MO HealthNet Oversight Committee Meeting August 9, 2023

MO HealthNet Oversight Committee Meeting August 9, 2023

Agenda August 9, 2023 1:00–1:15 Welcome/Introductions/Minutes Approval of February meeting minutes 1:15–1:45 Director’s Update 1:45–2:00 Chief Operations Officer Update Jessie Dresner 2:00–2:45 Family Support Division Update Kim Evans, FSD Director 2:45–3:00 Chief Transformation Officer Update 3:00–3:15 Managed Care Update 3:15–3:30 Pharmacy Clinical Update 3:30–3:45 Legislative Update 3:45–4:00 Public Comment Dr. Nick Pfannenstiel, Chairman Todd Richardson Kirk Mathews Alex Daskalakis Josh Moore Ryan Conway Next Meeting November 7, 2023

DIRECTOR’S UPDATE TODD RICHARDSON

Overview of Program of All-Inclusive Care (PACE) Rate Development AWOP -Defined as the amount that would otherwise have been paid (AWOP) under the State plan if participants had not been enrolled in the PACE program (42 CFR 2460.182) The State and its Actuary utilize Medicaid experience within the PACE defined regions to develop the amount of the AWOP The AWOP is developed as a monthly capitated per member per month payment. Two AWOPs for each of the three anticipated PACE regions, one for Dual members and one for Non-Dual members Final rates are based on a discount off the AWOP rate, currently the discount is 5%. The AWOP is updated annually and approved by CMS on a calendar year.

Future Value Based Components for PACE In State Fiscal Year (SFY) 2024, PACE organizations (POs) will begin to monitor baseline quality measures which will be utilized to incorporate a value based payment approach in PACE. In Calendar Year 2025, the State anticipates implementing the value based quality measures for POs exceeding 36 months of operation in the form of a percentage return of the discount applied to the AWOP PMPM. Potential quality measures will include two phases: Phase One: Voluntary disenrollment's (%), ER visits, number of falls resulting in hospitalization or death, flu immunizations (%), and pneumococcal immunizations (%) Phase Two: A1C test recipients (%), acute inpatient days, days sent in a nursing facility over 89 days, days spent in a nursing facility less than 90 days, number of prescription drugs filled (monthly)

FY24 6

Chief Operating Officer Update Jessie Dresner

Update: Medically Complex Children’s Health Home Ace Kids Act: Public Law No. 116-16 signed in 2018 State option to begin as of 2022 Voluntary for children and families Eligible children Qualifying providers States must develop plans to educate providers and families

Update: Medically Complex Children’s Health Home MHD: Hired a dedicated full-time employee Has been in contact with CMS Has established a time-line Is beginning stakeholder outreach

Update: 12-month Post-Partum Coverage MHD will submit to CMS by September 7: Eligibility State Plan Amendment (SPA) CHIP SPA F-MAP SPA addendum

Update: Education and Training MO HealthNet provider manuals Maternal Health efforts Provider forms All-inclusive Provider Enrollment Guide

FAMILY SUPPORT DIVISION UPDATE KIM EVANS

Empower Missourians to live safe, healthy, and productive lives. August 9, 2023 13

FSD Charts 14

FSD Charts 15

FSD Charts 16

Update on Technology Projects Centralized Mail – Implemented New Citizen Portal Appointment Scheduler Insights Engine (Electronic Data Services) Document Recognition 17

PHE Unwind April 1, 2023, Missouri started the unwind process Currently FSD is in the process of mailing annual renewals forms for reviews due in September and processing annual renewals for August Information on the unwind process https:// mydss.mo.gov/renew New Annual Renewal Monthly Metrics published at https://dss.mo.gov/mis/clcounter/ 18

PHE Unwind 20

PHE Unwind 21

PHE Unwind 22

Transformation Office Update Kirk Mathews 1. Overview of ToRCH Pilot Program 2. Brief update on Hospital Reimbursement Transformation

Three Primary Goals 1. Improve Population Health in Rural counties by addressing “upstream” causes of poor health related to social factors (such as no transportation, poor nutrition, etc.) These improvements will, over time 2. Reduce the cost of care when better population health results in fewer hospital admissions and avoidable ER visits. The resulting savings will then be shared with the hospital in order to 3. Help make rural hospitals more viable and sustainable

Basic Construct of the Program To qualify, hospital must be sole hospital provider in its home county Selected hospitals will serve as a health hub, establish a leadership board and develop a Community Care Management program that coordinates social care for Medicaid participants in their county in conjunction with community based partners The leadership board will identify its top Population Health priorities along with the Community Based Organizations best suited to assist in improving Population Health outcomes MHD will “baseline” Medicaid spending in each selected county (regardless of WHERE those services are delivered), provide funds to each hub with which the leadership board can make investments in CBO’s, pay for SDOH screenings and pay for selected SDOH services delivered to MHD participants Model is dependent on engaging a closed-loop referral platform to make SDOH referrals, track outcomes, authorize billing, etc. Ongoing Medicaid spending will be monitored and savings shared back to the hub hospital 25

