Colorado and Michigan have joined Oklahoma to become the nation’s pioneering states with approved State Plan Amendments (SPAs) that enable Medicaid alternative payment models (APMs) for prescription drugs in the form of outcome-based contracts with pharmaceutical manufacturers.
In early May, state experts from Oklahoma, Colorado, and Michigan shared their experiences implementing their APMs during a NASHP webinar. A recording of the webinar is available here.
The SPAs enable states to negotiate contracts based on agreed-upon outcome measures tailored for specific drugs. Outcomes measures vary but may include measures such as patient adherence or reduced hospitalizations. If the drug’s performance fails to meet agreed-upon outcomes and triggers the need for additional manufacturer payments to the state, those payments are made in the form of supplemental rebates. The contract template was developed with the support of the State Medicaid Alternative Reimbursement and Purchasing Test for High-cost Drugs (SMART-D).
Though these outcomes-based APMs are valuable tools for states to manage escalating drug costs, APMs are best understood as “one more tool in our toolbox,” which are most effective when used in tandem with other strategies rather than in isolation, explained Cathy Traugott, pharmacy office director of the Colorado Department of Health Care Policy and Financing. Though these APMs may help states manage payment for high-cost drugs, the high-list prices themselves remain a problem that states are also attempting to address head on. During this year’s state legislative session alone, 47 states have filed 254 drug-cost-related bills (as of May 22, 2019).
Executing and implementing outcome-based contracting can be a time-consuming endeavor for states because of the necessity for state officials to engage with multiple manufacturers in exploratory discussions to identify drug candidates, followed by the data analysis necessary to design, and then track the outcome-based measures.
Oklahoma, whose work NASHP supported through a subgrant from the Laura and John Arnold Foundation, found that the process took longer than anticipated. Terry Cothran, director of the University of Oklahoma’s College of Pharmacy, advised states that pursue outcomes-based contracting to consider dedicating a project coordinator to execute the work most effectively.
To date, these contracts are with state Medicaid agencies only, and have not included inter-agency efforts. Rita Subhedar, state assistant administrator for Michigan’s Department of Health and Human Services, stressed the importance of broad engagement within a Medicaid department to effectively implement these APMs, including pharmacy, medical, and behavioral health staff. A separate, subscription-based payment approach, known as the “Netflix” model, utilizes a cross-agency approach engaging both Medicaid and a state corrections department. This approach was explored in another NASHP webinar, How States Pay for Hep C Drugs Using a “Netflix-style” Subscription Model.
The first results from outcome-based contracting will come from Oklahoma, whose first, one-year contract is scheduled to end July 2019, with three other contracts concluding soon after. Colorado and Michigan have not yet executed contracts.
The National Academy for State Health Policy (NASHP) provided a grant to the Colorado Department of Health Care Policy and Financing to develop a new payment methodology for physician-administered drugs (PADs). PADs are drugs delivered by intravenous infusion or injection in clinical settings. The category includes costly drugs, such as chemotherapy and other specialty medications.
Developing an appropriate payment methodology is a challenge for states due to a lack of information about how much providers actually pay to acquire these drugs. Colorado’s current methodology reimburses providers based on an average sales price (ASP) plus 2.5 percent – however, it is unknown how closely these prices reflect what providers actually pay. One recent analysis suggested that hospital markups for a variety of brand name drugs ranged from three- to seven-times more than the average sales price. Hospital markups for generic drugs were even higher.
To determine what providers actually pay for PADs, Colorado contracted with Myers & Stauffer to survey Medicaid providers from July to August 2018 to establish their actual acquisition costs. Using the aggregated acquisition cost data, Myers & Stauffer developed an average acquisition cost-based payment rate model and compared them to existing payment rates in Colorado.
They found that current Colorado payment rates were 12 percent higher overall than the average acquisition cost-based rates, meaning this new methodology could produce significant savings for the state.
The new model for payment rates based on the average acquisition cost survey is similar to the average acquisition model that many states currently use to pay for pharmacy-dispensed prescription drugs – called the National Average Drug Acquisition Cost (NADAC).
For more information about Colorado’s trailblazing work and research findings on the impact of NADAC on state drug spending, register for the upcoming NASHP webinar State Tools to Lower Medicaid Prescription Drug Costs: Exploring Payment Methodologies for Retail and Physician-Administered Drugs, from 2 to 3 p.m. (EST) Friday, March 29, 2019.
