This spring, Georgia passed the Patients First Act authorizing the state to seek federal approval for a Section 1115 waiver to implement an alternative Medicaid expansion model and an Affordable Care Act (ACA) Section 1332 waiver to pursue a range of options affecting individual market coverage. Last week, the state released draft versions of both waivers, outlined below.
Most of the components of the state’s 1115 waiver proposal are similar to Medicaid expansion models that have been approved in other states. However, the changes Georgia proposes through its 1332 waiver are more notable for their potential implications and the questions they raise about the parameters and administration of the state’s individual market. This is also the first example of a state seeking a broader 1332 waiver based on guidance released by the Centers for Medicare & Medicaid Services last year, which changed the interpretation of the 1332 waiver’s “guardrails.”
Proposed 1332 Waiver
Georgia is seeking to use Section 1332 waiver authority to implement significant changes to coverage available through its individual market. The proposal includes two phases — the first part of the plan would implement a reinsurance program, and the second portion involves transitioning from a federally-facilitated marketplace (FFM) to a more state-controlled, decentralized model — though it would not be the same as an ACA state-based marketplace.
- Reinsurance program: Similar to many other states, Georgia is proposing to create a statewide reinsurance program beginning in plan year 2021 with the goal of stabilizing the individual market, reducing premiums, and ensuring an adequate selection of insurance carriers. The program would reimburse carriers at tiered rates according to geographic regions in order to provide larger reimbursements to areas with higher premiums.
- Georgia Access Model: Beginning in plan year 2022, the state would implement a number of changes through the proposed Georgia Access Model, including:
- State individual market operational changes: As part of the state’s plan to no longer use the FFM, the state’s Office for Health Strategy and Coordination along with other state agencies would be responsible for determining consumers’ eligibility for coverage, certifying plans offered on the individual market, licensing web brokers, and distributing tax credit dollars and addressing any related appeals.
- State-run subsidy program: The state would develop and administer its own subsidy program, using both federal advance premium tax credits (APTCs) as well as state funds, to help individuals who earn 100 to 400 percent of the federal poverty level (FPL) purchase individual market coverage. The state is also requesting permission to cap consumer enrollment if state costs reach a certain threshold, and if this occurs individuals seeking coverage would be placed on a waiting list.
- Enrollment through web brokers and carriers: The state is proposing to allow consumers to directly enroll in individual market coverage through web brokers and carriers rather than through a centralized state agency model. This would involve giving the web brokers and carriers the responsibility for developing the functions needed to help consumers enroll in coverage, such as plan comparison tools and shopping portals.
- Allowing consumers to purchase alternative coverage options: Although consumers using the Georgia Access Model will still be able to use subsidies to purchase qualified health plans (QHPs), state-certified “non-QHPs” will also be available as a subsidized coverage option. These non-QHPs will not be required to meet QHP standards, including Essential Health Benefit requirements, and consequently would likely be less expensive — although they will be required to maintain pre-existing condition protections. They will also be required to be a major medical health plan and in the individual market’s single risk pool, but they will not be allowed to be medically underwritten.
- Implementation timeline: The state is seeking comments on the proposal through Dec. 3, 2019, and plans to submit the waiver application to federal officials by Dec. 20, 2019, after which a federal comment period would be opened.
Proposed Pathways to Coverage – 1115 Waiver
Rather than implement the ACA’s full Medicaid expansion, Georgia is requesting to expand Medicaid only up to 100 percent of the FPL — at the enhanced ACA Medicaid expansion match rate, which has not yet been approved in any other state — along with the following conditions:
- Eligible individuals: Individuals ages 19 to 64 who are not currently eligible for Medicaid, which would include adults without dependent children with incomes up to 100 percent of the FPL, and parents, caretakers, or guardians with income between 35 to 100 percent of the FPL.
- Work requirement: To be eligible for coverage through the Georgia Pathways to Coverage program, individuals would be required to demonstrate they are working or engaged in other approved activities (e.g., community service, job training) for at least 80 hours per month.
