Health Policy Roundup: State Policy Analysis and Priorities
January 28, 2022
This event was Part III of the Alliance’s Health Policy Roundup and 2022 Forecast series.
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While significant attention has been paid to shifts in national health policy, it is equally important to understand the promise, tradeoffs, and impacts on various stakeholders that state policies have demonstrated. Within the last two years, state policymakers have introduced various innovative proposals to try to contain health care costs and improve access and affordability of care for consumers. States are generally uniquely positioned to enact and implement policies more quickly than their federal counterparts to generate change in some key areas, including provider payments, long-term care, and prescription drugs.
This briefing provided a round-up of state-level policies enacted during the past few years that are focused on cost containment, complex care, and drug pricing reform. Panelists overviewed health policies implemented and evaluated at the state level, synthesize major lessons and takeaways from these policies, and highlighted states or programs to watch in 2022.
Speakers:
- Stephanie Anthony, J.D., MPH, Senior Advisor, Manatt Health
- Colleen Becker, MPP, Senior Policy Specialist, National Conference of State Legislatures
- Suzanne Delbanco, Ph.D., MPH, Executive Director, Catalyst for Payment Reform
- Maureen Hensley-Quinn, MPA, Senior Program Director of Coverage, Cost and Value, National Academy for State Health Policy
- Mark E. Miller, Ph.D., M.A., Executive Vice President of Health Care, Arnold Ventures (moderator)
This event was made possible with support from Arnold Ventures.
Presentation: Health Policy Roundup: State Policy Analysis and Priorities
Event Resources
Key Resources
(listed chronologically, beginning with the most recent)
“Roundup of Selected State Health Developments, Fourth-Quarter 2021.” Stamm, C., Glass, R., Marshall, K. Mercer Law and Policy Group. January 21, 2022. Available here.
“Roundup of Selected State Health Developments, Third-Quarter 2021.” Stamm, C., Glass, R., Marshall, K. Mercer Law and Policy Group. October 22, 2021. Available here.
“Roundup of Selected State Health Developments, Second-Quarter 2021.” Stamm, C., Marshall, K. Mercer Law and Policy Group. July 30, 2021. Available here.
“Roundup of Selected State Health Developments, First-Quarter 2021.” Stamm, C., Marshall, K. Mercer Law and Policy Group. April 26, 2021. Available here.
“Covid’s Deadly Trade-Offs, By the Numbers: How Each State Has Fared in the Pandemic.” POLITICO. December 15, 2021. Available here.
“Reducing Health Care Spending: What Tools Can States Leverage?” Chernew, M., Cutler, D., Shah, S. The Commonwealth Fund. August 18, 2021. Available here.
Additional Resources
(listed chronologically, beginning with the most recent)
“A Looming Decision on Medicare Coverage for Biogen’s Alzheimer’s Drug Could Shock State Medicaid Programs.” Silverman, E. STAT News. January 10, 2022. Available here.
“Specific Steps to Improve the Fairness and Sustainability of Medicaid’s Financing of Long-Term Services and Supports for Older Americans.” Warshawsky, M. American Enterprise Institute. January 18, 2022. Available here.
“How Price Regulation is Needed to Advance Market Competition.” Berenson, R., Murray, R. Health Affairs. January 2022. Available here.
“Disrupting Hospital Price Increases: Using Growth Caps in Insurance Rate Review.” Butler, J. National Academy for State Health Policy. December 14, 2021. Available here.
“Telehealth Payment Parity Laws at the State Level.” Dills, A. Mercatus Center at George Mason University. November 30, 2021. Available here.
“States Use Appendix K and Emergency Waivers to Support Home- and Community-Based Services in Response to COVID-19.” National Academy for State Health Policy. November 3, 2021. Available here.
“HCBS Spending Plans and the Untapped Potential of D-SNPs.” Janoski, B., Abdnor, A., Mir, A. Arnold Ventures. October 11, 2021. Available here.
“Part 3: After a Groundswell of Success in 2021, Stage is Set for Broader Rx Reform in 2022.” Williamson, K. Arnold Ventures. October 1, 2021. Available here.
“Part 2: In Quest to Lower Rx Prices, States Deploy New Tools.” Williamson, K. Arnold Ventures. September 29, 2021. Available here.
“Part 1: As Congress Debates Lowering Drug Prices, States Waste No Time.” Williamson, K. Arnold Ventures. September 28, 2021. Available here.
“Strengthening Long-Term Services and Supports: The Difference Federal Investment Can Make.” Feder, J., Skopec, L., Favreault, M. Urban Institute. September 27, 2021. Available here.
“2021 State Legislative Session Recap on States’ Efforts to Lower Drug Costs.” Lanford, S. National Academy for State Health Policy. August 2, 2021. Available here.
“Long-Term Care Financing Reform Proposals That Involve Public Programs.” Hanna, C., Uccello, C., Schoonveld, S., et al. American Academy of Actuaries. July 2021. Available here.
“Potential Impact of Additional Federal Funds for Medicaid HCBS for Seniors and People with Disabilities.” Chidambaram, P., Musumeci, M. Kaiser Family Foundation. May 28, 2021. Available here.
“New Federal Funding Allows States to Rethink Long-Term Care.” Arnold Ventures. May 11, 2021. Available here.
“A Status Report on Prescription Drug Policies and Proposals at the Start of the Biden Administration.” Cubanski, J., Freed, M., Neuman, T. Kaiser Family Foundation. February 11, 2021. Available here.
“State All-Payer Claims Databases: Tools for Improving Health Care Value, Part 1- How States Establish an APCD and Make it Functional.” McCarthy, D. The Commonwealth Fund. December 10, 2020. Available here.
“State All-Payer Claims Databases: Tools for Improving Health Care Value, Part 2- The Uses and Benefits of State APCDs.” McCarthy, D. The Commonwealth Fund. December 10, 2020. Available here.
“How the Massachusetts Health Policy Commission is Fostering a Statewide Commitment to Contain Health Care Spending Growth.” Waugh, L., McCarthy, D. The Commonwealth Fund. March 5, 2020. Available here.
Experts
Speakers
Stephanie Anthony, J.D., MPH
Manatt Health, Senior Advisor
santhony@manatt.com
Colleen Becker, MPP
National Conference of State Legislatures, Senior Policy Specialist
colleen.becker@ncsl.org
Suzanne Delbanco, Ph.D., MPH
Catalyst for Payment Reform, Executive Director
sdelbanco@catalyze.org
Maureen Hensley-Quinn, MPA
National Academy for State Health Policy, Senior Program Director of Coverage, Cost and Value
mhq@nashp.org
Mark Miller, Ph.D.
Arnold Ventures, Executive Vice President of Health Care
MMiller@arnoldventures.org
Experts and Analysts
Lauren Block, MPA
Aurrera Health Group, Principal of Medicaid Policy & Programs
Lauren@aurrerahealth.com
Erin Fuse Brown, J.D., MPH
Georgia State University College of Law, Catherine C. Henson Professor, Associate Professor of Law, and Director of Center for Law, Health and Society
efusebrown@gsu.edu
Michael Bailit, MBA
Bailit Health, President
mbailit@bailit-health.com
James C. Capretta, M.A.
American Enterprise Institute, Senior Fellow and Milton Friedman Chair
jcapretta@aei.org
Judith Feder, Ph.D.
Georgetown University McCourt School of Public Policy, Professor of Public Policy
federj@georgetown.edu
Lovisa Gustafsson, MBA
Commonwealth Fund, Vice President, Controlling Health Care Costs
ilg@cmwf.org
Heather Howard, J.D.
State Health and Value Strategies, Program Director
Princeton University School of Public and International Affairs, Professor of Practice
heatherh@princeton.edu
Erica Socker, Ph.D.
Arnold Ventures, Vice President of Health Care, Payor Reform
esocker@arnoldventures.com
Government
Jhamirah Howard, MPH
Office of the Assistant Secretary for Planning and Evaluation, Social Science Analyst
jhamirah.howard@hhs.gov
Carolyn L. Yocom, MBA
U.S. Government Accountability Office, Director, Health Care
yocomc@gao.gov
Stakeholders
Kelly Brantley, MPH
Avalere, Policy Practice Director
KBrantley@avalere.com
Elizabeth Cahn Goodman, J.D., MSW, Dr.P.H.
AHIP, Executive Vice President, Government Affairs and Innovation
egoodman@ahip.org
Shelby Hockenberry, Ph.D., M.A.
National Governors Association, Program Director, Healthcare Delivery
shockenberry@nga.org
Donald May, MPA
Federation of American Hospitals, Senior Vice President of Policy
dmay@fah.org
Pamela Roberto, Pharm.D, Ph.D., MPP
PhRMA, Deputy Vice President of Policy and Research
proberto@phrma.org
Transcript
This is an unedited transcript.
0:04
Hello, everyone.
0:06
Thank you for joining today’s third installment of the Alliance for Health Policy Health Policy Roundup series, State Policy Analysis and Priorities. I’m Madeline Cree, Health Policy Analyst here at The Alliance.
