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NAMD sends letter to CMS on modularity in Medicaid information systems; Guidance on 90/10 Match; Senate letter on EpiPen Price Increases; Drug Pricing

August 30, 2016
From the NAMD Desk
Texas Names Jami Snyder Assoc. Commish for Medicaid and CHIP Services
The Texas Health and Human Services Commission has a new Medical and Social Services Division that will be headed by Gary Jessee. Under this division, the new department lead for Medicaid will be Jami Snyder. Shemost recently served as chief deputy director for Medicaid and CHIP. Before coming to HHSC, she was the chief operating officer for the University of Arizona Health Plans, a division of Banner Health. She has more than 18 years of experience in the public and private sectors, overseeing Medicaid-contracted health plans, including adherence to established federal and state managed care regulations, as well as driving managed care organization performance in a variety of areas. Snyder graduated from Gustavus Adolphus College with a Bachelor of Arts in political science and has a Master of Arts in political science from Arizona State University.
NAMD Offers Feedback on CMS’ Modular Systems Strategy
On August 15, NAMD sent a letter to the Center for Medicaid and CHIP Services (CMCS) providing the association’s responses to a series of questions posed in a Request for Information (RFI) pertaining to modularity in Medicaid information systems.

In the letter, NAMD expresses support for CMCS’s overall goals for the modular approach to Medicaid management information systems (MMIS), which aims to enhance the efficiency and effectiveness for the development and acquisition of technology to support the Medicaid program. NAMD also makes three overarching points for CMCS to consider:

  • CMS should strike an appropriate balance between creating competition and valuing the experience of existing vendors, recognizing that states, CMS, and vendors are still learning the nuances of this new approach.
  • CMS should continue to work with states to identify opportunities for standardization and areas where states will need the ability to appropriately customize their systems to accommodate their state-specific programs.
  • CMS should frame its ongoing systems work in a manner that recognizes states as equal partners in the vision for Medicaid’s approach to MMIS and technology. State Medicaid leaders can and must serve a more integral role in this transformation.
In This Issue

NAMD Fall Meeting
Nov. 6-8, 2016
Information and registration here.



Reg Update


CMS Reports on 2015 Quality, Savings Results of Medicare ACOs
On August 25, the Centers for Medicare and Medicaid Services (CMS) released the 2015 quality and finance performance results for the Medicare Accountable Care Organization (ACO) program. The results show that the over 400 Medicare ACOs saved over $466 million in 2015, with 125 ACOs qualifying for shared payments by meeting quality and savings targets. ACOs with relatively longer experience in the program, either via the Pioneer ACO model or regular ACO model, were likelier to see the performance required for shared savings.

View a fact sheet on the findings.


CMS Issues Guidance on 90/10 Match for Medicaid Systems
On August 16, the Centers for Medicare and Medicaid Services (CMS) published a State Medicaid Director letter providing additional guidance on the availability of 90% federal match for Medicaid systems work. This letter, the third in a series of such guidance, focuses on Medicaid management information systems (MMIS) modular certification. The letter provides background on CMS’s rationale for transitioning to a modular certification approach, which is aimed at reducing the cost, length of procurement, and risk associated with large MMIS replacements.


Notably for states, CMS confirms that the federal agency is actively discouraging replacement of an entire MMIS as a monolithic activity. Modular certification will be applied to MMIS systems as new modules are introduced and as existing modules are replaced. States also should be aware that CMS may require modular certification of portions of a system when proposed changes or enhancements have been determined to be high risk.


CMS also advises states that the addition of a new module or changes or enhancements to an existing module or set of modules would call for modular certification, it would not require the recertification of the entire MMIS. Instead, review of a modular implementation would focus on that module’s functions within the MMIS, how it interfaces with other MMIS modules, and how effectively and efficiently it serves its purpose within the MMIS. Successful completion of regression testing must also be verified to ensure that the integration of the new module will not have a negative impact on other parts of the system. The process for modular certification is detailed in the Medicaid Enterprise Certification Toolkit (MECT), which provides states with three checklist options for certification.


