[{"_1":2,"_100":-5,"_101":-5},"loaderData",{"_3":4,"_26":27},"root",{"_5":6,"_17":10,"_18":19,"_20":21,"_22":10,"_23":-5,"_24":-5,"_25":10},"user",{"_7":8,"_9":10,"_11":10,"_12":-5,"_13":-5,"_14":15,"_16":-5},"roles",[],"isAuthenticated",false,"isPremium","planName","subscriptionStatus","featureFlags",{},"insightsBudget","isDevelopmentHost","userPreferences",{},"recaptchaSiteKey","6LcvOJcUAAAAAHsB-gPGfGktcRlKpH7OTIU_dMTD","isImpersonating","impersonation","affiliateStatus","isFreedomPortal","routes/v2/article/layout",{"_28":29,"_30":31},"notFound",true,"relatedArticles",[32,76,88],{"_33":34,"_35":36,"_37":38,"_39":40,"_41":42,"_43":44,"_45":46,"_47":48,"_49":50,"_51":52,"_53":54,"_55":56,"_57":58,"_59":60,"_61":62,"_63":64,"_65":66,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},"mediaId",6370289,"mediaKeyId","2151871-f07751e501c2b303d1a58640e2ef4881","parentId",2151871,"title","Officials flag rising specialty drug costs, rebates and accelerated‑approval risks in Medicaid pharmacy briefing","audioSeconds",2753,"startMs",3419000,"endMs",6172000,"viewUrl","/Search/View?dp=1&key=2151871-f07751e501c2b303d1a58640e2ef4881&start=3419&end=6172","thumbnailUrl","https://assets.pipeline.soar.com/2151871-f07751e501c2b303d1a58640e2ef4881/thumbnail_3419000.jpg","articleUrl","/articles/6370289/North-Dakota/Officials-flag-rising-specialty-drug-costs-rebates-and-acceleratedapproval-risks-in-Medicaid-pharmacy-briefing","mediaUrl","https://secure.pipeline.soar.com/6370289-9980b8f5d3cc468b5ebb3ee1b63b8e24/orig.mp4?Expires=1771163465&Signature=bE2o23EvTcGDRdZ1UBlltuVh5QeLXC5bH0oFcBryGFxyZVwQNaz5SsW16vksM0G9myhvlwB68ZXoP9h7dXXkOXN384qL5fpJIZbgoEEwQIcM-m~yLaGJmWMhq0hPiXNXANEzhUILvmgGRQncvHQ~iPex5QLjl5XiGymEdrY4cPjFLl1uvvFyFi1ZVs~7unlwapwBwsmc2CDvHtFueIQgIMrVx4pbRm8H1ihjhthMkZI5uvajLZbkBirGWjKMepsfSXd15VfdfIOWx~3-ZpdaUMFVGMNIRxaTEe7hx4Gk1FNq70~zkOG4zXkolHN6yRM1BU4WhzoiPC9Zxl0~vQ1B6g__&Key-Pair-Id=KUT5TJCACFTXG","author","House Appropriations - Human Resources Division, ND","date","2025-01-24T00:00:00Z","article","Brendan Joyce, clinical and pharmacy services director for Medicaid, told the Appropriations Human Resources Division that specialty and high‑cost drugs now dominate pharmacy spend and that rebates are central to managing net costs.

Joyce described several trends: a small number of drug classes and products account for a large portion of pre‑rebate spending (for example, six drug classes—cystic fibrosis, immunomodulators, migraine, non‑insulin diabetes medications, pulmonary hypertension, and tardive dyskinesia—produced a 138% increase in spend between Q1 2020 and Q3 2024 while claims volume rose only 14% for those classes). He also reported that 50 “hyper‑cost” drugs represent roughly a third of the drug budget and that a growing pipeline of cell‑ and gene‑therapy treatments includes several products with list prices in the millions.

