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NASHP Updates Model Drug Price Transparency Legislation, Featuring a Common Data Set for Cross-State Comparisons and Stronger Enforcement
Maine state Sen. Eloise Vitelli presents legislation, based on NASHP’s new drug cost transparency model legislation, to the joint Committee on Health Coverage, Insurance and Financial Services.
As drug price transparency measures proliferate across states, the National Academy of State Health Policy (NASHP) has released revised model transparency legislation featuring a common data set to reduce reporter burden and yield standardized, actionable data that will be comparable across states. The data — to be reported by manufacturers, pharmacy benefit managers (PBMs), wholesalers, and insurers — will help state policymakers understand what is driving high drug prices through a comprehensive look across the entire drug supply chain.
This 2.0 version of NASHP’s model transparency bill also contains stronger penalties for failure to report. States will have the ability to audit any data submitted, and require a reporting entity to submit a corrective action plan for reporting deficiencies. If reporting entities do not provide the required data or if the data they provided is inadequate, the model bill allows states to invoke subpoena authority.
NASHP developed the model bill and common data set in collaboration with a work group of states currently implementing or considering transparency laws and Mathematica Policy Research. Last week, Maine State Sen. Eloise Vitelli introduced legislation based on NASHP’s updated model transparency legislation. The model bill is available in a streamlined formed as enabling legislation, as well in a longer, comprehensive version that includes in-depth information detailing the reporting requirements of the minimum data set. Additional information about the legislation, including reporting thresholds and data elements that must be reported, are available in this Q&A document. In coming weeks, NASHP will also publish customized reporting templates for manufacturers, PBMs, wholesalers, and insurers.
While NASHP’s model transparency bill builds off existing transparency measures, the common data set requires the collection of additional information not otherwise publically available, including specific information about past and projected costs and revenues at the individual drug level. Some of this information may be considered proprietary, and the model bill includes language to protect it while still requiring an annual report and public hearing to share and explore findings – although in a manner that does not reveal information specific to any one reporting entity. This reporting will provide states with more information to determine what drives high prices – and how to take effective action to address them.
States interested in this model legislation will have access to NASHP’s technical assistance. Please contact Jennifer Reck for more information.
Medicaid Expansion in Maine Moves from the Legislature to the Courts
A successful citizens referendum to expand Medicaid stalled in the state Legislature and moved to the courts this week.
Over the past five years, the Maine Legislature has passed several bills to expand the state’s Medicaid program – MaineCare – under the provisions of the Affordable Care Act to cover a greater number of low-income residents. Every year, Maine Governor Paul LePage vetoed the legislation, and the Legislature was unable to muster enough votes to override his veto.
In November 2017, Maine voters approved Medicaid expansion in a referendum with 59 percent of the vote. Under Maine’s constitution, the governor cannot veto a referendum passed by citizens’ initiative, and the referendum became law in early January of this year.
The expansion law lays out a series of actions Maine’s Department of Health and Human Services must take to implement the expansion of coverage to people earning up to 138 percent of the federal poverty level. Specifically, the law directs the department to submit a state plan amendment (SPA) to the Centers for Medicare & Medicaid Services (CMS) no later than 90 days following the effective date of the law, which was April 3, 2018. It also directs the state to adopt any necessary rules required to make certain that people who are eligible for coverage under the expansion are enrolled by July 2, 2019.
In the most recent legislative session, Maine lawmakers reviewed the Medicaid expansion referendum language and debated how much should be appropriated to fund the expansion. Two weeks ago, the legislature adjourned without addressing or funding the expansion.
Governor LePage contends he cannot implement the expansion until it is funded. The law does not link implementation of the expansion to CMS approval of Maine’s SPA, nor does it require the identification of specific funding to underwrite any costs associated with the expansion. It simply compels the state to implement the law in the stated timeline.
To date, the Maine has not filed the SPA required by the language of the law and this week a group of advocates and individuals who would be eligible for Medicaid coverage under the expansion filed a lawsuit in state court to compel the state to file the SPA.
The lawsuit is the first salvo in what promises to be the judicial phase of the protracted struggle over Medicaid expansion in Maine. Frustrated advocates in a number of other states, where expansion has not yet been adopted, are considering mounting a referendum campaign similar to Maine’s. Advocates in Utah and Idaho have collected enough signatures to put an expansion referendum on the ballot, and advocates continue to collect signatures in Nebraska and Montana.
