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Blog

Highlights from HMA survey on state approaches to managing the Medicaid pharmacy benefit

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This week’s In Focus covers key takeaways and insights from a recently released HMA report, State Approaches to Managing the Medicaid Pharmacy Benefit: Insights from a National Survey for State Fiscal Years 2023 and 2024.

The report, released in August 2024 with support from Arnold Ventures, includes survey responses from 47 states (including DC) for state fiscal years (SFYs) 2023 and 2024. The survey instrument builds on questions posed in the 2019 Medicaid Pharmacy Study of all 50 states and the District of Columbia, which HMA and the Kaiser Family Foundation conducted.  

The report discusses state trends for how Medicaid pharmacy benefits are administered across the country, including planned priorities and anticipated challenges in SFY 2025 and beyond. The findings are based on information provided by the nation’s state Medicaid Directors, Medicaid Pharmacy Directors, and other Medicaid agency experts. 

Pharmacy Benefit Administration  

In many states, managed care delivery systems play a pivotal role in administering Medicaid benefits, including prescription drugs. As of July 1, 2023, survey results found that:  

  • A total of 33 states carved pharmacy benefits into managed care organization (MCO) contracts, with one state, Kentucky, directing its MCOs to use a single state-selected pharmacy benefit manager (PBM). 
  • Eight states carve-out the pharmacy benefit—double the number in 2019. 

MCO states were surveyed about their use of carve outs for certain drug products/classes, inclusive of physician-administered drugs covered under the medical benefit.  

  • In all, 19 states reported carving out one or more drug classes or select agents within a drug class—often high-cost specialty drugs. 
  • Of those states, 13 reported using the carve-out as part of a risk mitigation strategy.  
Bar chart titled "MCO PBM Contract Requirements as of July 1, 2023," showing various requirements for PBM contracts. The chart indicates that 25 states prohibit spread pricing, 17 states have PBM transparency/reporting requirements, 10 states have any willing pharmacy requirements, and 2 states plan changes in FY 2024. Notes at the bottom mention that Florida, Kansas, Minnesota, and Ohio did not respond.

Pharmacy Benefit Managers 

The significant role and market power of PBMs have prompted many state legislatures to enact greater transparency practices and require health plans to accept more responsibility for monitoring the PBMs they contract with, which reflect notable changes since the 2019 survey. More specifically: 

  • A total of 33 states reported contracting with a PBM.  
  • The most frequently reported PBM functions included utilization management, drug utilization review, claims processing and/or payment, and rebate administration activities.  

The 30 MCO states that carve in pharmacy benefits responded to survey questions about PBM transparency and spread pricing requirements. Of these states:  

  • 25 prohibit spread pricing in MCO PBM contracts—more than double the number of states reporting prohibitions on spread pricing in 2019.  
  • 17 reported having PBM transparency reporting requirements.  
  • 10 states reported having “any willing” pharmacy requirements.  

The Role of PDLs, Prior Authorization, and Step Therapy in Controlling Drug Costs and Utilization  

HMA’s experts also sought information on state payment strategies and utilization management protocols that are used to manage pharmacy expenditures. Nearly all responding states (44) have a preferred drug list (PDL) in place for fee-for-service prescriptions, which allow states to drive the use of lower cost drugs by encouraging providers to prescribe preferred drugs. Further, nearly two-thirds of responding MCO states (19 of 30 states) that do not carve out the pharmacy benefit reported having a uniform PDL for some or all drug classes, requiring all MCOs to cover the same drugs.  

Many states have implemented step therapy and prior authorization (PA) guardrails in their Medicaid programs through legislation. However, 85.1 percent of responding states (40 of 47) report utilization controls like PA or step therapy applied to drugs that are reimbursed through the medical benefit to control utilization and costs. States also play an active role in managing MCO clinical protocols or medical necessity criteria, with 22 out of 30 MCO pharmacy carve-in states reporting that they require uniform clinical protocols for some or all drugs with clinical criteria. Approximately one-half of responding MCO carve-in states also require review and approval of MCOs’ PA criteria (15 of 30 states) and step therapy criteria (14 of 30 states).  

State Adoption of VBAs: Improving Patient Access to Cell and Gene Therapies  

A growing number of states are actively considering entering into value-based arrangements (VBAs) with manufacturers, as pressure to improve patient access to cell and gene therapies increases. Nine states have at least one VBA in place, and 23 states reported that VBAs are among their future solutions for addressing coverage of new high-cost therapies. States will need to address common barriers to VBA implementation, which involves more upfront costs and operational challenges to implement than traditional contracts. 