0:17
For those of you who are not familiar with the Alliance Welcome, we’re a non partisan resource for the policy community, dedicated to advancing knowledge and understanding of health policy issues.
0:27
Today’s briefing is brought to you in partnership with Arnold Ventures.
0:30
You can join today’s conversation on Twitter, using the hashtag #allhealthlive, and join our community all at all health policy, as well as on Facebook and LinkedIn.
0:41
Today’s panel has a Q and A section at the end of the hour. We want you all to be active participants. So, please get your questions ready. You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark.
0:53
You can use that speech bubble icon to submit questions you have for the panelists at any time.
0:58
Will collect these and address them during the broadcast.
1:01
Throughout the webinar, you can also chat about any technical issues you may be experiencing and someone will attempt to help.
1:07
Leading our conversation today is doctor Mark Miller, executive vice president of health care at Arnold Ventures.
1:13
Mark leads Arnold Ventures work to lower the cost and improve the value of healthcare.
1:18
He has more than 30 years of experience developing and implementing health policy, including prior positions at the Medicare Payment Advisory Commission, the Congressional Budget Office, the Centers for Medicare and Medicaid Services, the Office of Management and Budget, and the Urban Institute.
1:33
Mark, we’re so excited to have you with us today to guide this discussion, And now, I’m happy to turn the page over to you.
1:41
I appreciate that. I feel throughout the rest of this, I hope everybody just refers to me as Mark. Nobody’s calling me doctor Miller for a long time. But I appreciate the intro. Just a little bit of orientation, Arnold Ventures is a philanthropy, meaning we give out grants for research and developing policy ideas and educating policymakers. We work at the federal and state level. We work on both sides of the aisle.
2:09
Our agenda is driven by affordability, reducing the cost of healthcare, or getting a better spend for the existing dollar.
2:18
And we focus very much on the root cause, or the, the payers that are, you know, truly paying the cost of healthcare, and the and the employer, the household, and the taxpayer, whether it’s a federal or state taxpayers.
2:34
Our research has led us to policy ideas that are market oriented, but we also think there are many market problems and market failures. And so we also have policies that are more regulatory in nature.
2:47
Some of our agenda includes the cost of drugs, market consolidation, and provider provide prices, particularly hospital prices, surprise, medical billing, and the integration of Medicare and Medicaid for complex populations, the dually eligible populations.
3:07
All of these have been implicated in one way or another at the federal level. But the objective today is to talk about these issues and related issues at the state level.
3:19
And we have four speakers, and I’m going to introduce them now.
3:24
And the speakers in order that they will be speaking are the panelists, I guess, in order that they will be speaking.
3:34
Maureen Hensley Quinn is the Senior Program Director of Coverage, Cost and Value at the National Academy of State Health Policy. She oversees the …
3:44
portfolio of work that support states, officials related to issues on Medicaid, chip, state based park at marketplaces. She also does work, specifically around lowering prescription drug costs and health care system costs, generally.
4:03
This research and analysis is, is for federal, around federal and state laws, regulations, and best practices, and she supports efforts to create and disseminate solutions to the state, to increase coverage, and to contain costs. Suzanne Delbanco is the Executive Director at the Catalyst for Payment Reform. Since its inception in 2010, Suzanne has led the catalyst for payment reform in its commitment to help employers and other purchasers send a C or a clear signal to the market about the need for higher quality and lower cost. Initially, there were focused on advancing payment reform. More recently, she has expanded their efforts to include price and quality transparency, benefit design, provider network design, provider consolidation of market power, and other topics. She has previously led the leapfrog group.
5:08
Colleen Becker is a Senior Policy Specialist at the National Conference of State Legislature.
5:15
Legislatures. She specializes in prescription drugs and affordability issues. She tracks and analyzes legislation rights policy, publications, convenes, and communicates that, and provides technical assistance to legislators, staff, and other experts.
5:35
Before NCSL, Colleen was a policy co-ordinator for the chronic care Collaborative, which advocated for people with chronic diseases in Colorado.
5:47
Finally, Stephanie Anthony is a Senior Advisor at Manatt Health, where she provides research, analysis, and advisory services on health policy and health law and public and private sector clients.
6:00
She offers counsel on healthcare reform, Medicaid, chip, program design waivers, post acute care, long term services, and supports.
6:11
and she also advises on best practices for care management, integrated care models and coverage options for the uninsured.
6:21
So, the way this is gonna work is each of the speakers is gonna go in order and speak for about seven minutes. We’ll move from speaker to speaker, holding questions until everybody has gotten a chance to get their opening comments out on the table.
6:38
To get things going, I’ll ask a few questions and get the panelists to start talking and get a little bit deeper on the comments that they’ve made. Meanwhile, we’ll be accumulating questions from the audience and as quickly as possible, move to those questions.
6:54
So if everybody is good, then I think we’ll move to Maureen as our first speaker.
7:06
Thank you so very much. I’m so happy to be able to join you all today, really appreciate the Alliance and Arnold for inviting Nashville’s participation.
7:18
So, I’ll just kick us off and, then, hand it over to my esteemed panelists. To get us started, I just wanted to let folks know who may not.
7:29
Nash P or the National Academy for State Health Policy, is a forum for and by state officials, We aim to support state officials in addressing health policy issues across agencies and offices, since health policy really does live in multiple places.
7:50
We are proud to be an Arnold Venture’s grantee. We operate the centers on prescription drug pricing and health systems costs.
8:00
So, today, we’re here to talk about how states are and others are addressing costs.
8:07
Health care costs keep rising for all purchasers of care, including states, employers, health plans, and consumers.
8:16
Over the past several years, there’s been increased interest at the state level on what’s driving these costs.
8:25
The release of new and very expensive prescription drugs, kut state leaders, attention, and increases in prices of existing drugs like insulin helped to spur substantial and varied state action. As you can see from this slide, that my colleagues pulled together to highlight state legislative action on prescription drug pricing.
8:50
Again, that’s aimed to reduce prices and costs between 2017 and 2021, so even during the pandemic, 50 states introduced legislation aimed at reducing drug costs 49 states have enacted over 200 laws.
9:10
You’ll see, and I know this slide is a little busy, but there are themes across some of these efforts that states have made.
9:19
What began as state interest in better understanding the drug supply chain and demanding, transparent, PBM ore, prescription pharmacy benefit manager practices is evolving into a sharper focus on drug prices.
9:38
However, it is challenging to legislate or regulate lower price.
9:44
With state guidance, …
9:46
develop model policies to set upper payment limits on high, certain high RX drug costs to reference price to Canadian pricing, the idea being, importing the price rather than the drug, and even a model that finds unsupported price increases by manufacturer.
10:10
Also, over this past year, there’s been an increase in state requests.
10:15
Understand prescription drug review boards, such boards, if established, can be used to help leverage available data on prescription drug costs to inform policy, including potentially setting upper payment limits for health plans, purchasing medications. Such limits are aimed to protect health plans and consumers.
10:40
Again, a, a real focus on trying to get at the prices of the drugs themselves rather than looking throughout the supply chain for efficiencies.
10:53
Although prescription drug prices have increased quickly over the past few years, by far, the largest proportion of US healthcare spend is on hospitals, health systems, and high cost providers, state leaders interested in addressing overall rising healthcare costs.
11:13
We’re looking holistically at what’s driving spend and seeking solutions, not only to address prescription drug prices, but also high hospital costs as well.
11:25
So, the next slide, highlights, very quickly, some of the, um, tools and policies, strategies that states are looking at, right now.
11:39
There are a growing number of states seeking the collection of detailed hospital price, cost, and financial data to inform their policy approaches.
11:50
They are using that information in a variety of ways.
11:54
As highlighted here, states are seeking authority to mitigate further consolidation or enforce anti competitive contracting among hospitals and health among hospitals health systems and health plans, which research shows helps drive up prices without improving quality.
12:17
States are also seeking to adopt reference based pricing some using a multiple of Medicare’s rate, which is aiming to constrain rising costs and also increasing cost predictability for health plans and state purchases of care.
12:35
Others are aiming to limit hospital rates through multiple levers, such as insurance rate review with affordability standards or limiting or prohibiting facility fees, and more.
12:50
State leaders are trying desperately to balance access, quality, and costs.
12:55
To achieve long term health care and coverage affordability for individuals, families, and employers.
13:02
Nash me anticipates that this activity will continue and evolve throughout 2022.
13:09
This last slide just highlights links to Nash Fees, Centers, first, prescription drug pricing, than unhealth system costs, where we are supporting states in their efforts to address these costs, while tracking what they’re doing and sharing their progress.
13:28
I look forward to handing it over to my co panelists and for an in-depth discussion. Thank you all so much.
13:40
So, Suzanne, you’re up.
13:45
Hey everyone. I’m very nice to be with you today as well, and thank you to the Alliance for Health Policy, and Arnold Ventures, for inviting me.
13:53
I am the Executive director of catalysts for payment Reform. And if we go to the next slide, I’ll share with you what I’m going to be speaking about.