Using Consumer Experience Surveys for Quality Improvement in Maine Health Centers
Maine was one of six states selected to participate in NASHP’s Medicaid-Safety Net Learning Collaborative. NASHP helped organize a series of web trainings for Maine’s health centers on using the Consumer Assessment for Healthcare Providers and Systems (CAHPS) patient satisfaction survey for quality improvement and staff training. CAHPS is being used in the state’s expansion of Patient-Centered Medical Home and accountable care strategies. This brief was supported by a cooperative agreement with the Health Resources and Services Administration.
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Maine
In Maine:
- As of July 1, 2011, there were 357,706 beneficiaries enrolled in MaineCare, the state’s Medicaid program. Of these, 176,335 were enrolled in a primary care case management (PCCM) program, including 130,824 children. The PCCM program is mandatory for Medicaid beneficiaries receiving TANF, children, pregnant women, and childless adults below 100% FPL. Medicaid-eligible children under age 19 with special health care needs who meet the criteria for the MaineCare Katie Beckett option are excluded from the PCCM program.
- Children with Intellectual Disabilities and/or Pervasive Developmental Disorders are eligible to receive benefits through the state’s home and community-based services waiver. The waiver provides an alternative to institutional care for children ages 5-20 who would otherwise require services through an ICF/MR or a psychiatric hospital.
As of 2012, 132,316 individuals were eligible for Maine’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT). According to 416 data from 2012, Maine achieved an EPSDT screening ratio of 93% and a participation ratio of 53%. 46,961 children received dental services of any kind, with 41,434 receiving preventive dental services.
Last updated January 2014.
| Medical Necessity |
Maine’s Medicaid Benefits Manual defines “medically necessary services” as those that are:
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| Initiatives to Improve Access |
Primary Care Case Management (PCCM)
The state operates a Primary Care Provider Incentive Payment (PCPIP) program which pays additional compensation to providers who delivery high quality healthcare to Medicaid PCCM patients and who rank above the 20th percentile for certain measures compared to other physicians within their specialty. Participating physician specialties include Family Practice, Pediatrics, General Practice, Obstetrics/Gynecology, and Internal Medicine. The goals of the PCPIP program are to increase access of Medicaid members to providers, reduce unnecessary/inappropriate ER utilizations, and increase utilization of preventive/quality services.
Improving Health Outcomes for Children (IHOC)
In 2010, Maine was awarded a five-year grant from the Centers for Medicare and Medicaid Services (CMS) to improve the quality of children’s health care. Under the grant, the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative was launched to “increase the rate of Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) services for children receiving MaineCare benefits by providing tools and data monitoring, offering comprehensive educational support, and engaging primary care practices in multiple change interventions to build patient centered medical homes for children.” The First STEPS Learning Initiative was implemented in multiple phases. Phase I (September 2011-April 2012) focused on improving pediatric immunization rates. Overall, immunization rates in participating practices increased by 5.1% after twelve months.
Phase II (May-December 2012) focused on improving developmental, autism, and lead screening rates for children under age three. Participating practices more than doubled the global developmental screening rates in all targeted age groups.
Phase III (April-November 2013) focused on oral health and healthy weight screening. Evaluation results of this phase are not yet completed.
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| Reporting & Data Collection |
Improving Health Outcomes for Children (IHOC)
The Improving Health Outcomes for Children (IHOC) grant works to:
Under the grant, Maine developed a Master List of Pediatric Measures that builds upon the CHIPRA Initial Core Set of Children’s Health Care Quality Measures. This list includes measures on topics such as well child visits, general development and autism screening, oral health, and behavioral health.
Primary Care Provider Incentive Payment (PCPIP) Program
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| Behavioral Health |
The focus of the Phase II First STEPS Learning Initiative was to improve developmental, autism, and lead screening rates for children under age three. Twelve pediatric and family practices, including 45 physicians who serve an estimated 20,000 children with MaineCare coverage, participated in the initiative. Practices agreed to track both improvements of specific Improving Health Outcomes for Children (IHOC) measures for developmental, autism and lead/anemia screening rates, and rates of referrals to developmental specialists and Children’s Developmental Services. As part of this phase, MaineCare added modifiers to the developmental screening and assessment CPT codes (96110 and 96111): HI for autism screening and HK for autism testing.
