Recent legislative committee hearings in Maryland, Florida, and Illinois provide a national snapshot of states’ diverse and innovative proposals to reign in drug costs.
Maryland’s drug affordability review board: Earlier this month, Maryland’s House Health and Government Operations Committee and Senate Finance Committee held lengthy hearings on an innovative bill that creates a state prescription drug affordability review board (see NASHP’s model legislation here.)
The board would review drugs whose price increases met or exceeded a certain threshold and set an upper payment limit if the board found the drug cost to be excessive. During the committee hearings, constituents stressed the urgency of finding a solution for increasing drug prices, and many shared their struggles of choosing between paying bills and purchasing necessary medication. There was also testimony from pharmaceutical industry representatives who voiced their concerns about the bill and said it could hamper innovation.
The committee hearings gave legislators the opportunity to hear details of the proposed bill. One Maryland state senator questioned how the upper payment limit established by the affordability board differed from the state’s anti-price-gouging law that was found to be unconstitutional last year, based on the claim that it regulated commerce beyond state borders. Supporters explained that an affordability review board would not encounter the same legal challenge because it clearly defines its jurisdiction over only drugs sold in the state. Another representative asked whether all drugs would fall under the purview of the board. The sponsor explained that only drugs that meet certain price increase thresholds would be subject to board review. As seven other states explore similar legislation, NASHP has compiled a Drug Affordability Review Board Legislation Q&A that answers many legislators’ questions.
Florida’s drug importation bill: Florida lawmakers are considering implementation of a wholesale drug importation program. Bills filed in both the Florida House and Senate would allow the state to import high-cost drugs from Canada at a lower price. Florida’s legislative process often requires that bills pass through two or three committees before a floor vote, giving lawmakers, stakeholders, and constituents ample time to consider a bill. In March, three House committees met to ask questions about the bill and learn more about importation. During hearings, the bill’s sponsor explained that more than 30 Canadian drug manufacturers are already registered by the US Food and Drug Administration to produce drugs for US markets, and that safety standards in Canada are comparable to those in the United States. Lawmakers had additional questions about cost savings and the supply chain. For more information about importation legislation, read NASHP’s importation Q&A.
Illinois’ prescription drug committee action: The Illinois House of Representatives created a Prescription Drug Affordability and Access Committee to address bills designed to curb drug costs. The committee is currently reviewing 17 bills, including legislation to create a drug affordability review board, similar to Maryland’s, and a wholesale importation program. It is also reviewing a bill that requires health insurers to ensure that at least 25 percent of their plans apply a pre-deductible, flat-dollar copayment structure to their entire drug benefit component. The committee is also considering a proposal to tax drug price increases that exceed the inflation rate. This tax would be paid by businesses that make the first sale in the state and could not be passed through to consumers. Any money collected from the tax will be deposited into a new fund dedicated to prescription drug cost fairness.
To date, the Illinois committee has met multiple times for informational sessions to learn how the drug pricing system works and to hear from consumer advocates and stakeholders. Establishing a specific committee dedicated to identifying solutions to the rising cost of prescription drugs indicates how important this issue is as the state legislature tries to help constituents afford medication and balance the state’s budget.
NASHP is tracking state legislative action across the country as lawmakers schedule more hearings on prescription drug costs. To find out the status of any state’s drug pricing legislation as they move toward enactment, explore NASHP’s Rx State Legislative Tracker. To learn more about NASHP’s prescription drug work, visit its Center for State Rx Drug Pricing.
Historically, most children and youth with special health care needs (CYSHCN) were not enrolled in Medicaid managed care (MMC) programs because of their medical complexity and the number of specialty services they required. These services, including community-based supports such as in-home and respite care, care coordination, and long-term services and supports, were deemed by state health policymakers as best delivered by a fee-for-service system. As states become more adept at designing and implementing managed care programs for adult Medicaid beneficiaries, they have begun enrolling populations with complex needs into managed care to better coordinate care, control costs, and improve health care quality and outcomes.
As of June 2017, 47 states and Washington, DC, used some form of managed care to provide services to all or some children and adults enrolled in Medicaid. Of states with managed care delivery systems, all enrolled at least some or all of the CYSHCN population into some type of MMC. Contracting with risk-based managed care organizations (MCO) is the most common managed care delivery system used to serve Medicaid beneficiaries, including CYSHCN.
Nearly 20 percent of US children ages birth to 18 years (14.6 million children) have a chronic and/or complex health care need (e.g., asthma, diabetes, spina bifida, autism) requiring physical and behavioral health care services and supports beyond what children require normally. CYSHCN are costlier to care for than children without special health care needs. Within Medicaid, for example, annual per enrollee spending is over 12-times higher for children who use long-term care services ($37,084) as compared to those who do not ($2,863). MMC gives states a unique opportunity to strengthen the structure and delivery of health care, improve quality, and control costs, particularly for beneficiaries with chronic and complex health care needs.