Subsequent to the submission of survey responses, the Centers for Medicare & Medicaid Services (CMS) released a Cell and Gene Therapy (CGT) Access Model, which begins with a focus on sickle cell disease, anticipated to go live on January 1, 2025. Under the model, CMS will negotiate outcomes-based agreements with manufacturers on behalf of the state to ensure that treatment pricing is related to treatment effectiveness. In the coming years, experiences with this model will help determine whether a CMS-led approach to developing and administering VBAs for CGTs improves Medicaid member access to innovative treatment and their impact on expenditures, if any.  

Map of the United States titled "States with Approved VBA State Plan Amendments as of March 14, 2024," showing states that have CMS-approved SPAs to enter into VBP-based SRAs with manufacturers. Each state is color-coded to represent its original effective date of approval, ranging from 01/01/2019 to 01/01/2023. The map includes a key indicating the original effective dates for each state, such as Arizona (01/01/2019), New York (04/01/2022), and Ohio (01/01/2021), among others. Source: CMS Medicaid Prescription Drugs website.
Source: VBPUpdate (medicaid.gov)

Looking Ahead  

Managing the Medicaid pharmacy benefit has never been more challenging. In FY 2025 and beyond, most states will be focused on managing their Medicaid pharmacy budgets, especially the development of VBAs and other policies and strategies for managing new high-cost therapies. Other top priorities and challenges cited by multiple states include management of PBM arrangements and considering coverage of the new generation of GLP-1 anti-obesity medications. States also must react to changing drug marketplace conditions driven, in part, by federal policy changes to the Medicaid drug rebate formula and changes designed to lower Medicare drug costs. Drug manufacturer responses to these changes have implications for Medicaid state budgets, but also for state PDL management decisions and beneficiary access to needed medications. 

Connect with Us 

The upcoming event, Unlocking Solutions in Medicaid, Medicare, and Marketplace, hosted by HMA, will offer more opportunities to engage with report author Kathy Gifford at the pre-conference workshop Paying for Innovative Pharmaceuticals: State and Federal Trends Shaping Public Programs. Leaders from various sectors will join Kathy to discuss trends in prescription drug policies in public and commercial insurance programs. 

For details about the report, contact our featured experts below.

Blog

Decoding your defense: a playbook to help your plan increase your Star rating

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Watch a replay of our webinar Mastering Star Performance: Strategies from the HMA Stars Accelerator Program.

WATCH NOW

HMA works with managed care plans to maximize Star ratings and improve program quality.

Star Ratings have been on a steady decline over the last two years resulting in large reductions in quality bonus and rebate payments, potentially impacting opportunities to improve member health outcomes.

How HMA can help improve a plan’s
Star rating:

We have developed a playbook that captures The HMA Stars Accelerator Solution with proven strategies for Stars improvement based on our diverse and extensive expertise in managed care plan (MCP) operations, MCP strategy, performance improvement, actuarial science, data analytics, risk adjustment, and federal and state policy.

Using our vast experience in the Medicare and Medicaid space, HMA can help you maximize ratings in programs like Medicare Stars and Medicaid quality performance. Together with our actuarial colleagues from Wakely Consulting Group and federal policy expert colleagues from Leavitt Partners, both HMA companies, we can provide the assistance you need to move your organization to a higher Star rating level. With guidance from HMA experts, the Accelerator is scalable for both functional and matrix organizations.

Want a copy of HMA’s
Stars Accelerator Playbook?

Fill out this form and one of our consultants will get back to you.

HMA can help your organization create momentum by combining HMA’s programmatic strategies with a robust actuarial and analytical basis, inclusive of integrated risk adjustment.

Meaningful data analysis ensures plans can prioritize the most important areas for strategic focus. Improving performance in Stars requires a multi-pronged, multifactorial approach. The HMA Stars Accelerator Solution is consumer-oriented and customizable to meet the unique needs of your members’ needs. It facilitates understanding of the organization’s current state, identifies opportunities for improvement, provides best practices for design of meaningful solutions to implement, and measures the effectiveness of improvements.

This image shows a diagram composed of hexagonal shapes connected in a circular flow, centering around the term "Continuous Improvement Methodology." Surrounding the center hexagon are six other hexagons, each representing a different element of a strategic process: Gap or SWOT Analysis & Assessment (top-right) Journey Mapping (right) Plan Preference & Plan Access (bottom-right) Member Outreach, Communication (bottom-left) Stratification, Co-Enrollment, Gap Support, Provider Support (left) Measure Strategies, Digital Readiness, Analytics (top-left) The visual implies a systematic and continuous approach to improvement, integrating these steps for enhancing operational or business strategies.

