Ohio

States Work to Improve Long-Term Care in the Age of COVID-19

November 23, 2020/in Policy Ohio, Washington, Wisconsin Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, COVID-19, Health Equity, Long-Term Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, State Recommended Resources, State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by Paige Spradlin

Nursing home residents account for at least one-third of COVID-19 deaths, and this disparity reveals numerous problems with infection control in institutional settings. As a result, many states are rethinking and restructuring their long-term services and supports (LTSS) programs.

A recent National Academy for State Health Policy (NASHP) annual conference session explored what states have learned during the current health crisis that could improve LTSS during and beyond the pandemic. State officials from Washington State, Wisconsin, and Ohio highlighted their states’ responses to the current crisis, emerging innovations, and prospects for restructuring LTSS in a post-COVID-19 era.

Maximizing the Flexibility of Home- and Community-Based Waiver Services

Washington State, home to the first nursing home to be ravaged by COVID-19 in the United States, immediately worked with federal partners to maximize the flexibility of home- and community-based waiver services following its first reported case. The state was among the first to receive approval from the Centers for Medicare & Medicaid Services (CMS) for its 1135 and 1115 Medicaid waivers, which provided enrollees with increased access to services during the COVID-19 pandemic and additional supports to LTSS workers. State officials noted that the presumptive eligibility measures incorporated into these new waivers ensured that individuals were able to access the LTSS they need without having to wait for their applications to be fully processed. This flexibility has helped minimize administrative burdens on eligibility workers as states face increased demands on their Medicaid programs.

Like Washington State, Wisconsin utilized waivers to implement much-needed flexibility within its home- and community-based services (HCBS) provided through the state’s 1915(c) Medicaid waiver. Importantly, the state expanded the ability of its HCBS agencies to provide waiver services remotely, including care coordination and day services. The state also modified service delivery for Medicaid acute primary services, allowing these to be delivered through telehealth and other technologies to comply with social distancing.

Leveraging State Resources to Prevent and Contain Outbreaks for High-Risk Individuals

To contain and prevent outbreaks, Ohio relied on the following guiding principles to support its nursing facilities throughout the pandemic:

Leverage regional and local leadership to coordinate a unified response; and
Provide resources to support nursing facilities, including additional health services and technical assistance. These efforts were supported by $314 million from the US Department of Health and Human Services (HHS), some of which was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, that was specifically dedicated to Ohio skilled nursing facilities (SNFs). Each SNF in Ohio with six or more certified beds was eligible to receive a fixed distribution of $50,000 plus an additional $2,500 per bed.

To coordinate a unified state COVID-19 response, Gov. Mike DeWine and leaders from a major hospital chain created three health care zones divided among the state’s large metro areas to manage hospital capacity and maintain patient level of care during an anticipated surge in hospitalization services. State officials in the three health care zones paired nursing facilities with local hospitals to manage distribution of personal protective equipment (PPE) and to ensure that staff were well-equipped to treat patients.

Additionally, the state developed the following resources to support nursing facilities, staff, and patients throughout the pandemic:

A toolkit developed by the Ohio Department of Aging, Department of Health, Department of Developmental Disabilities, and Department of Medicaid to assist nursing facilities with assessing residents and determining their care needs during a COVID-related surge in service utilization;
Increased testing services for nursing facility staff as mandated by a Public Health Order signed by the director of the Ohio Department of Health and conducted by the Ohio National Guard over a period of two months; and
Congregate Care Unified Response Team (CCURT) Bridge Team, composed of staff from the Ohio Department of Health and Ohio Department of Medicaid, to assist nursing home staff with decision making in emergency situations and coordinating facility communication with relevant state agencies, the Emergency Operations Center, health care zones, and hospitals in the area.

Many of the steps taken by Ohio state officials track with the principal recommendations issued by the CMS-appointed Coronavirus Commission Report for Safety and Quality in Nursing Homes, including establishing a statewide strategy for testing in nursing homes, coordinating with state and local leadership, leveraging resources to support the nursing home workforce, and assembling a long-term care emergency response team to evaluate and guide emergency care coordination. With these strategies and systems in place, Ohio and other states now have the infrastructure to better manage infection control in institutional settings for future public health emergencies.