- Employer-sponsored insurance (ESI) premium assistance program: If an eligible individual has access to ESI, the individual will be enrolled in that coverage instead of Medicaid and the state will pay the ESI premiums for the individual if it is more cost-effective for the state.
- Premiums: Some individuals will be required to pay premiums (tiered based on family income), and these premiums will be deposited in a Member Rewards Account.
- Individuals required to pay premiums: Individuals who are eligible for the Georgia to Pathways Coverage program who have incomes of 50 to 100 percent of the FPL, and individuals enrolled in transitional medical assistance.
- Exempt individuals: Individuals with incomes below 50 percent of the FPL; individuals in the ESI premium assistance program; and individuals who are enrolled in and two months after graduation from certain vocational education training programs of highly sought-after trades.
- Penalties for nonpayment: Enrollees required to pay premiums who fail to pay have a three-month period to retain eligibility before being disenrolled.
- Copayments: The same individuals who are subject to premiums will be required to make copayments for certain services that will be assessed retrospectively, but they are not to exceed 5 percent of an individual’s household income when combined with premium payments. Copayments are the same as in the existing state plan, with the addition of a copayment for non-emergency use of the emergency room.
- Member Rewards Accounts: Enrollees’ premium payments will be deposited in a Member Rewards Account, which will also be funded with state contributions. Funds in these accounts can be used for copayments or to pay for additional services that are not covered, such as vision or dental care. Individuals can earn points in their accounts by engaging in healthy behaviors.
- Benefit package and delivery system: The benefit package will mostly align with those provided through the state plan, with the exception of non-emergency medical transportation. Also, while the Early and Periodic Screening, Diagnostic and Treatment benefit for 19- and 20-year-old individuals is part of the state plan benefit package, the proposal requests to waive vision and dental services for these enrollees. For individuals for whom the state is covering the cost of ESI, wraparound benefits are not covered. The program will use a managed care delivery system exclusively.
- Eligibility effective date: The state is requesting to waive retroactive eligibility, and to have eligibility begin the month following the determination of eligibility and the payment of any premium required.
- Implementation timeline: The state is seeking comments on the proposal through Dec. 3, 2019, and is planning to submit the waiver to federal officials on or before June 30, 2020 for a federal comment period. However, if approved, implementation of the program would not begin before July 7, 2021.
Although the timing for implementation of the two waivers differs, the state comment period for both waivers closes on Dec. 3, 2019. For more information and to view the waiver documents, explore the state’s informational page. The National Academy for State Health Policy (NASHP) will be tracking Georgia’s plans as they evolve and will report on other states’ emerging proposals.
For more information about states’ implementation of the ACA’s Medicaid expansion, explore NASHP’s interactive map, Where States Stand on Medicaid Expansion, and for information about states’ marketplace models, view NASHP’s map, Where States Stand on Exchanges.
A patient with chronic obstructive pulmonary disease who was a frequent emergency room (ER) visitor now has a plan to manage his symptoms and now avoids the ER. A family caring for a parent with Alzheimer’s was considering nursing home placement, but after learning how to address challenging behavioral symptoms now feels equipped to continue to care for their loved one at home. A young woman treated for breast cancer had been hospitalized multiple times for pain, but is now managing her symptoms and is back at work.
These and similar stories illustrate why state policymakers are increasingly interested in palliative care and its potential to improve the quality of life of individuals with serious and chronic illnesses, while also reducing unnecessary hospital utilization and cost of care.
Palliative care services are delivered alongside curative treatment and can include pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services 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, fewer than 5 percent of individuals who could benefit from palliative care receive it.
Despite the alignment of palliative care with health policy goals, states face a number of challenges as they work to integrate palliative care across the health care continuum, including:
- Stigma that prevents providers, patients, and families from requesting/referring to palliative care;
- Workforce and provider capacity issues;
- Implementing and then sustaining these services through state health care systems; and
- Understanding the overall return on investment associated with palliative care.
In its research into state palliative care activities, the National Academy for State Health Policy (NASHP) has identified an overall lack of policy infrastructure to support state palliative care initiatives. Across the country, few models exist to help states implement and expand uptake of palliative care services.
