for care. Officials noted that evidence-based interventions that improve outcomes or lower costs must still be supported by patients and providers in order to warrant investment. As more telehealth evidence emerges, particularly relating to patient-focused tools, policymakers want to understand how likely members of their targeted populations are to use telehealth.

The Role of State Officials in Promoting Telehealth

Beyond adaptability, state officials want to know how they can invest or most effectively promote the adoption of telehealth through their roles as payers and/or regulators. Officials wonder if there could be opportunities to use existing funding to pay for or incentivize use of patient-directed telehealth tools, like an online portal, to work toward improved health outcomes for targeted populations. There is also interest among the affinity group in considering how state agencies could promote or encourage community-level collaboration, similar to the Alaska example, to implement a successful telehealth intervention.

While the two studies prompted more questions, state officials value the research investment in telehealth. While the affinity group discussions often raise issues outside the scope of testing specific interventions, researchers may benefit from understanding the broader context state officials work within when making or changing policy. It is critical for state officials to understand scalability, how to engage diverse, dynamic populations or to have tools to decide whether or not their states can make the investments needed to implement new interventions.

NASHP’s Telehealth Affinity Group will continue to meet and discuss emerging PCORI research on telehealth in the coming months. To learn about the group’s first meeting, read the NASHP blog, States Explore Emerging Evidence to Learn New, Innovative Uses of Telehealth.

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State Officials Consider Patient Preferences when Evaluating Telehealth Evidence

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