On September 26 and 27, 2019, MACPAC held the first meeting of their new 2019-2020 term. This meeting covered several sessions on topics of importance to the Medicaid program, including discussion on integrated care for dual-eligibles, Medicaid formularies, and oversight of directed payments.

MACPAC Reviews Medicaid Formularies

MACPAC staff presented findings on Medicaid drug formularies, noting that the differences in utilization between payers was generally small. In comparing new formulary coverage since Medicaid is required to cover drugs immediately after they become commercially available, MACPAC found that coverage between payors became more comparable after 3 to 6 months. Staff also found that Medicaid frequently had the lowest average gross cost per 30-day fill by brand/generic and payer. However, staff noted that they did not have access to data on drug rebates in Medicaid so they could only account for gross, not net cost. Overall, staff stated that no specific pattern emerged in the impact of formulary access on relative utilization in Medicaid compared to other payors.

 

No concrete next steps came out of the session. Based on commissioner comments, however, prescription drug coverage will likely discussed at future meetings as staff look at additional research options.

Commission Reviews SUD Patient Health Records Proposed Rule

The commission reviewed information about the proposed rule on substance use disorder (SUD) confidentiality of patient records, comparing provisions to MACPAC’s previous work and the commission’s recommendations from June 2018. During a brief discussion, commissioners decided to comment on the proposed rule, reiterating their previous recommendations.

Commissioners looking towards federal rulemaking for updates to oversight in directed payments

Since 2016, directed payments for Medicaid services have been under increased scrutiny due to federal regulations. As such, the commission requested further analysis of directed payments, and specific information on how federal oversight of these supplemental payments influences distribution to states. MACPAC’s report found a potential inability for rural hospitals with high Medicaid shortfall to appropriately capture directed payments due to federal oversight provisions, and a potential increase in quality outcomes when directed payments were based on value.

All commissioners were unanimous in their request for more information and analysis on how value influenced the amount of directed payments received by states. Further, commissioners stated trepidation that federal oversight may be adversely affecting hospitals in rural and underserved locations, fearing that the inability to capture the maximum directed payment for Medicaid services could eventually lead to an issues of healthcare access for beneficiaries.  The commission intends to revisit this discussion on directed payments in this term’s work after anticipated updates to the regulation have been made.

Washington State’s Integrated Care Program Saves Medicare $167 million between 2013-2019; Idaho’s Pilot Raises Medicaid Payment Rates

MACPAC’s session on integrating care for dually eligible beneficiaries was a panel discussion where CMS presented their priorities on integrated care, while both Washington state and Idaho presented an overview of their integrated care programs for their dual eligible beneficiaries.

CMS stated their strategic priority of caring for dual-eligibles, and the Agency is continuing to look for ways to partner with states to pilot these programs.

Between 2013-2019, Washington’s program has saved Medicare $167 million; the cost savings have been so significant that savings have been shared back to the state. Idaho’s savings are still pending.

Washington’s piloted integrated care model focuses on using care coordinators as patient advocates and coordinators for care and contracting community entities to focus on patient engagement. Contrastingly, Idaho’s integrated care model focuses on ensuring increased access to physicians by reimbursing Medicaid services at 100% of the Medicare rate.

Overall, commissioners were very interested in hearing more about each state’s programs, and the commission stated their intention to gather additional information on this pilot program in hopes that it can be generalized to other states.

MACPAC’s next public meeting will be October 31-November 1, 2019.