COVID-19 Webinar Series Session 17 – The Role of Medicaid

12:00 p.m. – 12:05 p.m.     Welcome and Introductions

Sarah J. Dash, President and CEO, Alliance for Health Policy

@allhealthpolicy

12:05 p.m. – 12:25 p.m.    Moderated Discussion

Sara Rosenbaum, J.D., Harold and Jane Hirsh Professor and Founding Chair, Department of Health Policy, George Washington University Milken Institute School of Public Health

Tom Betlach, MPA, Partner, Speire Healthcare Strategies

Karen Dale, R.N., MSN, Market President, AmeriHealth Caritas District of Columbia

@AmCaritas

Beth Feldpush, DrPH, Senior Vice President of Policy and Advocacy, America’s Essential Hospitals

@OurHospitals

Moderator: Rachel Nuzum, MPH, Vice President of Federal and State Health Policy, The Commonwealth Fund

@commonwealthfnd

12:25 p.m. – 1:00 p.m.       Moderated Discussion

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

0:09

Good afternoon, everybody, and good morning to those of you on the West Coast. I am Sarah Dash, president and CEO of the Alliance for Health Policy.

0:17

As we bring you today’s webinar in, what is now week 11 of our … Rapid Response series, and wants to take a moment to personally acknowledge the particularly sobering and serious times in which we find ourselves. And, in particular, the critically important conversation around race and equity that is now taking place both, as it relates to the impact of coven, 19. As well as more broadly in our country, as always, it is our mission at the Alliance to shed light on the back and to bring you a diverse set of perspectives and experiences on complex issues. And we always encourage you, our listeners, to reach out to us with any comments or suggestions.

0:59

Today’s webinar is about the role of Medicaid and the Kogod 19 response, and we’re going to have a very robust and interesting discussion today. And a moment, I’m going to turn it over to Rachel … from the Commonwealth Fund to moderate today’s event.

1:15

Before we begin, I’ll share a few very short housekeeping notes.

1:20

You can join today’s conversation on Twitter using the hashtag all health live and follow us on health policy. And I want to gratefully acknowledge our partners, the National Institute for Health Care Management Foundation and the Commonwealth Fund for supporting this entire series. We want you to all be active participants in today’s discussion, so get your questions ready. Here’s how you do it. You should see a dashboard on the right side of your web browser. There’s a speech bubble icon with a question mark, and you can use that to submit your question for the panelists at anytime throughout the broadcast. You can also use that icon in case you’re experiencing any technical issues. Please check out our website. I’ll health policy dot org, for background material and for a recording of today’s webinar, which will be made available there.

2:04

Now, I’m so pleased to introduce Rachel Newsom, Vice President of Federal and State Health Policy at the Commonwealth Fund who’s going to introduce our panelists and moderate today’s webinar.

2:15

Rachel, go ahead.

2:17

Thanks so much, Sarah. And thanks to everyone for joining us today. It is hard to begin talking about this issue without reflecting and honoring the somber realities playing out across the country this week.

2:28

Pandemic has brought to light the economic and social inequities in our country. And since its inception in 19 65, Medicaid has played a leading role in addressing these factors by ensuring our nation’s most vulnerable have access to affordable health care.

2:43

Many sheet has played a leading role in supporting access to health care during the 19 pandemic and will be critical in moving forward as States move to re-open and re-entry.

2:54

It’s being used to help people access testing furnishing health insurance for folks who have lost their jobs and increase federal funding to support their response to the pandemic. We know and you probably think of Medicaid as our nation’s healthcare safety net. The economic impacts of Cozy 19 and the Nature of Medicaid financing will exacerbate challenges for state Medicaid programs.

3:16

States right now are bracing for increased enrollment and the very real budget limitations, a perfect storm for our safety net program and the communities that they serve.

3:26

Today, I’m so pleased to be joined by a distinguished group of experts to discuss policy options to support Medicaid, especially during the kogod pandemic.

3:35

First, I’m pleased to introduce Sarah Rosenbaum, Barrels, and Jane Hersh, Professor, and Founding Chair of the Department of Health Policy, at George Washington University School of Public Health and Health Services Next. We have Tom Bad Luck, who’s a Partner Aspire Health Strategies, and former director of Arizona Health Care Cost, containment System, Arizona, State Medicaid, Agency.

3:57

Next, we have Karen Dale, who is the market president as a Mirror Health, Tara Task, Assertive Columbia, Medicaid Managed Health Care Plan.

4:05

Finally, we’ll be joined by Beth …, Senior Vice President of Policy and Advocacy. America is essential hospitals.

4:12

Thank you so much for joining us today. And looking forward to the conversation into the questions. You can submit questions for the speakers at anytime. And we will turn to those after the final formal remarks. So, we’re going to start and I’ll turn it over to Sarah Rosenbaum for opening. remarks, go ahead, Sarah.

4:31

Thank you so much, Rachel. It’s, it’s good to be with everybody. Thank you for including me in this very important session today. The opening remarks by Rachel and Sarah underscore the extraordinary time we live in. And the fact that, of course, you really cannot talk about health equity.

4:55

Without talking about the Medicaid program in the middle of a pandemic, this is the biggest Public Health First Responder we have. And there are certain attributes of the program that makes it especially amenable to the kinds of changes that states need to put into place. That health care providers need to put into place during a crisis as serious as this, which is disproportionately affecting the, very communities that depend on Medicaid the most.