Post-COVID-19 Planning

While many of the policy changes highlighted here are temporary and in effect only during the pandemic, it is important to understand the impact of these changes on cost and quality of life to determine which, if any, should be retained after the pandemic. State officials from Washington State, Ohio, and Wisconsin reported they found the following flexibilities especially helpful:

Presumptive eligibility for LTSS, so the state can initiate home- and community-based services as quickly as possible;
Waiving plan signatures and self-attestation in favor of post-enrollment verification to ensure that enrollees receive timely supports; and
Flexibilities for respite care for family caregivers, particularly those supporting individuals with intellectual and developmental disabilities, to reduce stress and burnout.

State officials noted it would be helpful to receive support from CMS in retaining these flexibilities. State officials also suggested that broader legislative changes to Medicaid, such as streamlining Medicaid authorities that support HCBS and making HCBS mandatory state plan services on par with nursing home care, would help reduce administrative complexity and facilitate rebalancing efforts.

States Craft Collaborative Approaches to House the Homeless and Curb COVID-19

July 13, 2020/in COVID-19 Ohio Blogs, Featured News Home Behavioral/Mental Health and SUD, Blending and Braiding Funding, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Equity, Housing and Health, Physical and Behavioral Health Integration, Population Health /by Eliza Mette and Jodi Manz

People with substance use disorders (SUD) who are experiencing housing instability or homelessness are particularly at risk during the COVID-19 pandemic, leaving states challenged more than ever to identify effective housing strategies that can simultaneously address the complex treatment needs of people with SUD while also curbing the spread of COVID-19 in congregate settings.

Addressing the needs of homeless individuals with SUD during the pandemic requires states to involve partners at various levels. Below are some of the collaborative and successful strategies states are taking to protect and support particularly at-risk individuals.

Separate, quarantine, and isolate. Massachusetts, through its COVID-19 Response Command Center, has worked to create sites for socially distanced living and quarantining across the state to minimize the spread of COVID-19 within congregate living settings. The state has also created five Isolation and Recovery (I&R) Sites, which provide a safe recovery space for individuals experiencing homelessness who have tested positive for COVID-19. Individuals recovering at I&R Sites are provided with all necessary services to ensure a safe recovery period, including behavioral health care and other supportive services. Interdisciplinary care teams offer comprehensive services to individuals recovering at the sites and ensure access to needed treatment, including prescriptions. Health care providers are also on-site, and partnerships with local behavioral health providers facilitate the provision of medications for opioid use disorder (MOUD) maintenance, telepsychiatry and counseling, support for self-administered MOUD, and other services.

Establish guidelines for non-congregate housing options. Ohio has published guidelines to assist communities across the state in leveraging hotels/motels for non-congregate housing options during COVID-19. The guidelines make clear that communities planning to establish isolation, quarantine, and specialized arrangements (units for people who are at high risk for poor outcomes or have significant behavioral health needs) must coordinate with local health departments and health care systems. The guidelines also establish procedures for hotels and motels providing housing, including staffing, equipment, and supply guidance. Ohio’s guidelines offer direction on support services, including telehealth for both medical and behavioral health services, case management, safe syringe disposal, assistance with prescription refills, and other supports for individuals with SUD.

Access to affordable, safe housing is a critical social determinant of health.

• People without stable housing experience significantly higher rates of both physical and mental illness.

• Investments in affordable housing programs lead to health care cost savings and better health outcomes.

Substance use disorder (SUD) and homelessness are mutually reinforcing. Underlying risk factors for homelessness can be aggravated by SUD, while people with SUD who lack stable housing have unique barriers to maintaining recovery, including lack of access to transportation to treatment, difficulty receiving and storing medications, and inconsistent social supports.

Reduce shelter density. Maine’s Department of Health and Human Services and State Housing Authority have collaborated to secure contracts with multiple hotels around the state to provide temporary housing for people who are homeless. Although not specifically tailored to individuals with SUD, this state initiative provides shelter to individuals during periods of quarantine and self-isolation. In total, the state has rented 115 hotel rooms at a cost of $7,950 per day. The state response has also resulted in innovative community partnerships with a state university. The University of Southern Maine formed a partnership with Preble Street Resource Center, a local shelter, to open one of its gyms to serve as an overflow shelter. At the beginning of the pandemic, Preble Street reached out to its community in search of additional space to allow for socially distant housing, and the university offered its space and staff to help set-up 50 beds. The state’s efforts have allowed its most populated shelters, which are frequently over capacity, to house appropriate numbers of individuals while keeping them separate from those who have tested positive for COVID-19 or are waiting for a test result.

