Nearly every panel at this year’s annual National Academy of State Health Policy (NASHP) conference—which took place from September 20-22—inevitably included some focus on the implications and impact of the COVID-19 pandemic. However, as in recent years, NASHP 2021 panels also explored topics that are top of mind for health policymakers, such as telehealth and prescription drug cost control.
Of the many interesting COVID-19-related panels at this year’s NASHP conference, one standout was “Quantum Leap: Long Term Services Post-COVID-19,” which examined the impact of the pandemic on long-term services and support (LTSS) and provided an overview of state approaches to investments aimed to support the LTSS clientele and workforce.
As HPN previously reported on this topic, the American Rescue Plan Act (ARPA), provides relief for Medicaid HCBS programs via scheduled, enhanced federal financing participation to offset state expenditures. Section 9817 of the Act provides enhanced federal funding for Medicaid home- and community-based services (HCBS) and certain behavioral health services through a one-year, 10% increase to the share of state Medicaid spending that is paid for by the federal government. This one-year increase in federal matching funds will result in new, time-limited dollars that can be invested in certain Medicaid HCBS and behavioral health services. These increased Federal Medical Assistance Percentages (FMAP) will be in place from April 1, 2021 to March 31, 2022, and states must spend the enhanced FMAP funding by March 31, 2024.
This panel provided lessons learned from leaders in both Washington state and Connecticut on ways they are working to not only rebalance the systemic imbalances precipitated by COVID-19, but also invest funds in a way that leads to “quantum leaps” in the delivery of LTSS.
Jason McGill, JD, Assistant Director of the Washington State Health Authority, spoke of a challenge Washington encountered during the pandemic: discharging clients that require complex, long-term care post-discharge from the hospital setting. Not only have the workforce challenges impacted the ability to move individuals from the hospital to community setting, but this was further compounded by the complexity ensuring safe group living settings for clients during a pandemic. Washington has outlined their spending plan for the ARPA funding and plans to allocate funds to address high priority immediate needs, as well as long term planning as follows:
- Long Term Support Services: $264 million dollars directed towards rate increases; behavioral health transitional support; COLA increases for personal needs allowance; provider rate increases; and rental subsidies for clients
- Intellectual & Developmental Disabilities: $178 million dollars for supportive living and provider rate increases; hourly wage increased from subminimum to minimum; and the phase in of 5 three-bed, state operated living alternatives.
- Community Behavioral Health: $81 million dollars to support provider rates and expand substance use services and short-term behavioral health housing support.
Washington submitted their spending plan in June 2021, and state is presently engaged in an ongoing question and answer process with the Centers for Medicare and Medicaid Services (CMS) related to the funding planning.
Dawn Lambert, Co-Leader of the Community Options Unit at the Connecticut Department of Social Services, spoke to the large increase in demand for HCBS during the COVID-19 pandemic—saying that tomeet this demand, the state needs to balance having an adequate supply of workforce with continued quality of care. The state’s number one priority was to enhance its HCBS workforce through ARPA funding, and it is seeking to allocate e funds to key items aimed at mitigating the increased need for care as well as caregiver burn-out. The following are examples of initiatives in Connecticut that will address the known needs of the state via ARPA funds:
- Temporary Workforce and Provider Stabilization: $95.5 million dollars to develop an incentive-based program to help with recruitment and retention of provider staff, and a one-time funding to offset COVID-19-related impacts on provider networks
- Provider Rate Increases: $80.7 million dollars to level the playing field and improve patient access to care, as well as target investments in identified services
- Support for Family Caregivers: $10.8 million dollars to provide tools and resources for families caring for older adults and relatives with disabilities
- Capacity Building & Training: $2.2 million dollars to establish a statewide “train the trainer” program for all HCBS providers to prevent racial inequality in care delivery, as well as capacity-building to expand medication-assisted treatment for substance use.
Connecticut submitted its spending plan, which includes the full details of the ways it plans to strengthen, expand, and enhance the HCBS program, in July 2021.
Both presenters expressed that while they had been planning and working on strategic investment in the area of long-term care, the COVID-19 pandemic precipitated this need, illuminated the current gaps, and provided an opportunity to invest the influx of funds from the ARPA in a way that will provide long-term improvements for all involved.