5:29

There are a couple of features of Medicaid make it so, so useful and important in this kind of a situation, obviously, it’s a program that’s that’s targeted to low-income and vulnerable populations and assess the point of Medicaid.

5:49

one of the key features of Medicaid is its flexibility. States, of course, face a huge number of issues and administering their plans, but as a matter of policy, just strictly as a matter of policy, Medicaid is the most flexible ensure. We have said there are no special enrollment periods. You can enroll when you need the coverage. You can enroll at the point of care. The program can be modified rapidly. Congress can make rapid changes to the programs and send money out the door and and and make accompanying changes. And those changes, of course, take a little bit of time to be implemented at the state level. But states can embrace those changes. They are incredibly experts at this during their Medicaid programs. And in many ways is as challenging as it is. It’s less cumbersome process than changing the …

6:48

Marshall insurance market and we can see changes, ineligibility. We can see changes in benefits. We can see changes in rules having to do with sending money directly to providers in the hardest hit communities and sure, something, that’s what we’ll talk about. So that’s number one. Number two.

7:06

Medicaid is a point that many people have made most recently the Medicaid Directors themselves in a letter to Congress and to light as having to do with with retainer payment policy, but the program is the fastest way we have of transferring funds. Once the Federal government should be addressed, as the formula issue, the States, of course, are spending in real time and they can rapidly draw down and enhanced rate of payment. Often, Federal Government, which is very different from, say, a grant program, like the Big Grant, program setup for healthcare providers, where there has to be application allocation formulas. All of that is sort of on autopilot in the Medicaid program, which which makes it qualitatively different and because of the special features.

8:06

Of course, Medicaid has played a prominent role in the legislation enacted to date and in pending legislation as well. So we’ve seen a new state option for uninsured testing and accompanying costs related to testing. We’ve seen an enhancement of the Federal payment formula for states during the period of the pandemic. And of course, that enhancement comes with certain roles having to do with continuous eligibility, enhance benefits, and the elimination of cost sharing.

8:48

And, those changes, of course, take time to implement, but the: But it can be made relatively expeditiously compared to any other way to move money quickly to, into into coverage mode. The pending legislation, I’ll just note in the Heroes Act, which passed the House, would build on what we’ve already seen enacted by extending the uninsured option to cover all treatment and immunization services related to the …

9:22

epidemic during the period of Declared Emergency, and would also close certain important loopholes to do with the immunization coverage for traditional adults who don’t get the benefit. I’ll see Affordable Care Act’s preventive services mandate. This would make sure that all adults are covered for immunization and administrative services along with children. Of course, through the Vaccines for Children Program.

9:53

So, all of these features of Medicaid makes it the go to program in a time like this. And there are enormous challenges, but but but the programs already Indispensible Nature essentially says, assumes a greater level of Indispensible, nus and all of this. So thank you very much.

10:20

Thank you so much, Sarah. Can I just ask one clarifying question? Tom, you referenced that a lot as dollars flowing out of Congress, over the last couple of months, in terms of both stimulus to and recovery dollars. What do we know about how those dollars are impacting Medicaid providers, Do we know anything about how that’s going yet in terms of providers receiving, you know, somebody’s enhanced payments to really ensure sustainability?

10:59

Yeah, so the question, And I’m sure this and, and, and perhaps Karen may have more to say about this, as well. What we know is that the movement of money, which has not been wrapped generally, there’s been a lot of concern about the fact that the money is moving slowly to providers, but especially problematic has been the movement of money to Medicaid programs. I don’t know, perhaps somebody, one of the panelists will now, why CMS didn’t simply allocate those funds on some sort of formula to States to put rapidly into motion. Essence, they are so much closer to the providers in their communities, but it’s my understanding that the allocation process for Medicaid was a slow to get off the ground, and, B, is still not happening.

11:57

The other thing that I think bears noting in all of this and I have a blog, actually going up at Health Affairs tomorrow on this, is that states have been pleading to be able to make the kinds of advance payments to their providers for the full range of services that beneficiaries need for months now. And there has still been no movement on this issue of retainer payments.

12:26

This becomes a huge issue not just for state Medicaid policies but because of the disproportionate concentration of poverty, it is minority communities that are so overwhelmingly affected by the potential disastrous collapse of primary care specialty services, hospital care, pharmacy services, dental practices. These are already underserved communities and with and, and and the blog basically says that CMS has more than ample authority to institute to allow States to institute a retainer payment policy. They’ve used this authority in the past, something they acknowledge, and yet they have just sort of decided not to, not to shift at this point. So that’s a key issue, along with the grant funding.

13:23

Thank you so much, Sarah. And we know that, in addition to that population, concentrated being concentrated in terms of the providers, that they’ve also been disproportionately hit listed coven. Pandemics hosting cases and Deaths, so thank you for for making that point. Let’s turn to you.

13:45

Thank you. Thank you, everybody. Thanks for the opportunity to be with you today. So, I’ll put my former Medicaid Director hat on and sort of come at it through the lens of what Medicaid Directors may be thinking right now in terms of not only dealing with the pandemic and looking at all the issues and the impact associated with that, but also the budgetary issues that are coming their way.

