Insights from the 2023 Annual Conference of the National Academy for State Health Policy
This year’s National Academy for State Health Policy (NASHP) conference took place in August. This was the largest NASHP conference to-date with over 1,000 attendees from across the country. As states continue to take-on the herculean task of post-Continuous Coverage Requirement (CCR) Medicaid redeterminations, the theme of this year’s conference was It’s a Marathon, Not a Sprint. As always, the conference addressed the full range of health policy issues and innovations, but state efforts relative to behavioral health, workforce, supporting patients across the age spectrum and health-related social needs (HRSN) were particularly highlighted.
PCG subject matter experts were pleased to be able to see so many colleagues from around the country as we both attended and hosted an exhibit at the conference. Below we share some key insights we gained.
Updates from the States on Justice Involved Waiver Programs
NASHP included an opportunity to hear from early innovator policy leaders implementing and working through first of its kind access to health care for the justice involved waiver population. HPN has been tracking the implementation of California’s Section 1115 Re-Entry Demonstration Waiver, the first waiver of its kind to receive approval from CMS. As previously outlined on HPN, the waiver addresses the federal Medicaid Inmate Exclusion Policy, under which states are prohibited from using Medicaid dollars to provide health care services to individuals who are incarcerated even if they would otherwise meet Medicaid eligibility requirements. HPN also outlined the April 2023 guidance provided via a State Medicaid Director’s Letter (SMDL) to states with insights into goals, and allowable covered services under1115 Re-Entry Demonstration Waivers. The SMDL provides states with Section 1115 Demonstration Waiver guidance for those exploring innovative solutions to promote continuity of care for inmates of a public institution who are soon to be released and are expected or likely to be Medicaid-eligible upon release. Under the current Medicaid Inmate Exclusion Policy, states are prohibited from using Medicaid dollars to provide health care services to individuals who are incarcerated, even if they would otherwise meet Medicaid eligibility requirements.
In a plenary entitled “Going the Extra Mile: Innovations in Perinatal Health Policy” policy directors and advisers from North Carolina, Pennsylvania, and Connecticut outlined various payment models being leveraged to improve birth and maternal health outcomes and reduce disparities in maternal morbidity and mortality.
The session was moderated by Dr. Shin-Yi Lin, PhD, a Program Manager in New Jersey’s Division of Medical Assistance and Health Services (NJ Medicaid), and featured David Grande, MD, MPA – a special advisor for Medicaid Innovation at the Pennsylvania (PA) Dept. of Human Services; Fatmata Williams, MS, RN – a supervising nurse consultant from the Connecticut (CT) Dept. of Social Services; and Dr. Emma Sandoe, PhD, the Deputy Director of Medicaid Policy in North Carolina (NC).
Ms. Williams detailed CT’s transition from an obstetric pay-for-performance (P4P) initiative that saw mixed results in perinatal outcomes to a mandatory maternity bundle that meaningfully incorporates lactation support and doula services, with the latter charged with advancing the state’s goals around equity, team-based care, and the integration of clinical and non-clinical services.
Dr. Grande shared findings and insight from PA’s maternity care bundle experience. Dr. Grande argued that the clinical timeframes and affected parties of maternal care bundles have been the subject of some debate. He outlined that the paradigm of pregnancy care starts with preconception through prenatal care, delivery, and post-partum care, and has historically been focused on just the birthing parent. Dr. Grande argued that the post-partum window, in particular, was often too narrowly defined and did not always include the newborn. Supported by the finding that in Philadelphia, over 50% of maternal mortality occurs between 43-364 days, PA designed its bundle to include prenatal care, labor and delivery, care coordination, and 60 days post-partum care for birthing parent and newborn.
Layered into the design of the bundle are quality measures regarding screening for SDOH, depression, substance use disorder (SUD) treatment and initiation, prenatal immunization, and well-child visits. Dr. Grande noted that the inclusion of newborns in the bundle has been an important, but challenging endeavor, to advance the coordination between traditional obstetrics and pediatrics in PA. In the future, PA aims to include more services in the preconception and late postpartum phase of pregnancy—with a focus on BH integration, doula supports, primary care, and HRSN services.