States, as regulators, payers, and innovators of health care, are uniquely positioned to improve the lives of Americans with serious illnesses by promoting access to palliative care. The National Academy for State Health Policy (NASHP) is working with state leaders to expand and improve palliative care, explore how these services align with other initiatives (e.g., value-based purchasing and delivery system reform), and identify what states need to effectively advance palliative care services.
Palliative care services can improve care and the quality of life of individuals with serious illness by better managing symptoms and stressors. They can also reduce costs, especially for complex populations with serious illnesses. A 2016 study that examined home-based palliative care found these services generated a 4.2 to 6.6 percent return on investment, primarily by reducing unnecessary hospitalizations.
At NASHP’s recent 2018 State Health Policy Conference, a group of state leaders explored these issues from a policymaker perspective and discussed what it would take to advance palliative care services in their states. Below are some of the key themes and opportunities raised during the session:
- States need palliative care definitions and standards: State officials identified the need for tools and resources to help states license, reimburse, monitor, and measure high-quality palliative care. Definitions and standards tailored to state regulatory needs can help jumpstart state efforts. California, Maryland, and Colorado have all implemented regulations defining palliative care, which can serve as starting points for other states.
- Workforce shortage is a potential barrier: States report that trained professionals — able to address palliative care needs in primary care and as members of specialized palliative care teams — are in short supply. To address this issue, Rhode Island supports provider education on palliative care as part of its cancer control program, and recently expanded the training to providers who treat other serious illnesses. As part of its State Innovation Model test grant, Rhode Island is also developing patient tools for advanced care planning and is offering education to providers to help them feel better equipped to hold these difficult discussions.
- Monitoring utilization and quality can be challenging: State Medicaid agencies can support reimbursement for palliative care in a number of ways, including:
- Through managed care contracting;
- As a distinct state plan option; and
- By leveraging existing physician billing codes.
While these payment mechanisms are readily available, participants noted limitations persist. Even with enhanced reimbursement rates for palliative care, one state official reported that provider uptake was low and that the enhanced payment was underutilized. Other officials from states that had activated specialized billing codes for palliative care expressed concern about the quality of care delivered and adherence to best practice standards. States without specialty codes or a specific benefit noted that it was impossible to gauge utilization or quality given the lack of claims data.
California, which requires its Medicaid managed care plans to cover palliative care services as a package of benefits, is an example of a state that has developed a comprehensive regulatory framework to address some of these issues. Its notice to plans outlines eligibility criteria, describes service components (including advance care planning, palliative care assessment and consultation, access to a palliative care team, and mental health services) and requires plans to monitor and report palliative care utilization and provider data to California’s Department of Healthcare Services.
- Stakeholder engagement can help when defining and developing palliative care services. State officials reported that engaging a broad range of agencies and stakeholders to develop palliative care initiatives was helpful. At least 27 states have multi-stakeholder taskforces or councils established specifically to advise on palliative care, and those groups provide a readymade forum for state policymakers.
State policymakers are working hard to move state systems toward more comprehensive and value-driven care, often with a special focus on populations that have chronic, complex, and high-cost care needs. Over the next two years, NASHP will convene a Leadership Council of state officials to identify promising policies and develop state recommendations and an implementation roadmap to increase access to and quality of palliative care.
NASHP will also be providing technical support to 10 states to assist them in advancing palliative care through resources, such as development of model legislation or Medicaid managed care contract language, and review of state regulations of palliative care providers and facilities. Look for announcements about publically-available palliative care resources and the technical assistance opportunities at NASHP’s website.
If your state has implemented or is exploring innovative strategies to support palliative care in Medicaid, please share your state’s experience with NASHP, contact Hannah Dorr.
During NASHP’s recent state health policy conference, state insurance experts explored the dramatic changes that recent federal action has foisted on their individual health insurance markets. In a second report from this conference session, they highlight strategies they’ve used to stabilize markets and identify lingering challenges to insurance markets’ affordability and choice.
While many state insurance commissioners and Affordable Care Act (ACA) marketplace directors work in tandem with state lawmakers to develop new policies that can support and stabilize markets, several experts noted that state leaders wield significant authority to influence their own markets. For example, through insurance rate review programs, state insurance commissioners have significant influence over the cost of premiums and scope of coverage sold in the markets they regulate.
