Across the country, federal and state policymakers are preparing to gradually reopen the economy while ensuring appropriate measures to limit the spread of COVID-19. This includes plans to reopen non-urgent health care facilities, particularly ambulatory care services. On April 20, the Centers for Medicare & Medicaid Services (CMS) released guidance for providers to reopen in states and regions that have met gating criteria. Like other industries, how health care is delivered will likely look different in both the near and long term and providers will need extensive support to transition to these new modes successfully.

Our nation’s health care system faces key challenges in the weeks and months ahead. First, many providers have been financially distressed by lower patient volume. Shoring up ambulatory care — particularly primary care and behavioral health — is a critical first step to meeting anticipated patient health needs. Many patients have delayed or have not been able to access necessary care; once able they will need to access care safely. Lastly, looming budget pressures stemming from declining state tax revenue will severely limit state financial resources and constrain health care expenditures.

This blog post is the second 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 reopening and restabilizing the health care delivery system.

State Medicaid agencies will play a critical support and guidance role in helping providers — particularly safety net providers — pivot to this next phase. These agencies have a vested interest given the significant negative downstream impacts on population health and health care costs related to delayed treatment of chronic conditions, mental health issues, substance use disorders, perinatal care, immunizations, and urgent oral health conditions. The potentially disproportionate impact of COVID-19 on Medicaid beneficiaries, due to health disparities and socioeconomic factors, requires states to be carefully attuned to the equity implications of the upcoming transition.

To support effective reopening, state Medicaid engagement and leadership will be critical across three key areas:  (1) care delivery; (2) health-related social needs; and (3) provider finances and payment. Successful reopening will require coordination with a broad set of partners, including providers, Medicaid managed care organizations (MCOs), beneficiaries, and public health and human service agencies. Below are potential approaches that Medicaid agencies can consider in developing their reopening strategies.

Medicaid Supports for Reopening Ambulatory Care Delivery

Medicaid beneficiaries’ near-term ambulatory care needs include: chronic disease care, behavioral health services, long-term supports, obstetrical care, immunizations, developmental screenings for kids, and oral health. State Medicaid agencies will want to ensure that people who urgently require these services can access them effectively, equitably, and in modes that protect patients and providers from further spread. To do so, Medicaid agencies can consider the following approaches:

  • Prioritize helping providers serving diverse populations, including Black, Hispanic, and disabled populations, to mitigate the health disparities associated with COVID-19;
  • Ensure appropriate personal protective equipment for safety net providers — including nursing home staff, home health aides, personal care assistants, community health workers — and their patients;
  • Ensure access to testing and antibody screening in low-income, diverse communities;
  • Collaborate with public health peers in disseminating new workflow protocols directing providers on how to effectively screen for COVID-19 and triage patients who are seeking care, and to deploy safer modes of care for services that require in-person interactions;
  • Provide guidance and require for MCOs and providers to identify and reach high-risk patients with near-term care needs, incorporating criteria that will drive greater health equity;
  • Expand and sustain telemedicine services through technical implementation support to ensure wide uptake among providers and patients across a variety of conditions. Identify and support telemedicine services that may have limited uptake but high need, such as mental health services and substance use disorder treatment, including medication-assisted treatment.
  • Develop guidance to ensure equitable access to telehealth services, including availability of translation services and options for patients with limited access to Wi-Fi or phones;
  • Train and pay family caregivers to deliver home-based services to patients (via Appendix K 1915(b) waivers) and reassess the types of patients and services that qualify for such services beyond emergency periods; and
  • Implement a learning forum for safety net providers focused on sharing and spreading new innovative forms of care delivery.

Addressing Health-Related Social Needs

Addressing patients’ health-related social needs is critical to an effective pandemic response for Medicaid beneficiaries. COVID-19 has amplified existing challenges related to housing, food security, and interpersonal safety. Within the constraints of their budgets, states can leverage existing Medicaid flexibilities to provide patients with the health-related services they need to quarantine effectively if infected and stay healthy if not, and to reduce health disparities. Specifically, states can:

  • Provide guidance to MCOs for covering value-added or in lieu of services, including in-home food delivery for patients who are quarantined or high-risk patients advised to remain in isolation, emergency shelter to support effective quarantines and social distancing, and masks for all beneficiaries;
  • Require providers to screen for health-related social needs, in particular food insecurity, housing instability, and interpersonal violence;
  • Implement incentives for MCOs and providers to accelerate local partnerships with human service agencies, community-based organizations, and public health departments to more effectively meet beneficiary needs;
  • Pursue “low hanging fruit” in terms of patient-level data sharing with providers and MCOs on SNAP, unemployment, and other social services enrollment; and
  • Collaborate with state human services agencies to align priorities and identify mechanisms for getting resources to patients and populations who need them the most.

