The Centers for Medicare & Medicaid Services (CMS) has awarded the Lewin Group and its partners, which includes the National Academy for State Health Policy (NASHP), a seven-year contract to support implementation and monitoring for CMS’ Integrated Care for Kids (InCK) Model.
Launched in January 2020, this model is part of CMS’s strategy to fight the opioid crisis and address its impact on vulnerable Medicaid and the Children’s Health Insurance Program (CHIP)-covered children and their caregivers. The InCK Model aims to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable payment models to coordinate physical and behavioral health care with services to address health-related needs. InCK funding will provide Connecticut, Illinois (2 awards), New Jersey, New York, North Carolina, Ohio, and Oregon with the flexibility to design interventions for their local communities that align health care delivery with child welfare support, educational systems, housing and nutrition services, mobile crisis response services, maternal and child health systems, and other relevant service systems. By bringing together medical, behavioral, and community-based services, InCK strives to reduce fragmentation in service delivery and expand access to care for children and youth.
The Lewin Group, NASHP, and the other team members will support implementation of the InCK Model through technical assistance, program monitoring, measuring awardees’ progress on critical program milestones and outcomes measures, data collection and analysis, and critical feedback loops to support awardees’ work toward their goals.
“The Lewin Group is excited to contribute to this innovative approach that breaks new ground in the delivery of child- and family-centered care and the development of pediatric alternative payment models. We look forward to working with CMS to positively impact of the health of the next generation,” said Lisa Alecxih, Lewin Chief Capabilities Officer.
“NASHP is delighted to partner with the Lewin Group to support this innovative CMS InCK model,” said Trish Riley, NASHP’s executive director. “We bring to this work our decades of expertise in state health care delivery system design, cross-sector partnerships, payment reform, and the unique needs of children and their families.”
The Lewin Group is an established leader in health care and human services policy research, analytics and consulting at the federal and state level.
As the coronavirus spreads around the world, state health policymakers with experience preparing for Ebola and Zika outbreaks know that emergency preparedness begins long before symptoms appear. An effective response requires well-coordinated cross-sector collaboration between public health infectious disease strategy and state Medicaid and emergency management policies.
State health officials from Texas, Pennsylvania, and Florida outlined their strategies for preparing for and responding to public health emergencies and infectious disease outbreaks at a National Academy State Health Policy conference. Their recommendations for navigating messaging challenges, especially when communicating with a restive and worried public, resonate in today’s climate of coronavirus fears.
- Communicate clearly, consistently, and credibly.
Communicating with the public and sharing facts and techniques for minimizing risk is central to preparing for and addressing outbreaks and emergencies. Texas honed its disease investigation and response practices in the crucible of the Ebola crisis. The first patient to be diagnosed in the United States with Ebola arrived at a Dallas hospital in September 2014, according to the US Centers for Disease Control and Prevention (CDC). Shortly thereafter, a health care worker who cared for the patient contracted Ebola. The state’s experience with this high-profile situation informed its strategy for responding to Zika and other infectious diseases.
The public health risks of confusion and panic, and the importance of having clear lines of communication and a flow of accurate, consistent, and timely information to the public and decision-makers were key lessons Texas learned in the aftermath of Ebola. Texas put this knowledge into practice in its Zika response by continually publishing health alerts and regular updates on Zika case counts.
Florida also relied on media to share accurate and up-to-date information and to enlist the public’s help in fighting Zika transmission. During the outbreak the Florida Department of Health continued to publish daily Zika updates, as well advertising the department’s process for Zika testing and investigation. Educational campaigns used social media and advertising to enlist residents’ help in preventing the spread of Zika by reducing mosquito breeding areas.
The Pennsylvania Governor’s Office broadcast on Facebook a Zika Town Hall meeting with the state’s departments of health and environmental protection. As it did during the Zika crisis, today the Pennsylvania Department of Health regularly updates its webpage, which now features information about coronavirus.
- Cultivate collaboration and partnerships.
State officials note the importance of collaborating with federal, state, and local partners when planning for and responding to emergencies. For example, Texas Medicaid covers insect repellent and other Zika-related items for some populations, the federal CDC provided expertise and nationwide coordination, and local officials were instrumental to mounting an on-the-ground response.