Pennsylvania, for example, requires insurers to file rates using standard rating factors (a specific percent that all insurers must use to account for cost-sharing reduction calculations). Standard rating factors help the state minimize arbitrary variability between insurers’ rates and encourages competitive pricing practices among insurers.
Panelists also noted the importance – especially this year — of investments in outreach and education to teach consumers about the varying coverage levels of insurance plans now on the market. This is especially important given the expanded availability of short-term and association health plans that may confuse consumers.
Jane Beyer, senior health policy advisor to Washington State’s insurance commissioner, suggested the development of simple tables comparing coverage options (e.g., short-term plans, health care ministries, and broader qualified health plans) as important tools to educate ACA exchange navigators and other outreach workers as they help consumers purchase policies.
States that operate their own state-based marketplaces are uniquely positioned to support their individual markets through effective marketing and innovative consumer tools to help attract consumers.
- Mila Kofman, executive director of Washington, DC’s health insurance marketplace, stressed the importance of a local approach to marketing and outreach. Beyer touted the benefits of Washington State’s new marketplace app and “Smart Planfinder” decision tool that assists consumers in making informed decisions about their coverage options.
- Kate Harris of Colorado’s marketplace explained, “People wildly underestimate what they are eligible for.” She said Colorado is constantly evolving its outreach strategy to find new approaches to expand its reach to uninsured consumers.
- Wes Trexler, Idaho’s Department of Insurance Actuary and Bureau Chief of Product Review, cited his state’s systems control and its ability to create an integrated outreach and enrollment process for its consumers as big factors to its success.
Addressing Affordability through Reinsurance and Other Reforms
Affordability remains a huge threat to stable markets, especially among consumers earning more than 400 percent of the federal poverty level (FPL) and individuals earning less than 100 percent of FPL in non-Medicaid expansion states (see more on Medicaid below), who do not qualify for federal tax credits to purchase individual market coverage. Trexler said states must address the plights of individuals who fall into coverage gaps, including individuals who cannot afford their employer plans but do not qualify for tax credits and individuals who struggle with eligibility for subsidized coverage because of variability in their income throughout the year. As insurance rates rise, these individuals are increasingly priced out of the market and opt for no insurance coverage.
State-based reinsurance programs, instituted through 1332 state innovation waivers, have been successfully leveraged by some states to help reduce premium costs. A state’s reinsurance program pays insurers that take on higher-costs, enabling those insurers to lower their insurance premiums. The payments are funded through a combination of state funds and federal savings achieved from lower tax credit payments paid to subsidize the premiums of coverage sold through the state’s health insurance marketplace.
However, panelists raised concerns about the high costs of implementing state reinsurance programs, the sustainability of these programs, and the political challenge of getting legislation passed to submit a 1332 waiver. Some state officials expressed support for a federally-funded reinsurance program, which could help stabilize state markets and lower federal spending on tax credits.
States, faced with the prospects of market erosion from the emergence of short-term and association health plans, are contemplating options that will balance affordability with the need to keep a robust risk pool that includes healthy and sick; young and old. They are looking into other creative solutions to offer more affordable plans to their consumers.
Colorado recently passed legislation to support a study to use a 1332 waiver to allow for the sale of catastrophic health plans to individuals older than 30. Catastrophic health plans have low premiums, yet high out-of-pocket costs to consumers. Under the ACA, they are only available to individuals under age 30. By adding these plans to its individual market, Colorado plans to offer more affordable options to consumers. The law stipulates that catastrophic plans must be sold through the state’s health insurance marketplace and that Colorado would only pursue the waiver if the study finds that the expansion of catastrophic plans would not lead to overall premium increases OR decreases in tax credits received by consumers.
Under an executive order, Idaho is exploring granting greater flexibility to insurance carriers to sell products that do not comply with federal requirements under the ACA, but would be part of the individual market risk pool. Specifically, these plans would:
- Not meet pre-existing condition protections,
- Allow for a 5-to-1 age rating ratio, meaning that insurers can charge older enrollees up to five times as much for coverage as younger enrollees (the ACA sets this cap at a lower 3-to-1 ratio);
- Allow for annual coverage limits of no less than $1 million; and
- Allow year-round enrollment and not limit enrollment to special time periods).