The letter also outlines CMS’s vision for how states will acquire modules (including advice for information to include in state RFPs); the role of the state’s system integrator in the new MMIS modularity world; independent verification and validation requirements; and MITA 3.0 compliance considerations.


Access the letter here.


CMS Seeks Input on Steering of Patients to Exchange Coverage
On August 18, the Centers for Medicare and Medicaid Services (CMS) issued a Request for Information (RFI) on the topic of providers who may be steering Medicare and/or Medicaid-eligible individuals into other ACA coverage sources in order to secure higher reimbursement. In a press release accompanying the RFI, CMS indicates its concern that patients may experience disruptions in continuity of care and coordination of services due to provider network changes accompanying a change in coverage. CMS is also concerned about program integrity impacts on Medicare, Medicaid, and the Exchanges as a result of this provider behavior. CMS is considering regulatory and policy options to limit this practice.


View the Public Inspection version of the RFI here.

Hill Update


Bipartisan Senate Letter to FDA Explores EpiPen Price Increases
On August 24, a bipartisan group of five Senators sent a letter to the Food and Drug Administration (FDA) seeking information regarding the FDA’s approval of the EpiPen medication to treat severe allergic reactions, as well as the agency’s work to approve competitor products. The letter notes that the price of EpiPen has increased by over 400 percent since 2007, despite the main ingredient remaining relatively inexpensive. The Senators note the impact this price increase is having across the nation, including on budgets for first responders and schools.
The letter poses five specific questions for the FDA, focused on the agency’s efforts to ensure a sufficient supply of EpiPens, work to approve generic versions of the drug, whether an EpiPen could become an over-the-counter medication, and the status of FDA reviews of any EpiPen alternatives.


Read the letter here.


In the News
Stat Analyzes Latest Drivers of Opioid Abuse Epidemic
On August 25, Stat News published an article titled “Illegal street drugs, not prescriptions, now powering opioid abuse, study finds.” The article reports on findings from the Centers for Disease Control and Prevention (CDC) and the Drug Enforcement Agency (DEA) indicating that illegal use of the synthetic drug fentanyl appears to be the primary driver of the past year’s opioid overdoses, rather than misuse or diversion of prescribed drugs. The findings state that law enforcement seizures of drugs containing fentanyl increased 426% from 2013 to 2014, and tripled again from 2014 to 2015, with synthetic opioid deaths increasing 79% from 2013 to 2014.


Read the article  here.


KHN Reports on Factors Impacting Prescription Drug Pricing
On August 23, Kaiser Health News published a story titled “Government-Protected ‘Monopolies’ Drive Drug Prices Higher, Study Says.” The article reports on a recent Journal of the American Medical Association (JAMA) study analyzing the complex interplay of factors influencing drug pricing in the United States. The study identifies five key facets that make drug prices in the country higher than other nations:
  • Drug manufacturers set their own U.S. price;
  • Government-protected monopolies exist for certain drugs, preventing generic competitors;
  • The Food and Drug Administration approval process is lengthy for generic drugs;
  • Certain federal and state policies limit the ability for generics to keep down costs; and
  • Drug prices do not reflect research and development costs.
Read the article here.


Stateline Explores Potential Medicaid Savings in Home Health Visits
On August 25, Stateline published an article titled “House Calls Might Save Medicaid Money for States.” The article notes findings from a Medicare demonstration which showed savings averaging $1,010 per beneficiary for physician home visits for persons with three or more chronic conditions. Experts suggest similar savings could be realized for such complex patients in the Medicaid program, as well. However, the home visit model for physicians is no longer widespread, though some demonstrations under the ACA have made funding available to reinvigorate this practice.


Read the article here.


New York Times Reports on Individuals Dually Enrolled in Medicaid and Exchanges
The Obama administration has taken steps to end duplicate coverage for tens of thousands of people who are enrolled in Medicaid and simultaneously receiving federal subsidies to help pay for private health insurance under the Affordable Care Act. The Department of Health and Human Services sent letters to affected individuals after congressional investigators from the Government Accountability Office identified the potential for duplicate coverage, stemming from unpredictable eligibility changes, obsolete information, and nominal exchange between government and state bodies. The article notes that the duplication arises, at least in part, because states run the Medicaid program and federal officials run the insurance exchanges for most states; this can make it difficult to exchange information in real-time.