The National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN) is a resource to guide and support states working to improve systems of care for CYSHCN, including Medicaid managed care. The National Standards for CYSHCN highlight the core components of the structure and process of an effective system of care for CYSHCN. The standards were developed with guidance from a national work group whose members include families of CYSHCN, state Medicaid agencies, public health, researchers, children’s hospitals, health plans, provider groups, and other stakeholders. Since its release in 2014, Medicaid and Children’s Health Insurance Program (CHIP) agencies, state Title V CYSHCN programs, health care systems, consumers, and others have used these standards as guideposts to improve systems of care for CYSHCN in an ever-changing health care landscape.
In 2018, the National Academy for State Health Policy (NASHP), in partnership with the Association of Maternal and Child Health Programs (AMCHP), led a national learning collaborative to help several states use the National Standards as a guide as they worked to improve MMC for CYSHCN. The following lessons learned highlight how these states effectively used the National Standards to strengthen their managed care systems for CYSHCN.
Analyzing and Enhancing Specialized Managed Care Plans
States can enroll special populations into health plans that are designed to uniquely serve enrollees with special needs (e.g., a specialized managed care program). Six states (Arizona, Florida, Georgia, Texas, Virginia, and Wisconsin) and Washington, DC have developed specialized MMC programs that exclusively serve all or some CYSHCN populations. These plans target health care benefits and services to meet the specific needs of Medicaid beneficiaries served by these programs. Georgia used the National Standards as a resource to strengthen collaboration across agencies to improve the state’s specialized MMC program — Georgia Families 360 — for children in foster care and the juvenile justice system. Learning collaborative participants from Georgia Medicaid, the Title V CYSHCN program, and the Department of Behavioral Health reviewed the National Standards for CYSHCN and selected the domains of Access to Care, Transitions of Care, and Care Coordination for their analysis. The state team created a crosswalk elements from three National Standards domains and elements their Georgia 360 contract as an internal evaluation tool. As a result of this review, the state updated its Medicaid policy manual with elements from the National Standards. Future work is planned to increase collaboration between the Georgia Families 360 MCO and the Title V agency to improve the provision of high-quality care coordination for the foster care population.
Providing a Framework to Design and Strengthen Care Delivery Systems
As a result of a state budget legislative mandate, in 2017 Delaware’s Medicaid agency developed a comprehensive plan to manage the health care needs of Delaware’s children with medical complexity (CMC). The agency formed a state steering committee and various work groups to develop the plan, working closely with MCOs and other stakeholders. The Models of Care Workgroup used the National Standards for CYSHCN to develop a framework on which to build a model of care for CMC. The framework was outlined in the final report to illustrate what an ideal system of care for CMC would look like. The Delaware Plan for Managing the Health Care Needs of Children with Medical Complexity was published in May 2018 and includes a comprehensive set of recommendations that the Delaware team plans to work implement in the future.
Strengthening Contract Language to Address the Needs of CYSHCN
New Mexico has coordinated across agencies and stakeholders to provide input into the state’s 1115 Medicaid waiver renewal and contract language development pertaining to CYSHCN. As part of this work, New Mexico Medicaid and state Title V CYSHCN officials developed a definition of CYSHCN, which enables the state to better identify CYSHCN and target services to this population within its managed care program. The definition is scheduled to be included in the next round of Medicaid contracts with MCOs. This work aligns with the first standard in the National Standards’ Identification, Screening, Assessment, and Referral domain that\ states, “the state system should have a definition of CYSHCN.” Additionally, the New Mexico Learning Collaborative team used the National Standards for CYSHCN Medicaid Managed Care Contract Language Tool to inform development of the definition.
West Virginia officials, led by the state’s Title V CYSHCN program director, wanted to take advantage of the changes required by the federal Medicaid Managed Care Final Rule and use the National Standards for CYSHCN to make improvements in how the Medicaid Managed Care system served CYSHCN. After meeting as an interagency workgroup, West Virginia officials identified the need for closer coordination between the Title V program and the individual Medicaid MCOs to improve care coordination and the services that CYSHCN received. To improve coordination, the team developed a memorandum of understanding (MOU) and an associated data-sharing agreement between Medicaid MCOs and the state Title V program. To assist with implementation of the updated MOU, West Virginia referred to Strengthening the Title V-Medicaid Partnership: Strategies to Support the Development of Robust Interagency Agreements between Title V and Medicaid. To ensure this MOU is enforced and coordination continues, state Title V program staff plan to meet monthly with MCO staff on an ongoing basis. Future work will focus on implementing standards for shared plans of care in cases where MCOs and Title V are both providing services to the same enrollees. The National Standards will be used to guide this work.
Improving Care Coordination and Transition to Adult Care
Rhode Island Medicaid and Title V agencies have worked to better understand the care coordination system in their state and specifically identify providers of care coordination for CYSHCN. Care coordination is a key component of a high-quality system of care and a crucial National Standards element. After reviewing the care coordination standards to learn what an ideal system of care coordination should offer, Rhode Island officials assembled key stakeholders and held monthly meetings to review the current status of care coordination services, identify available resources, and share experiences. The team also conducted an analysis of a specific group of CYSHCN enrolled in Medicaid managed care — the state’s Patient-Centered Medical Home program (PCMH-Kids) – who receive care in a community specialty care center. The children enrolled in this program require care coordination due to the complex array of services they receive. The state identified numerous barriers to providing care coordination, including limited communication between care coordinators, a lack of official designation for some care coordinators by Medicaid which prevents reimbursement, and an inability for care coordinators to authorize services, which caused delays in care. Now that it understands the barriers and complexity of care coordination for CYSHCN, Rhode Island plans to explore opportunities for policy changes, such as designating a lead care coordinator and linking a specialty care plan to the child’s medical home.
