In the face of rapidly rising prices, state Medicaid programs are asserting their prescription drug purchasing power through more active oversight of the administration of prescription drug benefits. As major drug purchasers, state Medicaid programs have leverage to lower costs without action from state legislatures. Ohio, Washington, and West Virginia have recently deployed a range of strategies to curb drug costs:
- Ohio requires Medicaid managed care plans to adopt transparent, pass-through payment models with their pharmacy benefit mangers (PBMs).
- To maximize rebate potential and reduce administrative burden, Washington State is implementing a single preferred drug list (PDL) across Medicaid fee-for-service and managed care plans.
- West Virginia carved out the prescription drug benefit from its managed care contracts and now acts as its own PBM to increase oversight of drug purchasing and reduce costs.
Below is a detailed explanation of how these three states have implemented innovative purchasing strategies for their Medicaid pharmacy purchases.
Ohio Requires a Transparent, Pass-Through PBM Payment Model
A 2018 report found that PBMs retained profits of $224 million by creating a “spread” between what Medicaid paid PBMs for pharmacy claims versus what PBMs paid pharmacies. In response, Ohio mandated that managed care plans switch to contracts with transparent, pass-through payment models with the PBMs. With a transparent, pass-through model, states can ensure PBMs do not profit off this spread-pricing practice and pass through drug discounts and rebates to managed care plans. PBMs are instead reimbursed more directly through fees. Wisconsin’s state employee health plan requires a similar, fully transparent, pass-through payment model. Through this change in contract terms, Wisconsin’s per member, per month drug costs were more than 10 percent below industry averages from 2016 to 2018.
Ohio state officials report making significant changes to managed care contracts to increase transparency, reporting, and accountability pertaining to their PBM contracts and drug payments. Through enhanced reporting from managed care plans, officials have been able to confirm the successful implementation of the pass-through model. Ohio’s 2020 budget goes a step farther, requiring all managed care plans to contract with a single PBM, which will be selected by Ohio’s Medicaid department, giving the state more authority over drug purchasing.
Washington State: Implementing a Single, Standard Medicaid PDL Across MCOs
In January 2018, the Washington Healthcare Authority implemented a single PDL – a list that indicates which drugs are “preferred” by the state and do not require prior authorization. Washington’s Medicaid program transitioned from six different PDLs across managed care organizations (MCO) to one. A single PDL provides a number of advantages, including:
- Administrative ease for providers, patients, and pharmacies;
- Rebate maximization by selecting drugs with the lowest cost or maximum rebate potential;
- Rebate transparency for more accurate cost management; and
- Fewer disruptions for patients who may switch between managed care plans.
To transition to a single PDL, Washington submitted two State Plan Amendments – one for the single PDL and one to include managed care plans in its supplemental rebate contracts through a multi-state purchasing pool for drugs on the PDL. Washington also added and amended contracts with a number of vendors to ensure the Medicaid agency and managed care plans had access to the same drug data sources to allow seamless collaboration – an important detail for ensuring care coordination. Officials met with managed care plans weekly to plan and roll out the three phases of implementation, ensuring that drugs added to the PDL were clinically appropriate and cost-effective for the state and the plans. Implementation began with 27 drug classes and is expected to be complete by April 2020 with almost 400 different drug classes included in the PDL.
West Virginia: Carving Prescription Drugs Out of Managed Care
In 2017, West Virginia Medicaid began acting as its own pharmacy benefit administrator under a fee-for-service model, after carving out prescription drug benefits from its managed care contracts. To accomplish the prescription drug carve-out, West Virginia:
- Added an additional pharmacist to its staff;
- Stress-tested its existing claims processing system;
- Increased its capacity for prior authorizations; and
- Educated the public and its help desk staff about the program change.
West Virginia’s Medicaid program now covers over 550,000 enrollees through a fee-for-service model. State officials report they are able to effectively manage the pharmacy benefit and maintain care coordination across MCOs, while obtaining savings for the state. The prescription drug carve-out led to a savings of $54.5 million in 2018. Additionally, changes to the state’s reimbursement methodology during the carve-out process led to an infusion of $122 million in dispensing fees to the state’s pharmacy community.