14:00
Actually, one more, and and share with you the perspective I’m coming from. So Catalyst for payment reform, in case any of you are not familiar with us, has been around 11 years.
14:12
We are a national independent non-profit, 501 C 3 organization. So primarily educational in nature. But we do aim to provide thought leadership to, and co-ordination among employers and other healthcare purchasers, who want to get better value for their health care spending.
14:30
And, as Marx said, in his introduction, to me, value being the best combination of quality and costs, what brought these purchasers together 11 years ago was the desire to see provider payment form come to pass. And even though Mark described us as later, coming into these other issues related to transparency and provider market power, later was about NaN later, because, you know, as much as we would like to impact with provider payment reform. If we don’t pay attention to all the incentives, both good ones and perverse ones that are in the healthcare system, you know, it’ll be sort of, you know, a little drop in the bucket of change.
15:10
So, we have a membership, as, if you look at the list of that you see on the slide here, We’ve got plenty of private employers, But we also work with a growing number of state Medicaid, employee and retiree agencies, as well as multi employer Union Trust Fund, some universities, a non-profit, And we have the three biggest benefit consulting firms that these purchasers turn to for advice in our membership as well so that, you know, we can push them to be our evangelists, if you will, with our other clients.
15:46
So, together we work each year to create a shared agenda, and if you go to the next slide, um, you know, we look at the healthcare system and say, What is it that’s broken, What do we need to fix? And what can purchasers by coming together in a critical mass, have a louder voice on and therefore maybe some more influence or leverage in changing?
16:07
So, our main goals are effective payment reform and effective purchasers, helping them really be very sophisticated and progressive buyers of health care as well as an effective marketplace. And what does that mean? You know, one that has transparency: competition, where prices perhaps reflect quality, which almost never happens, so, you know, we have lofty goals. We’ve been working away at them. I think we’ve come a long way with price transparency payment reform. We have a lot of it, maybe not so effective, and we still need to tinker there. But I do think that we have helped purchasers be a bit smarter about how they buy healthcare. So we, we work in a variety of ways to help bring that about, But let’s now turn to the topic for today on the next slide.
16:57
So in thinking about, you know, what do we really need to have our eyes on As we look at what’s happening with health care costs prices, at the state level, I think there’s a variety of approaches to cost containment by purchasers. And when I say purchasers, I mean employers and other entities that by benefits for, you know, populations of people.
17:19
And Maureen already shared some of these ideas because we see commonalities across both private employers and in-state purchasers and in fact when we started catalysts for payment reform, we kind of thought it would just appeal to private employers. But states quickly came knocking on the door, saying, Hey, you know, we buy in the commercial market too, and even Medicaid agencies were facing some of these same challenges. Let’s share ideas together.
17:44
So, some of these apply some of these ideas that are being tried to apply more to private employers or purchasers who are working in the commercial market, but some of them apply across the board. So, benefit design, you know, as, as, we’ve all followed …, health plans really took off as a cost containment strategy and frankly, they work in terms of the purchaser’s expense. There’s no question that they bring down the employer or purchasers expense. However, over time, we’ve learned through research that they have some unintended negative consequences, like when people actually need care, they don’t seek it, because they’re concerned about the out of pocket spending, and, frankly, we know that most Americans don’t even have enough money in the bank, to cover their deductible. So, at least the leading and sort of sophisticated purchasers that we work with at Catalyst for Payment Reform had started backing off on this. And some of them have also done reference pricing.
18:43
And now, when I say reference pricing in this context, I mean as it relates to the benefit design, not the payment to providers. And there has been some success here.
18:57
Otherwise, provider network design has a lot of promise, theoretically, but it has never really caught on like wildfire. We thought it would and it’s been really contain to no more than sort of 20% of large employers who are using narrow or tiered or high performance networks are centers of excellence for specific services. As a way to cut out the expense of providers and really connect their plan members to the high value providers. We see a little bit of direct contracting with healthcare systems, but it really takes a lot of bandwidth and sophistication that most employers don’t have.
19:31
And, of course, provider payment reform. In some cases, it saved a lot of money. I mean, look at 10 care and their episode based payment.
19:37
They have put out press releases about the money that they’ve saved, but I think, you know, the quality impact of it, you know, maybe just as important. And there’s other models that people are trying. None of them have been slam dunks.
19:51
So, if we go to the last slide, you know, it’s been interesting to watch ourselves. In the arc of our experience at Catalyst for payment reform. Start with really tried to support the use of market forces to effect change in the health care system and to really try to bring prices down, force transparency, you know, improve quality. And while we have made some headway, it’s very obvious that the playing field is not level. My son’s a soccer player, you know, they complained about field conditions all the time out here in California where there’s not enough water.
20:24
And so this analogy is really something I’m very comfortable with, know, there’s too little any force. Sorry antitrust enforcement out there to allow purchasers to have the same market influence that these consolidated providers have. And so the big question that I’m always asking myself is, Will purchasers live with the angst that they have? No health care, is too expensive. They’ve been saying this for decades.
20:50
Um, is it worth it to them to just keep complaining or will they get on the policy, no, train and say, you know, hey, it is time for government, intervene and help us. And some surveys suggest that. That’s where they’re heading. Although, in my experience, most surveys that ask about the future, and wouldn’t you support policy in the future to theoretical sense, you know, often get support that doesn’t materialize. But, let’s now, turn to the last slide, where, I’m just going to share some of the things that we’re seeing around state policy interventions that I think could have legs. And I know my colleagues are probably gonna mentioned some of these ideas, so I’ll just touch them quickly.
21:26
I think the policies that we’re seeing are really intended to try to level the playing field, enhance competition, where there is none or forced competition on the right things, like the quality of care, as opposed to prices. Or to just directly contain prices.
21:42
So, if you look at Rhode Island, California, Massachusetts, Oregon, these are some of the states we hold up as models, because they’ve figured out ways to understand what’s happening in their marketplace, and to tinker with things in ways that level, the playing field a bit.
21:59
But no one state has tried all these things at once. We have different States trying with bits and pieces. And so, we’re really pleased right now to have support from our ventures to think about what would be the ideal combination of policies that each state would have, to have a really effective policy agenda in place that really can make the market work better? So, with that, I will turn it back to you, Mark.
22:30
OK, Colleen, you’re up.
22:38
All right, well, thank you all. It’s also my pleasure to be here. And thank you to Alliance Health Policy and Arnold Fencers, as well, for the invitation. For those of you that are unfamiliar with NCSL, we are the bipartisan membership organization for all 50 state legislatures, Washington, DC, And the territories are, members include the 7383 legislators, and all 20,000 legislative staff.
23:09
Our mission is to advance the effectiveness, independence, and integrity of legislatures, and to foster inter-state co-operation, and facilitate the exchange of information among legislatures.
23:21
So what NCSL does not do, though, is we don’t take positions on issues, nor do we make policy suggestions, and we don’t craft model legislation.
23:31
So, next slide.
23:35
So, that, as you can imagine, when it comes to how state lawmakers are approaching cost containment for prescription drugs are coming at it in a wide variety of ways.
23:43
But I wanted to provide a few statistics for the audience to keep in mind during the discussion.
23:50
So, mashonaland spending on prescription drugs accounts for about nine to 10% of health expenditures, and that number has stayed relatively stable over the past few years.
24:00
And as far as what states spend, approximately five to 10% of Medicaid spending goes to prescription drugs, but it also depends on the state.
24:10
Then participation in the Federal Medicaid drug rebate program means that every state has access to statutorily set rebates, but in exchange, State Medicaid programs must cover all drugs made by participating manufacturers.
24:25
And then finally, for consumers, anywhere from 12 to 15% of overall personal health care, spending goes to prescription drugs.
24:32
But again, that number is a little squishy, depending on the source, and you can find several studies that show patients are increasingly having a difficult time affording their medicines.
24:44
So with that as our backdrop, I’d like to talk more about what step states are taking to contain drug costs. And there’s an enormous amount of momentum building, and has been for several years.
24:56
NCSL has been tracking prescription drug legislation since 20 15 in our public facing online database.
25:03
It currently houses over 7300 pieces of proposed and enacted legislation, and last year, we tracked over 750 bills, of which about 115 laws were enacted.
25:18
Next slide, please.
25:22
So for the purposes of today’s discussion, I kind of grouped state cost containment strategies into three buckets.
25:29
Those intended to impact state budgets, those intended to impact consumers out of pocket costs. And then there are those that kind of apply more broadly, and across both buckets.
25:40
So tracking 7000 Belles, you can imagine the wide variety of policy approaches that legislators have taken.
25:47
And what you’re going to see on the slides is just a few of the trends we’ve seen over the past few years.
25:52
But looking at these lists, it’s important to remember that this isn’t all of the options that legislators have considered, and that no policy is a one size fits all.
26:01
That said, many policy options listed have had bipartisan support across statehouses across the nation, and I’m not gonna go into each of these, but I wanted to highlight just a few.
26:14
So on for states, Alternative Payment models have been generating interest and I have three listed here, but there are definitely more options that states have considered.