Massachusetts has similarly focused on improving integration and coordination of care with the state’s recently launched Accountable Care Organization (ACO) managed care structure. Accountable Care Organization (ACO) managed care structure. The Massachusetts’ team focused its work on the feasibility of using the new ACO model to support transition of youth with special health care needs (YSHCN) from pediatric to adult health care settings using transition policies aligned with National Standards. The Massachusetts’ team analyzed some existing transition activities in the state. These include a hybrid transition model that is being piloted at Boston Children’s Hospital between pediatrics, pediatric neurology/developmental pediatrics and adult care. The Massachusetts Department of Public Health also surveyed Title V funded care coordinators and families of CYSHCN to learn about the barriers to transition. State officials learned about integrated care strategies used by other states and organizations for transition such as Got Transition and identified value based purchasing strategies that could be used to incentivize quality transition. Massachusetts is now planning to develop guidance around strategies to implement transition policies within the ACO structure.
As states expand the use of Medicaid managed care to serve CYSHCN, the National Standards for CYSHCN and recent state approaches to their implementation can provide valuable resources. For more information on the National Standards and tools and resources for their implementation, visit the National Standards Toolkit.
 National Academy for State Health Policy. State Medicaid Managed Care Enrollment and Design for Children and Youth with Special Health Care Needs: A 50-state Review of Medicaid Managed Care Contracts. Washington, DC: National Academy for State Health Policy, October 2017.
 Health Resources and Services Administration, “Children with Special Health Care Needs,” December 2016, https://mchb.hrsa.gov/maternalchild-health-topics/children-and-youth-special-health-needs.
 The Henry J. Kaiser Family Foundation. Medicaid Restructuring Under the American Health Care Act and Children with Special Health Care Needs. Washington, DC: The Henry J. Kaiser Family Foundation, June 2017.
 National Academy for State Health Policy. State Medicaid Managed Care Enrollment and Design for Children and Youth with Special Health Care Needs: A 50-state Review of Medicaid Managed Care Contracts. Washington, DC: National Academy for State Health Policy, October 2017.
 Children and Youth with special health care needs (CYSHCN) is defined as an individual younger than 21 years old, regardless of marital status experiencing a moderate to severe medical and/or behavioral condition.
- a) With significant potential or actual impact on long term health and ability to function
- b) Which requires specialized health care services and/or a variety of services from multiple diverse systems.
Protecting public health in an era when infections can quickly spread from remote areas to major world cities requires creative and well-orchestrated responses from national, state, and local governments. One of the critical partnerships states can forge before, during, and after such crises is between public health and Medicaid. This report, supported by the Health Resources and Services Administration, explores effective, collaborative approaches developed by California, Florida, and Texas that may help other states strengthen their Medicaid and public health partnerships to prevent and better respond to communicable disease crises.
Read or download: State Strategies to Prevent and Respond to Disease Crises Through Medicaid and Public Health Partnerships
The American Health Care Act, which proposes to repeal and replace the Affordable Care Act (ACA), would dismantle the Prevention and Public Health Fund (PPHF). States received over $625 million from the PPHF in fiscal year 2016,[i] and stand to lose more than $3 billion over five years if it is repealed.[ii] The bill would repeal all new appropriations for the PPHF starting in fiscal year 2019, and rescind any funds left over at the end of 2018.
States could lose $160 million per year from the Preventive Health and Health Services (PHHS) Block Grant, which has been entirely funded by the PPHF since 2014.[iii] The Block Grant awards funds to all 50 states and the District of Columbia to support state public health infrastructure, respond to emerging public health issues, and address the health priorities of states in “innovative and locally defined ways.” Although the Block Grant existed prior to the creation of the PPHF, it now relies wholly on it for funding.
Eliminating the PPHF could also hamper state efforts to respond to the opioid crisis. As states work to respond to increasing numbers of deaths from drug overdoses, state public health departments have stepped up prescription drug monitoring programs and other interventions with the support of the Centers for Disease Control and Prevention (CDC). Since 2010, Pennsylvania has received more than $83 million from the PPHF to support opioid prescription monitoring, along with vaccine programs, cancer screenings, infectious disease detection and response, and chronic disease prevention.
- Pennsylvania Secretary of Health Dr. Karen Murphy said, “Repealing the Prevention and Public Health Fund would resonate beyond the federal level and hit state and local health departments hard…The loss of this funding in the coming years arrives at a time when major health threats, like infectious diseases and the opioid epidemic, are on the rise. The PPHF is vital to help protect the health of the nearly 13 million people who call Pennsylvania home.”