While West Virginia is acting as its own PBM, California is carving out the prescription drug benefit from its managed care contracts and contracting with a single PBM to leverage the state’s immense purchasing power. California will use strict contracting terms to ensure greater transparency and cost savings with the contracted PBM. Michigan is currently considering a drug carve-out and legislatures in Louisiana and Nevada prompted their Medicaid programs to explore a potential carve-out of prescription drugs from managed care.
As states strengthen their oversight of drug purchasing, the National Academy for State Health Policy (NASHP) has created and will soon release a model PBM contract for states. Informed by Ohio and Minnesota’s contracts, NASHP’s model contract is designed to help states ban spread pricing and better understand rebate arrangements with their PBMs. To learn more about other administrative actions to curb rising drug costs, read the Administrative Action section of NASHP’s Prescription Drug Pricing website.
Friday, Nov. 1, 2019
3:30-4:30 p.m. (ET)
Faced with rising prescription drug costs, state Medicaid programs are implementing innovative policies to manage their pharmacy benefit and find savings. This webinar, for state officials only, is an opportunity to hear officials from three leading states:
- West Virginia carved pharmacy benefits out of its Medicaid managed care program in 2017 and reports that its shift to a fee-for-service model saved the state over $54 million in state fiscal year 2018.
- In response to a report demonstrating the cost to the state when pharmacy benefit managers (PBMs) profit from “spread pricing,” Ohio began requiring managed care plans’ contracts with PBMs to include a transparent, pass-through payment model and to prohibit spread pricing as of January 2019. Ohio’s recently passed 2020 budget bill goes a step farther, requiring all managed care plans to contract with a single PBM, which is selected by the Ohio’s Medicaid department.
- To lower the cost of drugs and maximize rebate potential, Washington’s Medicaid program implemented a single formulary for all managed care and fee-for-service pharmacy benefits on Jan. 1, 2018.
This webinar is for state officials only and will not be recorded.
Moderator: Trish Riley, Executive Director, National Academy for State Health Policy
- Brian Thompson, MS, PharmD, Director of Pharmacy Services, Bureau for Medical Services, West Virginia Department of Health and Human Resources
- Vicki Cunningham, PharmD, former Director of Pharmacy Services, Bureau for Medical Services, West Virginia Department of Health and Human Resources
- Maureen Corcoran, MBA, MSN, Director, Ohio Department of Medicaid
- Donna Sullivan, MS, PharmD, Chief Pharmacy Officer, Washington Health Care Authority
NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.
State policymakers have historically promoted early childhood development improvements, but this year a growing number are acknowledging children’s early years as critical in determining their future health and success during adulthood. As a result, governors are promoting investments in the future health of their states by focusing resources on their youngest citizens.
This investment can be a productive one – studies analyzing multiple programs have found that every $1 invested in early childhood programs can yield a $2 to $4 return.
California and Ohio are examples of states whose governors have taken this long view and focused on healthy child development.
Gov. Mike DeWine, who discussed the importance of early childhood development on his campaign website as an “opportunity for every Ohio kid,” signed an executive order on Jan. 14, 2019, creating the Governor’s Children’s Initiative. The goals of the initiative include:
- Improving communication and coordination across all state agencies that provide children’s services;
- Encouraging local, state, federal, and private-sector partners to align efforts and investments to have the largest possible impact to improve outcomes for Ohio’s children;
- Advancing policies to improve home visiting, early intervention services, early childhood education, foster care, and child physical and mental health; and
To coordinate and spearhead the initiative, Gov. DeWine created the director of the Governor’s Children’s Initiative position to be the point of contact for the many agencies that are involved. The position, recently filled by LeeAnne Cornyn, is situated within the governor’s office and has the authority to organize the initiative and issue directives across state cabinet agencies, boards, and commissions. To explore this and other organizational models that governors have created to carry out their health-related priorities, explore NASHP’s Organizational Models to Advance Health chart and read NASHP’s Toolkit on Upstream Health Priorities for New Governors.
