New Mexico Gov. Lujan Grisham recently signed into law SB 131, establishing a state Interagency Pharmacy Purchasing Council to leverage public purchasing power by reviewing and coordinating cost-containment strategies through procurement of pharmaceuticals, pharmaceutical benefits, and pooling of risk among state agencies.
Cosponsored by state Sen. Jeff Steinborn* and Rep. Joanne Farrary, the law also identifies private-sector opportunities to help residents not covered by state plans, either through existing private-sector discount programs or by leveraging the government’s drug spending. Importantly, the legislature appropriated $400,000 to support the council’s work. The council will include the department heads or their designees of these state agencies and groups:
- Departments of human services, health, children, youth, and families, and corrections;
- The Risk Management Division of the General Services Department;
- The New Mexico Retiree Health Care Authority;
- Public schools and the University of New Mexico; and
- Two members appointed by the governor who are officers or designees of organizations that represent county, municipal, and local governments.
The secretary of the state’s General Services Department will direct the council, which must hold its first meeting by Sept. 1, 2019.
The law preserves the authority of state agencies to make their own procurement decisions and lays out a list of strategies that the council can examine and possibly deploy, including:
- Benchmarking health care costs to Medicaid, with the understanding that federal authority may be needed for changes to the Medicaid program;
- Establishing a common drug formulary to be shared by state agencies;
- A single-purchasing agreement;
- Common procurement practices for expert services (e.g., a pharmacy benefit manager or actuarial services);
- Identifying opportunities to consolidate purchasing and pool risk between two or more state agencies;
- Negotiating advantageous pricing and incentives throughout the drug supply chain;
- Partnering with other multi-state purchasing collaboratives; and
- Identifying ways to leverage public purchasing to benefit residents who purchase services/drugs in the private sector.
The council will vote on which strategies to pursue and they will next be evaluated by the legislature’s Finance Committee, with the goal of incorporating agency savings into budget deliberations and measuring the council’s effectiveness and progress.
“I am thrilled that New Mexico has taken this important step to pursue greater cost containment of prescription drug costs,” said Sen. Steinborn. “We have crafted a bill intended to aggressively explore cost-containment options, while at the same allow flexibility and oversight. It has the potential to save our state a significant amount of money and I’m excited to have the council get to work.”
New Mexico is on the leading edge of a new wave of states’ efforts to more aggressively coordinate public purchasers and leverage their considerable buying power to lower pharmacy and other health care costs. By engaging key state agency leaders and requiring accountability and oversight by the legislature’s Budget Committee, New Mexico’s important initiative bears close watching by other states.
For more insights into states’ collaborative purchasing and cost control initiatives, read: Cross-Agency Strategies to Curb Health Care Costs: Leveraging State Purchasing Power.
*State Sen. Steinborn serves on the National Academy for State Health Policy’s Health System Performance and Public Health Steering Committee
Primary care practices transitioning to enhanced models of primary care require ongoing support to sustain their transformation efforts. Small and medium-sized practices in particular can benefit from shared resources facilitating care coordination and case management, use of data and technology, and ongoing practice improvement. This State Health Policy Briefing outlines key elements of a shared infrastructure to sustain primary care transformation, identifies policy levers available to federal and state policymakers to support these elements, and highlights relevant initiatives at both levels of government. It also summarizes key areas for policy improvement identified during a meeting of federal and state officials convened by NASHP.
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Primary care extension programs improve the quality of primary care services by educating providers on new and innovative practices in areas such as preventive medicine, health promotion, and chronic disease management. Section 5405 of the Affordable Care Act authorizes the establishment of a national primary care extension program. To pursue this goal, the Agency for Healthcare Research and Quality (AHRQ) established the Infrastructure for Maintaining Primary Care Transformation (IMPaCT) initiative as a pilot to build on states with strong existing extension programs to serve as a potential model for a national extension program.
This webinar will feature a high-level overview from each of the four lead IMPaCT states (New Mexico, North Carolina, Oklahoma and Pennsylvania) that highlights key components of their extension models. Following the overviews, a facilitated discussion with state officials from these states will illuminate the role of, and implications for, state agencies in this work. Following the discussion, participants will have the opportunity to ask questions of the speakers.