14:08

And so we know that Medicaid is a counter-cyclical program that as we experience economic contractions, the growth in the Medicaid program will occur and we’re seeing that in terms of increased enrollment. And, Tara touched on that. Also, the fact that you have this Federal State Partnership where states are an equity partner, and, and bring forward the state match necessary to draw down federal funds. We know Medicaid directors are getting calls from their state budget directors.

14:37

Most states, many states have identified shortfalls in terms of overall revenues, and we know that that has implications on the Medicaid program, which is, in many instances, the largest budget item for states.

14:52

So there are some additional funds that have been provided by Congress. Congress has provided an increased match of 6.2%. And that’s great in terms of additional resources for State essar identified. Those funds can flow right away, It’s a Lever, Congress has to help support states with that comes some maintenance of effort requirement. So increased enrollment is part of that in terms of states are no longer doing redetermination for individuals so that continuity coverage is good, but it has a cost. And so some of that increased matches is covering those higher costs. What’s different, though, this time around than a previous recession where Congress provided increased matches? There’s more uncertainty as it relates to when that match wind, right now, it’s tied to the emergency declaration. And so, not knowing when that will end, means that states have this uncertainty of, when will that additional federal funding come to an end, states have to be conservative.

15:50

In terms of there, assumptions around that, from a budgeting perspective, and most states, that I’m hearing from our, assuming that the longest, those funds may go till the end of the calendar year, as they’re looking ahead to their budget. But we know the CBO has scored at March of 2022. But, this is an issue, I think, that’s an issue that hopefully, federal policymakers can take up, in terms of. The House bill provides additional resources, but also more certainty in terms of when additional funding will be available for states and how long that will last.

16:25

Another interesting aspect, of course, is that when you look at the Medicaid Director position, the average 10 years, around two years, state budget directors. Governors, a lot of policy leaders, Medicaid directors may not have been in their chair during the last recession. And so, having to go through that dynamic of looking at what options are, what the implications are for a program, This is new to many folks that are having to make the decisions looking forward in terms of what impacts look like.

16:54

Another thing that people need to be aware of is the mass around Medicaid has changed for many states with the expansion. So with the expansion came the opportunity to offer more coverage. It came with considerable federal funds. That also meant that, as states look at potential budget cuts and having to get to a number.

17:19

What most people care about is, what is the state savings associated with that cut?

17:25

And now with the increased federal funds provided to the expansion for many states, the math has changed. So, for example, in the state, I used to work, And in Arizona, we were traditionally a 2 to 1 match.

17:38

And so in order to get $33 million in state savings, we had to cut $100 million out of the delivery system. And now with the expansion and the enhanced match to that. The overall weight and match looks more like a 3 to 1 ratio, which means that in order to get that same, $33 million, cut now has to be considerably higher. It has to be around $135 million in total funds. And that has tremendous impacts on individuals that need coverage for the program, on the providers that serve the members. And, really, when Medicaid directors are gonna go look at their options, are options for near term savings, are very limited, And largely our provider rate adjustments.

18:23

And we know that with all of the challenges of a pandemic layered on top of the economic impact associated with the recession, it makes it very challenging to look at providers and say, OK, we have to layer yet more cuts on top of the impacts associated with the pandemic. And the impacts could be either for providers like hospitals and nursing facilities, but may have higher costs or it may be providers who have seen less utilization and are just trying to keep their doors open as Sarah highlighted.

18:56

So, you have all of that. That’s being put on the plate. Now for Medicaid directors, as they look ahead, they’re dealing with everything that played out through the pandemic. In addition to that, now they have to turn their attention to potential budget impacts, budget reductions, and working with their policy makers and Governor’s Office on that.

19:18

Couple of positives I’ll just touch on in terms of the impact of where we are, obviously, many people have talked about the expansion of telehealth. We’ve seen that play out for a variety of populations, that Medicaid serves in very positive ways. And so excited to see how that rolls forward, in terms of opening up access. Being aware that there may be access limitations for some in the Medicaid population, but being able to leverage telehealth.

19:45

Also, you know, the investment made by Medicaid and the federal government, in terms of things like Health Information Technology Health Information Exchanges.

19:55

We’ve seen play out in Arizona, the ability to share on a real-time basis information around individuals who may be testing coven positive, which have really helped tremendously, in terms of care co-ordination. And then finally, efforts around providing better delivery systems for individuals that are dual eligibles. And they’re eligible for both Medicare and Medicaid. And we’ve seen where we’ve been able to build alignment and have individual served by the same organization for Medicare and Medicaid. Better care co-ordination occurring as it relates to the Managed Care Organization. States. Being able to serve that population and do better care co-ordination for those individuals. That are Testing coven Positive. And we realized that that’s been a disproportionate population impacted through Pokemon.

20:46

Finally, I’ll just end with this thought. You know, it’s interesting to look back to the great recession, and it was a very difficult time for states and working through that, and some very difficult decisions had to be made, But you also think about the fact that, you know, in essence, ACA was being implemented almost on a parallel track. And so, for many states that met new coverage opportunities, new resources to modernize systems. And Medicaid, really, I think over the last decade, has been the most important program, and advancing the delivery system around issues like social determinants of health home, and community based services when you look at value based purchasing and other things like that. And so, you have this tremendous uncertainty now, You have this tremendous uncertainty as it relates to the types of decisions Medicaid programs have, and it really calls into.