As envisioned by Idaho’s Department of Insurance, these insurance products, called “state-based plans,” would complement ACA-compliant products. They would bring consumers into the state’s individual market, help to stabilize the risk pool, and force any insurer that sold a state-based plan to also sell a fully ACA-compliant product through the state’s insurance marketplace, thus encouraging product competition through the marketplace.
The Centers for Medicare & Medicaid Services (CMS) rejected the proposal, due to non-compliance with federal law. However, Idaho is continuing conversations with CMS to develop federally-compliant solution for its market.
During the conference session, state officials described a slew of other proposals they plan to explore to help stabilize their markets, including:
- Merging individual and small group markets;
- Forging stronger links between ACA-compliant qualified health plans and public programs (see Washington’s public-employee law described below);
- Providing state-funded subsidies for insurance in addition to federal tax credits; and
- Working with insurers to create more efficient plan design (e.g., changing benefit and network requirements).
Several panelists said it was important to ensure that future solutions do not undercut their individual markets — as new federal policies promoting market segmentation do (e.g., promulgation of short-term plans and health care ministries). Several states have explored implementing a state-based insurance mandate to help ensure that consumers continue to participate in their insurance markets to help stabilize their risk pools for all.
Washington, DC’s new mandate , for example, is modeled closely after the federal mandate, though it made small changes, such as including an automatic exemption for those eligible for Medicaid based on their income even if they were not currently enrolled in Medicaid. Under federal law, these individuals had to actively pursue an exemption, and would often not apply on time if at all. Money collected from the mandate will be used to fund additional affordability programs and coverage outreach initiatives. Washington State leveraged its state purchasing power to require that any insurer offering school or state employee coverage must also offer individual market plans in those counties through the state’s health insurance marketplace.
Medicaid’s Bearing on Individual Market Costs
A few panelists cited the positive effect that states’ decisions to expand Medicaid have had on their individual markets. In Medicaid expansion states, Medicaid eligibility is raised to 133 percent of FPL, meaning that individuals earning between 100 to 133 percent of FPL — who would otherwise be eligible for subsidies for private coverage through the health insurance marketplaces — are enrolled in Medicaid coverage. Studies indicate that Medicaid expansion states have better individual market risk scores than those that have not expanded coverage, suggesting that populations at lower-income thresholds are in poorer health than those at higher-income levels. This suggests that the individual market risk pool in expansion states is healthier, leading to lower overall costs in those markets.
Building on this concept, Idaho, a non-expansion state, explored a dual waiver program in which it would use an 1115 Medicaid waiver and a 1332 state innovation waiver to allow individuals earning below 100 percent of FPL to receive subsidies for coverage through its health insurance marketplace, while enrolling individual earning between zero to 400 percent of FPL with complex medical needs in Medicaid. The program would have enabled more individuals to access coverage, while lowering premiums for marketplace enrollees by taking those with unhealthy risk out of the individual market risk pool.
The proposal was ultimately rejected by Idaho’s state legislature in part due to concerns over costs to the state’s Medicaid program. However, supporters of expansion in Idaho have secured a ballot initiative so residents can vote on whether the state should expand Medicaid in November. Similar initiatives will also be on the ballot in Nebraska and Utah.
Future State Solutions
Challenges remain for states pursuing stabilization strategies. Several officials expressed hope the federal government would refrain from new actions that could de-stabilize markets or reduce state authority over markets, such as restricting state decisions on “silver-loading” to account for CSR losses. Some also expressed a desire for greater flexibility over 1332 waivers that could ease states’ ability to apply for waivers or allow more state experimentation. .
This remains a unique time for states, observed Washington, DC’s Mila Kofman, with consumer groups, insurers, and state policymakers united in their goal to enact policies that create more stable and affordable insurance markets.
NASHP will continue to closely monitor state strategies and report on their efforts to create stable and affordable markets.
Despite vaccines’ effectiveness in preventing infectious diseases and strong public funding for childhood immunizations, vaccination rates among children living in poverty remain stubbornly lower than for children living above poverty and who are privately insured.
Recently, officials from several organizations, including the National Academy for State Health Policy (NASHP), AcademyHealth, and the Colorado Children’s Immunization Coalition, convened state officials and subject matter experts to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
What Vaccine Benefits Do State Medicaid Programs Offer?