A Florida official reported that robust partnerships were integral to the state’s Zika response. The Florida Department of Health refers pregnant women to the Health Start Coalition for care coordination and assistance applying for Medicaid if applicable. Infants born with Zika also receive support from the department’s Early Steps program, which has local offices and partners statewide.
Pennsylvania engaged cross-sector partners such as the March of Dimes and blood banks, as well as targeting communications to health care providers. Because the state did not have an existing birth defects registry, the March of Dimes’ birth defect surveillance was a helpful complement to the state’s disease monitoring and reporting infrastructure.
Officials from all three states acknowledged the importance of engaging local officials in emergency planning and response. State leaders have worked with local health departments, local mosquito control and environmental protection entities, local elected officials, and other community leaders in responding to Zika. An effective local engagement infrastructure is especially important for states such as Texas, which has a system of local control that grants considerable autonomy to local public health entities.
- Develop and maintain a robust public health infrastructure.
Robust public health data collection, monitoring, and laboratory testing capacity help states respond with agility to crises such as Zika. Florida’s birth defects registry, which has been operational since 1999, includes reportable conditions, such as microcephaly, that are potentially associated with Zika. The fact that this infrastructure was already in place permitted Florida to establish its baseline rate of microcephaly, which in turn helped the department monitor the possible impact of Zika on that rate.
States also identified the testing capacity and capabilities of their state laboratories as another key infrastructure element that supports emergency response. States that could test for Zika in-house — and had the capacity to meet the demand — were largely spared the delays and backlogs that could result when specimens have to be sent for out-of-state testing.
The Pennsylvania Department of Health built on the mosquito surveillance that the state’s department of environmental protection conducted for West Nile Virus. The existing cross-agency relationship between the two departments and the previous mosquito surveillance assisted the state with monitoring the potential for the disease to spread. The state law requiring infectious disease reporting was also broad enough to include Zika, which helped with surveillance efforts.
As these three tips show, state leaders can build upon existing communications, partnerships, and infrastructure capabilities to prepare for the challenges of the future, whatever form they take. For more information, please see Emergency Preparedness Policy in NASHP’s toolkit, Upstream Health Priorities for Governors.
The Centers for Medicare & Medicaid Services (CMS) recently released a request for information (RFI) for input from states, providers, health systems, and families to better coordinate care from out-of-state providers for children with complex health conditions enrolled in Medicaid. The deadline to submit comments is March 23, 2020.
States have long addressed issues of access to care, provider availability, service delivery system design, and public insurance reimbursement for children with medical complexity (CMC). This RFI addresses considerations for CMC who may require specialized treatment or therapy that is not offered by in-state providers and therefore need services in other states, complicating the ability of states to coordinate and deliver care effectively.
Coordinating care for enrollees from out-of-state providers can also present an administrative burden for state officials who are required to screen and enroll these providers in their Medicaid programs in order to provide payment for services. This RFI is part of a requirement from the Medicaid Services Investment and Accountability Act of 2019 which calls for the secretary of the Department of Health and Human Services to issue guidance to states on this topic.
CMS is seeking input from states and stakeholders who have experience with specific aspects of coordinating care from out-of-state providers, including:
- Sate initiatives that have promoted and/or improved the coordination of services and supports provided by out-of-state providers to children with CMC;
- Administrative, fiscal, and regulatory barriers that states, providers, and enrollees and their families experience that prevent children with CMC from receiving care, such as community and social support services, from out-of-state providers in a timely fashion, as well as examples of successful approaches to reducing those barriers;
- Measures that have been or can be employed by states, providers, health systems, and hospitals to reduce barriers to coordinating care for children with CMC when receiving care from out-of-state providers; and
- Best practices for developing appropriate and reasonable contract terms and payment rates for out-of-state providers in both Medicaid fee-for-service and managed care systems.
For a full list of requested information please review the RFI. CMS will review input from states and stakeholders and issue guidance by October 2020. The new guidance will include:
- Best practices for using out-of-state providers to provide care to children with CMC;
- Coordinating care provided by out-of-state providers to children with CMC, including services provided in emergency and non-emergency situations;
- Reducing barriers that prevent children with CMC from receiving care from out-of-state providers in a timely fashion; and
- Processes for screening and enrolling out-of-state providers, including efforts to streamline these processes or reduce the burden of these processes on out-of-state providers.
The National Academy for State Health Policy (NASHP) encourages states to submit relevant information to shape future guidance.
The RFI was posted on January 21, 2020 and comments are due March 23, 2020.