Gov. Dewine’s current 2019 budget proposal includes significant investment in young children. Notably, the budget:
- Recognizes the return on investment for home visiting programs, and proposes an additional $30 million to support evidence-based approaches to home visiting; and
- Proposes a $46.5 million investment in early intervention programs through Ohio’s Department of Developmental Disabilities. The additional funding would expand eligibility for early intervention services and care coordination.
- Improved early education and health care service access, which includes making preschool accessible to all four-year olds regardless of income, investing in child care, and improving access to developmental screening and referrals;
- A two-generation approach that supports parents through an expansion of paid family leave, home-visiting assistance, and medical screening so that they can support their children; and
- Easing financial burden on low-income parents, including increased California Work Opportunity and Responsibility to Kids (CalWORKS) grants that recognize the importance of stable food and housing as prerequisites for healthy development.
Ohio and California’s approaches recognize that supporting children’s well-being and development in their first years of life requires collaboration across multiple agencies to effectively focus resources and initiatives.
NASHP’s Healthy Child Development State Resource Center highlights successful state Medicaid and other early childhood policies nationwide, and illustrates how states can effectively promote early identification and intervention. The resource center will continue to be an information hub as the National Academy for State Health Policy (NASHP) tracks state policies that promote children’s health and well-being. NASHP will also continue to monitor how governors use policy levers to improve early childhood development so young children can become healthy, educated, productive citizens.
During the 2018 legislative session, 28 states passed 45 laws to curb the rising cost of prescription drugs. In addition to legislative solutions, states are taking administrative action to better manage state spending on Medicaid pharmacy benefits. Ohio, West Virginia, and Vermont offer examples of states taking innovative administrative approaches to rein in drug costs.
Ohio Medicaid Replaces Spread Pricing with More Transparency
In August, the Ohio Department of Medicaid announced it would require its five managed care plans to end contracts with pharmacy benefit managers (PBMs) that used “spread pricing.” Spread pricing is a payment model that allows PBMs to profit by charging insurance plan sponsors more for a prescription than the PBM pays the dispensing pharmacy. The lack of transparency in the spread-pricing model makes it difficult for states to identify how much spread pricing contributes to their overall drug costs.
Ohio investigated the impact of spread pricing and found it generated an 8.8 percent PBM markup on its Medicaid managed care pharmacy claims, a margin that enabled PBMs to pocket an average of $5.70 per prescription dispensed. In response, starting Jan. 1, 2019, Ohio will require managed care plans to use a transparent, pass-through payment model that requires PBMs to charge Medicaid exactly what they pay the dispensing pharmacy. To compensate PBMs under this pass-through pricing model, Medicaid managed care plans will pay PBMs an administrative fee estimated at 95 cents to $1.90 per prescription. To meet the deadline, managed care plans are working with PBMs to restructure contracts to comply with the pass-through requirement.
In contrast to Ohio’s administrative approach, Louisiana’s 2018 spread pricing law, Act 483, bans PBMs that contract with the state from retaining any revenue in excess of the amount the PBM paid to the pharmacy through spread pricing.
West Virginia Ends Use of PBMs
In 2017, West Virginia stopped using PBMs altogether after an audit revealed that public employee health plans were charged 1 percent more for prescription drug claims than PBMs were paying pharmacies. Lawmakers determined the 1 percent cost the state $10 million per year.
Instead of using PBMs to administer pharmacy benefits for state workers and Medicaid beneficiaries, West Virginia now acts as its own PBM under a fee-for-service model run by its Bureau for Medical Services’ Office of Pharmacy Services (OPS). In addition to managing the single state preferred drug list, which had previously been used across managed care plans, OPS developed a Preferred Diabetes Supply List. The state pharmacy board estimates that carving out pharmacy benefits from its Medicaid managed care program will save the state $38 million in the first year. Administrative cost savings and modifications to dispensing cost formulas helped achieve those savings.