As COVID-19 continues to sweep through communities across the country, states are being called to action to support their most vulnerable populations – and often those populations are in congregate care settings that pose social distancing and other pandemic-related challenges. States are developing approaches to effectively provide safe housing while treating complex health and behavioral health care issues and are doing so while anticipating significant impacts to their budgets. Investing in collaborative partnerships to implement service-driven models of care and learning from rapidly developed COVID-19 housing interventions can help states provide cost-effective care while working to prevent the rapid spread of COVID-19 within these communities.

Six States’ Strategies to Providing Home Health Services to Children Enrolled in Medicaid

July 6, 2020/in Policy Connecticut, Delaware, Iowa, Maryland, Ohio, Washington Blogs, Featured News Home Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, Chronic and Complex Populations, Community Health Workers, COVID-19, Health Coverage and Access, Health Equity, Integrated Care for Children, Long-Term Care, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health, Workforce Capacity /by Olivia Randi and Kate Honsberger

To improve the quality of services for children and youth with special health care needs (CYSHCN) and reduce health care costs, states are implementing strategies to improve access to home health services. Of particular importance as states confront COVID-19-related budget challenges, home health services can help to avoid costly emergency department use, hospitalizations, and institutional care.

The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) Medicaid benefit mandates coverage of all medically necessary services for children under age 21 who are enrolled in Medicaid. However, states vary in their definitions of medical necessity, prior authorization processes, and approaches to home health service delivery.

Prior to National Academy for State Health Policy’s (NASHP) analysis, there was limited information available on home health services for CYSHCN, and few studies had analyzed states’ approaches to delivering these services.

In its new report, State Approaches to Providing Home Health Services to Children with Medical Complexity Enrolled in Medicaid, NASHP examines six states’ (WA, OH, IA, MD, DL, CT) strategies to support access to home health services for CYSHCN. These include addressing provider capacity, advancing the person-centered medical home model, streamlining prior authorization processes, collaborating with Title V Maternal and Child Health Services Block Grant Programs for CYSHCN, and promoting stakeholder collaboration.

Home health services are provided in a person’s residence and include:

Nursing services;
Home aide services provided by a home care agency;
Medical supplies and equipment for use in home-based settings; and
Physical and occupational therapy, or speech pathology and audiology services.

Through analysis of these states’ home health service delivery systems, NASHP identified several key insights that other state health policymakers can leverage in their own systems to improve service delivery and reduce costs. A shortage of home health providers was the primary challenge that states faced in delivering these services to CYSHCN, which states have addressed through training programs and by increasing or modifying reimbursement policies.

Partnerships across agencies and families were recognized as key to developing informed strategies to improve home health services for CYSHCN. States have leveraged these partnerships, as well as implemented technologies and streamlined processes, to deliver more coordinated, cost-effective home health services.

Prioritize efforts to address provider shortages. To address the lack of home health provider capacity, several states have focused on developing, enhancing, and raising awareness of training programs to increase the supply of home health agency staff. States have also modified their reimbursement policies, including increasing their reimbursement rates for home health providers, and proposing a structured fee schedule to streamline the reimbursement process for home health agencies. Ohio, for example, allows for reimbursement of family caregivers for providing services for children enrolled in its Medicaid waivers in an effort to increase home health service provider capacity.
Leverage the benefits of cross-sector and stakeholder collaboration. Partnering with a variety of state agencies, including Title V CYSHCN programs, provider groups, families, and other key stakeholders helps build the infrastructure necessary to deliver comprehensive home health services to CYSHCN. Stakeholder groups in Ohio, Maryland, and Delaware were crucial to developing strategies to improve access to home health services for CYSHCN. Two of these states also referenced the importance of family engagement to inform the work of the stakeholder group. In Ohio and Iowa, Medicaid agencies, providers, and Title V CYSHCN programs have formed collaborations to improve care coordination and access to home health services for CYSHCN.
Adjust service delivery models to increase capacity. The medical home is a primary care service delivery model that emphasizes coordinated care through a team-based approach. Connecticut and Delaware, have looked to this model to encourage providers to improve care coordination for CYSHCN, including home health services. States have also looked to streamline their prior authorization processes to reduce administrative challenges for CYSHCN to access home health services. Delaware and Iowa are implementing changes to simplify this process through a “flag” in their data system and by developing a standardized prior authorization form for all managed care plans, respectively.