Recognizing their critical role in protecting public health, Medicaid covers all recommended vaccines for children and many state Medicaid programs do not charge pregnant women copayments for vaccinations in order to remove financial barriers. As a result of this publicly-funded initiative, immunization rates for Medicaid-covered children are higher than for children without health insurance, demonstrating the value Medicaid provides in overcoming socioeconomic barriers to provide essential health benefits.
|What is the Community of Practice?
With support from a CDC cooperative agreement, NASHP and AcademyHealth, with support from the Colorado Children’s Immunization Coalition, are leading a Community of Practice to identify ways to improve immunization rates among Medicaid-enrolled children and pregnant women.
These partners, participating states (CO, HI, KY, MT and NM), and experts will continue to convene the Community of Practice and share findings with other states seeking to increase immunization rates.
Vaccination rates also vary by vaccination type. For example, Medicaid-covered newborns are vaccinated with the hepatitis B birth dose at higher rates than newborns covered by private insurance, demonstrating Medicaid’s effectiveness. Considering that Medicaid covers nearly half of all children in some states, this state program can build on its successes and serve as a change agent to make sure even more children receive crucial vaccinations.
Socioeconomic Disparities in Vaccination Rates Persist
Despite Medicaid’s success in boosting immunization rates, according to Centers for Disease Control and Prevention (CDC) data, socioeconomic disparities persist in vaccination rates among young children enrolled in Medicaid and pregnant women. Children living below poverty level, as well as Medicaid-enrolled and uninsured children, have significantly lower immunization rates for many vaccines compared to children living at or above poverty level and/or with private insurance. Similarly, Tdap (diphtheria, tetanus, and whooping cough) and influenza immunization rates are lower among pregnant women living below the poverty level and/or enrolled in public insurance programs.
CDC shared these findings recently when NASHP, AcademyHealth, and the Colorado Children’s Immunization Coalition gathered state officials and experts together to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
Strategies to Narrow the Immunization Gap
Attendees noted that lower vaccination rates among Medicaid enrollees could result from many factors, including poor access to care or lack of provider recommendations. Meeting participants discussed several evidence-based interventions recommended by the Community Preventive Services Task Force to increase immunization rates among Medicaid beneficiaries. These include:
- Monitoring immunization status during home visits;
- Providing immunizations in school-based health clinics, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) settings, and other non-traditional venues; and
- Using standing orders for age-appropriate immunizations as defined by CDC during well-child visits.
Meeting participants also suggested leveraging relationships with managed care organizations and patient-centered medical homes, where applicable, to increase immunization rates and providing non-emergency medical transportation to help families adhere to well-child and prenatal appointments, where immunizations are commonly administered.
Meeting participants also identified use of data, primarily Immunization Information Systems (IIS), as a strategy to identify disparities and target immunization outreach. An IIS records immunization doses administered by participating providers and can provide both patient immunization histories for use by providers in a clinical setting. IIS can also collect data at the population level to guide actions to improve immunization rates.
However, attendees identified barriers to using IIS effectively at both the state and provider level, including:
- A lack of funding to support development and maintenance;
- Legal and technical barriers to data exchange;
- Data silos within and between agencies;
- Data-sharing challenges between electronic health records and other health information exchanges; and
- Onboarding and implementation hurdles.
Tools and websites are available to help states fully maximize their IIS and data-sharing capacities, and additional tools are under development.
States participating in the Community of Practice have employed successful strategies to reduce barriers to immunization among Medicaid participants. For example, Colorado has engaged in provider outreach and collaborated with WIC programs to share the immunization status of WIC clients. Montana developed performance-tracking measures for immunization rates and incorporated these into managed care organization contracts.
The Community Preventive Services Task Force also recommends the following evidence-based best practices to increase immunization rates:
- Reduce client out-of-pocket costs for vaccinations (Medicaid pays for vaccine administration, but low-income, uninsured patients must pay for administration of the free vaccines);
- Establish vaccination requirements for childcare, school, and college settings;
- Create client or family incentive rewards;
- Design client and provider reminder/recall systems;
- Encourage provider assessments and feedback;
- Generate provider reminders; and
- Create combination community- and health care system-based interventions.
As Community of Practice states identify strategies and lessons learned to improve vaccination rates among Medicaid-covered children and pregnant women, they will be shared nationally to support similar efforts in other states.
Photo Courtesy of the CDC
As states pursue a wide range of legislation to address rising drug costs, four more states have joined Utah and Vermont to introduce bills to import prescription drugs from Canada through a state-run, wholesale operation.