Vermont Explores a Direct Relationship with a Wholesaler
The Department of Vermont Health Access (DHVA) released a Request for Information (RFI) in September to explore potential savings from establishing a direct relationship with a drug wholesaler. The RFI was in response to a legislative mandate in Act 193 that requires the state to identify opportunities for saving in the prescription drug supply chain. Under this model, payment for drugs would flow directly from DHVA to the wholesaler. Currently, pharmacies purchase drugs directly from wholesalers and are then reimbursed by DHVA. All publicly-funded prescription benefits in Vermont are reimbursed under a fee-for-service model, and pharmacy reimbursement rates are set by the state, not a pharmacy benefit manager. As a result, DHVA makes all payments to pharmacies directly, and not through a third party.
A direct relationship between a wholesaler and the state would allow DHVA to purchase drugs in a manner similar to the 340B Drug Pricing Program model, which may present savings opportunities. DHVA must report its findings to the Vermont legislature by Nov. 15, 2018.
Recent action, both administrative and legislative, reflects states’ growing demand for more transparent pricing and payment models. Learn more about all state action on curbing drug costs at the National Academy for State Health Policy’s Center for State Rx Drug Pricing, a warehouse of resources, including model legislation, new state laws, and legal analysis.
State health policymakers know oral health is an essential component of overall health and well-being, but state Medicaid programs face increasing costs and growing demands. Many of their enrollees struggle with high-cost, chronic conditions — often linked to oral health issues.
To explore possible approaches to improve oral health care, NASHP interviewed key Medicaid officials from Alabama, Missouri, Ohio, Rhode Island, South Dakota, and Washington State about integrating oral health into Medicaid health homes or other chronic condition payment or delivery models.
In this new report, supported by the DentaQuest Foundation, state leaders recommend first steps to incorporating oral health, such as sharing Medicaid health home members’ dental data with both dental and medical providers and including oral health questions in health home screening tools.
Read or download State Strategies to Incorporate Oral Health into Medicaid Payment and Delivery Models for Chronic or High-Cost Medical Conditions
Greg Moody, director of Ohio’s Office of Health Transformation, has quietly spearheaded one of the most effective redesigns of a state health care payment system in the country, generating cost savings and improving public health by showing providers how the cost and quality of their care compares with their peers.
This value-based cost-savings and quality improvement approach, embraced by Ohio’s employers, insurers, and Medicaid managed care plans, pays for health care value instead of volume by analyzing two factors — how much it costs a provider:
- To provide high-quality comprehensive primary care, and
- To treat an “episode of care,” such as treating an acute asthma episode.
Providers are given a report card that assesses their charges, quality of care, and patient outcomes. If they deliver value-based care, they are financially rewarded with a $4 per patient per month bonus. If their care is over-priced and poor quality, compared to their peers, they get bad reviews and no rewards.
This value-based payment approach with its financial inducements has reduced acute asthma treatment costs by 21 percent and acute COPD treatment costs by 18 percent in 1 million Medicaid enrollees over a two-year period. Not only are the state’s Medicaid and employer plans saving money, patients are healthier because doctors are doing more to keep them well, which benefits overall population health.
“We can spend time fighting about health care coverage, like the federal government has for the last few years, or we can address the underlying health care costs,” observed Moody, a member of the National Academy for State Health Policy’s executive committee. “Today, I think it’s up to states to experiment and explore how to create sustainable health care costs.”
How Ohio Launched Value-Based Payment Reform
Ohio, which has been conducting its health care payment delivery reform experiment for eight years, is finding success with a value-based approach that replaces a pay-per-visit system with one that promotes comprehensive primary care and rewards providers who deliver efficient episodes of care. The state focused on improving care coordination, integrating physical and behavioral health, rebuilding behavioral health system capacity, strengthening home- and community-based services, improving community services for the disabled, and modernizing its Medicaid administration.
