Good afternoon, My name is Kathryn Haines and I am the Health Equity Manager for the Virginia Interfaith Center for Public Policy. I attended your in person meeting in Farmville, VA last month and mentioned the results of a "Prenatal Secret Shopper Survey" recently released by DMAS. I wanted to share with you that on July 9th, the PUSH Coalition, which my organization leads, held a press conference to discuss the survey's results. DMAS, enlisted a contractor, Health Services Advisory Group to conduct an External Quality Review for contract year 2023. As part of this external quality review, secret shopper surveys were conducted to audit wait times and accessibility of prenatal care among MCO enrollees. According to the report, in 95 percent of overall cases (1,844 providers were surveyed) providers were unable to be reached, did not offer prenatal care services, were not at the sampled location, did not accept the requested MCO, did not accept VA Medicaid, were not accepting new patients, or were unable to offer an appointment date. More details are available here, https://www.vpm.org/news/2024-07-09/virginia-medicaid-secret-shopper-prenatal-care-mco-insurance). PUSH coalition members were not surprised by the contents of the secret shopper report. Most alarming are some of the racial disparities in rural areas. For example, according to State available data, in 2022, the West Piedmont Health District reported a maternal mortality rate of 591.72 per 100,000 for the Black, non-Hispanic population and zero for the White, non-Hispanic population in that same category. According to VDH data, Henry County, located within the West Piedmont Health District, had a Medicaid birth percentage of 72.5% in 2022. The percent of women with late or no prenatal care for the Black, non-Hispanic population in the West Piedmont Health district is 8.1%, which is more than 2 and ½ times the 2.9% percent of pregnant women with late or no prenatal care for the White non-Hispanic population in that District. The new MCO contract DMAS released in its request for proposals last fall has tremendous potential to address the access concerns highlighted by the prenatal secret shopper survey. The PUSH Coalition appreciates the emphasis in the new contract on community partners and the requirement for relevant cultural competency and bias training. The new contract will not fix everything. At the press conference, coalition members put forth five legislative priorities that will help increase access to prenatal care: 1. Unconscious Bias Training (bias training is required with the new MCO contract, should not be limited to MCOs), 2. Perinatal Health Hub Funding and Support, 3. Presumptive Eligibility for Pregnant Women, 4. Expanding Medicaid Benefits to increase Access: Community Health Workers and Continuous Eligibility and 5. Requiring Fetal and Infant Mortality Review Teams. We hope to work with legislators next year to advance these priorities. The PUSH Coalition's intent is not to attack MCOs. Our hope is that MCOs see this as an opportunity to advocate for much needed legislation, such as Medicaid rate increases, and an improved transportation benefit, that they need to improve access. In closing, I would like to share one of the articles from the press conference: https://virginiamercury.com/briefs/state-survey-shows-barriers-to-prenatal-care-access-for-medicaid-patients/. Sincerely, Kathryn Haines Kathryn@virginiainterfaithcenter.org

I would like to make note that I am disappointed that pharmacist are not included in the agenda about rural healthcare. There is one pharmacy closing everyday according to reports. The study we did last fall showed that on average MCOs paid an average of $1.09 above the cost of the medication. (That is after the increased dispensing fee for buprenorphine of $10.65. Pharmacies are turning medicaid patients away because they can’t afford to subsidize these MCOs any longer. Medicaid was supported to do a cost of dispensing study every 5 years and they have not only failed to do that, but we don’t get paid according to the study done in 2016 which was NADAC plus $10.65. There is going to be a patient access issue and it is going to be hard to reestablish this service

Rural pharmacies are closing at an incredibly alarming rate. Many of these pharmacies are the only healthcare access Virginians have in their community. There is a plan that will help save these pharmacies while also saving the state Medicaid program millions of dollars every year. Patients will have their healthcare access while Virginian money stay in our communities, AND it costs less than the current system. Restructuring pharmacy benefits in DMAS and setting a uniform reimbursement fee in Virginia is a no brainer that benefits all.