This market-based approach to providing more affordable medicines from Canada, where prescription drugs cost on average 30 percent less than in the United States, is appealing to a politically diverse group of states, and is currently under review by legislators in:
- Colorado (S 80);
- Missouri bill studies the creation of an importation program (SB 722);
- Oklahoma (SB 1381);
- Utah (HB 163);
- Vermont (S 175); and
- West Virginia (HB 4294).
A fiscal analysis recently completed in Utah indicated the potential for millions in reduced spending due to the significant price differences between certain products sold in the United States and Canada. This month, NASHP is convening state legislative sponsors to share information and expertise about the importation policies in their states. Many of the importation bills currently under review are based on National Academy for State Health Policy’s (NASHP) model legislation.
If an importation bill passes in a state legislature and is signed into law by the governor, the next step is to seek certification from the US Health and Human Services Secretary Alex Azar by proving that the state’s importation program meets federal requirements to ensure both product safety and consumer savings.
NASHP’s model legislation was designed to meet federal requirements by taking the form of a state-administered system of wholesale importation and distribution limited to pharmaceuticals from Canada. States can decide whether to purchase lower-cost drugs for public programs only, or to expand the importation initiative to also serve commercial health plans.
The program’s imported drugs would be safe and would produce savings because a state would:
- Select only Canadian suppliers who are licensed and regulated under Canadian law;
- Select only drugs to be imported that are already approved for the Canadian market;
- Provide the drugs only to distributors, pharmacies and other dispensers, and health plans, that volunteer to participate in the program. Participants would agree to purchase and reimburse drugs at the import price and patients would share the cost savings and pay the import price as well. The imported drug costs would be made publicly available to create greater drug pricing transparency for consumers;
- Ensure that the imported products are distributed in-state only; and
- Monitor/audit the system for compliance, safety, and savings.
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.
Tuesday, July 29, 2014
1:00 – 2:15 pm ET
View Webinar Here
This webinar explores the leap from health system transformation planning to practice by showcasing four leading states that are designing and implementing multi-payer payment reforms. Through a facilitated discussion, state officials discuss policy levers to shift payment systems away from fee-for-service, offer strategies for sustaining stakeholder momentum and commitment, and share perspectives on promising practices for and operational challenges of turning a plan for multi-payer payment reform into reality.
This webinar is the first in a six-webinar series, supported by Kaiser Permanente Community Benefit, highlighting specific policy and technical issues critical to achieving multi-payer payment reform. It is useful for all states contemplating, designing, or implementing multi-payer payment reforms, particularly SIM Round 2 Model Design applicants.
- Moderator: Anne Gauthier, Senior Program Director, NASHP
- Marcela Myers, Director, Pennsylvania Center for Practice Transformation and Innovation, Pennsylvania Department of Health; Pennsylvania SIM Project Director
- Karen Matsuoka, Director, Health Systems and Infrastructure Administration, Maryland Department of Health and Mental Hygiene; SIM Project Director
- Mark Schaefer, Director, Healthcare Innovation, Connecticut’s Office of the Healthcare Advocate; Connecticut SIM Project Director
- Vatsala Kapur Pathy, Founder, Rootstock Solutions; Colorado SIM Project Director
State Medicaid programs offer a variety of treatment services to meet the needs of children with physical and behavioral health conditions. Under federal law, Medicaid programs must cover services for children, as long as the treatments are necessary to correct or ameliorate the child’s condition, even if the services are not covered for adults. This NASHP webinar provides a federal perspective from the Centers for Medicare & Medicaid Services on how states can leverage the Medicaid benefit for children and adolescents (also known as EPSDT) to meet the treatment needs of children. This is followed by a conversation with presenters from Colorado and Washington about treatment services under the EPSDT benefit and their processes for determining service coverage.
This webinar is the fourth in a series on the Medicaid benefit for children and adolescents: the final webinar in the series will focus on care coordination services for children. In conjunction with this webinar series, NASHP launched a Resource Map to disseminate state-specific resources and information about strategies that state policymakers and Medicaid officials can use to deliver the Medicaid benefit for children and adolescents.
- Laurie Norris, Senior Policy Adviser, Centers for Medicare & Medicaid Services
- Gail Kreiger, Section Manager, Washington Health Care Authority
- Gina Robinson, Program Administrator, Colorado Department of Healthcare Policy and Financing