View the CMS RFI for instructions on how to submit comments. NASHP will share the release of any future CMS guidance on this topic as part of its ongoing work in the area of children with medical complexity.
To review NASHP resources related to children with medical complexity and children and youth with special health care needs, please visit its resource page.
Why is creating a state purchasing pool for prescription drugs a good strategy for states?
State purchasing pools for prescription drugs leverage public buying power to reduce drug costs. Today, every state purchases prescription drugs for its employees through its state employee health benefit plan. States are among the largest employers in the state and therefore the state employee health plan – or any other public plan a state administers – can leverage the size of its prescription drug purchasing pool to negotiate better prices for entities participating in a state purchasing pool for prescription drugs.
NASHP’s proposal for a state purchasing pool for prescription drugs provides additional details about this approach. NASHP has also developed model legislation to establish a state purchasing pool for prescription drugs.
How does creating a state purchasing pool for prescription drugs save money?
By expanding the number of people buying prescriptions through a plan, the pool’s purchasing and bargaining power grows to benefit both current state employee health plan enrollees and those who join the prescription purchasing pool.
What about adverse selection?
Concerns about adverse selection, which would be relevant to medical benefits, are not a factor for this model because prescription drug plans do not “pool risk”. Unlike health insurance plans – in which the health of enrollees influences premium costs – prescription drug prices are based on the volume of drugs purchased, not individuals’ health status. The discounts for prescription drug plans are based on the number of covered lives so the more covered lives in a purchasing pool, the greater the savings due to the increased purchasing power of the plan.
Who could join a state purchasing pool for prescription drugs?
Health insurance carriers offering plans to individuals and small and large businesses could all participate in a state purchasing pool for prescription drugs. Self-funded employer plans could also participate.
Non-state public employers such as municipalities, counties, state universities, and public school teachers could also participate.
Could the uninsured participate?
Uninsured individuals could be given access to a drug discount card to allow them to access the discounted drug prices available to state employees and other members of the purchasing pool. While the state would enable access to the discounted prices it negotiates, it would not pay for the drugs purchased by the uninsured who use the discount card. Uninsured individuals using the discount card would pay for their own prescription drug costs, but they would benefit from the deep discounts the state was able to negotiate via the purchasing pool.
Would a state employee prescription drug plan lose its ERISA-exemption if it allowed non-state employers to participate in the purchasing pool?
A state employee prescription drug plan can maintain its government exemption under the Employee Retirement Income Security Act (ERISA) by creating an administratively separate – but coordinated – state drug purchasing pool in which both the state employee prescription drug plan and self-funded employers can participate. NASHP’s proposal for a purchasing pool provides details on strategies for structuring and implementing a state drug purchasing pool to avoid potential legal and regulatory challenges.
How could potential purchasing pool participants determine if they would save money?
Potential purchasing pool participants could share information about specific drugs and quantities they currently purchase for their members with the administrator of the purchasing pool, such as a sample claims file for a given period of time. All information would be treated as confidential. Proprietary information about pricing for specific drugs would not be required.
The administrator of the state purchasing pool could run the prospective participant’s sample claims experience through the pool’s cost model and the state could then offer aggregate information detailing what the potential pool participant would spend for those drugs if they joined the pool. The potential pool participants could then compare that number to their current costs in order to determine whether they would save by joining the pool.
Would it be necessary to align prescription drug benefits and formularies to participate in the drug purchasing pool?
Depending on the pharmacy benefit manager (PBM) and the plans in question, it may not be necessary to align benefits (e.g., copays, deductibles, and coinsurance) and formularies, in order to achieve savings. However, an even deeper level of savings could be realized if participants do elect to align benefits and formularies.
Are there examples of this approach working successfully?
The City of Hartford joined a prescription drug purchasing pool with the Connecticut state employee drug benefit plan in 2012 after legislative authority opened up the state employee drug plan to municipalities and other public employers. Hartford maintained its own drug benefit design. The contract between Hartford and the PBM was separate from the state’s, but included the same base contract terms found in the PBM and state employees’ contract. This alignment allowed Hartford to access the larger drug discounts available to state employees and to realize significant savings – more than $1 million annually – or about 10 percent of its prescription drug spend.
As more entities join a drug purchasing pool, the increase in participants creates a win-win scenario. As the volume of drugs purchased grows, the purchasing pool’s negotiating power increases, resulting in lower drug prices for all participants.