Joyce emphasized the role of rebates: North Dakota invoiced just over $4,000,000 in supplemental drug rebates in a single quarter (Q3 2024), and the department has collected about $811,000,000 in total drug rebates since 1991. He showed that post‑rebate net spend has grown much more slowly than pre‑rebate payments and said the supplemental rebate program (begun in 2015 for the state) is a material offset to gross spending.

The session included a review of congressional and federal rule changes that have altered rebate mechanics. Joyce told the committee that removal of an AMP cap and changes to the unit rebate offset amount (UROA) reduced the department’s effective rebates for some products and contributed to recent net spend increases in several classes.

Joyce also described clinical and program‑integrity challenges: drug shortages force switches to higher‑cost alternatives; accelerated‑approval products (drugs approved on surrogate endpoints pending confirmatory trials) carry risk—some approvals were later withdrawn or had delayed confirmatory evidence—and Medicaid can continue to pay while confirmatory trials remain pending.

The committee reviewed a pending bill, House Bill 1451, that would require Medicaid coverage for anti‑obesity medications. Joyce said the bill’s fiscal note (when posted) indicated a roughly $4.4 million per‑year net increase—about a 10% rise in the drug budget—if broader GLP‑1 coverage similar to other states were adopted. He and other lawmakers noted early evidence on those drugs’ clinical effects but also described high drop‑off rates and the time required for any medical‑cost offsets to appear.

Ending: Joyce told the committee the department pursues supplemental rebates, value‑based agreements where feasible, utilization management and prior‑authorization rules for high‑cost products, and ongoing work to track shortages and the impacts of federal rebate rules. He said staff will continue to provide data to the committee on fiscal notes and specific drug classes where possible.","mediaType","Video","parentTitle","House Appropriations - Human Resources Division Jan 24, 2025","oneSentenceSummary","Brendan Joyce, clinical and pharmacy services director for Medicaid, told the committee a small number of high‑cost drugs now account for a large share of prescription spending and that supplemental and mandatory rebates are critical to keeping net pharmacy costs manageable.","taxTitle","Appropriations - Human Resources Division, House of Representatives, Legislative, North Dakota","taxId",28888,"location","North Dakota","headline","","shortSummary",{"_33":77,"_35":36,"_37":38,"_39":78,"_41":79,"_43":80,"_45":81,"_47":82,"_49":83,"_51":84,"_53":85,"_55":56,"_57":58,"_59":86,"_61":62,"_63":64,"_65":87,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6370293,"Lawmakers hear low performance on children's dental access; rebasing not in governor’s budget",671,1391000,2062000,"/Search/View?dp=1&key=2151871-f07751e501c2b303d1a58640e2ef4881&start=1391&end=2062","https://assets.pipeline.soar.com/2151871-f07751e501c2b303d1a58640e2ef4881/thumbnail_1391000.jpg","/articles/6370293/North-Dakota/Lawmakers-hear-low-performance-on-childrens-dental-access-rebasing-not-in-governors-budget","https://secure.pipeline.soar.com/6370293-c3a91b82a7b7f5508142826b44f19382/orig.mp4?Expires=1771163465&Signature=N7SAUiCfesrT7ytj5PyyVnz5~c86slWayDYt~weR6kocI4fFRTYPhaOEaa92Yhvm~~tomkssnezgOertom5PjKmykYgrj879ajBBwUnAhKuOGAnI948lKbxmXM2xII5fV4f9-6G8ZGClQqqRQM7O2J2DPiPhyfF10M4patb8xummo300mJxLnauu-fK9y09~~rv0csbuYkqGdtdJmhsrU7c5nw8GccvHTJP0BdEIc5dTa11RxbPrChLKY-xImvcT8ybCdvH-p~rHy7Ce83Mm2uSTM0be~yhjxzpFh5lpPymzc8Y~EZIF4y5oH5W-GSLOHk6t3d7~Y86E26Ao4hjMjg__&Key-Pair-Id=KUT5TJCACFTXG","During an Appropriations Human Resources Division presentation, Sarah Acre said North Dakota Medicaid dental rates were last rebased in 2009 and have risen roughly 42% since that rebasing, but the state ranks 47th nationally on a child oral-evaluation performance measure.