Other key insights from this analysis include seeking regular feedback from families, strengthening oversight, and customizing fee-for-services and managed care approaches. States interested in improving children’s access to home health services through Medicaid may benefit from the approaches implemented by the six states highlighted in this issue brief. For a list of NASHP’s reports, blogs, and other resources related to improving care for CYSHCN, please click here.

Ohio CHIP Fact Sheet

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

States Assert their Drug Purchasing Power to Capture Savings for Medicaid

November 18, 2019/in Policy Ohio, Washington, West Virginia Blogs, Featured News Home Administrative Actions, Cost, Payment, and Delivery Reform, Health System Costs, Model Legislation, Newly-Enacted Laws, Prescription Drug Pricing, State Rx Legislative Action /by Johanna Butler

In the face of rapidly rising prices, state Medicaid programs are asserting their prescription drug purchasing power through more active oversight of the administration of prescription drug benefits. As major drug purchasers, state Medicaid programs have leverage to lower costs without action from state legislatures. Ohio, Washington, and West Virginia have recently deployed a range of strategies to curb drug costs:

Ohio requires Medicaid managed care plans to adopt transparent, pass-through payment models with their pharmacy benefit mangers (PBMs).
To maximize rebate potential and reduce administrative burden, Washington State is implementing a single preferred drug list (PDL) across Medicaid fee-for-service and managed care plans.
West Virginia carved out the prescription drug benefit from its managed care contracts and now acts as its own PBM to increase oversight of drug purchasing and reduce costs.

Below is a detailed explanation of how these three states have implemented innovative purchasing strategies for their Medicaid pharmacy purchases.

Ohio Requires a Transparent, Pass-Through PBM Payment Model

A 2018 report found that PBMs retained profits of $224 million by creating a “spread” between what Medicaid paid PBMs for pharmacy claims versus what PBMs paid pharmacies. In response, Ohio mandated that managed care plans switch to contracts with transparent, pass-through payment models with the PBMs. With a transparent, pass-through model, states can ensure PBMs do not profit off this spread-pricing practice and pass through drug discounts and rebates to managed care plans. PBMs are instead reimbursed more directly through fees. Wisconsin’s state employee health plan requires a similar, fully transparent, pass-through payment model. Through this change in contract terms, Wisconsin’s per member, per month drug costs were more than 10 percent below industry averages from 2016 to 2018.

Ohio state officials report making significant changes to managed care contracts to increase transparency, reporting, and accountability pertaining to their PBM contracts and drug payments. Through enhanced reporting from managed care plans, officials have been able to confirm the successful implementation of the pass-through model. Ohio’s 2020 budget goes a step farther, requiring all managed care plans to contract with a single PBM, which will be selected by Ohio’s Medicaid department, giving the state more authority over drug purchasing.

Washington State: Implementing a Single, Standard Medicaid PDL Across MCOs

In January 2018, the Washington Healthcare Authority implemented a single PDL – a list that indicates which drugs are “preferred” by the state and do not require prior authorization. Washington’s Medicaid program transitioned from six different PDLs across managed care organizations (MCO) to one. A single PDL provides a number of advantages, including:

Administrative ease for providers, patients, and pharmacies;
Rebate maximization by selecting drugs with the lowest cost or maximum rebate potential;
Rebate transparency for more accurate cost management; and
Fewer disruptions for patients who may switch between managed care plans.

To transition to a single PDL, Washington submitted two State Plan Amendments – one for the single PDL and one to include managed care plans in its supplemental rebate contracts through a multi-state purchasing pool for drugs on the PDL. Washington also added and amended contracts with a number of vendors to ensure the Medicaid agency and managed care plans had access to the same drug data sources to allow seamless collaboration – an important detail for ensuring care coordination. Officials met with managed care plans weekly to plan and roll out the three phases of implementation, ensuring that drugs added to the PDL were clinically appropriate and cost-effective for the state and the plans. Implementation began with 27 drug classes and is expected to be complete by April 2020 with almost 400 different drug classes included in the PDL.