How does the purchasing pool model fit in with NASHP’s model PBM contract terms?
The efficacy of NASHP’s model legislation to allow buy-in into state purchasing pools for prescription drugs depends on the ability of a state’s employee drug plan to secure favorable contact terms with its PBM in order to secure the best pricing deals for participants. The first step in implementing this model is to ensure that the state’s contract with the PBM managing its drug benefit reflects best practices in PBM contracting. NASHP has released model PBM contract terms for that purpose. NASHP developed the model PBM contract terms based on input from states that have secured favorable terms in their PBM contracts to maximize cost-savings on prescription drugs. Key provisions include:
- Administrative-fee only compensation;
- 100 percent pass-through of rebates and revenues;
- Cost-trend and pricing guarantees;
- Transparency; and
- Member cost-sharing protections.
Once a state has established a favorable contract with a PBM that includes these terms, the next step is to allow other purchasers (insurance carriers, self-funded employers, and other public employers) to benefit by establishing a state prescription drug purchasing pool.
NASHP helps state leaders advance legislation to contain prescription drug prices and tracks states’ efforts at its Rx State Legislative Tracker. State officials who are interested in developing a state purchasing pool for prescription drugs can contact Jennifer Reck (email@example.com) for additional information.
Kentucky passed SB 1: School Safety and Resiliency Act, which sets a goals to hire more resource officers and mental health staff at schools, mandates suicide prevention training for staff, creates a new school security marshal position, and requires all districts to restrict access to each school building by July 2022. Building on this momentum, Kentucky legislators this year introduced SB 8, with the goal of increasing security presence within schools and increasing funding to hire at least one mental health professional per school.
In Michigan, Section 388.1631n of the State School Aid Act of 1979 supports the presence of licensed behavioral health providers in schools. It was amended by HB 4242 to increase aid to public school districts in the state for this purpose. In 2020, the University of Michigan will begin its partnership with the city of Detroit to implement the Transforming Research into Action to Improve the Lives of Students (TRAILS) program to expand access to mental health in schools, after successful implementation in another Michigan county.
Texas passed HB 18, which requires school districts to offer mental health and suicide prevention curricula alongside physical health curricula. The legislation encourages schools to partner with local mental health authorities for content and promotes training and resources around mental health and grief counseling in schools. Texas also passed SB 11, which created a school safety allotment per student to make safety improvements within the school and established the Texas Child Mental Health Care Consortium. In the new year, the state is expanding this consortium by funding the West Texas regional hub of the Child Psychiatry Access Network at Texas Tech University Health Sciences Center El Paso.
Utah passed HB 373, which approved $26 million for hiring additional school counselors, psychologists, social workers, and school nurses, and provided funds to improve partnerships with local mental health authorities. A 2019 survey requested by the Utah School Superintendents Association found that the state had also made significant progress investing in safety measures to protect students and teachers.
In New Hampshire, Executive Order 2019-03 established the Statewide Oversight Commission on Mental Health Workforce Development, a 10-year commission charged to develop a plan to address the shortage and high turnover rate of mental health professionals in the state.
The Indiana School Safety Hub is a comprehensive resource center highlighting state mental health services, equipment and technology, and policy considerations needed to keep students safe. This School Safety Hub is part of the state’s strategy to consolidate information and streamline safety-related resources to communities across Indiana.
The office of Vermont Gov. Phil Scott, along with the Vermont-National Education Association and Vermont Agency of Education, launched a “See Something, Say Something” PSA contest for videos promoting awareness and reporting of school safety threats across the state.
The Pennsylvania Office of Attorney General developed Safe2Say Something, an online platform with resources that teach people how to recognize warning signs and signals of young people who might be in danger of harming themselves and or others.
Clearly, school safety is a complex puzzle that requires numerous solutions. These state strategies build on years of ongoing, collaborative work and continue to highlight the need for state policymakers to work to ensure students can learn in a safe school environment that supports their mental and physical well-being. As more governors share their 2020 priorities in the weeks ahead, more initiatives to bolster school safety and supports are expected to be presented.
This project was produced in partnership with the de Beaumont Foundation. The authors would also like to thank Kerri Nickerson and Elly Stout at the Suicide Prevention Resource Center, and Jill Rosenthal, Amy Clary, and Trish Riley at NASHP for their review.