To address these challenges, NASHP convened a cross-agency group of state policy leaders to provide guidance in developing a framework for how states, as agents of change, can foster access to quality palliative care services. While policy development is always driven by the varied goals and priorities of individual states, the following recommendations offer a roadmap to help policy makers identify state-specific opportunities, areas of alignment, and ideas to aid in future planning.
Recommendations to Promote Access to Quality, Palliative Care
Recommendation 1: Educate policymakers, providers, and the public about the role and value of palliative care across the health care continuum.
Lack of familiarity, discomfort with the topic, and stigma can inhibit providers from offering palliative care, and can prevent families and patients from asking for services that can support their individual goals and quality of life. States can use public health and other health system infrastructures to promote understanding and acceptance of palliative care services. In recent years, many states have created cross-disciplinary task forces and passed legislation to educate providers and the public. Minnesota, for example, has established a palliative care website that offers information and resources to the public about what palliative care is and why is it important.
Other states have instituted policies that require providers to identify and reach out to individuals who may benefit from palliative care. Vermont requires providers to demonstrate competency in identifying and engaging patients who could benefit from palliative care. Educating providers, who often have long-standing relationships with patients and their families and are able to coordinate with other community resources, places them in an ideal position to assist patients at a time when they are especially vulnerable.
Recommendation 2: Use state policies and regulations to help define palliative care services and standards, and distinguish it from hospice services.
While hospice care is offered near the very end of life, palliative care, importantly, can be delivered alongside curative treatment. Statutory or regulatory definitions that limit palliative care to the end of life can prevent access to these services. States can define palliative care in their regulation and licensing requirements to address this. Colorado’s licensing standards for hospitals and providers define palliative care as “focused on providing patients with relief from the symptoms, pain, and stress of serious illness, whatever the diagnosis… Palliative care is appropriate at any age and at any stage in a serious illness and can be provided together with curative treatment.”
States have a range of policy options to define and describe palliative care, including state Medicaid plans, waivers, managed care contracts, and provider reimbursement manuals. In crafting regulations, state policymakers may consider how palliative care services fit into their states’ care continuum and relate to other strategies and initiatives (e.g., enhanced primary care models, long-term services and supports, etc.) States may also need to tailor definitions of palliative care depending on policy goals – some definitions may be fairly detailed (e.g., for a specialty palliative care benefit with an enhanced payment), while other policies are better served by broad guidance (e.g., for public messaging).
State leaders also cautioned that regulating must take into account the evolving field of palliative care, and the need to support growth and workforce. Working with stakeholders to develop capacity may be a necessary first step. As states define their goals related to palliative care, they can then consider how/if current licensure or other regulations support or impede this work.
Recommendation 3: Promote evidence-based standards and practices across a variety of settings and across the lifespan.
Palliative care is an evolving field with diverse services and models for children and adults delivered in home and community settings, hospitals, and nursing facilities. The recently revised Clinical Practice Guidelines for Quality Palliative Care offers a consensus-driven, nationally recognized resource for state policymakers interested in understanding the key features ofhigh-quality palliative care services.
States can foster this high-quality care through policy activities such as disseminating guidance for providers, adopting practice standards in licensing or payment regulation, and embedding palliative care in value-based purchasing models or managed care contracts. New York’s Palliative Care Education and Training Council provides resources and guidance to providers on evidence-based palliative care practices and therapies, and has developed recommendations for provider education and training. Maryland’s hospital licensing regulations outline staffing and other standards that hospitals in that state must adhere to. Regulations require programs to be marketed to patients and families, meet specific staffing and training requirements, develop an inter-disciplinary care plan for each patient, and complete Medical Orders for Life-Sustaining Treatment forms in accordance with state law.
Recommendation 4: Identify quality measures and reporting strategies to improve access to and quality of palliative care.