States also rely on the PPHF to help them keep children and families healthy. Louisiana depends on $9 million annually from the PPHF to support programs such as lead testing for children and home visits for low-income pregnant women and new mothers, which reduce premature births, according to Louisiana Secretary of Health Dr. Rebekah Gee. In 2016, $17 million in PPHF funding helped states reduce childhood lead exposures and conduct blood-lead testing and surveillance. Those funds helped states respond to disease outbreaks such as the flu and measles, as well as bolster their immunization infrastructure.
Virginia received just under $10 million in 2016 from the PPHF, including funds to fight heart disease and stroke, immunize children, and reduce health disparities and premature deaths, according to one report. Virginia State Health Commissioner Dr. Marissa J. Levine was quoted as saying that if all of ACA repeal goes forward, “we could pretty rapidly lose about $27 million like that.” Over $324 million in the CDC immunization funds that support states would be jeopardized by a dismantling of the PPHF.
States could also lose $40 million from the Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Cooperative Agreement if the PPHF is abolished by the American Health Care Act. The ELC also gave cities and states an additional $60 million in July 2016 to fight Zika. The ELC, which receives over 40 percent of its funding from the PPHF, enhances state laboratory and epidemiological capacity and supports state health information technology infrastructure. The ELC also funds state efforts to address tick-borne diseases, influenza, drug-resistant infections, foodborne illness, and hospital-acquired infections, among others. It also helped pay for more than 1,000 jobs in state and local health departments. [iv]
What can we learn from states?
Recent state experience illustrates what is at stake in conversations about reducing federal support for state public health infrastructure. The 2016 Zika crisis stretched to capacity the existing disease surveillance and response infrastructure of some states. Florida relied on additional support from the CDC to speed up the processing of laboratory testing for the Zika virus by providing thousands of test kits and seven laboratory technicians to help process them. Texas received scientific expertise, cross-state coordination, and a $5 million grant from the CDC’s supplemental Zika funding approved by Congress to combat the disease. The state also received Zika response funding from the PPHF.
Even when states are meticulously efficient stewards of resources, the ability of state public health agencies to respond to crises may be compromised if the American Health Care Act takes away the PPHF funding from states and the CDC. Responding to outbreaks and new infectious diseases is a matter of fiscal as well as public health: Infectious diseases cost the U. S. more than $120 billion per year, yet funding for core public health preparedness and response has been cut by more than one-third in the last 10 years.[v]
Questions for policymakers
- What public health functions will states have to cut or scale back if the PPHF is eliminated? Would state cuts lead to a failure to reduce drug overdoses, injuries, or infectious, chronic, and/or vaccine-preventable diseases?
- Would state cuts to public health programs lead to greater expenditures by Medicaid, criminal justice, or other state agencies? If so, how can those expenditures be quantified and budgeted for?
- Will the PHHS Block Grant be discontinued if the PPHF goes away? Or will the Block Grant be continued with a different federal funding source? If so, what will be the source of funding? How would funding levels change?
- Will states be able to afford to use general fund dollars to make up for the loss of federal prevention funding? What other state funding will be cut to make up the difference?
The ACA created the PPHF to fund both new prevention programs as well as programs that predated it. As the House bill to repeal and replace the ACA and eliminate the PPHF moves through Congress, policymakers should reflect on the impact of its repeal on states. There is much to learn from states stretched thin by responding to infectious diseases and the opioid crisis at the same time as battling preventable diseases and chronic conditions. We see what happens when under-resourced states are called upon to respond to extraordinary events; what will we see if robust federal help is no longer available to states? What do policymakers need to protect states’ ability to safeguard the health of their residents?
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.
[i] U. S. Centers for Disease Control and Prevention (CDC), “Accomplishing CDC’s Mission with Investments from the Prevention & Public Health Fund, FY 2010-FY 2016,” https://www.cdc.gov/funding/documents/cdc-pphf-funding-impact.pdf
[ii] Trust for America’s Health (TFAH), “Special Analysis: Prevention and Public Health Fund Federal & State Allocations,” January 2017, https://tfah.org/reports/prevention-fund-state-facts-2017/
Preterm birth, which accounts for approximately 11.5 percent of all births and 50 percent of pregnancy-related costs, is the largest cause of infant morbidity and mortality. This creates a significant burden on the U.S. healthcare system. A leading strategy for decreasing infant morbidity and mortality related to preterm birth is for states to use perinatal regionalization, a designation system where infants are born in or transferred to specific facilities based on the amount of care needed.
Regionalization of perinatal care is characterized by a tiered system of risk-appropriate care delivery whereby hospitals choose or are given specific designations based on the level of care they can provide. The system’s purpose is to ensure that high-risk mothers and infants are cared for at appropriate level facilities. For example, evidence suggests that an infant born at less than 32 weeks gestation or weighs less than 1500g should be cared for at a Level III facility with a neonatal intensive care unit. Perinatal regionalization has been shown to improve maternal and neonatal outcomes, and to be cost effective.
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization.
Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system.
A new joint issue brief by the National Academy for State Health Policy (NASHP) and NICHQ explores Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered.