26:23
I have both purchasing arrangements listed and what I mean by that is both aggregating, purchasing drug purchasing, prescription drug purchasing among state agencies and across state agencies.
26:37
Importation is still percolating out there and even though eight states have importation laws, state must first get their importation plan approved by the federal government and thus far. Those states that have submitted a plan have not received certification.
26:54
So if I focus on the consumer column, many legislators have focused on reducing a, consumer’s out of pocket costs, and one of the most prominent examples of that is insulin.
27:05
Of course, cost of insulin has been at the forefront of policy debates, both at the state and federal level.
27:11
And the most common state action is limiting co-pays for insulin and 19 states currently have laws, which limit that amount.
27:20
And they range anywhere from $25 to $100 for a 30 day supply.
27:26
And there has also been momentum around access to supplies, such as continuous glucose monitors.
27:33
And some states have even developed a state run patient assistance program.
27:38
And then the last thing I wanted to point out on this slide is and something that’s gaining legislative attention, is limiting the use of co-pay accumulator policies. And these are, basically, policies that limit the effect. A manufacturer’s coupon has on a patient’s out of pocket costs, such as their deductible.
27:58
Currently, 12 states and Puerto Rico have a requirement that any payment or discount made on or by on, on our behalf of the patient, must be applied to a patient’s annual out of pocket cost sharing requirement.
28:13
Next slide.
28:16
Then there’s more. PBM reform has consistently risen as a top concern for legislators. And that’s pharmacy benefit manager reform. And last year, we tracked about 247 bills related to PBM reform.
28:33
And that’s about a third of total proposed prescription drug legislation.
28:38
And about half of those were enacted.
28:41
This is very much an area where we’ve seen bipartisan support, and there is a wide variety of policy states pursued. But just highlighting a few here. A common approach is requiring PBMs to register or obtain licensure to do business in the state.
28:56
Perfect, Pro prohibiting contractual, gag clauses, which that would allow a pharmacist to disclose to a patient, a cheaper alternative at the pharmacy counter.
29:09
And even though that prohibited gag clauses is now a federal provision. Over 30 states have this type of legislation implemented and we’re seeing already proposed, proposed for 2022.
29:20
Then your idea gaining traction is implementing a reverse auction process and that’s where a PBM competes or PBMs compute for a state’s business and the lowest offer wins the business.
29:34
And then as Suzanne had mentioned, I, another option gaining traction as prescription drug affordability boards are key dabs.
29:44
And some board, some folks, are seeing these boards as having the potential of helping policymakers drill down on costs and really helping to find viable solutions.
29:54
So eight states have pursued this approach, and so far we’re tracking three states for 2022.
30:01
So, and then, the last thing I wanted to mention is that, over 12 legislatures have enacted price and cost transparency laws, which require health plans, PBMs manufacturers, and others to report certain pricing and cost information to the State.
30:17
And even though that’s not necessarily a direct cost containment strategy, it’s definitely seen as a tool to inform lawmakers about which strategies to pursue.
30:27
Next slide.
30:29
So a question that always gets asked this time of year is what can we expect from lawmakers looking forward into 2022 and beyond?
30:38
But one thing that NCSL doesn’t try to do is make predictions about the future, And if the past is any indication of the future, anything we speculate could very well go out the window.
30:48
But here’s what we do now, is that about 40 states and DC, and the tort territories are back in session.
30:55
And already, we’re tracking about 120 bills in 25 states, and we anticipate many more in the days and weeks ahead.
31:03
We’re already seeing many of the same themes, and that I just mentioned in the policies that I just mentioned.
31:09
But, of course, for some variations, then also, 2022 is an election year, and over 6000 legislative seats are going to be up for grabs. So, as you can imagine, that typically assumes a lot of lawmakers time.
31:25
For that reason, it may deter some legislators from putting forth any legislation or legislation that doesn’t have broad or clear bipartisan support or stakeholder support But, for other legislators, it can motivate them to put forth, novel, or interesting ideas.
31:42
Then, lastly, legislators are definitely watching what may or, more likely, may not happen with the Federal government. So, of course, we have the Build Back Better Act, that included several drug pricing provisions. But as many of you know that has kind of stalled, and it remains to really be seen, if any movements by the Feds will happen on drug pricing in the coming months.
32:04
So I just want to re-iterate that this is just a snapshot of strategies. States are pursuing, and lawmakers will really need to consider which ones will work best for their states and their constituents.
32:15
So with that, I will pass it back over to, Mark, I appreciate that. Stephanie? Europe.
32:24
OK, I think I’m here, OK.
32:27
Everybody. Thank you, Mark. And thank you also to the alliance and to Arnold Ventures for inviting me an, after this session, if, for those who don’t know, … Health as an integrated legal and policy consulting and advisory firm. That works across the country with clients across the healthcare spectrum. And I work in the long term care space, mostly with states, but also with providers and health plans, and other clients. And I’m going to buck the trend a little bit, and I don’t have slides, I’m just going to talk. So, I’m going to talk to you today, about state initiatives and policies in 20 21 that strengthen their long term care systems, including both institutional and home and community based services for older adults, and people with chronic conditions or disabilities, and then also talk about some activity that’s happening in 20 22.
33:13
So, as you know, these populations who have, you know, have been severely impacted by the pandemic, because they’re at higher risk for experiencing severe cases if they contract coven, but also because they face disruptions and access to critical services If they or their caregivers gets sick. The pandemic also illuminated and, actually, worse, in some long standing truths in about our country’s long term care system that is direct care workforce.
33:38
It’s home health aides, personal care, a certified nursing assistants, that that workforce is very is struggling. It’s under capacity, while the demand for the services that these populations populations use grows.
33:51
The long-term care systems often operates in silos disconnected from the rest of the health care system and met most of the beneficiaries.
33:59
We learn this sole source during Cove, and that most beneficiaries want to receive care in their homes and communities rather than an institutional setting to the extent appropriate.
34:09
So, when we think about state activity in 20 21, states kinda had their feet and two worlds, the present, and the future, they were continuing to respond to the ongoing pandemic. Whether it was by continuing to implement and monitor the impacts of the temporary Medicaid regulatory flexibilities that were granted as part of the Emergency coven relief. These are the, you know, I don’t know to what extent people are familiar with these terms. But these federal waivers, 135 waivers, appendix Ks, and such that provided emergency regulatory relief.
34:40
So people states could respond quickly, ensure seamless access to care for for their populations. They were also related to the pandemic, assessing Federal, …, Public Health Emergency Unwinding guidance that came out from CMS late in 20 20 but then was updated in August of 2021. To begin to plan for the eventual end of the Public Health Emergency and return to normal Medicaid operations, including ending the continuous Medicaid coverage requirements that were in the Families First Corona Relief Act. So States were focusing on that, and actively participating and vaccination and testing campaigns.
35:20
That was kind of the current world, but there were also looking forward of it and strategically investing in, strengthening their long term care, long term services, and supports systems.
35:30
Over a longer horizon by leveraging the American rescue plans, $11 billion in enhanced federal funding for state, home and community based services spending, which they can tap into through, actually, March of 2022, just a couple more months. They can tap into that enhanced F map rate.
35:48
And then they can re-invest the freed up state dollars from that to support their covered related HCBS, the Home and Community based Service Needs, or HCBS capacity building and rebalancing efforts. And that can do that through March of 2024. So, within this very dynamic framework, I’m going to highlight a few key activities around around the country in 20 21.
36:12
So, despite the pandemic continuing, some states have decided to make some select temporary Medicaid flexibilities permanent. For example.
36:21
In March of last year, Arkansas revised its policies to expand its pharmacy scope of practice, to allow pharmacy technicians to administer coburg vaccines and do other things.
36:31
In September of 2021, Pennsylvania expanded the scope of services for which it, for which tele medicine may be used to include physical and behavioral health services.
36:41
It also made audio only telehealth a permanent modality.
36:45
And it expanded the scope of providers who may render Medicaid services through telehealth.
36:50
That was one big bucket.
36:52
Secondarily, all 50 states, plus the District of Columbia worked to develop and submit their what what was required from CMS, the so-called HCBS spending plans that enabled them to leverage those enhanced federal dollars through the American Rescue plan.
37:09
So, in 20 21, states like Massachusetts, Minnesota, and Virginia put out RFIs a request for information and conducted other stakeholder engagement activities to get broad input onto where they should invest these dollars going forward to strengthen their systems.
37:27
The biggest, you know, you can see, all the State spending plans at, CMS has a website, but when you look across, and they definitely bubble up into some key areas around, provide a rate increases.
37:37
Behavioral health Service, Investments like mobile crisis services, direct care workforce, supports, wages, recruitment, training and education programs, and retention programs, and health information technology infrastructure investments.
37:52
Third, states continue to advance large policy initiatives that actually predated coven, but we’re no doubt informed by ….
38:00
Including California, which finalized and negotiated with CMS, a extremely large transformation to its Medi-Cal program is called ….