21:42

Question, you know, how will Medicaid be able to get the momentum back to be able to be a leader like it has been over the last decade.

21:51

Much time. That was terrific. Just one question. before we move on, you, you reflect on, you know, Medicaid was designed to be counter-cyclical in its funding and to expand when need increased and said, this is something that the program is familiar with. But what are we seeing in terms of enrollment increases and what isn’t too early to say, what to say, what is the impact is, just a tremendous amount of job loss, an increase in unemployment? How is that playing out and kind of intersecting with the Medicaid dynamic in the states?

22:30

Most states measure their enrollment on a monthly basis. You know, some some have looked at it more incrementally now, and they’re getting regular reports on a weekly basis and things like that. Obviously, there’s growth going on. That’s occurred from the changes around redetermination, which was part of the maintenance of effort requirement to put in place by Congress. So States have reported back saying 5, 5 to 10% growth associated with that. And some States have reported now seeing upticks in terms of increased enrollment, increased applications, but we’re only two months into this. And so I think that when you look at how individuals often come into the Medicaid program, It maybe they show up at their federally qualified health center. They show up at a hospital to get services. Yet we know from the utilization reports that in many instances, people are not yet going to seek care because they’re concerned about the pandemic.

23:25

And so, I think that, you know, as as things start to open up a little bit here, over the next several months, we’ll see individuals coming into care, not having coverage, and we’ll start to see at that point in time. I think the Medicaid enrollment grow even more considerably.

23:42

Thank you. Great. And now we’ll turn to Karen. Karen, go ahead.

23:57

Karen? Thank you so much.

24:02

So Sarah talked about this wonderfully flexible program that certainly has demonstrated its utility during this time, and Tom gave us a great overview of opportunities, challenges, and budget constraints, and I will focus on the needs of beneficiaries and what Medicaid Managed care organizations are doing.

24:26

I’m very proud of the agility that many Medicaid Managed Care organizations have demonstrated to take a whole person approach to address the needs of their beneficiaries. In the District of Columbia, Mirror Health …, DC serves about 120,000 beneficiaries, and we have implemented very quickly a variety of strategies to ensure that those we serve are connected to services, resources, and medical care. Those activities include quickly implementing telehealth services.

25:02

We saw a wonderful uptake, very quickly, re enabled our providers by getting communication out to them about billing, helping to get them connected to various platforms that would support them using telemedicine, and launched an extensive outreach campaign to our beneficiaries, so that they could be aware that this was available to them, enabled, our call center, and member beneficiary facing staff to be able to provide assistance.

25:40

On the technology side as well. We have a wonderful HIE health information, platform in the district, which was leveraged and even added additional components, so that we could know the status of someone who had been tested.

25:57

So, they had various resources to get the lab results. And so, at the point of care, it was very quickly accessible. What someone’s status was, Recognizing that many people were staying at home, as they should, however, wanting them to still get what was needed to address any condition they may have, especially those with chronic conditions.

26:23

We began shipping blood pressure cuffs and scales and connecting our pregnant enrollees to services that offer either remote monitoring or additional telemedicine focused visits in order to continue with monitoring their condition. What we’ve heard back from our providers, is that there has been really high utilization of services, and that our beneficiaries have kept appointments at a much higher rate, around 82%, versus when they were doing in person visits. And so that’s a very positive thing, that we hope to see carry forward. We rapidly enabled 90 day supply for maintenance medications in 30 day supply for non maintenance medications, and had contactless delivery to people’s homes.

27:23

We used Uber and Lyft for enrollees that needed to get to urgent and essential medical visits.

27:31

We also recognized that, in many communities, where people were disproportionately affected, and they did not have the ability to go multiple times to grocery stores, which, you know where the shelves were getting emptier and emptier, or, there were lines, etcetera. We expanded our delivery of medically tailored meals, and ready to eat meals and groceries to the homes of those beneficiaries that were coven Positive.

28:02

Or, Due to a medical condition, we’re at much higher risk for complications if they weren’t eating a stable and healthy diet. We also worked with our pharmacy to provide free delivery of medications and educate health literacy and education components included with the delivery, just to remind our beneficiaries of what they should be doing and how they could get additional support from our pharmacist if they needed help. We enhanced our care and resource navigation by adding a dedicated website with critical information and links. So our beneficiaries could in one place get to what they needed. And, again, giving the additional support of being able to call us, should they have questions or need more information.

28:59

And we utilized data analytics to identify those enrollees that we believed would be most vulnerable based on a combination of their medical condition and what we knew about them from a social determinant of health perspective, to do proactive, outbound check in calls. And again, doing a lot of reinforcement and letting people know about resources and that we have the capability for them to reach out to us 24 7. Finally, we are in the process right now of delivering personal protective equipment kits to our enrollees. What we’ve observed is that as some of our providers are re-opening the process, it’s very different. You need to have a mask. You check in, that you have to go back and wait outside. your waiting in a line. People do try to practice social distancing.

29:54

And so doing now more re-education, preparatory planning As our beneficiaries are going to get appointments and making sure they have the types of things they need. Should they need to go for appointments sooner?

30:10

Finally, I’ll just talked a little bit about the evolving regulatory and healthcare delivery landscape and how that has affected the plan.