15 Million NDI recommended by Governor Parson and approved by the legislature First “Cohort” target is six rural hospitals with plans to add future cohorts of six more hospitals every two years. CMS regulatory path is “underway” Closed-loop SDOH referral platform vendor has been engaged Initial Cohort sites have been selected

Initial Cohort Sites Citizens Memorial Hospital, Bolivar, MO Bothwell Regional Health Center, Sedalia, MO Golden Valley Memorial Healthcare, Clinton, MO Phelps Health, Rolla, MO Salem Memorial District Hospital, Salem, MO Ray County Memorial Hospital, Richmond, MO

15 Million NDI recommended by Governor Parson and approved by the legislature First “Cohort” target is six rural hospitals with plans to add future cohorts of six more hospitals every two years. CMS regulatory path is “underway” Closed-loop SDOH referral platform vendor has been engaged Initial Cohort sites have been selected

MANAGED CARE UPDATE ALEX DASKALAKIS

Pharmacy Clinical Update Josh Moore

General Update MHD continues to respond to drug shortages. Flexibilities include changes to preferred drug lists, removing certain quantity limits, and paying for the brand name as needed Some of the shortages are due to increased demand, decreased supply, and manufacturing issues Providers should reach out to [email protected] if there is a shortage on an outpatient drug. MHD will review the information and may make changes as needed. High investment cell and gene therapy approvals are accelerating The FDA approved 9 cell and gene therapies in the last 12 months List prices: 2 to 4 million range per participant for one time treatments Requests are currently low but starting to increase

Substance Use Disorder Treatments MHD has open access for Medication-Assisted Therapy (MAT) MO HealthNet continues to encourage the use of MAT with no prior authorization required for preferred opioid use disorder medications. MO HealthNet does not require ongoing counseling to receive MAT for opioid use disorder MO HealthNet does not have a limit to the duration of MAT or number of attempts The data contained within is for MO HealthNet participants only, it does not include commercially insured prescriptions (unless MO HealthNet is secondary) or self-pay prescriptions The paid amount included within is the amount paid to the MO HealthNet provider and does not include any rebates from pharmaceutical manufacturers.

Reimbursed Amount for Select Substance Use Disorder Treatments SFY Participant Count Total Paid Amount 2019 6,724 16,782,692.42 2020 7,006 18,546,196.75 2021 8,025 21,294,980.94 2022 10,757 24,082,333.40 2023 17,227 37,766,698.30 Chart includes unique participants who received at least one claim for one of the following products (or generic) during the state fiscal year (SFY): Suboxone (buprenorphine/naloxone sublingual tablets and films) Subutex (buprenorphine sublingual tablets) Sublocade (buprenorphine long acting injectable) Vivitrol (naltrexone long acting injectable) Data Accessed on 6/21/2023 All data is based on paid MO HealthNet claims through 6/7/2023

Substance Use Disorder Treatments Specialized treatment and rehabilitation services for substance use disorders (SUD) are provided through Comprehensive Substance Treatment and Rehabilitation (CSTAR) programs. The state match for these services is in the Department of Mental Health budget. MO HealthNet covered services for SUD in addition to those provided through CSTAR programs include all of the following: Detoxification services provided in hospitals Screening, brief intervention, and referral to treatment provided by primary care health homes Diagnostic assessment and individual, family, or group counseling/psychotherapy provided by licensed behavioral health professionals (i.e., psychologists, social workers, professional counselors, marital & family therapists) Physician/psychiatrist and advanced practice nurse services to assess/diagnose SUD and prescribe and manage medications – office based MAT Managed care members also receive care coordination and care management services for SUD

Reimbursed Amount for Opioid Rescue Agents SFY Participant Count Total Paid Amount 2019 4,385 554,465.00 2020 4,105 542,561.80 2021 9,049 1,471,902.51 2022 15,328 2,198,417.28 2023 23,436 3,384,061.66 In April 2021 MO HealthNet implemented a policy to require participants on an opioid and another agent that places the participant at higher risk of overdose to receive a naloxone rescue agent in the past 2 years to be able to continue to receive the opioid and/or the other high risk agent Chart includes unique participants who received at least one claim for one opioid rescue agent during the state fiscal year (SFY) Data Accessed on 6/21/2023 All data is based on paid MO HealthNet claims through 6/7/2023