The goal of Phase II was to improve these rates by 50% with the target of achieving rates of 75% for each measure. Information on rates was gathered from chart reviews, MaineCare claims data, administrative data supplied by other programs, self-reported pre/post office surveys, and key informant interviews. The Phase II evaluation found that:
Ultimately, developmental screening rates for practices participating in the initiative rose from the year prior to Phase II to the year after Phase II. The rates rose from:
2703 Health Homes |
| Support to Providers and Families |
Support to Families
MaineCare, the state Medicaid program, operates the MaineCare Member webpage, which includes a tool to find participating MaineCare providers, a Member Handbook and benefits manual, among other resources. Support to Providers
The state operates a provider webpage that contains resources on EPSDT, including Maine Well Child Visit forms, schedules and referral forms, fact sheets on dental services, and toolkits. The primary care case management (PCCM) program website also contains information on how to become a participating provider, and additional information on the incentive payment program.
Providers participating the Patient-Centered Medical home (PCMH) pilot receive a variety of supports, including a learning collaborative, practice coaching, and consultation with experts. Eight community care teams also support primary care providers in implementing the medical homes.
First STEPS Learning Initiative
As part of Maine’s Improving Health Outcomes for Children (IHOC) grant, Maine Quality Counts is leading the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative. In Phase I of the initiative, 24 participating pediatric and family practices received monthly coaching calls, two all-day learning sessions, and tools for practices to track their immunization rates. In Phase II, 12 pediatric and family practices participated in the learning collaborative, which focused on improving developmental, autism, and lead screenings. |
| Care Coordination |
Patient-Centered Medical Home (PCMH)
In 2008, the Maine legislature authorized the development of the Patient-Centered Medical home (PCMH) Pilot. Three collaborators jointly lead the PCMH pilot development, including the Maine Quality Forum, Quality Counts, and the Maine Health Management Coalition. Fifty practices were selected to participate in the pilot, including four pediatric practices. Practices participating in the PCMH pilot receive per member per month (PMPM) payments from Medicaid, Medicare, and commercial payers. Practices also receive support from a learning collaborative, practice coaching, and consultation with experts. Eight community care teams (CCTs) provide support to providers in operating as medical homes. CCTs coordinate services and connect patients to additional community resources to support their health improvement goals, achieve better health outcomes, and reduce avoidable costs.
Section 2703 Health Homes
In January 2013, CMS approved Maine’s 2703 health home state plan amendment. To be eligible for health home services, adults and children enrolled in Medicaid must have two qualifying chronic conditions, or one qualifying condition and risk of a second. Health home enrollees are linked to a primary care provider who serves as the patient’s medical home, providing acute and preventive care, managing chronic illnesses, coordinating specialty care and referrals to social, community, and long-term services and supports. The roughly 159 health homes across the state are closely tied to the PCMH pilot; practices are required to participate in the PCMH pilot learning collaborative and also receive support from community care teams. Accountable Communities
Maine is in the process of implementing accountable care organizations through its Accountable Communities Initiative, which seeks to achieve the triple aim by using shared savings based on quality performance, practice-level transformation, coordination across the continuum of care, and community-led innovation. Under this initiative, Medicaid providers will enter into direct contracts with the Maine Department of Health and Human Services using a shared savings model linked to provider attainment of quality benchmarks. These ACOs will be responsible for the coordination of primary, acute, and behavioral health care, as well as long-term services and supports. All MaineCare members who receive the full Medicaid benefit package, including children, will be eligible for accountable community attribution. |
| Oral Health |
Phase III of the First STEPS (Strengthening Together Early Prevention Services) Learning Initiative, which ran from April-November 2013, is entitled “Encourage Healthy Habits by Improving Oral Health and Healthy Weight Screening, Treatment, and Referral.” Participating practices were provided with training on prevention of early childhood caries, including strategies such as completing an oral health risk assessment, an oral health screening, and fluoride varnish application. |
Lessons from the Field: State- and Practice-Level Policies to Foster High Performance in Cervical Cancer Screening in Federally Qualified Health Centers
States can make important strides in eradicating cervical cancer deaths. This report features promising state and federally qualified health center policies that support high performance in cervical cancer screening within the context of the medical home. Drawing from Colorado, Maine, Maryland, New York, Texas, Vermont, and Virginia, this report summarizes innovative programs, practices, and partnerships that facilitate improvement in cervical cancer screening. Experiences in these states offer examples for adoption by others to ensure high-quality preventive care for women. This publication was made possible through the support of the Health Resources and Services Administration.