For more information, download and read the new issue brief.
State Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
For example, California has identified transportation as a critical element to its perinatal regionalization system and, more broadly, the health of high-risk mothers and infants. The provision of transportation can be challenging due to both the structure of their perinatal regionalization system and the different modalities used for providing transportation under the Medi-Cal Benefit (e.g. Local County Agreements and/or Fee-for-service and Medicaid managed care systems). In regards to transportation services, Medi-Cal currently serves as the payer of last resort. However, when Medi-Cal eligible individuals need coverage for transportation services, Medi-Cal will cover the cost from either fee-for-service or managed care delivery systems. Transportation to a hospital as well as transfer between hospitals is also a common benefit in health plans available under the California Medi-Cal Access Program. Medi-Cal’s Comprehensive Perinatal Services Program also partners with the California Perinatal Transport Systems and Regional Perinatal Programs of California to promote and cover services integral to perinatal regionalization. These two programs are supported by the state Title V Maternal and Child Health Services Block grant.
The Georgia Medicaid Program plays a key role in funding the Georgia Regional Perinatal Care Network (GRPCN) along with state general revenue funds appropriated to the Georgia Department of Public Health (DPH). GRPCN is managed under the DPH. GRPCN is made of up six regional care centers for the treatment of high-risk mothers and infants. These six centers are designated based on regional need and available funding. The GRPCN’s funding comes from Medicaid, state funds appropriated to the DPH and state matched funds. Available funding is intended to support costs associated with cost of care, and regional center administrative costs for outreach, education and transportation services. Georgia also uses the state Title V Maternal and Child Health Services Block grant to support a range of programs and initiatives focused on preventing infant mortality, including perinatal regionalization.
 Anne Rossier Markus, Elie Andres, Kristina D. West, Nicole Garro, and Cynthia Pellegrini, “Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform,” Journal of Women’s Health Issues 23, no.5 (2013): e273, doi:10.1016/j.whi.2013.06.006
New issue brief
California Case Study
Georgia Case Study
Today, nearly 40 states have a system of risk appropriate perinatal care. As the payer for nearly half of all births nationwide, Medicaid is a key partner in the financing of perinatal regionalization. Medicaid covers specific services that can maximize access to risk-appropriate care for mothers and infants, including the coverage of pre- and post-natal care, delivery, and other services such as transportation. Medicaid coverage of neonatal transportation is a critical component of timely provision of care and overall patient health, specifically for high-risk mothers and infants, and a core element of a comprehensive perinatal regionalization system. This chart includes selected state initiatives and highlights Medicaid as a key partner in financing perinatal regionalization systems.
For more information on Medicaid funding opportunities in support of perinatal regionalization systems, read the blog post and issue brief that further explore Medicaid’s role as an important partner in developing perinatal regionalization policies and strategies given its significant investments in a disproportionate share of high-risk births and flexibility in the range and scope of services covered. Case studies of California and Georgia demonstrate how state Medicaid agencies have developed various approaches to support risk appropriate perinatal care.
This resource was developed by NASHP in partnership with the National Institute for Children’s Health Quality (NICHQ) as part of the Health Resources and Services Administration’s Collaborative Improvement and Innovation Network to Reduce Infant Mortality (IM CoIIN).
|California||The Regional Perinatal Programs of California (RPPC) were established in 1979 due to the need for a more comprehensive network of healthcare providers within specific geographic areas to promote access to high quality levels of maternal and infant care.[ii] Today, the RPPC has divided California into 9 separate regions, each of which include between 18-38 hospitals each.[iii]The California Perinatal Transport Systems (CPeTS) act of 1976 appropriated funds for the development of a dispatch service to facilitate transportation of mother and infants to NICUs.[iv] It also provides collection and analysis of perinatal and neonatal transportation data.|
|Florida||Developed in the 1970’s, Florida’s eleven Regional Perinatal Intensive Care Centers (RPICCs) provide access to high-risk perinatal care and are managed by FL’s Department of Health. Each facility provides community outreach education, and consultative support to other obstetricians and Level II and III NICUs in their areas, in addition to inpatient and outpatient services.[x]|
|Georgia||The Georgia Regional Perinatal Care Network Project (GRPCN) is a statewide initiative funded by the state Medicaid agency and state general funds appropriated to the Georgia Department of Public Health. Georgia’s six regional care centers are designated based on regional need and available funding.[xiii]|
|Illinois[xv]||First adopted in 1976, Title 77 created a perinatal regionalization system through Illinois Administrative code. [xvi] The Illinois Department of Public Health oversees the system and works with a Perinatal Advisory Committee (PAC) that offers recommendations relating to perinatal care. Today, Illinois’ perinatal regionalization system includes 10 administration Perinatal Centers that supervise 122 obstetric hospitals. In additional to a supervisory role, each Regional Perinatal Center has both clinical and administrative responsibilities.[xvii]|