West Virginia: Carving Prescription Drugs Out of Managed Care

In 2017, West Virginia Medicaid began acting as its own pharmacy benefit administrator under a fee-for-service model, after carving out prescription drug benefits from its managed care contracts. To accomplish the prescription drug carve-out, West Virginia:

Added an additional pharmacist to its staff;
Stress-tested its existing claims processing system;
Increased its capacity for prior authorizations; and
Educated the public and its help desk staff about the program change.

West Virginia’s Medicaid program now covers over 550,000 enrollees through a fee-for-service model. State officials report they are able to effectively manage the pharmacy benefit and maintain care coordination across MCOs, while obtaining savings for the state. The prescription drug carve-out led to a savings of $54.5 million in 2018. Additionally, changes to the state’s reimbursement methodology during the carve-out process led to an infusion of $122 million in dispensing fees to the state’s pharmacy community.

While West Virginia is acting as its own PBM, California is carving out the prescription drug benefit from its managed care contracts and contracting with a single PBM to leverage the state’s immense purchasing power. California will use strict contracting terms to ensure greater transparency and cost savings with the contracted PBM. Michigan is currently considering a drug carve-out and legislatures in Louisiana and Nevada prompted their Medicaid programs to explore a potential carve-out of prescription drugs from managed care.

As states strengthen their oversight of drug purchasing, the National Academy for State Health Policy (NASHP) has created and will soon release a model PBM contract for states. Informed by Ohio and Minnesota’s contracts, NASHP’s model contract is designed to help states ban spread pricing and better understand rebate arrangements with their PBMs. To learn more about other administrative actions to curb rising drug costs, read the Administrative Action section of NASHP’s Prescription Drug Pricing website.

Webinar for State Officials Only: Innovations in Medicaid Pharmacy Benefit Management Policies – A Look at Three States

September 30, 2019/in Policy Ohio, Washington, West Virginia Webinars Administrative Actions, Cost, Payment, and Delivery Reform, Health System Costs, Prescription Drug Pricing, Quality and Measurement, State Rx Legislative Action, Value-Based Purchasing /by NASHP Staff

Friday, Nov. 1, 2019
3:30-4:30 p.m. (ET)

Faced with rising prescription drug costs, state Medicaid programs are implementing innovative policies to manage their pharmacy benefit and find savings. This webinar, for state officials only, is an opportunity to hear officials from three leading states:

West Virginia carved pharmacy benefits out of its Medicaid managed care program in 2017 and reports that its shift to a fee-for-service model saved the state over $54 million in state fiscal year 2018.
In response to a report demonstrating the cost to the state when pharmacy benefit managers (PBMs) profit from “spread pricing,” Ohio began requiring managed care plans’ contracts with PBMs to include a transparent, pass-through payment model and to prohibit spread pricing as of January 2019. Ohio’s recently passed 2020 budget bill goes a step farther, requiring all managed care plans to contract with a single PBM, which is selected by the Ohio’s Medicaid department.
To lower the cost of drugs and maximize rebate potential, Washington’s Medicaid program implemented a single formulary for all managed care and fee-for-service pharmacy benefits on Jan. 1, 2018.

This webinar is for state officials only and will not be recorded.

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

Speakers:

Brian Thompson, MS, PharmD, Director of Pharmacy Services, Bureau for Medical Services, West Virginia Department of Health and Human Resources
Vicki Cunningham, PharmD, former Director of Pharmacy Services, Bureau for Medical Services, West Virginia Department of Health and Human Resources
Maureen Corcoran, MBA, MSN, Director, Ohio Department of Medicaid
Donna Sullivan, MS, PharmD, Chief Pharmacy Officer, Washington Health Care Authority

Ten States Selected to Attend Palliative Care Summit in Chicago

June 18, 2019/in Policy Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, Texas Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, Chronic Disease Prevention and Management, Cost, Payment, and Delivery Reform, Health Coverage and Access, Long-Term Care, Medicaid Managed Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Primary Care/Patient-Centered/Health Home, Quality and Measurement /by NASHP Writers

NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.

New Governors Take the Long View in Addressing Early Childhood Development

April 8, 2019/in Policy California, Ohio Blogs Chronic and Complex Populations, Chronic Disease Prevention and Management, Eligibility and Enrollment, Health Equity, Healthy Child Development, Integrated Care for Children, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Elinor Higgins

State policymakers have historically promoted early childhood development improvements, but this year a growing number are acknowledging children’s early years as critical in determining their future health and success during adulthood. As a result, governors are promoting investments in the future health of their states by focusing resources on their youngest citizens.
This investment can be a productive one – studies analyzing multiple programs have found that every $1 invested in early childhood programs can yield a $2 to $4 return.