Dr. Sandoe of NC gave a comprehensive history of the state’s pregnancy bundle evolution—which has existed in various designs since 1985. In 2011, the state launched Pregnancy Medical Home (PMH) an opt-in value-based payment initiative whereby participating providers delivered coordinated and comprehensive care during pregnancy in exchange for one-time payments for certain activities and an increased payment for most service packages. It was widely adopted by providers and yielded key outcomes including 20% lower rate of low-birthweight compared to general NC Medicaid population and 70% of birthing parents (compared to 40%) received prenatal care in the first trimester.
Building on these laudable achievements, NC transitioned its PMH to the Pregnancy Management Program (PMP) in July 2021. Like the PMH, the PMP maintained incentives payments for risk screening and post-partum care, equal pay for vaginal and c-section births, most quality requirements, and exemptions from prior authorization for ultrasounds. The key differences were that providers were automatically enrolled in the PMP program, and health plans were permitted to offer additional payment programs to promote pregnancy outcomes.
Dr. Sandoe said that one strategic asset was NC’s local health departments which play a key role in delivering intensive care management services such as member/family outreach, care plan creation, and coordination across health plans and providers.
The plenary opened with consensus around the essential role Medicaid plays in supporting low-income parents, funding more than 40 percent of births nationwide. Further, known health disparities by race and ethnicity formed the bedrock for many of the experts’ presentations, quality measure slates, and next steps, and panelists acknowledged the significant role technical experts play in advancing data-driven equitable frameworks and billing to comply with programmatic requirements.
Interestingly, attendees’ questions were mostly focused on data-access opportunities/challenges and the appropriateness of leveraging personal technology, e.g. smart-phone apps and remote monitoring to engage members and identify rising risk. The panelists were fairly uniform in recognizing the opportunities technology can unlock. However, as stewards of sensitive data, member- and provider-experience, and budgets, the panels each highlighted the importance of working with vendors that had well developed efficacy data and frameworks for addressing these concerns.
The session was supported through the Health Resources and Services Administration of the U.S. Department of Health and Human Services under the Supporting State Maternal and Child Health Policy Innovation Program.
Federal Partners Plenary
As is common at NASHP, the final day of the conference provided an opportunity for state policymakers and others to hear directly from leaders at the Centers for Medicare and Medicaid (CMS) about their current priorities. This plenary featured federal partners from the CMS Innovation Center, Center for Consumer Information and Insurance Oversight (CCIIO), and Center for Medicaid and CHIP Services (CMCS).
Not surprisingly, the top focus of CMCS Director Dan Tsai is the Medicaid CCR unwind and supporting states as the undertake Medicaid eligibility redeterminations for the first time in three years. Tsai noted that they are focused on minimizing procedural disenrollments and messaging that speaks about coverage broadly instead of specifying coverage types. They also are also working to encourage employers to assist with coverage transitions, including by offering Special Enrollment Periods during the unwind period.
Director Tsai noted that they have received an unusually large number of Medicaid Section 1115 Waivers recently. CMCS is seeing a mix of similar priorities nationwide (including related to coverage for justice-involved populations, HRSNs), as well as unique submissions. Tsai noted that they are engaging with their partners in the Innovation Center around waivers. While they cannot provide permanent flexibility related to nationwide priorities without statutory changes, they are trying to pave a more sustainable path to waivers.
Other priorities for CMCS include promoting access to care and quality of care through Medicaid programs, including through the proposed Medicaid regulations released last May.
Director Ellen Montz of CCIIO also spoke of her center’s focus on the CCR unwind, aiming to ensure a seamless transition to Exchange coverage. Other priorities of CCIIO include enforcement related to agents and brokers, continued implementation of the No Surprises Act and work related to Mental Health Parity.
Director Liz Fowler from the Innovation Center spoke of her center’s focus on Accountable Care Organizations, with a focus on care navigation and cost accountability. As it seeks to promote value-based care efforts, the Center has its eye on supporting participation of Federally-Qualified Health Centers (FQHCs) in such efforts. They are hoping that focusing more on quality improvement than upfront investments and providing a longer implementation runway will support engagement of a broader range of providers. Other topics the Center is focused on include HSRN, health equity, behavioral health and maternal health.