|South Carolina||Established in the 1970’s, South Carolina’s regionalized perinatal system of care, is now made up of five perinatal centers in four regions that contract with the SC Department of Health. Key elements of the system include early risk assessment and referral to appropriate care; coordination and communication between hospitals and community providers; monitoring systems through data; and ensuring access to services from preconception through the first year of life.[xx]|
|California||Medi-Cal works with a variety of different partner programs to ensure coverage and access to services for pregnant women and neonates. These programs include the California Children’s Services Program (CCS),[v] The California Medi-cal Access Program (CMAP),[vi] and the Comprehensive Perinatal Services Program (CPSP).[vii] Through these programs, Medi-cal provides a variety of benefits, but the most notable is reimbursement for transportation services.[viii]|
|Florida||All RPICC Program patients are potential Medicaid Recipients. RPICC Medicaid reimbursement is inclusive for all services provided by the neonatology or obstetrical groups. [xi] The Agency for HealthCare Administration pays claims for inpatient-only services provided to Medicaid recipients by neonatologists and obstetricians enrolled in RPICC with Medicaid funds.|
|Georgia||Georgia Department of Public Health services for Medicaid members include: Perinatal Health Partners (PHP), Perinatal Case management, and Presumptive Eligibility Determination. [xiv]|
|Illinois[xv]||Two main programs offering coverage are available for pregnant women: Medicaid Presumptive Eligibility (MPE) which offers immediate temporary coverage for pregnant women who meet income requirements (outpatient care) and Moms & Babies, which covers healthcare during pregnancy and 60 days post-partum (inpatient, outpatient, and transportation).[xviii] Illinois’ Medicaid managed care plans are required to pay for and ensure the same level of care for pregnant women as in the fee-for-service benefit package.|
|South Carolina||Overall, the ability to link and contract with Medicaid providers has been difficult due to variations in policies and services of the Medicaid managed care plans. [xxi]|
|California||Funding for the RPPC and CPeTS is provided via Federal Title V Maternal and Child Health (MCH) Block Grant Funds.[ix]|
|Florida||The RPICC program is funded through a combination of Federal Title V MCH Block Grant Funds and Medicaid dollars. [xii]|
|Georgia||GRPCN is jointly funded by Georgia Medicaid and the Georgia Department of Public Health.|
|Illinois[xv]||IDPH allocates state funds to target preventative services, and provide grants to designated APCs responsible for the administration and implementation of the perinatal program.[xix]|
|South Carolina||Majority of the funding is through SC Department of Health and Hospitals. Additional funds are provided by the Title V MCH Block Grant.[xxii]|
|California||There is a neonatal transportation policy and it includes maternal transportation. Medicaid reimbursement policy exists for neonatal transportation.|
|Florida||There is a neonatal transportation policy and it includes maternal transportation and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation.|
|Georgia||There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants, and inter-hospital transportation. Medicaid reimbursement policy exists for neonatal transportation.|
|Illinois[xv]||There is a neonatal transportation policy and it includes maternal transportation, back transportation for infants and mothers, and inter-hospital transportation.|
|South Carolina||There is a neonatal transportation policy and it includes maternal transportation, back-transportation for infants, and inter-hospital transportation.|
[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[ii] “Regional Perinatal Programs of California Fact Sheet,” California Department of Public Health, Accessed August 24, 2016, https://www.cdph.ca.gov/healthinfo/healthyliving/childfamily/Pages/RPPC.aspx[i] E. M. Okoroh, C.D. Kroelinger, S.M. Lasswell, D.A. Goodman, A.M. Williams, and W.D. Barfield, “United States and Territorial Policies Supporting Maternal and Neonatal Transfer: Review of Transport and Reimbursement,” Journal of Perinatology 36 (2016):30, doi:10.1038/jp2015.109
[iii] California Department of Public Health- Maternal, Child, and Adolescent Health Program – Epidemiology, Assessment, and Program Development Branch, “Regional Perinatal Programs of California (RPPC),” October 2015, https://www.cdph.ca.gov/programs/rppc/Documents/RPPC_Regions_Oct2015.pdf
[iv] California Perinatal Transport System, “California Perinatal Transport System,” Accessed August 24, 2016, https://www.perinatal.org/
[v] California Department of Health Care Services, “Program Overview – California Children’s Services,” Accessed August, 29, 2016, https://www.dhcs.ca.gov/services/ccs/Pages/ProgramOverview.aspx
[vi] California Department of Health Care Services, Medi-Cal Access Program, “What Services are Covered in MCAP?,” Accessed August 24, 2016, https://mcap.dhcs.ca.gov/Services/?lang=en
[vii] County of Los Angeles Public Health, “Comprehensive Perinatal Services Program,” Accessed August 24, 2016, https://publichealth.lacounty.gov/mch/cpsp/CPSPwebpages/cpsp_rev.htm
[viii] “Medical Transportation – Ground,” in: California Code of Regulations, 2015, https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0ahUKEwi7_PmV7trOAhXDHx4KHScUBtkQFggeMAA&url=https%3A%2F%2Ffiles.medi-cal.ca.gov%2Fpubsdoco%2Fpublications%2Fmasters-mtp%2Fpart2%2Fmctrangndcd_a05.doc&usg=AFQjCNFzBYxIjWfYOw5gAKxm32BkzRkHug&sig2=QFlVSnGrnpIL6_Y7Sjbd2Q