38:10
It spans all aspects of the Medi-Cal program plus, you know, involve two waiver negotiations.
38:17
And the reforms include care delivery and care management of improvements for populations that use long-term services and supports, including institutional long-term care, people with behavioral health needs and dual eligibles, Massachusetts and Vermont. Similarly, we’re negotiating, you know, developing and negotiating big 115 waivers with CMS to continue. You know, their delivery assistance improvements for populations that include those who use LTSS.
38:44
1 last 2021 area I want to highlight is health equity stake. Stakeholders in Massachusetts and California supported work that examine racial and ethnic health disparities in their states.
38:56
And really identified significant gaps in race, ethnicity, and other demographic data.
39:01
Collection, and reporting that can be used to informed ongoing state discussions about advancing health equity, so those, you know, those inputs will be important to those discussions in those states.
39:11
So looking ahead to 20 22 I’m going to highlight four main areas. one is going to be more post pandemic planning. Second is going to be efforts to enhance care management programs for complex populations.
39:24
Primarily through managed long-term services and supports programs, about 25 states have managed care programs that serve long-term care populations and cover long-term care services. So, there’s some efforts there to really improve and enhance those care management programs.
39:39
Some states are increasing focused on addressing social determinants of health. And then we’re going to talk at the end about improved care delivery for dual eligibles. So, quickly on the first one, just all states really are starting to more comprehensively prepare for the end of the public health emergency. It will end someday. Right now, it’s scheduled to end of April 15th, think the President has the administration is committed to giving 60 days’ notice in advance, or the end of the …, the public health emergency.
40:05
So I know, think people expect it will probably get extended a little longer, but eventually it will come to an end. In many States are starting to think about that and determine their approaches for restarting eligibility, determination, redetermination, and renewals.
40:20
After the, again, the Families first Corona Relief Act, Medicaid continuous coverage requirements, and when those N states, you’re going to have to reach do eligibility determinations, and renewals for collectively across the nation, millions of people.
40:37
They’re going to have to put notices our outreach, so that’s going to be a big endeavor for states.
40:42
States are also thinking about how to unwind the permanent, the temporary flexibilities that they were granted during the pandemic, but also again like Arkansas in Pennsylvania is starting to think about which ones they want to make permanent because they’re just better policies.
40:56
They realize that they worked well to produce better access, or better care to to folks, so that’ll be a big bucket area.
41:03
States are going to continue to focus on improving care management and care co-ordination for populations with complex care needs.
41:10
This year, in 20 22, North Carolina is going to launch what they call tailored plans, which are specialized Medicaid managed care plans for individuals with significant behavioral health needs as well as intellectual and developmental disabilities.
41:24
And Traumatic Brain Injury Tailored Plans are going to cover comprehensive, state plan, physical health, behavioral health, and long-term services, and supports, as, well as far as C, but they’re also going to cover a broad array of home and community based Waivers, type services, and provide rus robust care management for, yeah, holistically, across all of the service needs of, of enrollees.
41:47
Virginia is actually going to merge or consolidate its mainstream Medicaid Managed Care Program, which is called Medallion for Now, with its existing Medicaid Managed Care program for medically complex individuals, which is called commonwealth commonwealth co-ordinated Care CCC Plus.
42:04
Part of the impetus for merging these programs are consolidating them is to really address that bridge, you know, that, those silos and bridge those silos between populations who use long term services and supports and those who don’t.
42:17
The state is going to streamline its model of care requirements for all populations to ensure access to care co-ordination, based on members’ needs and level of risk, rather than whether they use long-term services and supports or not.
42:31
Um, other states, I’m going to talk about these quickly, North Carolina, and California, as examples, are increasing access to services and supports like housing navigation, medically tailored meals, and caregiver respite, that impact and improve people’s social determinants of health like housing and employment stability, food security, and transportation access.
42:53
North Carolina’s healthy opportunity’s pilot.
42:56
It’s been designed for a couple of years, again, there’s a little pause, I think, because of the pandemic, but it’s going to launch this March and a couple of months to test evidence based, non medical interventions designed to reduce cost and improve the health of Medicaid beneficiaries.
43:12
The pilots are going to provide up to $650 million in Medicaid funding for these services related to housing, food, transportation, and interpersonal safety and toxic stress in three regions of the State.
43:25
And California, it’s part of the waivers I mentioned earlier, had authorized by CMS 14 community, what they’re calling community supports, which are, again, medically appropriate and cost effective alternatives to services covered under the Medicaid state plan.
43:40
So, these are going to be offered by managed Care plans across the state, and, you know, be offered at the Managed Care plans option and used at the enrollees Medicaid managed care enrollees option also. And last, but not least, for 2022, states are going to continue to develop and improve integrated care programs for dual eligibles who are individuals eligible for both Medicare and Medicaid programs. These are high need high cost populations for both programs. I think they just me about 15% of both programs enrollment, but a third, you know, over 30% of these programs. Total costs right now there’s about 12 million dual eligibles across the country and only about 10% of them are in a, you know, tightly integrated programs that kind of look to integrate Medicare and Medicaid co-ordination and care management.
44:31
So, there’ll be a lot of activity, I think, going forward in states across the country, in it really improving care models and experiences for those populations.
44:40
Um, to federal activities, are going to influence states in this, in this endeavor, Reese, just about a couple of weeks ago, January sixth, the federal government issued a proposed rule.
44:52
It’s really around Medicare Advantage plans, but among other things, it does focus on improvements in integration for dual eligibles who are served through a special type of Medicare Advantage plan called a D snip or a dual eligible special needs plan.
45:07
And those plans are contract with states to co-ordinate Medicaid and Medicaid services across across the enrollees who enroll in those programs, if those rules are implemented.
45:19
Then it’s going to impact the SNPs to the dual eligible special needs plans, and all states, including the nine states that still participate in the federal. It was called the Duals Demonstration or Financial Alignment initiative.
45:33
Because, the rule is going to require the plans that operate in those tools demonstration, to transition into these more integrated, dual eligible, special needs plans with these new requirements under this proposed rule, um, Virginia and New York have already done that in California, is going to do that in 20 23, move away from these what they called Medicare, Medicaid plans under the duals demonstration into these Medicare Advantage decent products, and more states are going to do that, that are enrolled in that.
46:05
The Duals demonstration Massachusetts, is just finalizing its plans going forward for its dual programs.
46:12
Texas, Ohio, Michigan, these states are really going to have to assess the impacts of this new rule on their other programming going forward.
46:19
And then finally, Map Pack, just last week, Discuss some recommendation.
46:23
It’s going to bring to Congress in June, about ways that Congress to better support state efforts to integrate care, either through requiring states, to develop comprehensive, integrated care strategies, and even providing federal funding that’s tied to states moving in that direction. So more to come from probably many states in 20 22 on integrated care programming for duals.
46:44
And with that I’m going to stop and just say the states are operating in a very dynamic environment, continuing to be influenced by the pandemic but also heightened federal attention and investment in Medicaid home and community based services as well as integrated care programs for dual eligibles and just ongoing workforce shortages and mister growing demand for these services.
47:05
Thank you.
47:08
OK, thank you for each of your opening comments. So we’re accumulating questions in the, and I’ll, I’ll start to walk through those in a moment from the audience. But I want to give you an opportunity to talk about a couple of other things, and also, if there’s any cross-talk that would make sense at this point.
47:35
I’m going to ask questions about state, but I’m also asking about employer activities. I’ll look to Suzanne to speak to that, but of course, anybody can speak to that if they have things to say. And, Suzanne, you are free to talk about the state, as usual. You as you see fit as well, but I will be looking for Suzanne, Always. You know, take somebody on the employer. So, here’s a question.
47:59
So, if you think about the cost pressures, you know, whether it’s drug costs, or whether it’s the, you know, say, the hospital costs or the sector more broadly, these have been pressures on state and on employers for a long period of time. Anybody who’s been around, well, around the blocks, I’ve been around, I’m the oldest one here, I’m pretty sure. I’ve known this for awhile. What would you say is driving the State interests?
48:28
Is it things like some patient experience that catalyze’s attention? Is that some behavior on the part of a hospital system? Is it some group in this state, You know, what factors do you think start driving the attention and getting movement on these issues. And I’ll tell you what, I’ll just start an order, and I’ll ask Maureen to go first, but, you know, what will this work from there?
48:56
Sure, and it’s an excellent question.
48:59
I don’t think there is one thing in particular that was a catalyst or state action. I think it’s a number of different things.
49:08
I’ll start with the drug costs and prices, and just share our experience with states. So Nash B actually does have an Academy of State Officials volunteering their time. We brought them together in, we ought, we bring them together, often, but in 2000, 15, 2016, and asked, What is keeping you up at night?
49:33
And it was prescription drug costs, it came on the heels of the Hep C cure, which was amazing and groundbreaking, but incredibly expensive.
49:46
And so at a million dollars for a treatment cycle, it was taking over Medicaid budgets.
49:53
And at the time, state officials, I don’t know if they weren’t paying close attention attention to the pipeline, or if the actual price tags surprised them.