30:21

I’m very pleased with the way that the regulatory changes have occurred. They occurred in a very agile fashion, very well thought out. And what I’d love to see as we go forward, is that we recognize that our provider landscape is very fragile, and we will need to reduce even more the administrative burden for providers.

30:45

And carry forward. those things that we have done so far that will help to bring a level of stability for providers. so that they can make the necessary changes to their practices to rebuild and get sufficient access, particularly in the communities that have been most affected, which are black and brown communities.

31:09

We cannot afford for there to be further destabilization of the level of access or resources that are needed for them to get the care they need, considering the higher disease burden that they are, those person in those communities are often carrying.

31:32

Thank you so much, Karen. I was wondering if you would just follow up for a minute on some of the regulatory changes and just. Specifically, which ones were, you know, most useful to you all? Are there Are there things that you are hoping will carry through beyond …? Just want to get further thoughts on the regular regulatory changes that were rolled out. That enables you all to meet the need.

32:05

Sure. Top of my list is the telemedicine changes, the telehealth services being that any network provider could be compensated for evaluation, management counseling, and treatment over the telephone. So It didn’t Before. It had to be that.

32:24

It involved video conference services and so allowing for telephonic only was crucial in our providers, being able to very quickly connect knowing that they’d be reimbursed for that time.

32:39

My second favorite has to do with Behavioral Health, and saying that we’re going to relax in some ways, and not hold providers to this very high standard, that if they needed to reach out, let’s say, the primary care provider to help co-ordinate and address needs that we’re not going through this inordinate cumbersome process.

33:06

They’re doing the right thing for the right reason.

33:08

And in my remarks earlier, I didn’t touch on the fact that we’ve seen an uptick in behavioral health conditions, namely anxiety and depression. And, when we look at our re-admission data, we’re seeing that.

33:22

that is the coexisting condition for many of the people that ended up getting re-admitted.

33:29

And so, having that ability to be more flexible, and move quickly, to have providers get connected, to co-ordinate care for those persons that are either already diagnosed with a behavioral health condition, and, or it’s emerging, it’s invaluable in terms of how we move forward. I think keeping that as something as we go forward would would really help to ensure the whole person approach.

34:04

Does its best in serving the people we intend to have the healthy and resilient.

34:12

Great, Thank you so much. And with that, we’ll turn to our final speaker, Phone posh. Beth, go ahead.

34:20

I thank you. Thanks to everyone for joining us today, and thanks to my other panelists as well. So I wanted to talk a few minutes to talk about how Safety net hospitals have been responding to the pandemic. I will just note that my organization represents hospitals, so I can’t speak more broadly to other types of Safety net providers. Although there are many from clinics to individual practitioners out there that are, that are working with Medicaid patients and populations.

34:49

But for Safety Net hospitals, our members are often the first responders to any public health challenge. And sometimes we think of those as natural disasters, such as hurricanes or man-made disasters, such as Mass casualties. They do have trauma centers, and burn units, and high intensive services, in addition to the social services that they provide to their patients.

35:15

So when we think of their first responder role with respect to coven, they were often the receivers of the early cases in their communities. Although many hospitals took care of many patients after that, but they’re also the first responders to the social issues.

35:31

So, when we think about violence, whether it’s a mass casualty event or a more frequently one-on-one violence, those types of cases and patients end up at our hospitals. But beyond that, you know, we really view food insecurity, poverty, housing insecurity. All of those social issues are very damaging to communities and the patients that our members serve, as well. And our hospitals are really the first responders to deal with those social issues.

36:02

In addition, this stress that all of those social issues, places upon populations, it makes it even more challenging for folks in those communities to keep themselves safe and get the care that they need during the pandemic. And while many of them are Medicaid patients and Medicaid is the predominant payer for my member hospitals. It’s also true that many of the patients at these facilities don’t have any insurance or coverage at all, or they may be under insured with private coverage that does not provide coverage for all services, hospital services, or other.

36:40

Um, we know that there have been serious racial and ethnic disparities in terms of the impact of … on these communities. These communities have been hit harder across the country, in terms of the number of patients that have been impacted, as well as the severity of the disease, and the mortality rate. And that really ties back to those larger social challenges.

37:06

So our hospitals have been working to think of not only caring for the medical needs of patients that come in with …, but somebody’s social needs, as well. So if you have patients that are homeless, we actually put on a webinar with our member hospitals, sharing amongst themselves. How are you carrying for homeless patients who have coded? Where are you discharging them too? Many of our hospitals are working with local hotels in the community who have obvious capacity these days to give people a safe place to stay while they recover from kogod. They are looking at how do you address rehab for folks that may have ongoing cardiopulmonary rehab needs after coded if patients don’t have insurance or are in an unstable home environment and obviously food and transportation plays into that as well.

37:59

one more note I want to say about the patients that worked and serving through covert before I can switch to the challenges that the providers are facing is that these same patient populations that have been hit harder by the pandemic have often been more challenged to stay at home and take themselves out of harm’s way from being exposed to the virus in the first place. They tend to be workers that are either working in our hospitals, health care providers, or workers who are working in public transit grocery stores. They have less ability than some of the rest of us do to sit in our home offices and log in remotely to work. They are out there on the front lines every day to keep their jobs to earn their paychecks, and that all comes back to the social issues that they face.