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Payment and Delivery System Reform: It's All About the Data, States!
For states and their partners seeking a better integrated delivery system through multipayer reform initiatives, effective use of data is the foundation, the “building” itself, and roof above. Easier envisioned than done, data can help participants in multi-payer initiatives offer constructive feedback on performance to providers, distribute rewards in value-based payment systems, and hold system participants accountable for the costs and quality of services delivered. This webinar will explore the types of data multi-payer initiatives need to succeed, where states can get data, and how to use it. It will also highlight approaches to using various types of data from three leading states.
Speakers/Presenters:
- Lisa Dulsky Watkins, Associate Director, Vermont Blueprint for Health, Department of Vermont Health Access
- Brooks Daverman, Director, Strategic Planning and Innovation, Tennessee Division of Health Care Finance and Administration
- Karynlee Harrington, Executive Director; Dirigo Health Agency; Acting Executive Director, Maine Health Data Organization
| Click here for the Webinar Agenda | 140.8 KB |
| Click here for the Webinar Presentation Slides | 4 MB |
Care Management for Medicaid Enrollees Through Community Health Teams
The effective management of patients’ complex illnesses across providers, settings, and systems places extraordinary demands on primary care providers, especially those that work in resource-limited small or rural practices. Medicaid programs in some states have adopted strategies to build practice capacity to care for high-need Medicaid beneficiaries through the development of local community health teams, with members in fields such as nursing, behavioral health, pharmacy, and social work. Using data from a 2011–2012 review of state Medicaid medical home programs, we identified community health team programs in eight states that provide an array of targeted services, from care coordination to self-management coaching.
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Maine
MaineCare had developed a value-based purchasing strategy centered on three components: creating “Accountable Communities”, improving transitions of care, and strengthening primary care. Under the MaineCare Accountable Communities initiative, Medicaid providers will enter into alternative contracts directly with the Maine Department of Health and Human Services. These contracts will use a shared savings model, with the amount of shared savings linked to provider attainment of quality benchmarks.
The Department of Health and Human Services released a Request for Information in November 2011 to gauge the interest of organizations and seek input on proposed design features of Accountable Communities. A subsequent Questions and Answers document provided more information about the initiative. Twenty-eight organizations—including health systems and provider groups—responded and indicated a high level of interest in the Accountable Communities Initiative. The initiative is still in development.
In October 2013, the Department of Health and Human Services released a Request for Applications for Accountable Communities, as well as a concept paper describing the initiative. The state intends to begin implementation of the initiative on May 1, 2014.
In early 2013, Maine received a State Innovation Model testing grant from the Center for Medicare & Medicaid Innovation. This grant will allow the state to implement the Maine Innovation Plan, which is intended to support “formation of multi-payer ACOs that commit to value and performance-based payment reform and public reporting of common quality benchmarks, and that build on the model of MaineCare accountable communities.” Among the state’s goals for this initiative are to:
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Implement payment reform across public/private payers;
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Spread the patient-centered medical home model of enhanced, integrated primary care, and;
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Achieve transparent understanding of the costs and quality outcomes of patients across all payers statewide.
To learn more about Maine’s medical home initiatives, visit the Maine page of NASHP’s medical homes map.
Last updated: November 2013.
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Eligible Patient Population: All MaineCare members who receive full MaineCare benefits, including Categorically Needy, Medically Needy, SSI-related Coverage Groups, Home and Community-Based Waiver and HIV Waiver members, and others are eligible for attribution to the Accountable Communities.
Provider Population: All willing and qualified providers will be eligible to participate in the Accountable Communities initiative. Accountable communities will not be limited by geographic area.
Attribution: The Department of Health and Human Services has proposed to align Accountable Communities’ member attribution methodology with that used in the Medicare Pioneer Accountable Care Organization program.
Based on historical claims analysis, members will be prospectively assigned to an Accountable Community associated with the primary care practice or specialist where they received a plurality of visits for primary care services (as defined by HCPC codes or revenue codes for Federally Qualified Health Centers). Members who moved or received more than 50 percent of their primary care services in a non-contiguous geographic region to the Accountable Community will be excluded after the performance year. Members not assigned through a primary care or specialty practice will be assigned to the Accountable Community associated with the hospital where the member receives the majority of their emergency department care. Member freedom of choice will not be restricted.