Why is a high Star rating important for a health plan?

This image shows a rating table with three columns: Numeric, Graphic, and Description. It uses a star system to visually represent performance or quality levels, with the following details:

The Centers for Medicare & Medicaid Services (CMS) publishes the Medicare Advantage (Medicare Part C) and Medicare Part D Star ratings each year to measure the quality of health and drug services received by consumers enrolled in Medicare Advantage (MA) and Prescription Drug Plans (PDPs or Part D plans). Star ratings impact a managed care plan’s financial performance, competitiveness, growth, and member retention. They are based on measures of multiple aspects of plan performance including:

Member experience and satisfaction

Administrative performance

Medication safety and/or adherence

Hospital readmissions

Healthcare Effectiveness Data and Information Set (HEDIS) and Health Outcomes Survey (HOS), both of which measure performance improvement.

Contracts are rated on a scale of one to five stars (rounded to nearest half star) based on approximately 45 measures related to preventive care, member experience (health plan customer service, physician point of service care, and perceived health), prescription drug monitoring, health plan operations, etc.

The industry has meaningfully improved traditional quality metrics (e.g. preventative care and medication adherence rates). As performance peaks in those measures, CMS is placing increasing emphasis on the member experience with their health plan and their providers during care.

Plans with 5 stars can market year-round.

The marketing advantage is a distinction for a high rated plan.

Poor performers (under 3 Star rating for 3 years) receive a Poor Performance Icon and may not be able to renew with CMS.

In 2024 there were 29 Part C (Medicare Parts A & B) and 11 Part D (Pharmacy) measures, and they can change every year. CMS recently released plan preview Star performance data for health plans to review. Final scores and Star ratings will be released by CMS in early October 2024 for Star Year 2025 based upon 2023 dates of service.

Star Rating High Level Timeline

CMS Star Ratings are a lagged pay-for-performance system. For 2026 Star Ratings, 2024 and early 2025 performance timeframes are critical to success, even though payments for this performance will not be received until 2027.

This image shows a high-level timeline for CMS Star Ratings from 2024 to 2027. It highlights key milestones and includes the following steps: 2024 / 2025: Performance; 2025: Data Collection; 2026: Star Ratings (Published October 2025); 2027: MA/MAPD Payments (Star Ratings used in bids filed in June 2026).

What plans do in 2024 and 2025 impacts your 2026 Star rating which will affect your plan’s revenues in 2027.

Is your plan building a strategy for next year based upon underperforming measures?  Are you looking for ways to lean in on any remaining Consumer Assessment of Healthcare Providers and Systems (CAHPS) and HOS opportunities? Do you know where to start?

See our HMA Solutions page, Star Rating: We Can Help You Navigate to a Higher Level, for more information.

Contact our experts below for more information about HMA’s Stars Accelerator Solution.

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Amy Bassano

Managing Director, Medicare

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Caprice Knapp

Managing Director, Quality and Accreditation

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Tom Lutzow

Principal

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Daniela Simpson

Senior Consultant II

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Mary Walter

Principal

HMA News

New experts join HMA in second quarter of 2024

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HMA is pleased to welcome new experts to our family of companies in the second quarter of 2024. This group of leaders has decades of experience in health policy, Medicaid, public health, and healthcare strategy. They have led initiatives to enhance access, operational efficiency, and equity and have expertise in areas such as behavioral health, data analysis, and serving underserved populations.

Learn more about our new HMA colleagues

APRIL

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Maria Balderas

Associate Principal

Thomas Curry

Vice President of Finance

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Farah Hanley

Managing Principal

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Marilyn Johnson

Senior Consultant

Ryan O’Connor

Associate Principal

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Neil Rolland

Principal

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Denise Valder

Principal

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Geneva Vogelheim

Senior Consultant

Anya Wallack

Principal

MAY

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Warren J. Brodine

Principal

Headshot of Jenn Forster

Jennifer Forster

Senior Consultant

Headshot of Marilyn Johnson

Marilyn Johnson

Senior Consultant

Kate Lerner

Associate Principal

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Chris Senz

Managing Principal

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Alex Smith

Senior Consultant

JUNE

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Loren Anthes

Principal

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Jeff Booth

Principal

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Tricia Christensen

Senior Consultant

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Erin Dorrien

Principal

Headshot of Alicia Johnson

Alicia M. Johnson

Managing Principal

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Alex Smith

Senior Consultant

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Aany Tazmin-Ewing

Senior Consulting Actuary II

Blog

How states are shaping Medicaid managed care and marketplace participation

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This week, our In Focus section reviews state policies designed to increase insurer participation in Medicaid managed care and Marketplace programs. As states seek to address healthcare costs, affordability, and consumer experiences, they are exploring a range of initiatives—from the rise of prescription drug affordability boards to cost containment commissions, cost growth benchmarks, transparency, and examination of mergers and acquisitions.  