[ix] California Department of Public Health, “Maternal and Child Health Services Title V Block Grant – California,” 2015, https://www.cdph.ca.gov/programs/mcah/Documents/Title%20V%202016%20Application%202014%20Report%20final.pdf
[x] Children’s Medical Services (CMS), “Regional Perinatal Intensive Care Centers,” Accessed August 29, 2016, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/rpicc.html
[xi]Florida Department of Health, Regional Perinatal Intensive Care Centers Handbook, August 2010, https://www.floridahealth.gov/AlternateSites/CMS-Kids/providers/documents/rpicc_handbook.pdf
[xiii] National Perinatal Information Center, “Medicaid Funding – The Georgia Regional Perinatal Care Network, Accessed August 24, 2016, https://www.npic.org/projects/MedicaidFunding.php
[xiv] Georgia Department of Community Health, “Georgia Public Health Services Available for Medicaid Members,” Accessed August 29, 2016, https://dch.georgia.gov/sites/dch.georgia.gov/files/Georgia_Public_Health_Services_for_Medicaid_Members.pdf
[xv] Bruce Rauner, Felicia F. Noorwood, and Teresa Hursey, Report to the General Assembly, January 2016 – Public Act 93-0536, (2016), https://www.illinois.gov/hfs/SiteCollectionDocuments/perinatalreport2016.pdf
[xvi] Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640: Regionalized Perinatal Health Care Code, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/07700640sections.html
[xvii] Illinois Department of Public Health, “Perinatal Regionalization,” Accessed August 29, 2016, https://www.dph.illinois.gov/topics-services/life-stages-populations/infant-mortality/perinatal-regionalization
[xviii] Illinois Department of Healthcare and Family Services, “Moms and Babies,” Accessed August 29, 2016, https://www.illinois.gov/hfs/MedicalPrograms/AllKids/Pages/MomsAndBabies.aspx#momsbabies
[xix]Joint Committee on Administrative Rules, Title 77, Chapter 1, Subchapter 1, Part 640, Section 640.80: Regional Perinatal Networks – Composition and Funding, Accessed August 29, 2016, https://www.ilga.gov/commission/jcar/admincode/077/077006400000800R.html
[xx] Association of State and Territorial Health Officials, “South Carolina’s Perinatal Regionalized System of Care: Reducing Premature Births and Infant Mortality,” (2013), https://www.astho.org/Presidents-Challenge-2013/SouthCarolina/
[xxi] South Carolina Department of health and Environmental Control, Healthy Mothers, Healthy Babies: South Carolina’s Plan to Reduce Infant Mortality & Premature Births, (October 2013), https://www.scdhec.gov/library/cr-010842.pdf
[xxii] The Title V Maternal and Child Health Block Grant funded components include: obstetric and neonatal outreach education, transport coordination, and physician consult and follow-up.
Association of Maternal and Child Health Programs, “South Carolina – Maternal and Child Health Block Grant 2016 State Profile,” Accessed August 29, 2016, https://www.amchp.org/Policy-Advocacy/MCHAdvocacy/Documents/South%20Carolina%202016.pdf
High-profile diseases such as Ebola and Zika grab headlines, but state health policymakers know that emergency preparedness begins long before the first news stories — or symptoms — appear. Preparedness and response often includes cross-sector work that addresses the intersections between public health infectious disease strategy and state Medicaid and emergency management policies. At the nexus of federal policy and local concern, state health policymakers are well-positioned to lead prior to, and during, health emergencies.
The recently announced Centers for Medicare & Medicaid Services funding opportunity to support Zika prevention and treatment activities could help state health departments invest in public health infrastructure that would position them well to respond to the next crisis when it occurs.
As concern about Zika virus continued deep into autumn, state leaders from Texas, Pennsylvania, and Florida spoke at the 2016 NASHP State Health Policy Conference about their strategies for preparing for and responding to public health emergencies and infectious disease outbreaks. They shared tips for navigating messaging challenges, especially when communicating with a restive and worried public. Panelists also noted the importance of robust public health infrastructure and cross-agency collaboration in developing and refining preparedness and outbreak investigation strategies.
- Communicate clearly, consistently, and credibly.
According to state leaders, 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 U. S. with Ebola came to a Dallas hospital in September 2014, according to the CDC. Shortly thereafter, a healthcare worker who cared for the patient contracted Ebola. The state’s experience with this very 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. At the time of writing, Florida Department of Health continues to publish daily Zika updates, as well as the department’s process for Zika testing and investigation. Educational campaigns such as “Be a Hero. Spill the Water!” use 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 July 2016 Zika Town Hall meeting with the state’s departments of health and environmental protection. Pennsylvania also continues to update its Zika web page.
- Cultivate Collaboration and Partnerships.
One Texas official noted 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 are integral to the state’s Zika response. The Florida Department of Health refers pregnant women to the Healthy 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 healthcare providers. Because the state did not have an existing birth defects registry, the March of Dimes’s birth defect surveillance was a helpful complement to the state’s disease monitoring and reporting infrastructure.