50:04
But state budgets are truly being dominated in a way that they were not anticipating by the this drug, and state officials across Medicaid, and other health plans. Employee health plans and others did not want to be in a position to say, No, we can’t provide you this lifesaving life-changing prescription drug.
50:28
And so, I believe that was an initial catalyst and then as we’ve been working with states on prescription drug pricing, a number of officials came to us and said, prescription drug prices are still something we need help with.
50:43
But, as we start looking at costs, we recognize that prescription drug costs are only about nine to 10% of the overall health spend. And now we start looking at what else is driving these cost. And hospital and health system costs are dominant. There, they’re over 25, 30% of the health spend. And then the next leading.
51:09
Health spend is high cost providers, And then they look to primary care and behavioral health providers that need more of our health care dollar.
51:18
And so I think there’s a number of things driving all of this, but it really is state’s attention to cos and looking at data that is spurring them into action in a number of different ways.
51:31
And I’m sure Suzanne can speak to this more, but, But the other issue is high insurance premiums. It is something that individuals and employers are going to, their state officials asking for assistance with.
51:44
And there’s only so much that can be done to further subsidize some of these premiums, Though, there is an interest to look at what’s driving them in the first place, which is some of these high costs.
51:59
Susanne, do you want to jump?
52:02
Yeah.
52:02
I think I think that was a really great arc that Marine shared, That resonates with my experience, too, in terms of what is put, cost front and center.
52:13
You know, we as an organization, have focused on the hospital side, you know, for over a decade now.
52:21
Sort of dating some of the specialty drug stuff, and, and continuing through, and with the specialty drug costs. So I think, that’s what caught the attention of the employers, that we work with first.
52:34
But also, I think that happened at the same time as a recognition that these high deductible health plans were just not good for low wage workers.
52:44
And four anybody, but the highest paid workers.
52:49
So I think the affordability issue is really what has sparked a lot of the desire for reform. Whether it’s payment reform, delivery, reform, benefit design changes, network changes, et cetera.
53:07
You know, we’ve gotten to the point where most Americans, you know, even with their health insurance, can’t afford to use it, and I think that’s just a crisis that a lot of people are hearing about and recognizing.
53:22
What is fascinating to me, and I’ll just pose like, a challenging question to the rest of us, is, employers have been saying that there’s a health care cost crisis for the 20 plus years I’ve been working on behalf of employers to change the healthcare system.
53:38
And, now, at such a crisis point, it’s still a minority that really take action. And the big question I have is: Why is that? Is it because they don’t know how, which we try to, you know, help with?
53:52
Is it because, you know, their executive serve on local hospital boards?
53:57
Is it because the healthcare industry in this country is so large that everybody is making some money off of it and that maybe that revenue outstrips the rising costs of the health benefit.
54:10
You know, it’s just it is a conundrum that, you know, for someone like me, who has worked very closely with it for years, continues to be a mystery that I’m chasing the answer to.
54:20
So, affordability seems like a loud, you know, cry.
54:28
But why is it that even with that, there’s not more action taken?
54:33
So I think it’s, it’s so important that states are stepping in on this issue, because, know, some employers certainly do so but not enough to solve a problem.
54:45
Yeah. Just a quick Yeah, the Hep C event. I think is a really good reference point for following up on Maureen’s and Suzanne.
54:53
I also think some of the realization across people that I have insurance but I’m still not protected.
55:02
It’s starting and surprise billing certainly played into that.
55:07
I’ve also knew of I’ve had this conversation on the employers.
55:11
I think the other thing on the employers, As they realize that, they may need government intervention, but then they don’t necessarily, as an ideological point of view want that.
55:23
And so I think that’s yet another area. We’re gonna move on with the the question to Colleen, but I also want to do one clarifying comment here, because it’s it’s come from the audience. There was a question around the nine, 10% on drug spend in a sense that that’s a bigger number. And I think, and, Maureen, you can, you can address this if this is wrong. I think there’s the NAACP. The national health expenditures numbers, which part of the drug spending is actually housed in other parts of it. And the … number is really the, you know, retail pharmacy number. And I think those numbers are larger more on the 15 and 17. And then of course as you go across markets, whether it’s commercial, Medicare, and Medicaid, those percentages jump around.
56:11
But I just thought I would clarify that because there was a question in the chat and if I haven’t done you, any injustice, Maureen, I’ll jump on to Cali and move on to Colleen to know what’s driving this, the attention to these issues now.
56:33
Thanks, Mark, and yeah, just to, to concur that, that’s where I had all my number from two, is the National Health Expenditures Data.
56:41
And I agree with both Marine and Suzanne, that it’s really hard to just pin down one thing that, of what’s driving these conversations, and truly, these issues aren’t necessarily new, They just are evolving year over year. You know, new things come up, and how are our legislators reacting to that, and then, you know, also, Marine brought up the hep C example, and that’s, that was just my point. I think just as costs and prices for, especially as we’re seeing some of these, these newer therapies emerging, you know, there, they are life-changing and do you know, like hep C in the case of hep C they save lives. But there are, some, now, are reaching millions of dollars. And as I mentioned in my presentation, you know, Medicaid has to pay for those drugs. So I think that has renewed. Or heighten the interest in these issues. We’re seeing constituents mobilizing in a way that we haven’t before.
57:45
You know, in the case of insulin you know, constituents are making their voices heard about how detrimental some of these these costs are to them. And especially as we’re in a pandemic and with inflation and rising and all of those, those type of issues.
58:04
I think coupons and states are particularly particularly sensitive to fluctuations in price and cost.
58:11
So that’s something I would add on.
58:15
That’s so cool.
58:17
We’ll move to Stephanie to add, to get her answer, and I just want to revise it a little bit for you, given the focus of your discussion.
58:27
You know, the dually eligible Complex care populations have been huge problem for the states and the federal government for years. And there has been some sense of trying to move more towards integration, that type of thing. But what do you think drives the state interests now? And as you mentioned, there are some discussion of this in the new MA rule that’s app.
58:49
What do you think, you know, is driving the sudden interest in a problem that’s probably existed for quiet, quiet?
58:57
I think that’s exactly right. I think these are long standing problems, I said it early on, about longstanding truth, sending these populations.
59:05
I think the startling thing was how impact a, particularly in the early part of the pandemic in nursing homes, these high need vulnerable populations were impacted. It was just devastating. We all saw, we all know and I think, you know, I guess I’ve been working in this sector of healthcare for a long time now and I think it bubbled up to the rest of healthcare. It goes to another truth I made around the siloing, sometimes, of the long-term care system, for the rest of the healthcare system.
59:33
I think, I think people were just so startles about the devastating impact it had on these populations, particularly living in congregate care settings and et cetera.
59:43
So I think that was part of it. Was just so startling to all of society. You know, we’ve always people have known as you work in Medicaid or work in launch your care of, They’ve also known it if they have a loved one who might be living in a residential setting. But I think that was part of it.
59:59
And then, like you said, these are longstanding issues for decades where, and I mentioned earlier the statistic about, you know, dual eligible populations, Older adults, people with disabilities be, who are dually eligible, being about 15% of Medicare and Medicaid enrollee’s, but 30% and higher up there costs.
1:00:18
So, this is an area that states and the federal government have been looking to improve and figuring out ways to improve for decades around care management and care co-ordination.
1:00:31
But, it also goes to some of the discussions we had earlier about, you know, value based payments and where there you can bring more long-term care providers into some of the Tigers arrangements. And better quality measurement in this space. There’s, I just think there’s a, there’s a lot more to be done in that space around purchasing and measuring quality and value in that space.
1:00:58
Um, OK, question, and we’re going to move to the audience questions just momentarily, and we have a few.
1:01:08
So, I want to ask you this in the states or, and there may be an employer angle here, but this may be more of a state question.
1:01:22
When they move on, say, drug reform? Or, you know, the spending on hospital services, or whatever systems as, as the case may be. What markets do, they tend to focus on today will focus on the commercial market. And if they’re in the commercial market, is that the large employer, small, employer individual do, they focused on the state employee.
1:01:48
You know, let me put it this way: I have heard some states say we go to the state employee as our first place because that is under particular pressure.
1:01:58
You know given an appropriation. So I’m just curious, what markets do, the States tend to focus on? And, of course, you know, the answer could be all different in every state, but at least pitched the question.
1:02:13
And you know, just, I’m going to start at the top of the lineup again, Maureen.
1:02:19
Sure, I’m happy to take the first shot at that question.
1:02:24
My understanding of where states direct some of their attention is maybe who the loudest voice is within the different markets.
1:02:35
The other place that’s very strategic is where they have levers existing already. So, for instance, thinking about Medicaid versus the commercial market versus the State employee market, which I know is already oversimplified, but thinking about those, sort of three, very broadly, States have different levers in each of those.
1:03:00
And so, looking to, we’re looking, identifying the problem, we often start talking with states about, what is the issue that you’re trying to solve? What is the best solution look like, and then how do you get there? And so creating some new levers is the hardest approach.