A notable trend is the use of state policy and purchasing power to encourage or mandate that Medicaid managed care organizations (MCOs) offer Marketplace plans. Dual-market participation can help smooth coverage transitions, ensure continuity of care, and expand consumer choice. The remainder of this article addresses original research and analysis of this trend by our Health Management Associates, Inc. (HMA), featured experts.

Current Landscape  

In 2024, enrollment in the Marketplace program has surged to more than 21 million, approximately a 30 percent increase from 2023. This growth was largely attributed to the temporary enhanced subsidies that allowed more people to access affordable coverage. Over the past several regulatory cycles, federal policymakers also have taken steps to further align the Marketplace framework with Medicaid on key issues, such as essential community provider access, eligibility and enrollment processes, and plan design standards. In response, states are innovating to meet federal requirements while pursuing their own healthcare goals related to coverage, affordability, access, and healthcare outcomes.  

Value Proposition  

A compelling value proposition for Medicaid MCOs to participate in the Marketplace (and vice versa) includes the ability to market to and retain people moving from one program to another as life circumstances change. Dual-market participation also supports diversification and growth strategies. In fact, enrollment in the Marketplace has nearly doubled since 2020. For Medicaid MCOs in particular, expanding product offerings to include Marketplace plans presents a unique opportunity to leverage existing provider networks and reimbursement arrangements to deliver more competitive rates. 

Consumers benefit when the same organization participates in both markets. Families with parents and children who obtain coverage under different programs have an opportunity to work with a single organization and choose providers from the same or overlapping networks. Income fluctuations may result in disenrollment from one program (e.g., Medicaid) and eligibility for a new program (e.g., Marketplace subsidies). Continuity of care policies can smooth these transitions in areas such as prior authorization, care management, and provider network.  

State Strategies to Increase Dual-Market Participation 

The Affordable Care Act expanded access to affordable health insurance coverage for as many as 45 million individuals by giving states the option to expand Medicaid and provide federal subsidies to people who purchase Marketplace plans. States are now using various strategies to encourage or require insurer participation in both programs to ease transitions for individuals and families “churning” from one program to another, increase competition and choice of Marketplace plans, and reduce the risk of coverage gaps. For example:  

  • Nevada is requiring any bidder that plans to respond to its upcoming Medicaid MCO procurement to separately submit a “good faith” response to the Battle Born State Plans (BBSP) RFP. This state-contracted, public option will be available on the Silver State Health Insurance Exchange beginning in 2026. Failure to submit a good faith proposal will disqualify an organization from participating in the Medicaid MCO procurement later this fall. Nevada’s current Medicaid MCOs must participate in the Marketplace by offering at least one Silver and one Gold qualified health plan (QHP) that has overlapping provider networks, serves the same service area, and charges reasonable premiums. 
  • Rhode Island and New Mexico require or intend to require that their Medicaid MCOs participate in the Marketplace. As an awardee of Rhode Island’s recent Medicaid MCO procurement, UnitedHealthcare, must reenter the HealthSource Rhode Island market in 2027. These states also have designed their Medicaid MCO auto-assignment methodology to favor enrollment in a Medicaid MCO affiliated with an individual’s previous Marketplace plan or a family member’s Marketplace plan.  
  • In its last Medicaid MCO procurement (2018), North Carolina offered bonus points to any bidder that agrees to offer a Marketplace MCO. The resulting contract codified the market entry commitment and included implications for failure to follow through. Nonfulfillment could result in the highest level of contract noncompliance and associated penalties. 
  • Arkansas expanded its Medicaid program using federal matching funds to purchase QHP coverage through the Marketplace. Minnesota, one of the few states offering a basic health program, contracts with the same organizations to provide coverage under both programs.  
  • Iowa uses contract language to encourage, but not require, Medicaid MCOs to participate in the Marketplace to facilitate continuity of care during coverage transitions. 

The Centers for Medicaid & Medicare Services (CMS) collaborated with states to promote continuity of coverage following the end of the Medicaid continuous enrollment requirement established in the Families First Coronavirus Response Act of 2020, also known as the Medicaid public health emergency (PHE) unwinding. This support includes the clarification of permissible outreach activities by Medicaid MCOs that also offer a Marketplace plan, information sharing, and other assistance. Many states have incorporated the CMS guidanceiii into Medicaid MCO contracts. North Carolina, Utah, and West Virginia include additional contract terms supporting their Medicaid MCOs’ ability to co-market Medicaid and Marketplace plans, including when an individual is losing Medicaid eligibility.  