Effective measurement is an important tool to promote quality and incentivize the delivery of palliative care services. However, comprehensive measurement for palliative care services, at either a practice or systems level, is an emerging area. The National Committee for Quality Assurance has 36 measures relating to serious illness care, measuring domains such as management of physical symptoms, pain assessment and management, and advance care planning. However, these measures may not be validated for all settings or payers, and the organization notes that “most community-based serious illness care delivered outside hospice or home health benefits is not subject to performance measurement designed to address the quality of care.”
Despite these challenges, at least five states currently include palliative care-related metrics or quality improvement requirements in their Medicaid programs. These measures are generally part of targeted initiatives that reach a subset of the total Medicaid populations – Colorado, Illinois, New York, and Rhode Island include at least one palliative care-related quality metric in their financial alignment demonstration or Medicaid long-term services and supports contracts. Both New York and Texas incorporated palliative care into quality improvement strategies in their Delivery System Reform Incentive Payment (DSRIP) waivers. Under Texas’ DSRIP Measure Bundle Protocol, hospitals, physician practices, community mental health centers, and local health departments can elect to report on eight palliative care metrics to earn incentives. The goal of the program is to better coordinate care and transition patients from acute hospital care into home care, hospice, or a skilled nursing facility.
Recommendation 5: Develop strategies to build capacity.
Palliative care access can be limited due to a lack of trained providers, especially in rural areas and in smaller hospitals. To increase availability of services, states may consider a range of options:
- Rhode Island and other states require physicians to complete at least four hours of continuing medical education every two years on priority topics that include end-of-life and palliative care.
- California recommends its managed care plans contract with Medicaid providers with palliative care training, and partners with California State University’s Institute for Palliative Care to offer palliative training to Medicaid providers and practice staff.
Building on systems that can support palliative care may be another way to foster access. New York’s DSRIP program had an uptake of palliative care services within patient-centered medical homes, a model supported by many states that features team-based, multi-disciplinary care. Health home state plan options for individuals with serious or chronic illness may provide future opportunities. Telehealth in rural or under-served areas can offer another tool to broaden the reach of palliative care services – models and payment strategies for states to support these modalities are still emerging.
Recommendation 6: Develop sustainable reimbursement.
Medicaid programs – bound by state balanced budget requirements – have different approaches to how they pay for palliative care. Sustainable reimbursement can incentivize greater access, and can also provide the state with additional levers to track, understand, and improve the delivery of palliative care services. States can consider using existing fee schedules or codes, creating specialized payment models (e.g., capitation, bundled payment, case rates), or using health plan contracting to promote reimbursement for palliative care services.
In Arizona, a recent Arizona Health Care Cost Containment System (state Medicaid) policy change made palliative care available to most of its Medicaid population, including those enrolled in fee-for-service managed care and managed long-term services and supports plans. California recently established palliative care standards for its Medicaid (Medi-Cal) managed care health plans that provide access for all age groups and include disease-specific criteria to target the benefit (e.g., congestive heart failure, chronic obstructive pulmonary disease, advanced cancer, or liver disease). NASHP’s report, Advancing Palliative Care for Adults with Serious Illness: A National Review of State Palliative Care Policies and Programs illustrates the various ways that states can support palliative care services.
States may also target their limited resources by including palliative care services in more specialized Medicaid policy vehicles, such as Programs of All-Inclusive Care for the Elderly (Florida, Iowa), financial alignment demonstrations for individuals dually eligible for Medicare and Medicaid (Michigan, New York, and South Carolina), and Medicaid managed long term services and supports.
Recommendation 7: Identify opportunities to incorporate palliative care into state health care reform efforts.
State health reform efforts increasingly focus on providing comprehensive and well-coordinated care to high-need populations – such as those with chronic or serious conditions – as a way to improve quality and drive down costs. Palliative care is a natural complement to this work. As payment and delivery system innovations evolve, states can look for emerging opportunities to incorporate and expand palliative care initiatives that:
- Value person-centered planning;
- Improve care coordination; and
- Seek to help older adults and others with significant health care needs remain in their homes and communities.
Palliative care and its whole-patient approach is an evidence-based strategy that improves the care of people with serious illness, often while realizing savings and avoiding unnecessary care. For both states and patients with chronic or serious illness, palliative care adds value. These recommendations offer an initial framework for states to advance the uptake and quality of palliative care services in their delivery systems. In the coming months, NASHP and state policy leaders will showcase successful state strategies to put these recommendations into practice.
