Across the nation, government, business, and community leaders are devising plans to re-open the economy and public spaces, while minimizing the risks associated with a second wave of infection. These plans necessitate a dramatic increase in targeted surveillance activities that involve: (1) widespread testing; (2) contact tracing; (3) isolation of infected individuals; and (4) supports to seniors and other high-risk populations. This reality raises important questions about how to build surveillance capacity at the scale and speed necessary to phase down current restrictions without recreating the conditions that led to the initial surge in infection and mortality. State public health and Medicaid agencies are well-poised to leverage existing partnerships and complementary skillsets to collaborate on these efforts.

Historically, health surveillance activities have been the domain of federal, state, and local public health departments. While these agencies are experts in organizing crisis responses to public health emergencies, the scale of the current pandemic is extraordinary. Along these lines, the Centers for Disease Control and Prevention (CDC) recently discussed plans to repurpose thousands of Census Bureau workers to augment contact tracing capacity. However, even with these supports, the magnitude of the current pandemic will require partnerships and resources from multiple sectors to create a response at a sufficient scale and within an acceptable timeframe to allow for safe restoration of public life.

This blog post is the first of a two-part series exploring Medicaid’s evolving role as states move to reduce restrictions on public gatherings and restore public life. Part I focuses on Medicaid’s role as a partner in necessary public health surveillance activities; Part II explores Medicaid’s role in restabilizing the health care delivery system.

Medicaid Stakeholder Opportunities for Supporting Surveillance

As the health care counterparts to state public health departments, state Medicaid agencies and their delivery system partners can play critical complementary roles to support surveillance efforts and ensure effective use of health care system resources. Whereas federal funding through the CDC and others will provide foundational support for these activities in the near-term, states are unlikely to rely on federal funding to sustain a surveillance infrastructure over the long-haul. By contrast, state Medicaid agencies, as the largest and most resilient health care funding source in most states, could supplement these supports to ensure that right-sized efforts persist. Specifically, state agencies and their delivery system partners could play the following roles:

State Medicaid agencies can potentially contribute the following assets:

  • Regulatory and administrative guidance produced in a timely manner to ensure consistent protocols, payments, and reporting at the health plan and provider level;
  • Program development capacity to support high-risk populations that need continued protection or isolation (e.g., nursing facility residents, individuals using home- and community-based services, people with disabilities, etc.)
  • Payment flexibility and incentives to appropriately resource required surveillance activities and implement these at scale; and
  • Logistics support to assist health plans and providers with procuring and distributing resources and staff needed for surveillance activities in an efficient way.

Medicaid managed care plans also have strengths that could be mobilized to expand the traditional reach of public health departments. This is particularly the case for managed care plans that work in communities with populations that have been hardest hit by the pandemic. Among the contributions that health plans could make include:

  • Established workforce with expertise in telephonic and community-based outreach and engagement to support testing, contact tracing, and quarantine/isolation services for members;
  • Risk stratification expertise to identify high-risk members for targeted outreach and support;
  • Payment arrangements with providers and community-based organizations to reimburse surveillance activities, including hiring of on-the-ground workforce such as community health workers (CHWs);
  • Financing and coordination of social services, such as food and temporary housing for members that need to be quarantined or isolated; and
  • Data capacity to support public health surveillance and reporting, including specific information about health disparities across factors such as race/ethnicity, disability, and underlying health conditions.

Health care providers can also contribute to population-level health surveillance efforts, including:

  • Likely first point of contact for testing or testing referrals;
  • Potentially available capacity to provide new services, since well-visits and elective care have been postponed and as the widespread adoption of telehealth strategies create new efficiencies;
  • Ability to deploy team-based care, using existing or hiring new non-licensed staff (e.g., CHWs) to conduct contact tracing and leverage invaluable community- and neighborhood-level relationships; and
  • Trusted information source about local social resources for individuals who need to isolate/quarantine.

Ensuring Alignment across Agencies

In many states, Medicaid and public health agencies have a strong foundation for partnership including collaborative efforts related to tobacco cessation, diabetes prevention, reductions in health disparities, and other important population health priorities. COVID-19 is an opportunity to use these partnerships in building sustainable systems that will persist into the “new normal” brought on by the pandemic. To effectively leverage the strengths and capacities identified above, careful attention to alignment between state public health and Medicaid agencies is important. Without aligned strategies, efforts will at best be temporary and at worst create confusion and delays with profound impacts on individuals.  Time-tested strategies to support long-term alignment and collaboration include:

  • Establishing shared vision and priorities: While the goals of these surveillance activities may seem obvious, it is very easy for different stakeholders to maintain their own understanding of what success means and the key activities for achieving it. Clear messaging from state leadership, shared agency goals and milestones for reopening, and rapid-cycle feedback loops that include all partners will ensure that efforts are reinforcing and mutually feasible.
  • Shared decision-making: With an effort of this scale, no single entity possesses all the necessary information and authority to direct the overall effort. Mechanisms, such cross-agency SWAT teams, can enable timely input into design and implementation decisions as well as ensure shared buy-in and accountability.
  • Timely access to actionable data: The effectiveness of any surveillance approach relies on the availability of timely data to inform decision-making. Data related to testing and tracing efforts will need to be standardized and aggregated across multiple partners’ systems, with uniform guidance on what is collected and how it is shared.
  • Alignment of incentives: To create a health surveillance response of this scale will require careful attention to the financial interests of all parties. Medicaid programs have many financial levers (many pre-existing and some newly created in the recent federal stimulus laws) and existing contractual relationships at their disposal, and will need to ensure that their plan and provider partners are appropriately incentivized to marshal their respective resources to these activities.

Building Capacity to Support a New Normal

The initial steps necessary to safely re-open our economy and public life require efforts traditionally deployed by public health experts at a scale never realized in recent times. As already demonstrated in efforts to build capacity to provide care to individuals infected by COVID-19, partnerships between public and private stakeholders will be essential. The growing history of successful collaboration between public health and Medicaid stakeholders offers one such partnership opportunity. These partnerships will require significant attention to align strategies and ensure that Medicaid involvement helps rather than hinders surveillance efforts. Beyond these surveillance activities, these partnerships can serve as the foundation for future COVID-19 recovery efforts to improve individual and population health and reduce the underlying inequities and health disparities that the current epidemic has laid bare.

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David Labby MD PhD

This is exactly the discussion we need to be having NOW. Yes, the country does not have the public health infrastructure it needs to do the surveillance required for a truly safe reopening. But we do have a national “front line” primary care infrastructure — and a growing number of Medicaid and other health plans — that have been developing “population health” skills and workflows for several decades, as well as a growing interest in addressing health related social needs, such as food and housing, that will become increasingly critical as the pandemic plays out. Rather than trying to urgently… Read more »

Allison Hamblin, CHCS

Thanks, David. We couldn’t agree more, and would love to hear from primary care providers, rural health care providers, and other Medicaid stakeholders about any partnerships they have in the works. Such examples can be a model for other collaborations.