What to Watch For 

Coverage transition challenges throughout the Medicaid PHE unwinding have highlighted the real-life impact of coverage gaps and the importance of policies and practices that promote uninterrupted access to healthcare coverage. Historic Marketplace enrollment levels and recent CMS guidance clarifying the allowability of outreach to people who are losing Medicaid coverage about Marketplace plan available make the prospect of dual-market participation increasingly attractive for Medicaid MCOs. A greater focus on improving continuity of care and Marketplace plan choice may lead to more states encouraging or requiring Medicaid MCOs to participate in the Marketplace.  

Connect with Us  

The upcoming HMA event, Unlocking Solutions in Medicaid, Medicare, and Marketplace, will offer more opportunities to engage with leaders from various sectors who are advancing innovations in Medicaid managed care and Marketplace programs and the points at which these programs intersect. State Medicaid and insurance commissioners, health plan executives, and community leaders, among others, will share insights into their market success and initiatives designed to address healthcare costs and insurance affordability.  

Experts from HMA and our family of companies have extensive experience in the policy, structure, and administration of healthcare markets and health plan contracting. For more information, contact our featured experts below.

Solutions

HMA fosters harm reduction from street to suite

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HMA’s trusted experts have a wealth of harm reduction experience, from training volunteers for community outreach to managing state procurement processes for harm reduction tools, to policy analyses at all levels of government.

Our consultants have worked with stakeholders of all walks of life including people with lived and living experience of drug use, sex work, and homelessness. In fact, we believe in talking to them first to understand local needs and feasible solutions.

What is harm reduction?

The term “harm reduction” is often used to describe:

provision of risk reduction tools, like condoms, naloxone, and sterile syringes;

approach of meeting people where they are and supporting them at their own pace, without judgement, to pursue self-determined goals; and,

philosophy that promotes equitable access to resources for people who use drugs and struggle to meet basic needs due to the impact of social structures.

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines harm reduction as a practical and transformative approach that incorporates community-driven public health strategies — including prevention, risk reduction, and health promotion — to empower people who use drugs and their families with the choice to live healthier, self-directed, and purpose-filled lives. 

The President’s National Drug Control Strategy is the first-ever to champion harm reduction to meet people where they are and engage them in care and services.

People are dying from drug overdose at an alarming rate in the U.S. For the fourth year in a row, we have lost over 100,000 people (enough to fill the University of Michigan stadium). Many of these deaths are preventable. Harm reduction interventions proven to stop overdose deaths include making the overdose reversal drug naloxone available to all at risk of overdose, reducing barriers to medications that treat opioid use disorder, and providing supervised drug consumption services for rapid overdose response. Moreover, successful harm reduction programs rely on reducing the stigma of drug use and people who have an addiction.

How HMA can help

Harm reduction is more than handing out naloxone or syringes; it’s a nonjudgemental approach that affirms participant autonomy and engages people in care over the long term.

Here are just a few services HMA can offer to help clients establish, expand, or improve services for people who use drugs, respond to overdose and infectious disease syndemics (combinations of two or more diseases or health conditions that interact within a population, often due to social and structural factors and inequities), and prevent the next drug crisis.

HMA provides training and technical assistance to a range of clients – from community-based organizations conducting outreach, to medical providers wishing to better serve their patients, to large hospital systems wishing to incorporate drug user health into their systems. HMA can:

  • Plan, coordinate and evaluate learning collaboratives.
  • Provide 1-1 coaching to staff and teams.
  • Produce and implement industry-specific toolkits aimed at reducing overdose, like for construction businesses, restaurants or harm reduction vending machines.
  • Train different audiences and teams, including youth treatment providers, primary care settings, and carceral settings, on harm reduction.
  • Support startup of new naloxone distribution and/or syringe services programs and develop capacity building plans for program growth.
  • Improve access to medications for opioid use disorder.

A quality improvement (QI) strategy is vital for healthcare organizations to maximize patient outcomes and satisfaction, achieve efficiency, and ensure compliance with regulations. HMA can:

  • Apply established QI models to increase reach of harm reduction and drug user health services within community-based programs, government agencies, and provider programs and systems.
  • Plan, assess, and evaluate QI efforts.
  • Increase team buy-in for harm reduction as a QI initiative.
  • Provide QI tools such as rapid assessment participant surveys, risk screeners, provider checklists, and guides.