1:03:19
Creating new regulations, creating new laws is extremely challenging for a lot of different reasons. There’s usually a cost involved at the state angle, and then, of course, there’s also stakeholder pushback and addressing those different dynamics.
1:03:37
But if there is a way that a state can use an existing lever to help them move in a more positive direction that guides the solution, that’s where they want to start. That’s where we often help them start. There’s also something to be said for small, but market wins along the way.
1:03:58
And so, building up some momentum, as we’ve seen in the prescription drug space, has been extremely helpful, but then also realizing that maybe those smaller win’s did not achieve their ultimate goal, and being able to articulate where they need to go next.
1:04:15
So I’m not sure that that totally answered your question. But it is different for different states. And they do look at it very practically.
1:04:24
Susanne, do you want to jump?
1:04:27
Yeah.
1:04:27
I mean, I’ll just say that the State employee agencies that we work with all have different relationships with their state legislature.
1:04:36
Some of them are completely independent, except for the funds, and some of them have a much tighter relationship, So, their ability to the state’s ability or the legislature’s ability to influence exactly what they do varies. But we find state employee agencies to be among the most innovative and progressive purchasers out there.
1:05:00
And I think it’s in part because they have an actual budget and it’s not about just eating into margin or eating into profit. They have an actual budget, and they feel a sense of accountability, you know, to the taxpayer.
1:05:13
So, we are thrilled to have them in our membership simply because they provide so many models for innovation and trying new things. So we definitely see states work there, you know, Medicaid is an area that’s obviously very complicated.
1:05:29
But we also see the same with the Medicaid members that we have, that they’ve done extremely innovative things.
1:05:35
They’ve been the first to do many things, I think, for similar reasons, um, you know, slightly different population, but overlapping with the commercial purchasers that we have in our membership.
1:05:47
And what we don’t see that often is a lot of co-operation across state agencies around some of the reforms, so you’re like the state employee agency working with the Medicaid agency or no, or other other possibility.
1:06:04
So, you know, state employees are definitely at the forefront of trying to reduce spending and and contain costs.
1:06:15
And so, you know, not every state has their vantage bunny by any stretch, but there are certainly I would say you know, 5 to 10 that really stand out as as putting energy there.
1:06:28
An open air, not required to, but, Colleen, do you want to comment?
1:06:33
You can feel free, but I don’t want to put anybody on the spot.
1:06:38
Sure, no.
1:06:40
So, again, you know, states only have the ability to regulate in a few different ways, right? First, they can only have they only have authority over state regulated sam, such as individual plans and those sovereign state exchanges. And then, second, they can only negotiate prices that they pay for drugs in certain instances.
1:07:00
So, again, state employee health plans, but they can negotiate additional rebates and Medicaid. So, negotiate supplemental rebates.
1:07:10
So, but that said, I wouldn’t say that states are focusing on any one particular strategy, and they’re really coming at it again. I can’t stress it enough, that states are really coming, coming out the issue of prescription drug access and affordability, and a really wide variety of ways. And so, you know, there, we, we consistently see legislators and states coming up with creative solutions to really try to ease that cost burden for both both states and for their constituents.
1:07:41
And, Stephanie, do you, just very quickly, I think I want to add on to something you said, Mark and others touched upon it, just about how diverse the states are. when you look across the country and Medicaid programming and policy decisions.
1:07:54
The states are so vastly different so that whether it’s politics or political philosophy, around whether a state chose the Medicaid expansion, whether, you know, um, see that the robustness of their Medicaid coverage of certain services, whether it’s behavioral health services, or et cetera. I live in Massachusetts. It’s a very generous Medicaid state, and it ends up being one of the drivers of what happens outside the Medicaid market in the state. So it does impact what goes on in the commercial space in Massachusetts.
1:08:23
And so, just that diversity around the country, it really is, so state dependent about what is driving policy design across the markets in the state and where the levers are.
1:08:35
OK, so what I’m gonna do is I’m gonna move to some audience questions and comments, but I still want, I want to talk one question in your head, because if we get time, I’m gonna come back to it. So just using my prerogative here. I’m also curious that, you know, if you, I was asking you, what triggers what moves states forward?
1:08:56
There a significant resistance to these changes when you think about the drug industry or the hospital associations. And what I want to come back to you, if time permits is the notion of how States have been able to move through those, through that kind of resistance. So having many scars of my own, I’d be very curious to hear about that.
1:09:20
So I want to move to some questions. And comments there is, I’m going to first start with a comment. And I’ll give a partial answer. But anybody else should, should step up. Someone in the audience is concerned, perhaps even agitated that the Hep C pricing has been overstated that it’s not millions of dollars in that competition has driven the price down.
1:09:45
Why I’m aware of that, I thought that the, the triggering comment from Maureen was more the question of when it started and what drew attention to, you know, the cost. And I know, for myself, I had to states all over me on, how are we going to deal with this? Of course, the states took the approach and restricting access. And of course, that raised all other kinds of issues. I think everybody on the screen is aware of that, competitors event, or in the unit price has driven down, although, I don’t think it’s insignificant still for states to try and deal with some of the populations. And are often dealing with very large populations, even Medicaid prison populations.
1:10:26
And so I think they’re still concerned over, but I think everybody on the panel, as well aware that the price has been driven down, you know, launch. So, I just wanted to make that clarification. Maureen is if there’s anything that you want to add or if I’ve missed, you know, five Ms.
1:10:45
sampled that please, You know, Nice.
1:10:49
That’s exactly what I intended it, to list, at the launch price of the first Hep C drug, before there was competition. And Colleen noted, Medicaid was in a situation where they had not as many resources to handle that.
1:11:06
And disproportionately a lot of individuals covered in Medicaid who benefited from the drug, which created a budget issue in states that drew attention who prescription drug costs.
1:11:21
I agree.
1:11:23
And that’s how That’s how I took your comment. I’m sorry. If anybody in the audience felt like we were unaware OK? So now I’m gonna deal with a different question from the audience. And it, and it sort of works like this. There are some concern that and, as as you think about this, I mean, there is, well, the the audience or, sorry.
1:11:50
The audience question is pitched as, drug list. Prices are the problem.
1:11:56
And I would say there is a list price problem for sure. There’s also a net price problem.
1:12:00
We can, particularly as it relates to specialty drugs, brand drugs, which is where the pipeline is going, but that’s the first clarification I would put unattainable.
1:12:10
But nonetheless, the question is lots of the the policy ideas that are, you know, being talked about here. And I’m going to, they aren’t listed, but I’m going to say things like transparency, as an example.
1:12:24
Don’t necessarily address price that they are, Right? And so, the concern is, you know, I think the question is, are there policies to direct price?
1:12:36
And there’s also a further statement in the question that these things that don’t directly affect price interfere with activities on the part of se commercial payer or an employer.
1:12:49
And I’d like to see if there’s any reaction to that.
1:12:54
And I, I’ve gone to Maureen as the opening, bad or a cup of time, so I’m going to switch it up, and maybe I’ll go just randomly to Colleen first. Unless she says, no, I don’t want to be first.
1:13:08
In, which case, that would be really awkward, I liked the order we were going, and I’m happy, I’m happy to answer. So, I think, you know, I think that’s one thing that frustrates lawmakers, right? As we hear, you know, oh, well, it’s the lowest prices oh, no, what’s the rebates from pharmacy managers?
1:13:27
And then, you know, the health plans are in there, too, so there’s a lot of this finger pointing going on.
1:13:33
And I think that also, you know, to kind of piggyback on the earlier question, is, driving a lot of this momentum, too, is that legislators are just, you know, tired of the finger pointing.
1:13:45
And they just want to get down to the nuts and bolts of how to affect drug prices, and costs, save costs, and affordability, and access, without all the finger pointing, and the blame game going on.
1:13:59
And so I think with the transparency laws, yes, they, you know, don’t directly impact prices, but again, they’re being used as a tool to get into that data, to figure out where exactly is the money going, you know, what policy levers might be effective.
1:14:16
And so I think that’s what is, driving some of those, those discussions and some of those policies for states as just to get out that data and see exactly what the numbers are and where the money is going.
1:14:29
So way to be laid off, batter Cowling, I’m going to ask Suzanne to go next and, and, Suzanne, you can do anything you want but if if you have particular comments about when the states do this, it gets in the way of the employer. That would be a good thing but you can take this anywhere you want to it. just that’s part of the question.
1:14:53
Yeah. I mean, at least the employers that I work with, well, I think they kinda fall into two camps.
1:14:58
one is they’re huge and they’re fine working with the big PBMs because they know they’re getting some kind of volume discount, and even though they know there’s all kinds of shell games going on out there, they’re just kinda counting on their size.
1:15:13
So, I don’t, I don’t think they are, you know, too focused on what’s happening externally, then there are other employers who are just so sick of the game and, and not understanding it and feeling like there’s so much complexity that they’re purposely held at a disadvantage so that they can’t uncover what’s really going on.