To date, a handful of states have taken small steps to develop a value-based payment system, but early results have not yielded dramatic, financial successes and many state policy makers are still casting about for a system that quickly delivers cost savings and quality care. According to Moody, Ohio found it and has spent more years implementing and refining it than any other states.
Moody, who worked for then-Congressman John R. Kasich researching Medicaid funding while staffing the US House Budget Committee, was appointed by newly-elected Governor Kasich to Ohio’s new Office of Health Transformation in 2011.
“Governor Kasich did something I never saw anyone do and it is key to how we got it done,” he explained. “About 18 months before he became governor, he assembled a health care team and told us, ‘I’m not running for governor unless we have ideas to propose.’ Now normally, you start recruiting and developing policy proposals after you get elected, but on his third day in office in January 2011, we had already done our homework and released our strategic plan. Now, eight years later, we are using the same plan.”
Ohio modernized its Medicaid system by creating a stand-alone Medicaid department with a new claims payment system and it provided an online eligibility tool to residents who no longer had to travel to county offices to apply. It also consolidated mental health and addiction services as the state’s opioid epidemic exploded and expanded Medicaid.
State leaders also began engaging partners, including provider groups, health plans, and Medicaid managed care organizations, to identify public health priorities that their payment reforms – in this case applying the episodes-of-care payment system – could support. “The starting point,” Moody explains, “is to be clear about our population health priorities – or in payment terms, define what we want to buy.’”
Ohio decided it wanted to prioritize improvements in three main health care areas:
- Mental health and addiction, addressing depression, suicide, drug dependency, and drug overdoses;
- Three chronic diseases: heart disease, diabetes, and asthma; and
- Maternal and infant health.
Shaping Physician Reimbursements to Improve Population Health
Next, Moody’s office asked high-performing primary care practices what they did to keep patients well. “The problem is none of these activities [recommended by doctors] are properly reimbursed under fee-for-service – for example, holding time for same-day appointments, providing 24/7 access to care, risk stratification of patients, and scheduling based on risk.” Moody knew that a new value-based care system had to reward providers who delivered those successful — though uncompensated — services.
To achieve these goals, Ohio created a Comprehensive Primary Care Model that enrolled 161 primary care practices to serve 1 million patients. Ohio collected and evaluated 1,800 performance reports that included patient cost and care quality measures. It also provided $3 million in “enhanced payments” to providers who delivered value-based care. To qualify for the $4 PMPM bonus, providers had to keep patients well by meeting the new quality requirements, including the same-day appointments, team-based care, patient outcomes, and reduced hospitalizations and emergency department use.
In December 2014, Ohio won a federal State Innovation Model test grant to implement an episode-based payment model statewide. The timing of the grant was perfect, Moody noted. It allowed Ohio to expand the state’s limited data analytic capacity, and create new insights about how best to improve health outcomes while holding down the total cost of care. Ohio could now pull in all insurance claims related to certain episodes of care for its value-based analysis.
For example, to assess a joint replacement episode of care cost, Ohio combined the total cost of the surgeon, implanted device, hospitalization, medication, and rehabilitation, and used the data to compare providers’ cost-effectiveness across the state. “We then take back money from the rates of the high-cost providers (in red) and share savings with the high-value providers (in green),” Moody explained.
To qualify for bonuses, providers had to meet both cost and quality targets. “This creates a powerful incentive for the principal accountable provider to pay attention to the total cost of the episode,” Moody explained, “[which is] very different from fee-for-service, which pays the surgeon the same regardless of other costs.”
In January, 2018, Ohio started paying the 161 practices that participated in Ohio’s comprehensive primary care pilot program $4 PMPM for meeting the basic efficiency and quality targets. “In addition, practices that meet quality targets while holding down the total costs of care compared to peers and based on self-improvement earn a significant annual performance bonus,” Moody explained.