Many funding opportunities require (or can benefit from) a detailed assessment of the community’s need for the services being funded. Our experts can help gather both quantitative data and qualitative stakeholder input to ensure that the client’s proposed plan targets the populations, communities, and gaps in service for which resources will be most impactful. HMA can:

  • Conduct interviews and focus groups with people who use drugs and the service providers they interact with to identify local needs and solutions.
  • Assess and predict drug user health syndemics using infectious disease and overdose metrics.
  • Demonstrate trends among diverse populations, including youth and racial, ethnic, sexual, and gender minorities .
  • Guide efforts to integrate harm reduction into a broader continuum of care, including prevention and treatment interventions.

The legal landscape related to drug use varies across communities and does not always facilitate a public health approach. HMA can:

  • Identify policy options and facilitate choice of the most effective and feasible one for the client’s local context.
  • Evaluate new or existing policies that impact people who use drugs such as Good Samaritan laws, opioid treatment program regulations, and criminal charges.
  • Apply statistical methods to policy evaluation such as time-interrupted analysis.

Multi-sector collaboration is essential to develop sustainable, impactful solutions to reduce physical and structural harms related to drug use. HMA can:

  • Facilitate workgroup-driven policy recommendations for expansion of behavioral health treatment and overdose prevention approaches such as safer supply.
  • Design social media campaigns that center the voices of people most impacted by overdose.
  • Strategize, create, and plan marketing and communications campaigns for harm reduction, stigma reduction, or program promotion.
  • Facilitate community mobilization efforts and multi-sector alliances to generate and implement strategies for policy change.
  • Build harm reduction resource libraries for stakeholder use.

HMA consultants work with clients to review program efficacy and cost efficiency based on process, outcomes, costs and more, considering quantitative and qualitative data sources and using data-driven tools to assess and measure impact. HMA can:

  • Conduct environmental scans of jurisdictional resources to highlight opportunities for and threats to harm reduction programs .
  • Build maps that overlay various metrics of drug user health, including infectious disease burden, overdose, and socio-economic indicators.
  • Map overdose fatality and naloxone saturation to prioritize distribution efforts in areas of high-need.
  • Conduct regression analysis to identify risk profiles and predictive values to evaluate impact.

Project Spotlight

COMPASSIONATE OVERDOSE RESPONSE SUMMIT
WASHINGTON STATE SAFER SUPPLY WORKGROUP

Contact our experts:

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Anika Alvanzo

Principal

Dr. Anika Alvanzo is a distinguished healthcare executive with over 20 years of experience in specialty addiction treatment, behavioral health … Read more
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Jennifer Bridgeforth

Associate Principal

Jennifer Bridgeforth is a dedicated executive with more than 17 years of experience in the healthcare industry. She is a … Read more
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Ana Bueno

Senior Consultant

Ana Paola Bueno is an accomplished nonprofit professional with more than 16 years of senior level experience in the state … Read more
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Mayur Chandriani

Senior Consultant

An experienced non-profit manager, Mayur Chandriani is committed to programs focused on immigrant healthcare, maternal and child health and community … Read more
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Tricia Christensen

Senior Consultant

Tricia Christensen is a harm reduction and drug policy expert focused on high impact relationship building and policy change to … Read more
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Liddy Garcia-Bunuel

Principal

Liddy Garcia-Buñuel has the vision, passion and expertise to effect organizational and systematic change. She takes a collaborative approach. She … Read more
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Rachel LaFlame

Research Associate

Rachel LaFlame, MPH, is a driven, early career professional interested in the intersection of public health and policy. She is … Read more
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Nicole Lovitch

Research Associate

Nicole Lovitch is a skilled generalist researcher with extensive public health and healthcare experience. She has worked with clinicians, providers, … Read more
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Trish Marsik

Principal

Trish Marsik has extensive experience supporting providers, healthcare organizations, and state and federal governments to provide quality behavioral healthcare.  Prior … Read more
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John O’Connor

Managing Director

John O’Connor is a seasoned executive with extensive management, program, strategy, media, fundraising and advocacy experience in dynamic foundation, corporate … Read more
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Charles Robbins

Principal

Charles Robbins has been transforming communities for the past three decades. His extensive community-based organization career spans healthcare, child welfare, … Read more
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Deborah Rose

Associate Principal

Deborah Rose is an experienced executive with a demonstrated history of designing and scaling new initiatives in the healthcare industry. … Read more
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Erin Russell

Principal

Erin Russell is a dedicated harm reduction expert with an unwavering commitment to public health and equity.   Prior to joining … Read more
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Kate Washburn

Associate Principal

Kate Washburn is a public health and program leader with over 20 years of experience in both public health departments … Read more
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Chris Wilks

Senior Consultant

Chris Wilks is a senior consultant for HMA. She manages long-term research projects and works closely with clients and project … Read more
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Emily Wilson

Associate Principal

A multi-disciplinary public health leader, Emily Wilson is passionate about bringing people together to solve the most pressing problems in … Read more
Blog

Harnessing opioid abatement funds to prevent overdoses and enhance community care

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This week, our In Focus section recognizes International Overdose Awareness Day (IOAD), August 31, by highlighting how states can use opioid abatement funds to mitigate the persistent overdose crisis in communities across the country.  