38:49

So that sums up the patient communities and the challenges that Safety Net providers have in addressing these challenges around … in the communities that they serve By talking now about the providers themselves or at least the hospitals.

39:04

Our hospitals, because they care for so many more Medicaid and uninsured patients than the average hospital out there, went into the pandemic, on slimmer financial footing than your average US hospital.

39:18

So, across our membership are 300 plus Safety Net hospitals, their margins before the pandemic were about 2.5% compared to an average margin of 7.6% across all hospitals. That’s the 2018 data, the most recent we have available.

39:36

So when all providers began to experience the financial challenges of the kogod pandemic, which included increasing their operating costs as they went to stand up, more space for more patients, more ICU space, look at their staffing by more protective gear instituting child care on site for their workforce.

39:57

All of those things raised cost per providers. And at the same time, every provider lost revenue, every hospital, at least lost revenue, because they were doing fewer, if not, none. of the other services they provide. Whether it’s elective procedures, cancer treatments, clinic visits. All of that decreased in volume and revenues took a huge hit.

40:21

So for Safety Net providers, those hospitals that really rely on Medicaid predominantly for their payment, they were in slimmer financial footing to begin with. And then those increased costs and decreased revenue really hit them very hard. We spoke with a number of our member hospitals who had, you know, just 1, 2 days, cash on hand, negative cash flow, trying to meet their payroll. And again, they are often the largest providers in these underserved communities. So the very population that’s at risk for economic insecurity sometimes has that stable hospital job. That was kind of in jeopardy as well. So huge financial challenges for Safety Net hospitals, and that really stems from the fact that they rely more on Medicaid funding in the first place to make their revenue goals.

41:14

So Medicaid as we know, is not as good a payer as Medicare and commercial insurance, uninsured patients, patients that have charity care hospitals absorb the cost of that uncompensated care more.

41:27

And so they had more challenges to begin with.

41:31

We’re concerned as Congress and as the administration have begun to, and have been supporting providers moving forward that there has not been as much of a focus on taking care of providing funding to Medicaid dominant providers as at least other hospitals. And I know Sarah touched on this a little bit in her comments.

41:54

So when HHS began to push out the first few rounds of emergency funding, the way that the formulas were written, the allocation formulas, Those providers that had more Medicare patients or more commercial patients, and therefore higher patient revenue to begin with. Those providers received more of that funding than Medicaid dependent providers did release in the hospital space. We know that the administration is looking at pushing out funding to Medicaid. Providers were eagerly awaiting that we’re concerned that we have not seen it yet, and the financial challenges continue for Medicaid dependent hospitals.

42:35

In addition to the funding, which is absolutely critical. I think there’s a number of other flexibilities in the Medicaid phase that we’re hopeful the Administration would push forward, but, again, we have not seen it that yet, So the urgency continues to grow, but looking at more flexibility in terms of waivers and looking at the retainer payment policy that Sarah mentioned, that is an issue to us.

43:00

Another issue that would be incredibly helpful is if more money on Medicaid dish or supplemental payments could be pushed out to providers, that would be helpful. That will involve either some legislative or regulatory changes. But we know that just increasing the amount of Medicaid dish that’s available to states is not enough, but we would also have to kind of raise provider additional limits as well.

43:26

And I just want to make one note about the F map. We’re very supportive of increasing the F map and continuing to increase the map. That is incredibly helpful to states.

43:36

But for those of you that are policy makers or work on policy issues on the line, you know, it’s important to note that increasingly F map to States does not automatically flow money to providers that we’re asking Congress to make sure that if and when they increase F map again, that there be it an OEM maintenance of effort that some of that money flow directly to provider rates. We absolutely recognize the challenges that states are going to be facing with their budgets, and again, F map money is a great help to the states.

44:09

But we do want to make sure that some of that flows through to providers, as well as provider rates are going to be challenged in the upcoming budgetary constraints. And a final note, I wanna say that we’re concerned about, is, there is a pending Medicaid regulation out there from the administration, The Medicaid fiscal accountability rule still pending, but would really have a drastic impact on how states could fund states share of their Medicaid program. And we have been urging the administration not to finalize that regulation. Because we think even, you know, we disagreed with the policy before, and it would take flexibility away from state to fund their Medicaid program. But now with the pandemic, it would be absolutely a crisis for states to lose some of the tools that they’ve been using for years to fund their Medicaid programs as we see budgetary impacts and increased Medicaid utilization likely to come in the future.

45:08

With that, I will conclude.

45:10

Thanks so much, fast. That was fantastic.

45:13

And I wanted to touch on almost all of our panelists talked about Telehealth and some new flexibilities that have been provided in the lifeline, if you will, that that’s been providing, but that’s, maybe we’ll start with you. And then there’s something I’m curious as to what we know about telehealth serving as it is. Is it serving as a substitute care for care, especially in underserved communities? And.

45:54

Maybe why don’t we start with there is it is it isn’t equally successful across the country and lists a variety of populations and how have you all been seeing this kind of play out in the Safety Net hospitals and then I’ll turn to others to jump in.

46:12

Sure. So I actually think that Telehealth has been one of the successes that we’ve seen during the pandemic. It’s timely. I actually received an e-mail from one of my member hospitals today that serves a very disadvantaged patient population, and they noted that they went from zero telehealth visits in February to about 40,000 in April. So the relaxation of federal rules, state, federal regulations, payment issues, as well as from the commercial providers. And commercial insurers as well. I think, has been one of the success stories.