With support from Arnold Ventures, the National Academy for State Health Policy (NASHP) is expanding its capacity to help states lower the trajectory of their health care spending through its new Center for State Health Care System Costs.
Modeled on the work of its Prescription Drug Pricing Center, this new center will address health system and hospital costs, provide states with research, analytics, model legislation, and other tools, as well as opportunities for cross-state collaboration and learning.
The center’s mission will be guided by a work group of experienced state leaders who will ensure this work effectively addresses state policy priorities, and that its products are both actionable and practical.
NASHP is grateful that these exceptional state leaders are willing to make time in their hectic schedules to advance this critically important work. Many of these leaders have already been instrumental in building the foundation of the center by participating in several state officials-only summits NASHP has convened to explore these issues.
NASHP is very pleased to announce the following members of this important group:
Commissioner, Pennsylvania Insurance Department
Senior Health Policy Advisor to the Commissioner, Washington Department of Insurance
Commissioner, Office of the Health Insurance Rhode Island
State Rep. Matt Hatchett
Majority Caucus Chairman, Georgia House of Representatives
Executive Director, North Carolina State Health Plan
Board Member, Vermont Green Mountain Care Board
Special Assistant to the Attorney General, California Department of Justice
State Sen. Heather Sanborn
Chair, Maine Joint Committee on Health Coverage, Insurance and Financial Services
Executive Director, Massachusetts Health Policy Commission
State Rep. Norm Thurston
Utah House of Representatives
Director, Health Policy and Analytics, Oregon Health Authority
Executive Director, Connecticut Office of Health Strategy
Strategic Policy Advisor, Wisconsin Department of Employee Trust Funds
Kara Odom Walker
Cabinet Secretary, Delaware Division of Health and Social Services
Executive Policy Advisor for Health and Human Services, Office of New Mexico Governor Michelle Lujan Grisham
Senior Policy Advisor, Office of Colorado’s Lieutenant Governor
Executive Director, Maryland Health Services Cost Review Commission
In the next few weeks, NASHP soon will announce the staff of the new center and looks forward to sharing its work in the months ahead.
Recognize, Assist, Include, Support and Engage (RAISE) Family Caregivers Act
Family Caregiving Advisory Council (FCAC) Meeting
Holiday Inn, 550 C Street SW, Washington, DC 20024
August 28-29, 2019
Day 1 – August 28, 2019
|8:30 – 9:00 AM||Arrival/Sign-in: Non-federal Members Arrival & Registration|
|9:00 – 10:15 AM||Session 1: Required Ethics Training for Council Members
Facilitator: HHS Ethics Staff – closed session
|10:00 – 10:30 AM||Arrival of Federal Members: Sign-in|
|10:15 – 10:30 AM||Break|
|10:30 – 12:00 PM||Session 2: Family Caregiving Advisory Council and Advisory Council to Support Grandparents Opening Ceremony
Swearing-in of non-federal council members
Remarks by HHS Deputy Secretary Eric Hargan
Remarks by Lance Robertson, ACL Administrator
Housekeeping Remarks, Greg Link
|12:00 – 1:00 PM||Lunch on your own|
|1:00 – 2:00 PM||Session 3: Getting Started: Council Housekeeping
Facilitator: Greg Link
– Council member introductions
– Review of legislation, council charter, tasks, & deliverables
– Overview: The RAISE Family Caregiver Act Resource and Dissemination Center
· Rani E Snyder, MPA, Vice President, Program, The John A. Hartford Foundation
· Kitty Purington, JD, Senior Program Director, Chronic and Vulnerable Populations, National Academy for State Health Policy
|2:00 – 4:00 PM||Session 4: The National Landscape Supporting Family Caregivers
Facilitator: Kitty Purington, JD, Senior Program Director, Chronic and Vulnerable Populations, National Academy for State Health Policy
