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  • Washington Highlights

    MACPAC Delivers June 2018 Report to Congress

    Kate Ogden, Physician Payment & Quality Specialist

    The Medicaid and CHIP Payment and Access Commission (MACPAC) released its June 2018 Report to Congress, which focuses on the high cost of prescription drugs, the opioid epidemic, and implications for the growing trend of delivering long-term services and supports (LTSS) through managed care.

    The report acknowledges that high rates of spending for prescription drugs are a concern within the Medicaid program. To address this problem, the commission developed two recommendations for the Medicaid Drug Rebate Program with a goal of reducing spending:

    • Close a loophole in current law that allows a manufacturer to sell its authorized generic drug at a low price to a corporate subsidiary, reducing the rebate obligation for its brand drug, and
    • Give the Health and Human Services (HHS) Secretary clear authority to impose intermediate financial sanctions on manufacturers that misclassify a brand drug as a generic to lower their rebate payments.

    The report also discusses federal regulations governing consent to share substance-use disorder (SUD) treatment-related patient records and overall access to SUD treatment for Medicaid beneficiaries. Federal regulations that govern privacy and consent to share SUD treatment patient records are now more restrictive than Health Insurance Portability and Accountability Act (HIPAA) requirements.

    MACPAC says that some providers and payers assert that the regulations are not only confusing and difficult to implement but also contribute to barriers to integrated care as they inhibit the sharing of information between providers. Additionally, some providers contend that these regulations inhibit delivery system reform efforts that hold providers accountable for costs and outcomes. It also notes that patient advocates say that the enhanced restrictions protect patients and that loosening the regulations could discourage patients from seeking treatment due to broad stigmatization of SUD. Increased disclosure of a patient’s SUD treatment could have implications for employment, housing, and criminal arrest.

    There is broad agreement that the regulations are confusing, restrictive, and challenging to implement. As such, the commission recommends the HHS Secretary direct relevant agencies to issue joint subregulatory guidance to clarify the regulations and coordinate efforts to provide education and technical assistance.

    The report also discusses barriers to access that Medicaid beneficiaries face when seeking SUD treatment, building on analysis from the June 2017 report [see Washington Highlights, June 16, 2017]. MACPAC notes that only 12 states pay for the continuum of care of SUD, with a specific deficiency in residential and partial hospitalization services. Many states cite the institution for mental disease exclusion as a barrier to providing SUD treatment services, but the commission reports that states can pay for the services through other waivers, though many choose not to. Only 23 states applied for waivers to deliver comprehensive SUD treatment services.

    The report also reviews other barriers for access to treatment, including areas with no outpatient SUD treatment programs and low Medicaid participation for the providers and facilities that do exist. The commission would like to complete additional research on the services that Medicaid agencies provide and monitor states’ efforts to expand SUD treatment options.

    Beyond the pricing of prescription drugs and access to SUD treatment, MACPAC also provides a status report on the increased role of managed-care in providing LTSS to Medicaid beneficiaries. As of January 2018, 29 states have managed care LTSS programs, which represents an increase from eight states in 2003. As more states implement managed care LTSS, the programs often expand their scope, including patients with intellectual and developmental disabilities as well as dual-eligible beneficiaries.

    While there has been some modest evidence of success, the commission acknowledges that there are still unanswered questions due to limited data. Insufficient targeted quality measures have made evaluation difficult, and efforts to implement new quality measures and collect better encounter data may improve the monitoring and oversight of these programs.