What would you do if your pharmacy closed its doors for good? Is there another pharmacy nearby that you could visit instead? If there is an alternative, what happens to the already long lines and wait times when your new pharmacy absorbs all the patients from the one that closed? Unfortunately, if we do nothing, these are the questions that Virginians will be faced with. This is particularly true for vulnerable populations, including minorities, older adults, individuals with disabilities, and those without access to a car. The lack of access to pharmacies creates serious health consequences for these groups, including interruptions in medication schedules and increased hospitalization. Across Virginia, we are losing one of our most accessible healthcare providers: pharmacists. Pharmacists serve a vital role in our communities. The importance of the pharmacists’ role has been amplified in the past four years largely due to the COVID pandemic, which saw the crucial role the profession had in ensuring hundreds of thousands of Virginians were able to get lifesaving vaccinations as quickly as possible. But pharmacists do much more than just dispense prescriptions and administer vaccines; they also provided management of patients with chronic diseases (such as diabetes, high blood pressure, use of blood thinners), tobacco cessation use and monitoring, opioid de-escalation and comprehensive medication management. Pharmacists are best positioned to be health care professionals ensuring patients are adherent to medications and providing patient care that ensures optimal medication therapy outcomes. Pharmacists are readily accessible and are available for extended hours and on weekends, allowing them to more quickly initiate and modify therapy for patients. In fact, they are the only healthcare provider you can speak to without an appointment by simply walking into your local pharmacy. There is a nationwide shortage of primary care doctors, and this directly impacts the ability to get care in Virginia. Pharmacists have and continue to step up to address this gap. With the expansion of pharmacist’ scope of practice in Virginia in recent years, the role of pharmacists have become even more vital to community health. However unfortunately, many independent pharmacies are having to shutter, creating “pharmacy deserts” in areas of Virginia which directly affects patient access and safety to needed medications. Most commercial pharmacies in Virginia are concentrated in three major urban areas – Northern Virginia, Central Virginia and Hampton Roads. As a result, these pharmacy deserts tend to be in the more rural areas of the state, particularly in the western and southern parts of the Commonwealth. As of 2023, five counties in Virginia had no pharmacy, and 15 had only one. Mail order prescriptions are not a good substitute when many patients need a more personal approach and help in understanding their prescriptions, reading the instructions, or asking basic questions regarding the drug. Pharmacists want to help provide service and support to all of those in their area, but resources and the changing climate with insurance and PBMs makes it difficult for them to do so. We would highly encourage members of this committee to go by and visit local pharmacies in your district to get a better understanding of the issues facing the profession and thus impacting the healthcare of Virginians. Thank you for your time and consideration today.

Del Willett, Del Orrock and Distinguished Committee Members - The following comments are intended to show the effects on healthcare for our patients (your constituents) under the current prescription reimbursement model in use in the Commonwealth today. Basically and to the point it is becoming increasing difficult for patients to receive adequate, consistent, and timely care with respect to their prescription needs. Currently there are at least 5 counties in the Commonwealth without a pharmacy and at least 15 counties with only 1 pharmacy. Through legislative actions pharmacists have been given the ability to expand their scope of practice. Through statewide protocols pharmacist can help patients with smoking cessation, do Covid testing, administer certain vaccines, administer tuberculin testing, dispense medications for HIV PEP/PrEP, screen and dispense hormonal and emergency contraception, dispense prenatal vitamins, naloxone, epinephrine, and test and treat (under protocol) urinary tract infections, influenza, group A Streptococcus, and Covid-19. Pharmacist are the most accessible and knowledgeable healthcare professions a patient can see and are many times an information source to assist patients to determine if they should seek more detailed, comprehensive care. These services are becoming harder to access due to a number of factors. Pharmacies, both chain/big box and community, are seeing reduced hours of operation, reduced staffing, increased stress and burnout, increased administrative metrics resulting in less time for the patient. This reduction in access to patient care is not limited to the independent/community pharmacies. The chains are suffering in providing access as well. CVS stated a goal of closing 900 of their pharmacies over a 3 year span, Rite Aid declared bankruptcy while closing almost 400 pharmacies, and Walgreens recently suggested they would close up to 25% of their pharmacies. So where are these patients getting their prescriptions filled? The prescription volume is still strong but the problem is reimbursement for services provided. In short and to paraphrase Walgreens CEO , Tim Wentworth, the current pharmacy reimbursement model is unsustainable . Our pharmacy, Remington Drug, has been forced to make changes due to the dramatic reductions in reimbursements. We have aggressively reduced our inventory, as staff has left or retired we have not sought replacements, and we have reduced our hours of operation all the while maintaining a high degree of patient service and access. The major reason for all these changes and the concern about access -----the drastically low reimbursements starting in 2024 by the Big 3 PBMs which are CVS/Caremark, Express Scripts, and Optum. They offer contracts but they are "take it or leave it" and if a pharmacy takes it many times filling certain brand medications result in a loss for the pharmacy. Continuing to fill those is a slow death for the pharmacy and a decrease in access for the patient because they have to find another pharmacy which may mean significant travel. Pharmacies need to be profitable to maintain access and provide services which means major PBM reforms, guaranteed consistent reimbursement using a universal product cost like NADAC (National Average Drug Acquisition Cost) and a dispensing fee at least equal to the Medicaid FFS fee of $10.65. Currently over 50% of dispensed medications are at a loss with little or no fee. Thank you , Al Roberts