Richard Schulz, Ph.D., Director, Center for Caregiving Research Education and Policy, University of Pittsburgh
Grace Whiting, JD, President and CEO, National Alliance for Caregiving
Tamar Heller, Ph.D., Institute for Health Research and Policy, University of Chicago
Donna Benton, Ph.D., Research Associate Professor of Gerontology, USC Davis
Larry Curley, MPA, Executive Director, National Indian Council on Aging
Jenna McDavid, B.S., National Managing Coordinator for the Diverse Elders Coalition
Nancy Murray, M.S., President, The Arc of Greater Pittsburgh at ACHIEVA
|4:00 – 4:15 PM||Break|
|4:15 – 4:45 PM||Public Comment Period
Facilitator: Lance Robertson, ACL Administrator and FCAC Chair
|4:45 – 5:00 PM||Session 5: Review of Day 1
Facilitator: Greg Link
A complete list of council members can be found at ACL.gov/RAISE
Day 2 – August 29, 2019
|Time||Session description (duration)|
|8:30 – 8:45 AM||Arrival/Sign-in|
|8:45 – 9:15 AM||Session 1: Review of Day 1 & Objectives for Day 2
Facilitator: Greg Link
|9:15 – 10:00 AM||Session 2: Overview of Federal Programs & Initiatives in Support of Family Caregivers
Brief presentations of Federal programs and initiatives impacting family caregivers.
Facilitator: Alan Stevens, Ph.D., FCAC Council Co-Chair
|10:00 – 10:15 AM||Break|
|10:15 – 10:45 AM
|Session 3: Discussion of Subcommittee Roles & Topics within the FCAC
Facilitator: Sarah Ruiz, Ph.D., ACL/NIDILRR
|10:45 – 12:00 PM||Session 4: Small Group Priority Setting Exercise—Challenges and Opportunities for the National Caregiving Strategy
Facilitator: Sarah Ruiz, Ph.D., ACL/NIDILRR
|12;00 PM – 1:00 PM||Lunch on your own|
|1:00 – 2:00 PM||Session 5: Report Outs from Small Group Leads
Facilitator: Casey Shillam, Ph.D., Council Co-Chair
|2:00 – 2:30 PM||Public comment period
Facilitator: Greg Link
|2:30 – 2:45 PM||Session 6: Review of Day 2, Next Steps, & Adjourn
Facilitator: Greg Link
A complete list of council members can be found at ACL.gov/RAISE
As state officials investigate reducing costs by leveraging their collective buying power to purchase prescription drugs, the National Academy for State Health Policy (NASHP) has developed a Checklist for Coordinating Public Purchasing of Prescription Drugs to help states establish baseline data across public purchasers and identify effective strategies to coordinate purchasing.
The checklist is designed to help states gather data on purchasers’ contract terms with pharmacy benefit managers (PBMs), how much is spent on drugs based on net cost and utilization, and plan benefit design.
Following California’s leading effort to implement bulk purchasing across state agencies, New Mexico, Delaware, and Minnesota have established interagency work groups of public purchasers, including those representing state government, state university, and public school employees and retirees as well as departments of corrections, state hospitals, and Medicaid programs.
These groups’ early meetings have focused on understanding current drug spending and plan design across purchasers. To help guide this work, NASHP’s checklist captures important information about these plans’ contracts with PBMs, including contract expiration dates and the inclusion of transparency provisions that:
- Prohibit spread pricing – when a PBM pays a pharmacy a lower rate than the rate the PBM claims for reimbursement from the health plan; or
- Require rebates to be passed through to the plan.
Once this data is established, interagency groups can identify cost and contract variations and explore various opportunities, including aligning PBM contracts across payers, which creates the potential to pool prescription drug purchasing to achieve savings.
NASHP’s checklist also asks purchasers to identify the 10 drugs with the highest net cost to health plans and the 10 most frequently prescribed drugs. Understanding the highest cost and highest use drugs across purchasers can guide the work of interagency groups, allowing them to prioritize efforts around specific drugs.