1:15:34
And, you know, there’s some move to, you know, working with some of these smaller sort of upstart PBMs that are promising transparency promising not to keep any rebates, et cetera, et cetera, because they’re, you know, sort of offering a fresh alternative to the tradition.
1:15:54
And so, I think those employers tend to, you know, be supportive of policies that are going to, you know, hold this mess accountable. And I’m just saying this mess, because there are many parties to it.
1:16:10
So, I think it’s, you know, lawyers are as diverse, as Americans, practically, as diverse as the states. You know, there’s a lot of different opinions. But I think those are sort of the two camps that I see.
1:16:20
And I appreciate you taking the employer point of view, any other aspects of the question you want to comment on before I move on to someone else?
1:16:30
No, That’s OK.
1:16:32
OK, I just, I don’t want you to feel like you’re being put in a specific line, OK. Well, we’ll go to Stephanie to see if she wants to comment on this particular question.
1:16:43
I think I’m going to defer to my expert colleagues on this topic about Drug I say, No problem. And just so you know, I have an audience question that is going to come to you directly, and you will be at the top the lineup for that one. You’re going to be just fine. It’s not going to anything to worry about on this question. What would you like to say?
1:17:03
Oh, I think my fellow panelists and colleagues did a great job. I agree. And even asking the question, hit on some of the complexity, list price, net price.
1:17:15
Rebates and There are a diverse amount and, number of rebates there is also co-pay assistance. There’s levels of prescription drug pricing, purchasing.
1:17:33
That is it’s just very complicated, and I do think that states, when they were starting this, and some have been doing it for a very long time.
1:17:42
So I don’t mean to suggest that some just starting to look at this. But transparency was trying to figure out the complexity with the drug supply chain where there were spots, where there were price changes, where there were rebate issues, where there may be spread pricing, where there could be opportunities to get some efficiency in what we already have, versus going directly towards price, which is a very, very hard thing to do.
1:18:12
And so, I think it, as I, as I noted in my comments, there’s an evolution to the policymaking and the levers that are being used.
1:18:23
OK, I’m going to jump to a clarifying question. I think this is pretty straightforward. This is the one I was gonna come to Stephanie.
1:18:30
First, on, someone in the audience asked for clarification on what states are engaged in caregiver respite types of policies.
1:18:42
Millimeter, hmm.
1:18:42
Well, so, the two I mentioned, as examples, were California and North Carolina that are starting to offer these social supports that impact, you know, again, people’s social determinants of health. So, those, those, in California, in North Carolina, those are being authorized through 11, 15 waivers through their Managed Care programs that serve their broad beneficiaries. But States have an offering.
1:19:10
Some of these types of services, particularly housing support, and employment supports, through 1915 C waivers for years. So, I think at this point, almost every state, if not, almost every state, has 915 C waivers, the Home and community based Services waivers. And across the country, many of these programs. And now they’re authorized through the Medicaid state plan, through these 915 I K authorities, where you can provide a certain level of employment supports, and housing support. So, in terms of caregiver respite respite is a service that’s offered, is, be able to be offered through 915 C waivers.
1:19:43
So, I don’t know exact number, which states most states have anywhere from, let’s say, 2 to 9 or 10 HCBS waivers for different populations who use these services. So, it may, that service may not be offered in every single waiver, but many of the waivers do offer that service, and then now California North Carolina are offering these services more comprehensively across the managed Care program at managed care plan option to, you know, different types of enrollees in the program.
1:20:13
OK, I’m gonna move to a different kind of question in just a second, But I want to give anybody else an opportunity to jump in on the last one if for some reason I, if, for some reason, they would like to do that.
1:20:29
OK, all right. Nobody jumped.
1:20:32
So we’re gonna go to a different question, which is a question about the role of venture capitalist capital private equity in health care.
1:20:42
And I’m going to modify the question a little bit and say, do you have views on kind of positive, negative, that type of thing. And then the other part of the question is, Should there be regulation of this activity?
1:20:56
So I’ll, that, that’s the question, and I as always, you are experts, so if you want to reframe the question a little bit, I’m I’m perfectly OK with that, and I’m going to start. Suzanne, could I get you to go first on this?
1:21:12
You good on this?
1:21:14
Yeah.
1:21:14
I mean, I, you know, I will not claim to be the deepest expert on all the perversions, you know, that people have claimed venture capital and private equity to be responsible for.
1:21:28
But I’m going to sort of twisted around in a different way, which is that the employers and purchasers I work with are very dependent on large, incumbent health insurance companies to do much of what they need to do to, you know, procure healthcare services for their populations.
1:21:49
And there has been so much consolidation among these, let’s call them, third party administrators because most of the big purchasers are self insured, so they’re not, you’re, they’re not seeking actual insurance.
1:22:01
They’re seeking the administrative services that a health insurance company can provide, there’s, there’s been so much consolidation.
1:22:08
There’s very little choice, and while very few of them actually have much market power in any given market, they do have market power.
1:22:18
When it comes to the limited choices that employers have and their ability to say, No, I don’t feel like doing that.
1:22:26
So, if an employer wants to do something really innovative, they may not be willing to, or be able to, because of contracts that they have signed with providers.
1:22:36
So, to the degree, that investment funds support the development of alternatives, alternative third party administrators, ways to help employers who don’t have the bandwidth to contract directly with providers, to have the ability to sort of do it in the semi direct way with the facility of a vendor. supporting that.
1:22:57
I think that’s a good thing, that’s a very different topic from the role that private equity has played in high out of network prices, and that sort of thing.
1:23:07
But I just wanted to add that sort of twist to it that, you know, the status quo isn’t working.
1:23:13
And so, to the degree, there’s innovation supported by investment that brings other possibilities to the commercial market, That’s good.
1:23:23
I am not a fan of any nefarious practices that make it impossible for patients, or those who pay for their care, too, to do? So. Affordably. Maureen, do you want to jump?
1:23:37
I can, but I will be honest with you. I think this is a question that states have and that we need to know more about. I, for instance, know that we’re getting questions about, even like, four versus non-profit hospitals and health systems.
1:23:52
And if that has an indication of quality of care, cost, price, and then there is in those conversations, then private equity comes into play, and I don’t know that, well, I know Nasby doesn’t know the answers yet, but it’s an area where states are very eager to learn more and to Suzanne’s point, I think everyone is open to innovation from wherever it comes from.
1:24:17
So if that’s part of the conversation, states would welcome that.
1:24:23
Yeah, I think in, some of the issue is, like the, there could be efficiencies gained, it’s whether they fully pass through, and whether the other side of it, the consolidation drives, that, you know, prices, even if there’s efficiencies being gained over here in this pocket, OK, we’re at 126, so we’re into the final stretch, so here’s what I’m gonna say to Stephanie and Colleen.
1:24:50
If you would like to make a comment on this question, please do, please be quick, I need to go into shut down, and then where, tell people where they get additional information and all all of that. But, I don’t wanna close you out. So, if there’s some quick comments on this, I do want you to get them in, and so, calling.
1:25:11
I’ll just make one quick comment, that in the prescription drug space, I mean, we’re seeing some, some newer and friends, you know, we, we’ve seen, like Amazon jump in and we’re seeing, I think Mark Cuban as the newest person that’s trying to make an impact.
1:25:27
And I think, you know, the it, like, like, Maureen was saying, I think that, you know, states are open to where innovation might flourish.
1:25:35
And, you know, it’s really kind of soon to know whether or not that’s going to impact, you know, competition, but We’ll see.
1:25:47
Stefani quick.
1:25:49
Yeah.
1:25:49
Just quickly actually, in the home health care and nursing facility space, there’s a huge infusion of, of joint ventures and equity investors in this space. So it actually played out in during the pandemic with it plays out all the time. But played out during the pandemic where in some cases there were concerns about accountability where ownership had been changing hands.
1:26:12
You don’t five times in two weeks And there were benefits people saw by the infusion of cash cash.
1:26:17
They were able to get PPE quickly and get there, you know, staff protected and patients protected. So, there’s just it’s just a big thing in the long-term care space actually.
1:26:30
Good, I appreciate that.
1:26:31
And I appreciate everybody, you know, being willing to, to respond quickly. So now I’m gonna go into, shut down, now, get to ask my special question that I asked you to think about. But I would like to thank all of you for doing this, and you know, everyone involved in putting this together.
1:26:54
I have a note here that everybody asking everybody in the audience to complete their evaluations. I personally think the moderating in this session has been just outstanding. And so I’ll just try and lead some people to that point also. There is a presentation on February fourth on FDA and user fees that you are invited. I’m sorry.
1:27:16
Maybe I’m going too fast, but everybody in the audience is invited to and a recording, and this will be available on the AHP website for people to follow up on, and actually, I might have done that too fast, but I think we’re coming to the end here, and so I’ll ask Matti. If, if there’s anything else I should say or do at this point.
1:27:45
Sure.
1:27:48
And she just said, I think we’re good, so I’d like to thank everyone. It’s nice to meet you in those cases, Suzanne, it’s really good to see you again, and I hope everybody stays safe and takes care of themselves.
1:28:04
Thank you very much, Carol.