- Thank you for the opportunity to provide testimony about the challenges and solutions for practicing Medicaid dentistry in rural communities. My name is Dr. Jernice Giles and I represent Spencer Dental and Pine Dentistry, two family-friendly dental practices focused on serving children and families, supported by Benevis for non-clinical services. - In 2019, Spencer and Pine Dental operated 16 offices in Virginia, caring for 100,000 Medicaid patients across 243,000 visits, with a workforce of 65 dentists and 488 total staff. Post pandemic workforce reductions coupled with inflation and Medicaid reimbursement rate challenges has forced us to reduce our offices in Virginia. We now operate 13 offices. As a result, for the year ending 6/30/23, we cared for 81,000 Medicaid patients with 187,000 visits, and employed 28 full-time dentists, 34 part-time dentists, and a total staff of 244. - Spencer and Pine Dental, supported by Benevis our dental support organization, see more Medicaid dental patients than any other entity in Virginia, providing general dentistry, orthodontia, and other expanded dental services. Currently, approximately 85% of our patients are Medicaid/CHIP beneficiaries, with about 80% being children. - Despite our efforts, Medicaid dental reimbursement continues to fall far behind usual and customary rates for dentists. It had been 17 years since rates were increased in 2022, and that increase was a much appreciated 30%, across the board, though the Virginia Dental Association had requested 50%. Dental practices have faced dramatic increases in supply, facility, and wage costs since the pandemic, with some estimates suggesting costs have risen approximately 40% in the past three to four years. - We are grateful for this year’s bipartisan legislative and administrative support for an additional 3% increase in traditional Medicaid and CHIP dental reimbursement. However, on a national average, Medicaid and CHIP programs pay just 61% of the rates paid by private insurers for child dental health services. - Staffing rural areas is particularly challenging. Hygienist, dental assistant, and dental schools are often not close by, and competition for limited talent is fierce. Additionally, with stagnant rates and rising practice costs, it is difficult to compete with non-Medicaid practices. Many staff prefer to live in cities or suburbs, forcing rural patients to travel long distances for dental appointments. As a result, some patients choose not to prioritize their dental care due to the time sacrifice. Most Medicaid dental providers must endure a 50% no-show rate, compounded by Medicaid redetermination and procedural disenrollments. This significantly impacts our ability to cover costs and pay staff. - To improve rural oral health, we recommend the following: 1) Increase Community Efforts: Integrate physical and oral health initiatives in rural communities to make a significant difference; 2) Loan Repayment Programs: Offer loan repayment programs for health providers serving low-access communities; 3) Meaningful Medicaid Rate Increases: Increase Medicaid dental rates to bring near parity with non-Medicaid providers; and, 4) Oral Health Education: Enhance oral health education in communities and schools. - Thank you for your time and consideration. We hope these insights and recommendations will help improve oral health care for rural communities in Virginia.