Interagency purchasing groups in New Mexico and Delaware have identified high-cost specialty drugs, such as Humira, as a major cost driver and a growing area of concern for public purchasers. Armed with this data, states working to leverage their purchasing power may be better positioned to respond to future drug spikes and the high cost of specialty drugs.
NASHP continues to develop model policies to help states address drug costs. See its latest proposal for a state purchasing pool for prescription drugs, which would allow individuals and businesses to join a public drug plan, increase the size of the state purchasing pools, and secure lower costs. Learn more about Delaware and New Mexico’s leveraging efforts in these NASHP blogs.
Tuesday, Nov. 12, 2019
NASHP is hosting a webinar to accompany and expand on its recently-published toolkit, State Strategies to Support Older Adults Aging in Place in Rural Areas. During the webinar, state officials from the Arizona Health Care Cost Containment System (AHCCCS) will describe their state’s initiatives to support older adults living in rural areas, highlighting the use of innovative technology to solutions to improve service delivery and address social determinants of health.
Despite the health benefits of immunizing pregnant women against influenza and pertussis (whooping cough) and protecting them and their infants from these life-threatening diseases, only half of pregnant women are vaccinated against both diseases and only one-third receive both the influenza and pertussis vaccines during pregnancy.
Three states are trying a number of innovative approaches to increase vaccination rates among pregnant women by providing incentives to health plans, increasing access to vaccinations through pharmacies, and using data to identify and target populations, regions, and providers with substandard influenza and Tdap (which protects against pertussis) vaccination rates.
Evidence shows pregnant women are at increased risk of developing complications from certain preventable diseases and can also risk passing those diseases on to their children. Following immunization, data shows that both mothers and infants are less likely to be hospitalized from complications. When a woman is vaccinated during pregnancy, she develops antibodies that are transmitted to her child before birth, which can then protect the infant during the first few months after birth. The US Centers for Disease Control and Prevention (CDC) recommends that women who are pregnant or planning to become pregnant get the flu vaccine and the Tdap vaccine during each pregnancy.
Low Immunization Rates Persist
Despite the CDC’s guidelines, many women do not receive the influenza and pertussis vaccines during pregnancy. According to the CDC’s recent report, Vital Signs: Burden and Prevention of Influenza and Pertussis Among Pregnant Women and Infants — United States, published in Morbidity and Mortality Weekly Report (MMWR), current rates of maternal immunization for influenza and Tdap are 53.7 percent and 54.9 percent, respectively. Only one-third of pregnant women received both the influenza and Tdap vaccines, and the rates are even lower for African-American pregnant women. The report noted that provider recommendations to patients can improve maternal immunization rates – when providers offered vaccinations or provided a referral to pregnant women, 65.7 and 70.5 percent received the flu and Tdap vaccine, respectively. Based on this data, the CDC recommends that providers begin discussing vaccinations with pregnant patients early and continue the conversation during each visit.
Overall, women enrolled in public insurance programs were less likely to be vaccinated during pregnancy than women with private insurance, due in part to access barriers. State Medicaid agencies, which cover 43 percent of all births across the United States and up to 60 percent of births in some states, can use innovative approaches to identify pregnant women in need of vaccinations, gather data to identify strategies and targeted approaches, and encourage providers to increase vaccination rates to improve health and save on costs.
The 2019 MMWR data are especially notable in light of the Healthy People 2020 goal to increase the number of pregnant women vaccinated against influenza to 80 percent. While most states remain far from that goal, California, Colorado, and Wisconsin are working to improve maternal vaccination rates for both their Medicaid populations and privately insured women.
California’s Medi-Cal Strategies
In California, pregnant women covered by Medi-Cal, the state’s Medicaid plan, see providers who are less likely to stock or recommend the Tdap vaccine. Women on Medi-Cal receive prenatal Tdap immunizations at much lower rates than privately insured women, and infants born to mothers with Medi-Cal coverage are twice as likely to contract pertussis compared to privately insured infants. California is using a number of strategies to improve maternal immunization rates for women on Medi-Cal, including setting expectations for contracted health plans, monitoring and providing incentives, and addressing barriers at the clinician and patient level:
- Medi-Cal managed care contracts require health plans to ensure the timely provision of all Advisory Committee on Immunization Practices (ACIP)-recommended immunizations for members, and report data to the California Immunization Registry (CAIR). Medi-Cal managed care contracts also require that contracted health plans monitor their primary care provider sites for the provision of preventive services, including all ACIP-recommended immunizations for adults and children.