Scope of services A Request for Applications issued by the state in October 2013 lists the defined set of 26 core services that will be factored into the total cost of care calculation for Accountable Communities. These services include primary care case management, behavioral health, inpatient and outpatient services, pharmacy, hospice and home health. Additional optional services—including dental, children’s private non-medical institution, and long term care services—can be included in the Accountable Community’s total cost of care at the Accountable Community’s discretion.
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| Authority |
MaineCare is developing a State Plan Amendment to authorize the Accountable Communities Initiative.
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| Governance |
The Maine Department of Health and Human Services released a Request for Applications (RFA) for its Accountable Communities initiative in October 2013. The RFA clarified that while the Accountable Community need not be an incorporated entity, each Accountable Community must establish a governance structure that is responsible for oversight and strategic direction of the Accountable Community and it must designate a Lead Entity. The Lead Entity must contract with all providers participating in the Accountable Community and the Lead Entity is responsible for receiving and distributing shared savings payments (or making shared loss payments to the Department of Health and Human Services).
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| Criteria for Participation |
Accountable Communities will be required to serve a minimum number of MaineCare (Medicaid) members (the minimum number has not yet been determined). They must include MaineCare-enrolled providers. Accountable Communities must deliver primary care services and directly deliver or commit to coordinate with specialty providers, including behavioral health for non-integrated practices, and all hospitals in the proposed service area.
Accountable Communities will also be required to commit to:
The Department of Health and Human Services has proposed to align member protection requirements with the Medicare Shared Savings Program. Providers participating in an Accountable Community would be required to:
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| Payment |
Under Maine’s proposal, two payment models would be utilized.
Accountable Communities that do not consist of integrated health systems will operate under a shared savings model. A target per member per month is identified for the Accountable Community based on risk-adjusted actuarial analysis of project costs. If the actual per member per month amounts is lower than the target amount, the savings are split between the state and the Accountable Community; the Accountable Community can share in a maximum of 50 percent of savings based on quality performance.
Accountable Communities that have capacity to assume risk will move toward a symmetric risk-sharing model over time: these Accountable Communities will be responsible for a portion of the loss associated with actual per member per month expenses that exceed the target PMPM. These Accountable Communities can share in up to 60 percent of savings (based on quality performance), but are held accountable for up to 5 percent of losses in year two and 10 percent of losses in year three.
The Department of Health and Human Services will cap the per member costs included in cost calculations for shared savings or penalties to protect Accountable Communities from being penalized for an abnormal distribution of catastrophic claims. Per enrollee costs are capped at:
Additional payment reform models will also be phased in under the Accountable Communities Program as part of a continuum of payment reform. This continuum begins with shared savings, moves to shared savings plus risk, then to partial capitation models, and finally to global capitation.
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| Support for Infrastructure |
The Department of Health and Human Services plans to provide participating providers with quarterly:
The state has partnered with the Maine Health Management Coalition (MHMC) as part of its State Innovation Plan. It will use the State Innovation Model testing grant funds to provide:
The MHMC’s Foundation, the lead agency for public reporting of quality information in the state, will continue to provide performance measurement and feedback to providers, employers, and insurers under this initiative.
For the innovation model, Maine’s health information exchange HealthInfoNet will provide several services, including emergency department notifications to community care teams, and capturing Health Homes clinical outcomes from electronic health records for reporting and analysis.
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| Measurement and Evaluation |
According to a Request for Applications released by the state in October 2013, Maine will finalize a core set of quality measures for use in the Accountable Communities initiative by December 2013.
The state has defined seven criteria on which to base its selection of quality measures. Metrics chosen should:
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Shared Decision Making: Advancing Patient-Centered Care through State and Federal Implementation
Shared decision making (SDM)—a process that engages patients in a dialogue with their providers to help them select health care options that conform to their values and preferences—is receiving increased attention as a tool for improving quality and patient satisfaction, and addressing unwarranted variation in care. Building on NASHP’s analyses of state health system improvement initiatives, this report reviews the definition, process, and rationale for SDM and potential roles of states in promoting SDM. The report and a companion document highlight state legislative, regulatory, and other approaches in Maine, Minnesota, Oregon, Vermont, and Washington. The report discusses the challenges of implementation, state strategies to overcome challenges, policy options states have pursued, and lessons from their experience.
| shared.decision.making.report.pdf | 457.6 KB |
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