“Making full-day kindergarten available and accessible for all children sets kids up to be more successful in school and throughout their lives — improving performance, narrowing achievement gaps, leading to earlier identification and intervention for those with special needs, even increasing high school graduation rates down the road. … It will save taxpayer money in the long run by increasing incomes and decreasing the achievement gap. It will strengthen families, our communities, and our economy.” – Colorado Gov. Jared Polis, 2019 State of the State Address.

California and Ohio are examples of states whose governors have taken this long view and focused on healthy child development.

Gov. Mike DeWine, who discussed the importance of early childhood development on his campaign website as an “opportunity for every Ohio kid,” signed an executive order on Jan. 14, 2019, creating the Governor’s Children’s Initiative. The goals of the initiative include:

Improving communication and coordination across all state agencies that provide children’s services;

Encouraging local, state, federal, and private-sector partners to align efforts and investments to have the largest possible impact to improve outcomes for Ohio’s children;
Advancing policies to improve home visiting, early intervention services, early childhood education, foster care, and child physical and mental health; and

To coordinate and spearhead the initiative, Gov. DeWine created the director of the Governor’s Children’s Initiative position to be the point of contact for the many agencies that are involved. The position, recently filled by LeeAnne Cornyn, is situated within the governor’s office and has the authority to organize the initiative and issue directives across state cabinet agencies, boards, and commissions. To explore this and other organizational models that governors have created to carry out their health-related priorities, explore NASHP’s Organizational Models to Advance Health chart and read NASHP’s Toolkit on Upstream Health Priorities for New Governors.
Gov. Dewine’s current 2019 budget proposal includes significant investment in young children. Notably, the budget:

Recognizes the return on investment for home visiting programs, and proposes an additional $30 million to support evidence-based approaches to home visiting; and
Proposes a $46.5 million investment in early intervention programs through Ohio’s Department of Developmental Disabilities. The additional funding would expand eligibility for early intervention services and care coordination.

California

In January, 2019, California Gov. Gavin Newsom proposed a budget with a special focus on early childhood intervention whose three-pronged strategy includes:

Improved early education and health care service access, which includes making preschool accessible to all four-year olds regardless of income, investing in child care, and improving access to developmental screening and referrals;
A two-generation approach that supports parents through an expansion of paid family leave, home-visiting assistance, and medical screening so that they can support their children; and
Easing financial burden on low-income parents, including increased California Work Opportunity and Responsibility to Kids (CalWORKS) grants that recognize the importance of stable food and housing as prerequisites for healthy development.

Ohio and California’s approaches recognize that supporting children’s well-being and development in their first years of life requires collaboration across multiple agencies to effectively focus resources and initiatives.
NASHP’s Healthy Child Development State Resource Center highlights successful state Medicaid and other early childhood policies nationwide, and illustrates how states can effectively promote early identification and intervention. The resource center will continue to be an information hub as the National Academy for State Health Policy (NASHP) tracks state policies that promote children’s health and well-being. NASHP will also continue to monitor how governors use policy levers to improve early childhood development so young children can become healthy, educated, productive citizens.

States Take Administrative Actions to Curb Medicaid Drug Costs

October 16, 2018/in Policy Ohio, Vermont, West Virginia Blogs Administrative Actions, Cost, Payment, and Delivery Reform, Health Coverage and Access, Medicaid Managed Care, Prescription Drug Pricing, State Rx Legislative Action /by Jennifer Reck