Reimbursed Amount for Dispose Rx Packets SFY Participant Count Total Paid Amount 2022 1,944 48,162.18 2023 5,558 165,935.13 In January 2022 MO HealthNet, Department of Health & Senior Services, and the MO Board of Pharmacy partnered to give access to Dispose Rx packets so that participants could safely dispose of medication at home Chart includes unique participants who received at least one claim for one Dispose Rx packet during the state fiscal year (SFY) Data Accessed on 6/21/2023 All data is based on paid MO HealthNet claims through 6/7/2023

Alternatives to Opioids MO HealthNet increased coverage of non-opioid medications by removing prior authorization requirements from several medications including: Lidocaine patches (generic Lidoderm ) Diclofenac gel (generic Voltaren Gel ) Celecoxib (generic Celebrex ) The following slides depict the increase in utilization of non-opioid medications after prior authorization requirements were removed MO HealthNet offers coverage of chiropractic therapy, acupuncture, physical therapy, and cognitive-behavioral therapy for chronic pain. https://dss.mo.gov/mhd/providers/pdf/bulletin41-55.pdf

Reimbursed Amount for lidocaine patches SFY Participant Count Total Paid Amount 2019 1,138 805,738.99 2020 940 419,778.09 2021 1,241 233,525.65 2022 6,614 579,646.18 2023 13,725 1,349,832.23 MO HealthNet previously required a specific prior authorization for lidocaine patches. Lidocaine is a non-opioid local anesthetic used to relieve pain. Chart includes unique participants who received at least one claim for lidocaine patches during the state fiscal year (SFY) Data Accessed on 6/21/2023 All data is based on paid MO HealthNet claims through 6/7/2023

Reimbursed Amount for celecoxib SFY Participant Count Total Paid Amount 2019 3,711 698,855.12 2020 4,081 559,288.25 2021 5,416 600,094.59 2022 7,093 518,775.77 2023 10,630 670,048.71 MO HealthNet previously required a specific prior authorization for celecoxib capsules (Celebrex). Celecoxib is a non-opioid non-steroidal anti-inflammatory oral medication used to reduce pain and inflammation. Chart includes unique participants who received at least one claim for celecoxib during the state fiscal year (SFY) Data Accessed on 6/21/2023 All data is based on paid MO HealthNet claims through 6/7/2023

Reimbursed Amount for diclofenac gel SFY Participant Count Total Paid Amount 2019 1,467 267,699.89 2020 3,128 411,924.63 2021 6,097 626,670.00 2022 6,642 502,343.19 2023 11,451 760,615.22 MO HealthNet previously required a specific prior authorization for lidocaine patches. Diclofenac gel is a non-opioid local non-steroidal anti-inflammatory drug (NSAID) used to relieve pain and reduce local inflammation. Chart includes unique participants who received at least one claim for diclofenac gel during the state fiscal year (SFY) Data Accessed on 6/21/2023 All data is based on paid MO HealthNet claims through 6/7/2023

Current Opioid Policies MO HealthNet established the daily morphine milligram equivalent (MME) limits based on the elevated risk of overdose at certain doses: 50 MME per day: risk of overdose is 2 to 5 times the risk at 0 – 19 MME per day 100 MME per day: risk of overdose is up to 9 times the risk at 0 – 19 MME per day Limit of no more than 7 days on initial prescriptions for opioids Prior authorization requirement for opioid regimens over 50 morphine milligram equivalents per day Prior authorization requirement and in-depth clinical review of opioid regimens over 90 MME per day Subsequent prior authorization requirements for any additional increases over 90 MME per day (i.e. an increase from 95 to 130 MME per day requires prior authorization.) No review is required when opioid regimens decrease daily MME (i.e. a decrease from 130 MME to 95 MME per day) In-depth clinical review prior to approval of any participants newly starting methadone https://www.cdc.gov/opioids/providers/prescribing/faq.html

Number of Participants by Daily MME Level per Month (Participants over 50 MME per day only) 6000 5000 4000 3000 2000 1000 0 MME 50 - 90 per day MME 90 - 150 per day Data Accessed on 6/6/2023 All data is based on paid MO HealthNet claims through 5/26/2023 MME 150 per day

Additional Links for More Information https://dss.mo.gov/mhd/cs/pharmacy/pdf/mhd-opioid-policy-update.pdf https:// dss.mo.gov/mhd/cs/pharmacy/pdf/select-oral-benzodiazepines-clinical-edit.p df https:// dss.mo.gov/mhd/cs/pharmacy/pdf/opioid-select-alcohol-dependence-agents. pdf https://dss.mo.gov/mhd/cs/pharmacy/pdf/high-risk-therapies-clinical.pdf https://www.disposerx.com/

LEGISLATIVE UPDATE RYAN CONWAY

PUBLIC COMMENT

NEXT MEETING NOVEMBER 7, 2023