Read the article here.


Denver Post Covers Recommendation that Colorado Expand HCV Coverage
On August 17, the Denver Post published a story titled “Colorado board recommends expanding coverage for hepatitis C drug.” The article reports on a recommendation made by the Colorado Drug Utilization Review Board to expand the state’s Medicaid coverage of hepatitis C curative therapies from the current criteria, which require a fibrosis score of F3 or F4, down to a fibrosis score of F2. However, the American Civil Liberties Union (ACLU) has indicated it plans to sue the state to remove all HCV coverage restrictions.


Read the article here.

Take Note


ASPE Issue Brief Finds Medicaid Expansion Reduces Marketplace Premiums
On August 25, the U.S. Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) published an issue brief estimating that states with expanded Medicaid programs under the ACA also see 7% lower premiums in their health insurance Marketplace. ASPE believes this finding is due to Medicaid expansion up to 138% of the federal poverty level (FPL) allows Marketplace risk pools to consist of relatively higher-income populations above 138% FPL. The brief notes that non-expansion states see individuals between 100% – 138% FPL making up nearly 40% of their Marketplace population, versus 6% for expansion states.


Access the brief.
Consumer Advocates Release Recommendations on Promoting Prescription Drug Access
Recently, a group representing consumer advocates to the National Association of Insurance Commissioners (NAIC) released a report detailing a series of recommendations to policymakers and stakeholders to increase consumer access to prescription drugs. The extensive set of recommendations covers several areas, including:
  • Improving Access to Comprehensive Prescription Drug Coverage;
  • Consumer Affordability of Prescription Drug Coverage;
  • Nondiscrimination in Formulary Design;
  • Improving Transparency of Prescription Drug Coverage;
  • Meaningful Oversight and Regulation of Prescription Drug Benefits; and
  • Addressing Emerging Therapies.
Access the report here.


CHCS Launches MLTSS Rate-Setting Resource Center
Recently, the Center for Health Care Strategies (CHCS) announced the launch of its Medicaid managed long-term services and supports (MLTSS) rate-setting resource center. The center, which emerges from CHCS’s MLTSS rate-setting initiative, compiles a variety of resources for states to inform their MLTSS programs, including:
  • Foundational MLTSS concepts
  • State policy and operational considerations
  • Risk adjustment for functional status
  • Federal and professional guidance
Access the center here.


Brief Analyzes Coordination Issues for Connecting Justice-Involved Individuals to Medicaid Services
Recently, the Center for Health Care Strategies (CHCS) and the Milbank Memorial Fund released an informational brief titled “Coordinating Access to Services for Justice-Involved Populations.” This brief, examines how innovative state and county authorities are improving health services for the justice-involved, mainly through comprehensive care coordination interventions to ensure access to physical and behavioral health services and social supports as individuals transition into their communities. Some of these interventions – in both expansion as well as non-expansion states – include peer supports, case management, and integrated mental health, substance use, and social supports.


Read the brief here.


AHIP Analyzes Orphan Drug Utilization Trends
In its new report, America’s Health Insurance Plans (AHIP) explores to what extent orphan drugs – those developed to treat rare diseases affecting patient populations of less than 200,000 people annually – have become a lucrative business opportunity for pharmaceutical companies. From a sample of 46 orphan drugs available, it finds that almost half of these drugs’ usage (47%) was for non-orphan diseases, and that
the Average Wholesale Prices (AWP) of these drugs increased by 26% between 2012 and 2014. The greatest price increase (37%) occurred for orphan drugs prescribed mostly for non-orphan uses, while orphan drugs almost exclusively used for their orphan indications saw the smallest price increases (12%).
With orphan drugs constituting almost half of all FDA medications approved last year, the results of the study raise significant concerns about the continued affordability of orphan drugs and their role as important, life-saving medications.


Access the report here.


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