Portland, Oregon, March 19, 2020.  The tri-county region around Portland is thought to be two weeks behind the pandemic course of Seattle, Washington, a major epicenter of early coronavirus morbidity in the US. Health Share of Oregon is the Medicaid Coordinated Care Organization (CCO) for the region’s Medicaid enrollees with responsibility for physical, oral and behavioral health benefits. The CCO covers 315,000 low-income vulnerable enrollees who are at increasing social, economic, and clinical risk as more and more places of employment, schools, and social institutions shut down in response to COVID-19.

We are responsible for the health of these individuals through this epidemic. We also bear financial responsibility for the wave of Medicaid hospitalizations and ICU admits that we know is coming.

Oregon’s Governor and state and county public health agencies have been the first to respond to the threat of viral spread, with strong engagement from health systems particularly around hospital preparedness. As is true elsewhere, the community doesn’t have enough personal protective equipment (PPE) or enough tests. But it has become clear as the public health response has escalated in the past two weeks that a community response, including a response from the CCO and other health plans, is needed.

How Can Health Plans Contribute to a Community COVID-19 Response?

The pandemic is moving quickly. We all need the best ideas yesterday. Going forward, we need to know what is proving effective and what is not. As new issues arise, we need to identify new ways to deal with them.

Below we describe the first efforts that Health Share of Oregon is launching — as well as issues we know we will face — in the hope that others will share what they are doing and planning. Here is what we and our partners are putting in place now:

  1. Reduce Health System Contact to protect patient, provider, and system safety, by:
    • Ensuring that outpatient providers can do telehealth visits (including phone calls), code/bill and get paid for them, and optimize tele-health capacity.
    • Coordinating and encouraging efforts to decrease non-urgent clinic visits, such as cancelling routine physicals and well-child checks in primary care, and limiting dental visits to urgent or emergent.
    • Extending authorizations for elective procedures that are now being cancelled to preserve hospital capacity.
    • Expanding access to pharmacy by allowing early refills, increasing supply amounts, and encouraging members to use mail order (90 days). One issue still under discussion is how to handle opioids (even in context of looser regulations).
    • Reducing non-critical Non Emergency Medical Transportation (NEMT) rides, shifting to single person-only rides, prioritizing life-sustaining treatment (e.g., dialysis) for NEMT, and educating drivers on patient and personal safety.
    • Maximizing communications with patients, providers, and health systems.
  1. Enhance Capacity to Use Medicaid Flexible Service Dollars to pay for health-related social services to at-risk members, particularly those without housing, by:
    • Coordinating with counties and community organizations to find and fund separate shelter, motel, or other facility space for those without housing who are symptomatic and awaiting tests, or who have tested COVID positive, or who will be discharged after a COVID admission.
    • Working with partners on the food challenges that our members face, including some caused by job loss and others because children are not in school; even if schools have food, sometimes families are unable to pick up food resources.
    • Thinking about ways to address the impact of social isolation on our elderly and other at-risk members.
    • Exploring further relationships with community-based organizations, including culturally specific organizations.
  1. Prepare for a Big Increase in Medicaid Enrollment as people lose jobs, in particular:
    • Given our delegated full risk model with large health systems that also serve commercial members (e.g., Kaiser Permanente, Providence Health Assurance, Legacy Health PacificSource, OHSU Health), ALL of our partner systems have agreed to keep individuals who move from their commercial plan over to Medicaid to maintain provider continuity – and are currently working on a mechanism to get information out about how to do this.

Immediate Issues at Hand

Following are some of the issues we are working on now:

  1. How can we continue to provide effective “high touch” complex care management while protecting both staff and members?
  2. How might we identify individuals at highest risk, both clinical and social – such as an immune-compromised person with few resources and little support – and help them avoid infection and possible hospitalization through the weeks and possibly months of the epidemic?
  3. With businesses closing, and aspects of federal help still being debated in Washington, how can we help those who live paycheck-to-paycheck, including families with young children, from losing their homes now? How do we find them? What do we have to offer?
  4. How will the increasing social isolation being imposed impact at-risk populations, not just at-risk older people with comorbidities, but individuals with mental and behavioral health challenges? How might we mitigate its effects?
  5. What kinds of social screening might primary care practices use, both in face-to-face and telephonic visits, related to the dislocations and stresses of the pandemic?

Issues for Future Consideration

And, here is what we know we will face as we look ahead:

  1. Health care practices are businesses like any other. How do we ensure the continued financial viability of our provider network, especially independent practices that have limited reserves to weather multi-month reductions in revenue?
  2. Possible pharmacy shortages as pharmacies do early refills and increase amounts… ala toilet paper! How should we prepare?
  3. Can we realistically redeploy major resources to address the pandemic and still meet all the regulatory, administrative, and performance requirements of our state contract? As the federal government moves to reduce administrative burden and red tape, what should we advocate for at the state level?
  4. How will we address the backlog of access needs that is being caused by oral health providers closing down to only urgent/emergent services, limits on preventive visits, non-emergent surgeries, etc.
  5. How do we incorporate the learnings from all the telehealth services we are providing now out of sheer necessity? How do we incorporate those lessons into regular scheduling and workflow practices?

A Call to Medicaid Health Plans across the Nation

As we navigate these challenges in the days and weeks ahead, we all need to understand how Medicaid health plans can be most effective in mitigating the myriad impacts of this pandemic. We welcome the opportunity to learn from other plans across the country. Now more than ever we need to share our best practices as they emerge and seek opportunities to rapidly learn from one other.

If you have ideas to share, please comment below or email CHCS at . CHCS is eager to support Medicaid stakeholders in their efforts to address COVID-19 and its many implications.

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Karen Brodsky
4 years ago

I applaud Health Share of Oregon for addressing continuity of care for individuals who will need to transition from commercial insurance to Medicaid by preserving their provider relationships. As they experience tremendous life setbacks from their loss of employment, maintaining provider relationships during this uncertain time is essential to access providers quickly if they need COVID-19 guidance, to: – Avoid member confusion during a tumultuous time; – Support members, especially individuals with chronic care needs, who are already experiencing major life transitions; – Facilitate telehealth services so providers can serve patients whose medical history they already know; – Help stabilize… Read more »

Susan Padrino, MD
4 years ago

The Collaborative Care Model, developed at the University of Washington, provides a model for delivering care to vulnerable populations through the infrastructure of primary care. It was developed and is most commonly used for behavioral health but it also has demonstrated benefits for “medical” diagnoses such as diabetes and hypertension (ie TeamCare). I am a primary care provider and a psychiatrist and I believe this model can be adapted to help identify, monitor, and treat patients in general practice–mostly over the phone. Instead of tracking behavioral health symptoms, the practice could choose the top 2-3 diagnoses of concern in their… Read more »