- Bob Mcnellis, Senior Advisor for Primary Care, Agency for Healthcare Research and Quality (AHRQ)
- Darren DeWalt, MD, MPH, Associate Professor of Medicine, Division of General Internal Medicine, University of North Carolina – Chapel Hill
- Robert Gabbay, MD, PHD, Chief Medical Officer and Senior Vice President, Joslin Diabetes Center
- Art Kaufman, MD, Vice Chancellor for Community Health; Distinguished Professor, Family & Community Medicine, University of New Mexico Health Sciences Center
- Jim Mold, MD, MPH, Director, Research Division, Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center
- Chris Collins, MSW, Director, Office of Rural Health and Community Care, North Carolina Department of Health and Human Services
- Marcela Myers, MD, Director of Pennsylvania Center for Practice Transformation and Innovation, Pennsylvania Department of Health
- Garth Splinter, Medicaid Director, Oklahoma Health Care Authority
|Download Webinar Slides||4.7 MB|
States seeking to promote better coordination of patient care, either within Medicaid or through participation in multi-payer initiatives, will run into long-standing challenges to delivering care and promoting health in rural areas. Rural areas often experience disparities in access to care, health status, and available infrastructure relative to their urban counterparts. This brief draws from health initiatives undertaken in Alabama, Colorado, Montana, New Mexico, North Carolina, and Vermont to identify common policy considerations and action steps for coordinating care in rural areas. The brief was supported by the Robert Wood Johnson Foundation’s State Health and Value Strategies.
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In 2009, New Mexico unanimously enacted Chapter 143 of the 2009 Laws, intended to provide medical homes for members of the state’s Medicaid, Children’s Health Insurance Program (CHIP), and State Coverage Initiative (SCI) program. SCI is a public-private managed care program in New Mexico that targets low-income adults without insurance working for small employers. The statute directs the New Mexico Human Services Department to apply for a waiver or state plan amendment to implement a medical home program, and to work with managed care contractors to “promote, and if practicable, develop” a medical home program.
Participating SALUD! managed care organizations (MCOs) are providing grants to a small number of primary care practices in the state with the goal of achieving NCQA PCMH certification. Initial estimates indicate that over 45,000 members are participating in PCMH delivery models through the SALUD! medical home pilots.
New Mexico Medicaid is focusing on four main objectives:
Enhance and standardize key components of the SALUD! physical health medical home model;
Implement and integrate a medical home model in the behavioral (mental health and substance abuse) and long term care delivery models;
Leverage new federal funding opportunities, specifically ACA Section 2703 health homes and Medicaid beneficiary incentive programs; and
Develop a consistent and transparent payment methodology.
HB34, introduced in the first session of 2011, would have required that all managed care plans to allocate funds to establish and maintain medical home programs, but the legislation was pocket-vetoed after passage in both the House and the Senate.
Federal Support: New Mexico has received a planning grant from the Centers for Medicare & Medicaid Services (CMS) to develop a state plan amendment to implement Section 2703 of the Affordable Care Act (ACA), establishing health homes for Medicaid enrollees with chronic conditions. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
Targeted population: Medicaid, CHIP, and SCI.
Last Updated: April 2014
New Mexico Medicaid plans to develop a workgroup including, but not limited to, the following organizations:
The workgroup will develop collaborative/cooperative protocols to support the goals and needs of medical homes.
New Mexico Medicaid also plans to develop managed care consumer advisory boards to educate enrollees and receive input on what enrollees want from medical homes.
|Defining & Recognizing a Medical Home||
Definition: Chapter 143 of the 2009 Laws defined a medical home as “an integrated care management model that emphasizes primary medical care that is continuous, comprehensive, coordinated, accessible, compassionate and culturally appropriate. Care within the medical home includes primary care, preventive care and care management services and uses quality improvement techniques and information technology for clinical decision support.” The statute [NMSA 1978 27-2-12.15 (1978)] also enumerates 18 specific attributes that may be included in a medical home.
Recognition: Chapter 143 of the 2009 Laws specified that medical doctors, physician assistants, and nurse practitioners are eligible for recognition as offering medical homes. Chapter 43 of the 2010 Laws expanded eligibility to osteopathic physicians, osteopathic physician assistants and pharmacist clinicians.
The SALUD! managed care organizations are funding Medicaid pilots and using contractual definitions based on NCQA PCMH principles and modules for PCMH implementation, including: Electronic Medical Record (EMR); Patient Tracking and Registry Functions; Test Tracking; Referral Tracking; e-Prescribing; Access and Communication; and Performance Reporting and Improvement.