Panelists from Washington state, Massachusetts, Nebraska and New Mexico shared insights into the future promise of telehealth, as well as its policy challenges and considerations. In framing the panel, Jane Beyer from the Washington State Office of the Insurance Commissioner shared that, unsurprisingly, telehealth usage peaked in March and April of 2020. Though telehealth appointments have since decreased to 10-20 percent of care being received currently, the use of telehealth for behavioral health has been sustained at a higher level.
Across the panel, speakers from both Medicaid agencies and insurance departments shared the telehealth-related policymaking that both preceded and has occurred during the pandemic in their states to support ongoing access to telehealth services during the PHE and after it ends. Common target areas for these efforts are: requiring coverage (or prohibiting coverage from being excluded based on care being delivered via telehealth); payment parity; transparency; and permitting telehealth appointments using audio-only technology. Some states have gone further than this: Massachusetts now allows asynchronous telehealth, while New Mexico explicitly allows targeted, telehealth-only licensure for out-of-state physicians.
Panelists also explored in detail issues that states must consider in regards to the future of telehealth, including:
- How telehealth access impacts network adequacy analyses – Most panelists agreed that network adequacy must at least primarily be based on “brick and mortar” locations; however, Julie Weinberg from New Mexico’s Department of the Superintended of Insurance shared that the state is exploring the breadth of telehealth access to determine how to fit access to services via telehealth into a network adequacy determination.
- Third party providers of telehealth – Jatin Dave from MassHealth urged states not to limit telehealth access to care from these providers who are not ongoing healthcare providers for patients. Further, panelists stressed that decisions regarding allowing providers to deliver services to individuals across state lines via telehealth should be considered differently for remote-only providers than for providers with whom a patient – who is travelling temporarily – has an established relationship.
- Audio-only telehealth – Panelists underscored the importance of allowing for audio-only access to promote accessibility, but also flagged challenges for patients with hearing or language access issues.
- What services are clinically appropriate for telehealth in a post-PHE world – Panelists encouraged states to get input from patients and clinicians when making these determinations, as well as to ensure patients are not limited to telehealth. They also noted that behavioral health services are a uniquely good fit for telehealth in many ways, and that states have seen a recent increase in individuals receiving behavioral health services—likely, in part, due to increased access to these services via telehealth.
- Payment rates – While many states are requiring payment parity to encourage participation in telehealth, Laura Arp from the Nebraska Department of Insurance cautioned that some effort and value are lost in a telehealth visit, such as general screening for other conditions.
- Challenges related to telehealth – including the impact of HIPAA rules and technology constraints.
Prescription Drug Cost Control
Panelists from New York state, Maryland and Colorado shared updates on their states’ efforts related to prescription drug prices. New York has the longest-standing process of the three states, and Amir Bassiri, New York’s Deputy Medicaid Director, provided an overview of the state’s Medicaid drug cap and supplemental rebate authority. In summary, if the state is projected to exceed its drug cap and the manufacturers of the top three drugs identified as contributing to the excessive spending are unwilling to negotiate a supplemental rebate, the state will refer to drug to the state’s Drug Utilization Review Board (DURB). The DURB will then request key data, perform an analysis, and recommend a supplemental rebate. If the manufacturer does not agree to this, the state is empowered to make a data request and work with Medicaid managed care carriers to remove the drugs from their formularies or require prior authorization. Using this authority, the state has negotiated over 50 supplemental rebates, and saved over $500 million, since 2017.
Andy York, Executive Director of the Maryland Prescription Drug Affordability Board (PDAB), and Senator Jaquez Lewis from Colorado provided information about their states’ more recent efforts to leverage prescription drug affordability boards. The Maryland board’s charge is to protect the state and residents from high prescription drug prices. Authorizing legislation directed it to consider tools such as setting upper payment limits, reverse auctions, and bulk purchasing, while allowing the Board the flexibility to institute other cost control measures. It is funded through fees on manufacturers, Pharmacy Benefit Managers (PBMs), carriers, and distributors, and its first reports and policy recommendations are due this December.
Colorado’s PDAB is made up of experts; industry representatives are included on an advisory board. The PDAB is empowered to collect and evaluate data, perform an affordability review, and set an upper payment limit that applies to up to twelve drugs per year. In addition to brand drugs, it also reviews prices of generics and biosimilars.