In honor of IOAD, the August 2024 edition of HMA’s Podcast, Vital Viewpoints, features Erin Russell, a Principal at Health Management Associates (HMA), who discusses the importance of emphasizing harm reduction as a compassionate approach to drug policy. Meanwhile, this article addresses current gaps, opportunities, and strategies for applying opioid abatement funds to make further progress in addressing overdoses and the crisis.  

Context for Opioid Abatement  

Overdoses have claimed more than one million lives since the late 1990s, with more than 100,000 deaths occurring annually. Exacerbating the overdose epidemic and the racial and ethnic disparities in fatal overdoses are persistent inequities in access to evidence-based treatment, which extend to biases based on physical and/or mental ability, sexual orientation and gender identity, geographic location, and socioeconomic and housing status. 

In 2021, nationwide settlements were awarded to resolve all opioid litigation that states and local subdivisions brought against pharmaceutical distributors and manufacturers, with subsequent agreements reached in 2022 against pharmacy chains and additional manufacturers. These historic opioid settlement agreements, which total more than $56 billion, will provide funds to state and local governments to address the crisis in their communities.  

Policy changes and investments to address this epidemic remain critical. These approaches require careful consideration of the data and evidence-based strategies that are responsive to the crisis. In 2024, the US Department of Health and Human Services issued a rule that updates the regulations regarding the governance of opioid treatment programs; for example, removing barriers to the treatment of substance use disorder (SUD) and expanding access to care. The State Opioid Response and Tribal Opioid Response grant programs are another significant tool to improve prevention, expand treatment, and deliver free, lifesaving medications. Medicaid, including Medicaid managed care plans, also can be instrumental in supporting harm reduction strategies and enhancing access to addiction treatment and recovery support.  

Opioid abatement funds offer states the opportunity to apply innovative solutions in response to the overdose epidemic. Despite their potential, however, HMA experts have identified significant opportunities across many states to effectively use available opioid abatement funds. 

Opioid Abatement Funds and planning for Community Needs  

Strategic planning processes allow state and community leaders to understand the needs of residents, examine current services offered and their existing strengths, and explore barriers to accessing care to make informed decisions about how the settlement funding can be used successfully. A strategic plan can assist in tracking progress and establishing a clear vision for an organization’s future and can yield a living document that guides the most advantageous use of the funds. HMA experts supported a strategic planning process for Carrabus County, NC, that identified strategies for designing, implementing, and evaluating tailored solutions for disbursing opioid abatement funds. The following are examples of approaches that are included in strategic plans for opioid abatement.  

Sequential intercept model (SIM). SIM, one of the models used to support communities in building a stronger system of care, helps identify intervention opportunities with the highest potential for success based on a community’s strengths and needs. SIM maps out the stages of intervention to pinpoint gaps and opportunities, ensuring funding is used to address the most critical areas for improving community care systems, including those integrated within Medicaid managed care delivery systems (see Figure 1).  

Figure 1: Sequential Intercept Model 

Low-barrier/low-threshold recovery supports and treatment. The expansion of low-barrier/low-threshold recovery supports and treatment, including access to medications for opioid use disorder, is essential to reducing overdose deaths. States, local jurisdictions, and individual providers can redesign their treatment delivery systems to incorporate person-centered, low-barrier treatment access, including flexible scheduling and walk-in visits, same-day admission and medication initiation, and revision of clinic policies and procedures to eradicate practices that produce high barriers to treatment.  

Though expanding low-barrier care in traditional treatment settings is an essential element of the response, implementation of nontraditional delivery modalities is another important target for using opioid abatement funds. Examples include:  

  • Emergency medical service (EMS)-initiated buprenorphine 
  • Medication units in unconventional locations (e.g., housing units) 
  • Mobile medication units and delivery of street/shelter medicine in which SUD treatment and services are brought to disenfranchised and marginalized communities. 

Finally, the availability of opioid abatement funds can introduce opportunities for local governments to partner with community members, including people with both past and current lived experience, to design, implement, and disseminate culturally responsive and tailored SUD treatment and recovery support services, including services to address health-related social needs to mitigate barriers to treatment entry and engagement.  