Acre displayed a side‑by‑side chart showing performance on the periodic oral evaluation measure (children under 21 who received an evaluation) and the reimbursement rate for that single service. She told the committee that North Dakota was third in the region for reimbursement but 47th in the nation for performance on that measure and said: “I think it’s something that’s worth looking into further and certainly something that me and my staff spend a lot of time on.”

Lawmakers and staff discussed access barriers. Committee members raised common explanations—dentists declining Medicaid patients because of administrative burden and missed appointments—and Acre described steps the department has taken: convening a dental work group, surveying licensed dentists about program hurdles, and reducing administrative barriers where federal rules permit. She said some enrollment and federal requirements (for example, certain provider enrollment steps) cannot be waived because they are federally mandated, but the state has used outreach and operational changes to try to make participation easier.

Two bills related to dental were cited on the record. Acre identified House Bill 1567 as requiring a study of dental and oral health care status for Medicaid members and workforce supports for low‑income children. She also identified Senate Bill 2231 (earlier mis‑stated on the record but corrected during testimony) as a bill that would add certain dental services for Medicaid expansion members; the department said the initial fiscal note draft addressed a select group of services and that a later note will show broader fiscal impacts if the sponsor’s intent is to extend full dental benefits to all expansion members.

The committee asked for follow‑up materials; Acre said staff would provide a list of administrative changes underway and noted a dental vendor project that compared no‑show rates between Medicaid and commercial patients, finding reminder practices (calls, texts, emails) had a strong effect on attendance.

Ending: The department stressed that a dental rebase was not included in the governor’s budget and recommended further study and operational remedies while the legislature considers bills that could expand covered services for expansion members.","Committee heard that North Dakota’s Medicaid dental rates were last rebased in 2009 and that the state ranks low on child dental access despite mid‑regional reimbursement; two bills were identified that would study dental access and add select dental coverage for Medicaid expansion members.",{"_33":89,"_35":36,"_37":38,"_39":90,"_41":91,"_43":92,"_45":93,"_47":94,"_49":95,"_51":96,"_53":97,"_55":56,"_57":58,"_59":98,"_61":62,"_63":64,"_65":99,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6370298,"Medicaid rates, capitation and budget drivers outlined as state weighs provider inflation and ambulance increase",1924,462000,2386000,"/Search/View?dp=1&key=2151871-f07751e501c2b303d1a58640e2ef4881&start=462&end=2386","https://assets.pipeline.soar.com/2151871-f07751e501c2b303d1a58640e2ef4881/thumbnail_462000.jpg","/articles/6370298/North-Dakota/Medicaid-rates-capitation-and-budget-drivers-outlined-as-state-weighs-provider-inflation-and-ambulance-increase","https://secure.pipeline.soar.com/6370298-f000e9b1dad7009697988470f1c075f5/orig.mp4?Expires=1771163465&Signature=TN1iWI4DNFvQ1Lm0ExFGuE-cDKbHL20l3Ypmi7UuKt7A7QZvwZ1ndgaQrk1knJZGXv4IAa3G2vxT5Sc05ZMcJ6IoqZME3OY2wcIglh1PBpKDgjomR1DsRAqUa5qfN2wF78Q9XQmmOJgtwO9KJDp~99L4fTMTdeQPNxgCJMLYyvA9IW566fp4KySpGnzBtwS6DpU9rwiAGTx0K4UPwAZLivfb-YUsU3GZxsEvl05wKvUHR~i5uova3xsD9rPeoYGvukg0xez4oA9-o6~oyDzHcdFRU8IZ85BBDVbVrmt3Nco6b00QItJc5tTE~deCaHSRjRVyJA0gVDfHfXuWEL4DeA__&Key-Pair-Id=KUT5TJCACFTXG","Sarah Acre, executive director of the Division of Medical Services at the North Dakota Department of Health and Human Services, told the Appropriations Human Resources Division that the governor’s executive budget includes a $16.2 million request to increase provider rates through inflation and a $4.3 million targeted increase for ambulance reimbursement.