Photo credit: Shutterstock.com

During the 2018 legislative session, 28 states passed 45 laws to curb the rising cost of prescription drugs. In addition to legislative solutions, states are taking administrative action to better manage state spending on Medicaid pharmacy benefits. Ohio, West Virginia, and Vermont offer examples of states taking innovative administrative approaches to rein in drug costs.
Ohio Medicaid Replaces Spread Pricing with More Transparency
In August, the Ohio Department of Medicaid announced it would require its five managed care plans to end contracts with pharmacy benefit managers (PBMs) that used “spread pricing.” Spread pricing is a payment model that allows PBMs to profit by charging insurance plan sponsors more for a prescription than the PBM pays the dispensing pharmacy. The lack of transparency in the spread-pricing model makes it difficult for states to identify how much spread pricing contributes to their overall drug costs.
Ohio investigated the impact of spread pricing and found it generated an 8.8 percent PBM markup on its Medicaid managed care pharmacy claims, a margin that enabled PBMs to pocket an average of $5.70 per prescription dispensed. In response, starting Jan. 1, 2019, Ohio will require managed care plans to use a transparent, pass-through payment model that requires PBMs to charge Medicaid exactly what they pay the dispensing pharmacy. To compensate PBMs under this pass-through pricing model, Medicaid managed care plans will pay PBMs an administrative fee estimated at 95 cents to $1.90 per prescription. To meet the deadline, managed care plans are working with PBMs to restructure contracts to comply with the pass-through requirement.
In contrast to Ohio’s administrative approach, Louisiana’s 2018 spread pricing law, Act 483, bans PBMs that contract with the state from retaining any revenue in excess of the amount the PBM paid to the pharmacy through spread pricing.
West Virginia Ends Use of PBMs
In 2017, West Virginia stopped using PBMs altogether after an audit revealed that public employee health plans were charged 1 percent more for prescription drug claims than PBMs were paying pharmacies. Lawmakers determined the 1 percent cost the state $10 million per year.
Instead of using PBMs to administer pharmacy benefits for state workers and Medicaid beneficiaries, West Virginia now acts as its own PBM under a fee-for-service model run by its Bureau for Medical Services’ Office of Pharmacy Services (OPS). In addition to managing the single state preferred drug list, which had previously been used across managed care plans, OPS developed a Preferred Diabetes Supply List. The state pharmacy board estimates that carving out pharmacy benefits from its Medicaid managed care program will save the state $38 million in the first year. Administrative cost savings and modifications to dispensing cost formulas helped achieve those savings.
Vermont Explores a Direct Relationship with a Wholesaler
The Department of Vermont Health Access (DHVA) released a Request for Information (RFI) in September to explore potential savings from establishing a direct relationship with a drug wholesaler. The RFI was in response to a legislative mandate in Act 193 that requires the state to identify opportunities for saving in the prescription drug supply chain. Under this model, payment for drugs would flow directly from DHVA to the wholesaler. Currently, pharmacies purchase drugs directly from wholesalers and are then reimbursed by DHVA. All publicly-funded prescription benefits in Vermont are reimbursed under a fee-for-service model, and pharmacy reimbursement rates are set by the state, not a pharmacy benefit manager. As a result, DHVA makes all payments to pharmacies directly, and not through a third party.
A direct relationship between a wholesaler and the state would allow DHVA to purchase drugs in a manner similar to the 340B Drug Pricing Program model, which may present savings opportunities. DHVA must report its findings to the Vermont legislature by Nov. 15, 2018.
Recent action, both administrative and legislative, reflects states’ growing demand for more transparent pricing and payment models. Learn more about all state action on curbing drug costs at the National Academy for State Health Policy’s Center for State Rx Drug Pricing, a warehouse of resources, including model legislation, new state laws, and legal analysis.

State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for People with Chronic Medical Conditions

July 31, 2018/in Policy Alabama, Missouri, Ohio, Rhode Island, South Dakota, Washington Reports Child Oral Health, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Coverage and Access, Maternal, Child, and Adolescent Health, Medicaid Expansion, Medicaid Managed Care, Oral Health /by Amy Clary, Carrie Hanlon and Najeia Mention

State health policymakers know oral health is an essential component of overall health and well-being, but state Medicaid programs face increasing costs and growing demands. Many of their enrollees struggle with high-cost, chronic conditions — often linked to oral health issues.
To explore possible approaches to improve oral health care, NASHP interviewed key Medicaid officials from Alabama, Missouri, Ohio, Rhode Island, South Dakota, and Washington State about integrating oral health into Medicaid health homes or other chronic condition payment or delivery models.
In this new report, supported by the DentaQuest Foundation, state leaders recommend first steps to incorporating oral health, such as sharing Medicaid health home members’ dental data with both dental and medical providers and including oral health questions in health home screening tools.
Read or download State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for Chronic or High-Cost Medical Conditions