Continuous quality improvement (CQI) plans. Locales that receive opioid abatement funds have the opportunity to develop strategies to create transformational systemic change. Each entity should have an intentional CQI plan in place. Ensuring the presence of strong CQI processes can streamline and improve services, connect data to practice, and ensure interventions are progressively more effective.  

Connect with Us 

The upcoming HMA event, Unlocking Solutions in Medicaid, Medicare, and Marketplace, will offer more opportunities to engage with leaders across multiple sectors and industries advancing innovations in the design of mental health and SUD systems, value-based purchasing, and care strategies. Notably, state Medicaid and behavioral health directors, insurance commissioners, health plan executives, and community leaders, among others, will share insights into major initiatives under way in their states to manage ongoing crises in mental health and SUDs.  

HMA has a strong, diverse bench to help communities maximize opioid abatement funds and build a stronger system of care. We provide technical assistance in large-scale initiative implementation, convening stakeholder groups, designing CQI strategies, developing planning documents, and facilitating strategic discussions. For more information about HMA’s work, contact our featured behavioral health experts below.

Blog

HMA believes “together we can” end the overdose crisis on IOAD

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On International Overdose Awareness Day (IOAD), August 31st, communities worldwide come together to honor, without stigma, the people who have lost their lives to overdose. It’s a day for families to recognize their loved ones and for all of us to acknowledge the grief of family and friends who have experienced this loss. It’s also an opportunity to think critically about the programs and policies our communities need to finally put an end to the overdose crisis. In honor of this year’s IOAD theme, “Together we can,” HMA recognizes the power of community when we all stand together with a united goal of ending overdose.

Overdose can affect anyone. In the last twelve months alone, there were more than 100,000 reported overdose deaths across the U.S., and 42 percent of Americans now report they know someone who has died of drug overdose. More than ever, we need strong, multifaceted coalitions to shift the narrative around overdose and ensure we are using resources effectively to reduce harm, increase chances of overdose survival, and promote quality of life for people who use drugs, people in recovery, and the communities where they live.

HMA brings together people with lived and living experience, local community members, and public health professionals to plan, evaluate, and implement meaningful programs across the continuum of care to address overdose as the health crisis that it is. Our trusted subject matter experts have their own lived experience that influences HMA’s approach, and we strive to center the voices of people who are most impacted at every opportunity.

HMA is committed to helping clients prioritize effective solutions to the overdose crisis, which includes promoting services that are evidence-based and designed with robust input from community stakeholders. HMA supports naloxone distribution by engaging in street-based outreach, developing mapping tools for organizations to see the impact of their efforts in real time, and training healthcare providers on harm reduction. In 2024, HMA also hosted the Compassionate Overdose Response Summit to address questions about naloxone dosing and the long-term effects of precipitated withdrawal. HMA continues to be a leader in helping clients revolutionize treatment, particularly for priority populations such as children’s behavioral health and the justice involved. Earlier this year HMA led a webinar series called the Substance Use Disorder (SUD) Ecosystem of Care Webinar Series: Pivoting to Save Lives describing a whole person, integrated, solutions-based approach to the ongoing overdose epidemic. The series encourages leaders to reconsider standard attempts to solve this crisis and be willing to pivot away from approaches that have not yielded the level of impact that this crisis demands.

On IOAD, and every day, HMA stands united with the communities that are left behind to experience the long-lasting impacts of grief, and we celebrate the thousands of people who have experienced overdose and survived. Every overdose survival is another opportunity to uplift the strategies that work to save lives. We honor everyone impacted by overdose by using a community-led approach that encourages collective action to prevent, and ultimately end, all overdoses.

For more information on HMA overdose prevention services, visit our Harm Reduction solutions page or contact our featured experts below.

Podcasts

How Is Harm Reduction Redefining Recovery in Modern Treatment Approaches?

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Erin Russell is a principal at Health Management Associates and joins our podcast to discuss the importance emphasizing harm reduction as a compassionate approach to drug policy. She shares her journey from volunteering at a syringe service program to becoming deeply invested in harm reduction, highlighting how these programs offer critical support and connections to treatment and reduce overdose deaths. Erin also explores the impact of drug policy on drug-related harms, advocating for the need to overcome stigmas that impede treatment.

This podcast is being released the same week as International Overdose Awareness Day (IOAD), which is observed on Saturday, August 30th. In honor of this important day, check out HMA’s special blog post highlighting the importance of harm reduction efforts in connection with IOAD at this link.

#TogetherWeCan #IOAD2024 #EndOverdose