Acre said traditional Medicaid still uses fee-for-service payment methods—cost-based per diems for nursing homes and per‑episode classification systems (DRGs and EAPGs) for hospitals—while Medicaid expansion is paid through a monthly capitation payment to a managed-care organization (MCO). “I am Sarah Acre. I’m the executive director of the division of medical services,” Acre said when introducing the presentation and then described the two distinct rate methodologies.

The nut of the discussion centered on how the state sets those payments and how the governor’s budget would change them. For professional services the state uses relative value units (RVUs) and a conversion factor; Acre noted North Dakota’s conversion factor in 2024 was 36.26 versus Medicare’s $33.29. The governor’s provider inflation request would apply a 1.5% increase in state fiscal year 2026 and another 1.5% in fiscal year 2027 to many fee‑schedule items.

On ambulance reimbursement, Acre said the targeted increase would raise statewide ambulance rates to the lowest Medicare rural quartile; the administration requested the $4.3 million to align Medicaid ambulance payments with that Medicare benchmark after providers reported sustainability concerns.

Medicaid expansion capitation and managed‑care safeguards drew sustained scrutiny. Acre said the state’s 2025 capitation rates were set with its actuary and Blue Cross Blue Shield of North Dakota; the blended per‑member‑per‑month capitation increased to $1,176.44 in 2025 from $1,006.44 in 2023. She also said the capitation rate development incorporated Senate Bill 2012 from the prior session, which the department interpreted as requiring an assumed ceiling so MCO provider rates would not exceed 145% of Medicare; North Dakota’s actuarial work showed aggregate MCO payments already at roughly 144.5% of Medicare, so no downward adjustment was applied for 2025.

Acre described the state’s shift in managed‑care risk controls: the state will not impose a profit cap in calendar year 2025 and instead will require a high medical‑loss‑ratio (MLR). As she stated, “we will require that 92.3% of our MLR be used again for those services and quality improvement.” The committee discussed how the prior approach combined a roughly 2% profit cap with a lower MLR; members and staff asked how those changes affect incentives for MCO innovation and the state’s exposure to market shifts.

Committee members raised questions about federal match and national policy risk. Representative Murphy asked what would happen if Congress reduced the Medicaid expansion federal match; members noted that a large federal change could force reevaluation of the expansion model and the state budget.

The presentation also outlined operational constraints that affect rate timing: Acre described the cost‑report to rate timeline (providers submit cost reports, the department has roughly 90 days to set rates for a January 1 rate year) and the need to finalize nursing‑home rates at least 30 days before a rate year to enable private‑pay notice.

Ending: Department staff told the committee they will provide additional comparative rate information on select services on request and will continue to monitor federal policy developments that could change match rates or capitation assumptions. The administration asked lawmakers to consider the requested provider inflation and targeted increases when reviewing the executive budget.","At an Appropriations Human Resources Division hearing, Medical Services Division leaders reviewed Medicaid rate methodologies, the governor's provider inflation request and proposed targeted rate increases for ambulance providers; officials also described 2025 capitation rates for Medicaid expansion and changes to managed-care safeguards.","actionData","errors"]

Article not found

Officials flag rising specialty drug costs, rebates and accelerated‑approval risks in Medicaid pharmacy briefing

Lawmakers hear low performance on children's dental access; rebasing not in governor’s budget

Medicaid rates, capitation and budget drivers outlined as state weighs provider inflation and ambulance increase