Bolstering Provider Finances and Transitioning to New Payment Models

Stabilizing the finances of providers that have been hardest hit is an important near-term goal for meeting patients’ care needs, COVID-19 has underscored the limitations of volume-based, fee-for-service payments. As such, it is an opportune time to transition to more flexible payment models that can support the changes in care delivery outlined above. Stabilizing providers financially will have positive downstream impacts on MCOs as well, helping them meet medical loss ratio requirements and support more predictable future capitation rate calculations. Careful attention is needed to ensure that financial supports to struggling providers facilitate the transition to more sustainable funding and effective financial incentives. State Medicaid agencies can consider the following approaches:

  • Seek CMS approval for retainers via 1135 waivers to give safety net providers access to previous levels of funding;
  • Provide a monthly prospective per patient per month payment to ensure a more predictable stream of revenue and the flexibility needed to creatively deliver care in new and safe ways;
  • Give hardest hit providers one-time grants so they have the capital needed to implement new modalities of delivering care;
  • Implement incentive payments or parity payments for MCOs and providers to promote telehealth care delivery, identify and provide care to patients who urgently need it, and address health-related social needs;
  • Pay for antibody testing and contact tracing activities; and
  • Avoid unfairly penalizing providers by assessing and implementing changes in existing value-based payment and MCO incentive arrangements, including performance metrics.

Bringing the Right Partners to the Table

Given extreme state budget constraints and increased demand for pent-up services, Medicaid’s ability to successfully deploy a targeted reopening strategy will benefit from close partnerships with other state and local entities. Expanding existing partnerships with Medicaid MCOs, safety net associations, state public health departments and human service agencies, and consumer groups will help inform, target, and assess these efforts. For example, at the outset Medicaid will need a quick way to assess which providers may have already benefited from federal relief funding to direct efforts toward providers that need financial assistance most. Without these partners at the table, it may be hard for Medicaid to anticipate the needed regulatory guidance, support consistent implementation approaches, and identify the flexibilities necessary to encourage ongoing innovation.

In working with these stakeholders, Medicaid may consider creating a “Reopening SWAT Team” of stakeholders that collaborate to enable timely input into design and implementation decisions as well as ensure shared buy-in and accountability. This Reopening SWAT Team can collectively streamline actions and use limited resources more effectively to:

  • Identify and address barriers that Medicaid MCOs are encountering;
  • Ensure consistent and aligned outreach and support to providers and beneficiaries;
  • Engage consumers and communities in meaningful ways to identify issues that need to be addressed;
  • Understand and respond to emerging needs and priorities for ambulatory care delivery, particularly among safety-net health systems and providers; and
  • Develop collaborative guidance to ensure common goals and strategies across health care, public health, and human services systems.

Responding to COVID-19 has required Medicaid agencies to have an all-hands-on-deck approach thus far — and this next phase of the response will be no different. By continuing to partner with core stakeholders in these efforts, Medicaid agencies will be better positioned to effectively tackle the next wave of issues. Through sheer necessity, COVID-19 has catalyzed the cross-agency partnerships that are fundamentally necessary to bolster health and health care in both the near- and longer-term.

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Kurt Elward, MD, MPH

This is very well done, but I would caution about the recommendation for antibody testing. There is very limited knowledge about what the results mean, in terms of both protection and infectivity. When dollars and clinical resources are precious, there may be higher priorities. Thank you for a well presented set of policy considerations. The other consideration is the usefulness in creating partnerships with the commercial and business sector as well. Medicaid does not operate in isolation and to optimize the health of Medicaid beneficiaries entails consistent and complementary approaches across society. Especially as Medicaid programs see huge influxes of… Read more »

Tricia McGinnis, CHCS

Thanks for sharing these thoughts — you raise very good points. States will certainly need to factor in limited resources when considering antibody testing coverage, as well as any forthcoming CDC guidance on the issue. And wholeheartedly agree that coordination across other payers and businesses would be extremely beneficial given the challenging circumstances.