46:49

Absolutely. There are still challenges in getting telehealth to disadvantage patients who may not have internet access at home. The ability to use it, I knew there are still issues with broadband in rural communities, so there are absolutely obstacles that we still need to overcome in terms of using it in vulnerable communities, but I think it has been quite a success story in the last several months.

47:15

To others, while I’m thinking about the communities, including maybe older, older adults as well, who’s also been really hard hit by this and potentially more social, socially isolated than other parts of the community?

47:34

Sure. So, one of the benefits of telehealth is it removes some of the time constraints that pose a barrier to going to an appointment.

47:49

I speak to some of our beneficiaries who have all the best intentions to address their health care needs.

47:56

However, child care, travel, time, work, hours, and constraints is where the challenge comes in. So, telehealth does help to address, in some ways, a number of the social challenges that a beneficiary may face in terms of going to an appointment. On the behavioral health side, there is still a relative amount of stigma and being able to have a telebehavioral health visit helps to reduce some of that. Especially for the populations we serve, where they are already, they’re not already diagnosed. Right?

48:37

So they are the emerging behavioral health conditions, and being able to, without the stigma of going to a behavioral health providers office, begin to access services early and get the support they need. It has been incredibly beneficial. It’s been beneficial as well for our teenagers, right? In some of our communities, the level of violence, and other issues that they are facing. And then, you pile on top of it, not being able to engage with their peer group and get the level of support. Many of them were participating in various programs, in the schools they attend.

49:19

Being able to quickly deploy other mechanisms through which they could stay, how they were feeling, and get necessary supports.

49:27

All of that really lends itself to how telemedicine plays an important role.

49:34

I wouldn’t say it’s a replacement, because there are some things that are really important to do in person. However, it certainly expands access and options so that people can choose what works best for them at a given time.

49:54

This is Sarah. There’s a good blog up, Unhealth first thing was up yesterday looking at the experience of community health centers and telehealth, the weekly data that the Health Resources and Services Administration is, publishing, shows, course, considerable growth, and Telehealth. Although the blog yesterday notes a number of ways in which community based clinics are struggling to sort of capture the full benefit of Telehealth and their end and the problems that their patients run into. I had one clinic, you know, remind me the other day, that, at some point with, a lot of these patients, they’ve gotta come in. For the care, that, they reach a point where they need to test on. They need something done. And so, it gets, you certainly are the initial hump, but it’s, you know, it has, it has its limits and requires a fair amount of resources to adapt to it.

50:54

I think the remarkable thing about telehealth as we took something that oftentimes we would pilot over months and then take years to implement, and we did it in days, in many instances, serving many populations. But I’m spending the last 75 days helping the state of Arizona and then working with the individuals with Developmental Disabilities Program, And we’ve seen successful significant uptake. And things like speech, occupational therapy, physical therapy. So, really, it’s been a tremendous transformation of the delivery system, responding quickly, trying to serve members, and really being successful. Is the fidelity perfect. No. There’s going to be a lot of lessons learned for providers to share amongst providers and payers to share with providers as well, but it’s been, I think, an incredible way that the delivery system has responded to them.

51:49

I think the point I think the point about providers of services to children and adults with developmental disabilities, Tom’s point is a really vital one It’s remarkable how how how effective these forms of communications with with with this particular population are. And, of course, it’s enormously important for family members who are trying to do the best they can with children and adults who suddenly have lost all of their community based services.

52:25

Great, thanks to all of you. That flexibility around the use of telehealth, in many cases, has been done through the approval process through the administration. We talked a little bit about waivers, but I wanted to give you a moment to terrorist about waivers that you have been most useful, critical changes, regulatory sensibilities beyond the telehealth piece that we’ve been talking about, and are there changes that may not be temporary just to kind of get us to the closing process. But you may just be lasting, and maybe Telehealth is in is in that boat, but are there other Weavers and regulatory flexibility is really useful in this time to help medical response?

53:24

Can I, can I just jump in for one second and say, I’m someone who writes a lot about various Federal waiver Authority, Program waivers, research, demonstration Authority?

53:36

But that’s the thing that is of greatest concern to me, at the moment, at least federal administrative policy, is concerned, is that CMS really does not need all of the sort of additional mechanical complexities of waiver authority. The Medicaid statute is a remarkable law. There are 2 or 3 provisions that gives CMS the authority, and they have used it. They have used it in the past To simply develop some new policy and guidance.

54:13

As it’s done its guidance, it can be, you know, time limited to the period of declared pandemics, but under their general authority to ensure that Medicaid is administered by States in a proper and efficient manner.

54:31

The end And in the best interest of recipients, switches, express requirements of the program. CMS could be doing a lot that simply, and it’s much more instantaneously give states the power to adopt flexibility options without having to file extended way for proposals. We sort of fallen into this Trap of thinking always about waivers And the agency seems to have lost its way in looking just Called legal. I, at the stats that say, you know, with this is, these are the, this is the power we have as, the, as the administrative agency, to put some guidance into action. And you know, why? I know, there are good reasons why they won’t take that route, but the waiver process is, in addition to being quite constrained, is just slow, is slow for states.