- California’s 2019-2020 budget includes funding for incentive payments in the managed care delivery system for timely prenatal care as well as for prenatal providers who administer the Tdap vaccine to pregnant members. Some of California’s Medi-Cal managed care health plans are also trying to lower the financial barriers to providing vaccines by allowing providers to directly bill the health plan outside of capitation rates, providing free Tdap starter doses to clinics, and encouraging group purchasing of vaccines.
- Medi-Cal encourages its health plans to follow up on potential quality of care issues when cases of pertussis in infants born to unvaccinated mothers are identified through public health department notification.
- California pharmacists are authorized to provide immunizations without a physician’s order. Most major chain pharmacies in California offer Tdap immunizations as part of their vaccine portfolio. All routinely recommended adult vaccines are covered by Medicaid without prior authorization (in both fee-for-service and managed care plans) when given in a provider’s office or in a pharmacy. Recent state regulations require pharmacists to notify providers of immunizations administered and to enter all doses into the California Immunization Registry, making it possible for providers to know whether vaccine referrals to pharmacies are successful.
Colorado and Wisconsin’s Use of Data
One of the challenges to improving maternal immunization rates is obtaining and monitoring data, especially as many states do not require providers to report immunizations to their Immunization Information Systems (IIS). Quality data, though, is needed by states working to tailor their strategies for improving immunization uptake to the areas of highest need and to monitor trends. Specifically, the Centers for Medicare & Medicaid Services identifies data linking of Medicaid eligibity and claims data with vital statistics data as a critical mechanism for surveillance, programmatic monitoring, and evaluation of maternal immunization.
- Colorado is using data matching to determine the rates of maternal immunization in each county. Colorado has successfully matched 96 percent of patient medical record numbers with Colorado Immunization Information System (CIIS) records. The CIIS data matching has allowed the state to map immunization rates by provider and region and identify gaps in maternal immunization uptake. Colorado is now using this data to determine the areas of highest need in the state to inform and guide outreach programs. Currently, Colorado is also piloting text and email reminders to encourage patients to get vaccinated.
- Wisconsin is also using data matching to obtain baseline immunization rates. Wisconsin matched 96 percent of women who gave birth in 2018, as recorded by the Vital Records Office, with data from the Wisconsin Immunization Registry. Like Colorado, Wisconsin used this data to create data maps to identify influenza and Tdap vaccination levels in each region of the state. Wisconsin was also able to track vaccination rates by age, race, type of insurance, and quality of prenatal care. Next steps for the state include monitoring these trends, identifying areas of highest need, and using the data to improve maternal immunization rates.
In addition to partnering with state public health departments and their immunization programs, state Medicaid agencies can partner with providers to ensure vaccines are stocked and to promote vaccine recommendations for pregnant women so they become routine. For example, the American College of Obstetricians and Gynecologists has released a number of resources designed to support health care providers in increasing maternal vaccination rates, including the Maternal Immunization Tool Kit, strategies for immunization implementation, and a guide to starting an office-based immunization program. The American Academy of Pediatrics also offers recommendations on cost-saving measures for the purchase and administration of immunizations. Finally, the CDC has compiled a toolkit for prenatal care providers that includes resources for provider and patient vaccination education.
In addition to these resources, other states can learn from the work California, Colorado, and Wisconsin have done to identify gaps and improve vaccination rates among pregnant women covered by state Medicaid programs.
The National Academy for State Health Policy (NASHP) would like to thank Abby Klemp at the Wisconsin Department of Health Services, Sarah Royce at the California Department of Public Health, and Karen Mark at the California Department of Health Care Services for their time and insight. NASHP would also like to thank the US Centers for Disease Control and Prevention for their assistance with this blog and for funding this project.