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 with 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 their 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.
Earlier this year, the U.S. Supreme Court’s decision in Gobeille v. Liberty Mutual dealt a blow to the 18 existing state-run all-payer claims databases (APCDs) by holding that ERISA prevents states from compelling self-funded insurers to report to their data systems. In response to the Court’s decision, a number of state APCDs and/or payers have temporarily halted data submission from all plans as both groups determine how data reporting will now be done.
While this work is ongoing, APCD states are looking to the words of the Supreme Court to determine if there is an opportunity to have continued access to payment data from self-funded plans. In the Gobeille opinion, the Court indicated that existing law might allow the United States Department of Labor (DoL) to collect and share payment data from plans subject to ERISA. In recent weeks, NASHP has convened a post-Gobeille Work Group of state officials and legal experts who have been considering potential options for continued data collection and have had preliminary conversations with DoL. NASHP will provide updates on the activities of the Work Group as recommendations are developed.
The Gobeille decision also has potential ramifications beyond the status of ongoing data collection in states with APCDs. The case has opened up the possibility of ERISA-exemptions expanding to new areas of law and has stifled states that were considering developing data systems and collecting payment information from health insurance plans. Updates below from Michigan and Florida, that are working through these issues:
- Parties in the Michigan Medicaid Tax case file new briefs in response to the Gobeille In March, the Supreme Court told the Sixth Circuit to reconsider whether a Michigan health insurance tax on all payers, including the self-funded, was preempted by ERISA in light of Gobeille. A decision against the state by either the Sixth Circuit or the Supreme Court could result in the end of state assessments on self-funded plans. In late April, Michigan and the group challenging the tax, the Self-Insurance Institute of America (SIIA), filed new briefs arguing how the Sixth Circuit should apply Gobeille. In the new briefs, Michigan argues that the Supreme Court saves the tax by distinguishing between the extensive reporting needed to comply with APCD requirements and the more minimal record keeping related to the Michigan law. In contrast, SIIA argues that the Court in Gobeille was concerned about the burdens that result from record keeping and reporting requirements, which they argue are an integral part of complying with the Michigan tax. SIIA also argues that Michigan retains the option of taxing health care providers, as is done in a number of states. The date of oral arguments on the new issue has yet to be published.
- Florida Governor signs new price transparency and data reporting law that state policymakers believe sidesteps the decision in Gobeille. The new law requires the state’s health care agency to contract with a private vendor to provide an easy-to-use, web-based database that allows consumers to research the cost of healthcare services. To support the database’s development, the law requires insurers participating in the Medicaid managed care or state group health insurance plan programs to submit claims data for all Florida policyholders. The state believes that by including data submission as a requirement of contracting, as opposed to mandating submission by law as in Gobeille, the program escapes ERISA preemption. We will keep you posted if challenges arise.
NASHP will continue to follow ongoing work on this issue. We encourage you to check back for further updates.
Gobeille v. Liberty Mutual Landing Page
Although federal funding for the Children’s Health Insurance Program (CHIP) was recently extended through FFY2017, it is unclear if CHIP will continue beyond that date. As a result, children may need to transition to other sources of coverage in the future. This two-year funding extension can provide state and federal policymakers with an opportunity to address important policy issues to ensure children continue to receive affordable and appropriate health care. Through this webinar, NASHP is bringing together a national expert and officials from three different state health and insurance agencies to surface issues and questions about the future of children’s coverage.
Some of the questions that will be explored on the webinar include:
- What lessons from CHIP in terms of benefits and cost sharing could help inform efforts to reform other sources of coverage to better support pediatric health and developmental needs?
- How can states ensure that coverage is affordable for families with children that transition from CHIP to exchange or other private market coverage? What policy options are available to prevent children from losing coverage due to affordability issues?
- What are some of the possible approaches to address benefit or service gaps that children moving from CHIP to other sources of coverage might experience, particularly in terms of accessing dental coverage, habilitative services and for children with special health care needs?
- What strategies can states implement to promote access to care and adequate pediatric provider networks, particularly for those in need of specialty care?
Anne Schwartz, Executive Director of the Medicaid and CHIP Payment and Access Commission (MACPAC), will kick off the discussion by sharing some of the key policy considerations the Commission has identified to maintaining accessible and comprehensive coverage for children in the future. Then Trish Riley, NASHP’s Executive Director will facilitate a discussion with three state officials—a CHIP director, an exchange official from a state operating a state-based marketplace, and a state insurance department representative from a state using the federally-facilitated marketplace—to explore challenges and potential policy solutions to ensuring there is appropriate, affordable pediatric and family coverage in the future.
Moderator: Trish Riley, Executive Director, NASHP
Background Presenter: Anne Schwartz, Executive Director, Medicaid and CHIP Payment and Access Commission (MACPAC)
- Carrie Banahan, Executive Director, Office of Kentucky Health Benefit Exchange (kynect)
- Sharon Carte, Executive Director, West Virginia Children’s Health Insurance Program
- Rich Robleto, Deputy Commissioner—Life & Health, Florida Office of Insurance Regulation