The participating SALUD! Managed Care Organizations (MCOs) are currently funding Medicaid PCMH models and payments to practices through a withhold fund established from capitated payments to the MCOs.
The state has met with the Department of Health to identify and target case mangers to work with the Managed Care Organizations and provider networks to identify and manage care for high-cost, high-risk children/patients.
New Mexico Medicaid plans to adopt a common set of performance measures for quality improvement, possibly drawing from NCQA and Electronic Health Record Meaningful Use requirements. Also, utilization measures and cost data will be included in the performance reporting and feedback process to practices and plans. The state is exploring methods to aggregate performance data to identify pockets of care disparities and high avoidable costs.
Initial quality measures have included monitoring diabetic and asthmatic patients. Annual reviews of PCMH pilots include implementation of a scorecard with cost, quality and satisfaction measures. New Mexico is also monitoring emergency department and inpatient utilization.
New Mexico’s Medicaid program is currently in transition.
- Before January 2014, physical and oral health services were provided to almost all categories of Medicaid-enrolled children and adults in the state through comprehensive managed care organizations (MCOs) under a 1915(b) waiver program known as Salud! There were a total of 551,017 beneficiaries enrolled in New Mexico Medicaid as of July 2011. Of these 401,318 were enrolled in MCOs. Some subpopulations were excluded, such as American Indian/Alaska Natives (though this group had the choice to opt in) and children in out-of-state foster care or adoption placement.
- Behavioral health services were delivered through a pre-paid inpatient health plan (PIHP). 374,013 beneficiaries received services through the state’s PIHP. The PIHP served the same populations as the MCOs.
- The state has received approval for an 1115 Demonstration waiver to implement Centennial Care beginning in January 2014. Under this program, four managed care organizations will provide physical health, behavioral health, long-term care and community benefits.
As of 2012, 380,612 individuals (aged 0-20) were eligible for New Mexico’s Medicaid benefit for children and adolescents (also known as the Early Periodic Screening, Diagnostic and Treatment benefit, or EPSDT) benefit. According to CMS data from 2012, New Mexico achieved a screening ratio of 79% and a participation ratio of 60%. 189,863 children received dental services, with 176,185 receiving preventive dental services.
Last updated December 2013.
In New Mexico, medically necessary services are defined in regulation as clinical and rehabilitative physical or behavioral health services that:
The state does not have distinct definitions for children, oral health services, or behavioral health services.
|Initiatives to Improve Access
The Human Services Department (home to Medicaid) is a partner in a children’s health care quality initiative spearheaded by the University of New Mexico, Envision New Mexico, that includes telehealth programs linking pediatric sub-specialists at the university with primary care providers throughout the state.
|Reporting & Data Collection||
The New Mexico Human Services Department (HSD) completes the CMS Form-416, using encounter data submitted by managed care organizations (MCOs) and the state’s fee-for-service third party administrator. Managed care organizations in the state transmit encounter data to the HSD electronically on a weekly basis. Data and system requirements for Medicaid managed care organizations are laid out in a MCO/CSP Systems Manual. The state’s Medicaid Management Information Systems edits the incoming data: the system verifies the validity of the recipient, as well as the validity of the diagnosis and the procedure. Data from fee-for-service claims and from managed care encounter data is housed together in the same database. However, each claim is marked as fee-for-service or managed care inside the data warehouse and tagged with information identifying the specific managed care organization that submitted it.
New managed care contracts under Centennial Care require that MCOs use the most recent version of the CAHPS Adult and Child Survey Instruments, including the Children with Chronic Conditions to assess member satisfaction as part of Health Effectiveness Data and Information Set (HEDIS) reporting requirements and report on them to the Human Services Department. The contracts also include performance measures that pertain to Medicaid services for children, such as a measure of the percentage of members ages 5-11 and 12-18 who are identified as having persistent asthma and who were appropriately prescribed medication during the measurement year.
New Mexico permits pediatricians to bill for developmental/behavioral screening at the 30-month well child visit. Physicians may bill for use of a validated screening tool using the 96110 code, in addition to a well child code on the same day.