Similar initiatives in other states are starting to yield substantial savings and care improvements. Minnesota achieved cost savings and an 89 percent improvement in quality measures and one regional initiative in northeast Pennsylvania achieved an 83 percent improvement in quality measures.
With this performance data, primary care providers are able to make value-based recommendations when referring patients to specialists, and insurance plans can also promote providers who receive high value-based rankings to their members.
Using Episodes of Care Costs to Tackle the Opioid Epidemic
By breaking down costs within each episode of care, Ohio has also been able to address another population health-related problem – opioid over-prescribing – by analyzing claims information to see which providers over-prescribe. The analysis, for example, revealed a provider who prescribed opioid painkillers 100 percent of the time for ankle sprains — meanwhile the state average hovered below 18 percent. More careful opioid prescribing data collections and oversight has produced a 28.4 percent decline in the number of opioid doses prescribed in Ohio between 2012 and 2017.
While the cost-savings opportunities generated by this value-based system appear tailor-made for simple procedures like joint replacement, its application to more complex care, such as perinatal episodes of care, is not currently clear. While acute COPD and asthma episodes of care costs dropped markedly 2014 and 2016, perinatal costs increased 3 percent, about what Moody would have expected in a conventional fee-for-service environment. “At this stage, these results create new questions,” he said, “for example, how do we make complex episodes more sensitive to value-based results? How do we identify the greatest sources of value in complex care and share that information with providers who can use it to improve?”
Ohio recently expanded its episodes of care data collection from three episodes to 43, which include many opioid clinical and quality measures. “Eventually, all of this needs to be transparent to the public and easily available online — it’s what we need everyone to see to make real progress on population health priorities,” he said.
Moody considers his work in Ohio as the pinnacle of his professional experience. He encourages other states to replicate Ohio’s approach. “You don’t wake up one morning and do this, it took years for us to get buy-in to make this happen,” he said. “This is something any state can do, but it takes time. We spent a lot of time defining the key health care delivery problems in Ohio, inventorying existing resources, and identifying the two to three policy changes that would leverage change, it’s a fairly rigorous process.
“There are now more than 30 states with gubernatorial elections in November, those candidates should start now to develop their policies and approaches,” said Moody, who will step down from his job in December when Gov. Kasich leaves office. “Ohio has created a blueprint to make these reforms. There are other ways to do this and be successful, but it’s critical that candidates start thinking and planning now.”
Read Ohio’s Health Transformation report, Moving Ohio’s Health Care Payment System Upstream.
Medicaid managed care provides a unique opportunity for states to strengthen the structure and delivery of care for children and youth with special health care needs (CYSHCN). The National Academy for State Health Policy (NASHP), studied how six states (Arizona, Colorado, Minnesota, Ohio, Texas, and Virginia) designed their managed care systems to serve CYSHCN and examined some of their best practices and strategies to meet the unique needs of these children in three reports:
- How States Structure Medicaid Managed Care to Meet the Unique Needs of Children and Youth with Special Health Care Needs and an accompanying chart that provides an Overview of Selected State Medicaid Managed Care Programs
- Structuring Care Coordination Services for Children and Youth with Special Health Care Needs in Medicaid Managed Care: Lessons from Six States
- State Strategies to Enhance Medicaid and Title V Partnerships to Improve Care for Children with Special Health Care Needs in Medicaid Managed Care
These studies reveal that while there is variation among states in the design, scope of services, and targeted populations, there are strategies that states can employ in Medicaid managed care to ensure delivery of quality care for CYSHCN, including:
- Assessing the needs of CYSHCN to better coordinate care;
- Establishing network requirements for specialty providers;
- Promoting continuity of care during transitions; and
- Creating quality measures around processes and outcomes.
These three studies build on NASHP’s 50-state scan of Medicaid managed care systems serving CYSHCN and states’ use of Medicaid quality metrics for CYSHCN.
These resources were developed with support from the Lucile Packard Foundation for Children’s Health and the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UC4MC28037 Alliance for Innovation on Maternal and Child Health.
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.
|Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students.|
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.