Medicaid's big lesson from H1N1: Expect rapid changes
During the HIN1 pandemic, state Medicaid directors were challenged to review their current coverage, service delivery mechanisms, and administrative operations to be sure they were delivering appropriate benefits efficiently and effectively.
"One potential financial impact on the Medicaid program that is an unknown could be an increase in emergency use by undocumented individuals," explains Patricia MacTaggart, lead research scientist and lecturer at the Health Policy Department at George Washington University. Ms. MacTaggart was formerly group director for the Centers for Medicare & Medicaid Services' Center for Medicaid and State Operations and director of Minnesota's Medicaid program.
"One of our concerns is the overwhelming of the system, from the standpoint of contracted providers," says Oklahoma's Medicaid director, Lynn Mitchell, MD. "We are seeing members going to providers just because of generalized concerns that may or may not be appropriate visits. They may be there just because they heard something on TV. They are choosing to go in and get checked out, when normally they wouldn't. If the system is overwhelmed with those kinds of issues, the members that really need care might not be able to access it as quickly."
The program routinely sees a cost increase during cold and flu season, and this is being closely monitored. "Our first concern is the things we can do proactively," she says. "We need to make sure we tap into all the available resources that are already out there."
Oklahoma's SoonerCare program doesn't put any restrictions on providers administering the rapid influenza diagnostic tests. Dr. Mitchell says she does expect to see an increase in physician office visits and in members asking for the flu test.
To try to stave off the problem of inappropriate visits, the state health department worked to educate the public on when to seek care and it worked hard to keep Oklahoma providers and sister agencies apprised of current recommendations for screening, testing, and treatment.
"We have a state health department that did a fabulous job in the wake of H1N1," says Dr. Mitchell. "If we learned one thing from this, it was making sure that there is ongoing communication for all the different resources and not doing anything in a silo."
Oklahoma's health department took the lead in sending out advisories from the Centers for Disease Control and Prevention in Atlanta as they became available. "We meet with them and the other health agencies on a monthly basis, so I know who to call there, and they know who to call over here," says Dr. Mitchell. "As questions occur, there is an open link of communication, so we can quickly ascertain who is taking the lead and who is taking what role. Otherwise, we might be telling providers one thing, and the health department might be telling their providers, who are also our providers, something else."
In addition, if a Medicaid agency has prior authorizations or limits on medications, Medicaid directors need to have the ability to respond quickly to control a pandemic. "Essentially, you need the ability to change the file for prior authorizations immediately," says Dr. Mitchell.
In California, the Department of Health Care Services (DHCS) assisted in the state's H1N1 flu response and provided the Department of Public Health with staff support for ongoing activities. A spokesperson for the Medicaid program says DHCS pharmacists are overseeing the movement, inventory, and packaging of antiviral drugs being sent to local health departments. In addition, Medi-Cal providers were advised that as an interim measure, prior authorization would not be required for antiviral drugs, including Tamiflu and Relenza.
In the past, Oklahoma Medicaid has worked with nursing home facilities to make sure they had appropriate information on getting their members immunized. "Going into this upcoming flu season, we will be putting information front and center in our member newsletter on getting the flu vaccine for individuals it's indicated for," says Dr. Mitchell. "We are making that one of our lead messages that is going out to our members. Also at times, depending on the issue, we have communicated with our members individually, and we reinforce the message at that point."
For example, postcards were sent out about issues such as appropriate use of the ED and immunizations for children, and the agency routinely uses outbound calls to members to educate them on health issues. "We can modify the script to touch on appropriate issues when calling, so a particular concern can be addressed if needed," says Dr. Mitchell.
According to Robert H. Moon, MD, medical director of the Alabama Medicaid Agency's Office of Health Policy, a big lesson learned was how rapidly things can change during a pandemic.
"Within one or two weeks, we went from something no one had ever heard of to fairly widespread activity," he says. "The lesson learned is to watch for public health updates and pay attention to seasonal coverage decisions."
While Alabama Medicaid normally takes flu medications off its preferred drug list after the flu season ends on April 30, the preferred status of these drugs was extended for an additional period of time. This allows physicians to prescribe the medications without obtaining prior approval. More than 700,000 people, primarily children, are eligible for coverage of the flu medications by Alabama Medicaid.
"We are likely to have increased demand for services by existing clients," says Dr. Moon. "We are also likely to have an increase in the number of eligibles due to job loss from illness or an overall slowing of the economy. Enough people could be sick that the overall economy would slow from pandemic flu alone."
Looking at the bigger picture, he says states are likely to have decreased revenue in the setting of a widespread flu. This could result in decreased provision of Medicaid funds at a time when demand is going up.
To be ready for future pandemics, Dr. Moon says state Medicaid directors should have a business continuity plan that will allow their agencies to continue to function.
"In a full-blown pandemic, up to 40% of our work force may be out of work due to their own illness or the illness of their children or other family members," says Dr. Moon.
Contact Ms. MacTaggart at (202) 994-4227 or [email protected], Dr. Moon at (334) 242-5619 or [email protected], and Dr. Mitchell at (405) 522-7365 or [email protected].
During the HIN1 pandemic, state Medicaid directors were challenged to review their current coverage, service delivery mechanisms, and administrative operations to be sure they were delivering appropriate benefits efficiently and effectively.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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