The state’s Medicaid periodicity schedule and preventive services guidance for children is based on the American Academy of Pediatrics’ Bright Futures guidelines, which recommend the following screening tools: Pediatric Symptom Checklist, Strengths and Difficulties Questionnaire, Checklist for Autism in Toddlers, Modified Checklist for Autism in Toddlers, and the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) Screening Questionnaires for substance abuse.
Cross-agency treatment options
In 2004 New Mexico created the Behavioral Health Purchasing Collaborative to coordinate resources being used for behavioral health prevention, treatment and recovery. While 15 state agencies are participate in the Collaborative, funds are contributed primarily by five agencies: the Human Services Department Medical Assistance Division (Medicaid); the Behavioral Health Services Division; the Children, Youth and Families Department; the Corrections Department; and the Department of Health. Funding from these agencies is combined, but managed separately to ensure compliance with reporting and other requirements.
Braided behavioral health funding allows the state to integrate and coordinate services: children have coordinated access to services funded by Medicaid as well as other state agencies. In addition, children with serious needs can access Comprehensive Community Support Services through the state’s system of Core Service Agencies (CSAs).
CSAs are typically Community Mental Health Centers that are enrolled as Medicaid providers and licensed by the Children, Youth and Families Department. They are responsible for coordinating a wraparound planning process that connects families to providers and resources in the local community necessary to implement an individualized plan of care. The CSAs serve as a single point of contact and entry to the state’s behavioral health system for children with serious behavioral health needs, including children with substance abuse or juvenile justice involvement. Medicaid managed care contracts require managed care organizations to make best efforts to contract with entities designated as CSAs.
|Support to Providers and Families||
Managed care contracts and a draft quality strategy for Centennial Care, the state’s new managed care program, require that managed care organizations provide member handbooks that include information on how to access services under the EPSDT benefit, including dental services, non-emergency transportation, and behavioral health services.
The Medicaid agency’s website has an overview of the children’s benefit that includes anticipatory guidance (in English and Spanish), as well as preventive health guidelines.
Each of the four MCOs participating in Centennial care is providing training to providers on Medicaid benefits.
In 2009, New Mexico enacted Chapter 143 of the 2009 Laws, intended to provide medical homes for members of the state’s Medicaid, Children’s Health Insurance Program (CHIP), and State Coverage Initiative (SCI) program (SCI is a public-private managed care program in New Mexico that targets low-income adults without insurance working for small employers). The statute directed the New Mexico Human Services Department to apply for a waiver or state plan amendment to implement a medical home program, and to work with managed care contractors to “promote, and if practicable, develop” a medical home program.
In amendments to the state’s MCO contracts that took effect in July of 2009, HSD encouraged the development of Patient-Centered Medical Homes (PCMH) via financial assistance to select provider groups to begin the PCMH certification process. New managed care contracts under Centennial Care also require MCOs to establish patient-centered medical home initiatives.
Managed care contracts also require that Medicaid MCOs work with the Child, Youth and Families Department (CYFD) to coordinate services with CYPD Protective Services, Family Services, and Juvenile Justice Services divisions.
||Managed care organization performance measures under Centennial Care include a measure of the percentage of enrolled members ages 2-21 who have at least one dental visit during the year.|
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email firstname.lastname@example.org.
Last updated: October 2012
The Affordable Care Act (ACA) offers states multiple policy levers to improve health status and care for racial and ethnic minority populations through delivery system reforms, public health and community interventions, and insurance coverage, as well as provisions specific to disparities reduction. This report synthesizes the experiences of teams from seven states (Arkansas, Connecticut, Hawaii, Minnesota, New Mexico, Ohio, and Virginia) that participated in a learning collaborative to advance health equity using select ACA and state policy levers. The report also presents opportunities for state and federal collaborations to strengthen these efforts, as well as important lessons for advancing health equity.
An accompanying issue brief provides a high-level summary of the full report.
By 2019, Medicaid is estimated to cover an additional 16 million of the most vulnerable Americans, significantly increasing the shape and size of the program.
On this State Refor(u)m webinar, officials from three states will provide a closer look at what states are doing to prepare.
Sonya Schwartz, Program Director, National Academy for State Health Policy
Sarabeth Zemel, Program Manager, National Academy for State Health Policy
Panelists will be:
Nathan Johnson, Medicaid Policy Manager, Washington Health Care Authority
Elena Nicolella, Medicaid Director, Rhode Island Department of Human Services
Julie Weinberg, Director, New Mexico Human Services Department