55:33

From my perspective, could go ahead, Karen.

55:36

Oh, I apologize. So, with the concerns that a number of us have expressed about the providers And, you know, how many of them may end up closing, or how long will it take for some of them to open and open under different circumstances, and, you know, having to change their practices.

55:59

one of the things, the district waiver that I sought should continue is the fact that we were allowed to reimburse out of state providers who are enrolled in Medicare and Medicaid and other states, to be able to provide services, to district residents, right? Because we will need that additional capacity as providers gain their footing.

56:24

And so, my recommendation would be that all the waivers are looked at, and we say, based on what we know about the trajectory of recovery, what are those things that should remain in place? So that the recovery can happen at a good cadence over time, and so that’s one of the ones I thought would be important going forward.

56:48

I was just going to touch on. I applaud Medicaid directors who, in addition to maybe looking at Federal waiver authority, have leveraged, oftentimes the flexibility that managed care could break. And they’ve done that through things like directed payments working with their plans. And so even though as Sarah has highlighted and others’ concerns about the retainer policy at the Federal level and it largely being limited to just a couple of different smaller services, state Medicaid directors have been working to leverage sometimes the flexibility that managed care up. And then Karen did a great job of talking about all the things her plan is doing. In addition to that, so, you know, I think that’s part of how states have responded to this very fluid situation.

57:40

Thank you so much. And thank you to everyone that’s been contributing questions. We have just a few more minutes, and I, there’s no way we’re gonna get to all of these questions. So I’m gonna end with the broader question and ask all of our panelists to jump in. So it’s a multi-pronged question.

58:03

Questions and concerns and interests around how, how large we, how much growth there might be in Medicaid this year. No total total Medicaid growth. It’s already the largest insurer. And given that does, does the expansion of Medicaid. And I mean, that not in the political expansion decision, in the expansion of enrollees in terms of the need to change the trajectory of the US, potentially moving to a more universal offering coverage. And what does the very real financial burdens? From the federal side we’ve talked a lot about the state budget situation to be counter-cyclical, but that means that.

59:01

It really will grow in terms of federal responsibility.

59:06

So, as we as we look back on this and see about the program that’s growing in size, and the need, but, also, the need to kind of limit spending. What are your thoughts on, you know, does this status for learner, Does that set us back on making sure all Americans have affordable health insurance?

59:27

So, if I can just jump in first, I think it reinforces the importance of Medicaid as part of the overall delivery system. And particularly, on many of the points the panelists have talked about, in terms of the population served, and I’m not making a political statement by this, I’m just looking at history. It’s ironic that people often talk about Medicare for all and things like that yet, but we look at, every time Congress has dealt with the uninsured or other things like that. It’s been Medicaid as the platform that they’ve used, whether it was a form of children’s coverage with chip, which often ended up in Medicaid, or the ACA, or other expansion opportunities going back over the last 50 years.

1:00:05

So Sarah knows the law a lot better than I do, but that’s been my observation of how this has played out.

1:00:12

I would just say I couldn’t agree more with Tom. I mean medicate just like looking in a mirror.

1:00:19

It’s just a reflection of a whole lot of other choices in society. So we have millions of people who work at low wage jobs, is no employer plan. We have chosen to create a marketplace where the subsidies don’t kick in until you hit 138% of poverty. We’ve done all kinds of things that have enrolled over onto the Medicaid program, We’ve allowed ESI cost to get so high that families can afford the coverage for their children, anyone. We can go on and on and on. And so looking at Medicaid grows is simply looking at a series of market in political failures in life, you know, if we want to replace a multi payer system with a single payer.

1:01:06

If we want to do more in the subsidized private insurance space, Medicaid would not be as necessary as it is but medicate Nesa … because of all of the failures in the co exist, along with it.

1:01:25

This is Beth. I would just kind of add with respect to the pandemic. You know, I think this has been an emergency that has shown us on one of the widest scales possible. How quickly, individuals’ personal situations and employment can change. And we went from pretty low unemployment rate to skyrocketing unemployment, virtually overnight. And a lot of folks who would never, perhaps, have seen themselves without health coverage. And, you know, any other circumstances find themselves without it now, and be turning to Medicaid, and probably even more so in the future. So, I think the importance and significance of the Medicaid program has really been highlighted through the pandemic as the backstop to provide coverage for folks who suddenly have lost and otherwise.

1:02:15

This is Karen. I would say that our economic recovery is going to hinge greatly on figuring out the right ways to leverage the flexibilities in Medicaid, the lessons learned through this pandemic.

1:02:31

If we cannot get people back to work much of the economic improvement, will it will fail, Right? So, we have to figure out those levers and policies to enact and keep or tweak that, help people to get back to work and they cannot get back to work if they’re not healthy. And so we have to figure it out, this has created a burning platform for us to have the important conversations and to do that re-imagining of what’s possible to, to do it in the most fiscally appropriate way. Certainly, however, we can’t avoid it. I don’t think anymore.

1:03:16

Thank you so much. But a great note to end on. Unfortunately, that is all the time we have today. Please stay tuned for announcements about additional programs in this series later this week. Please complete the brief evaluation survey that you’ll receive immediately after the broadcast ends, as well as via e-mail later today. As you mentioned, a recording of the webinar will be available on our website. And just a final thank you. to our panelists as Tom, Sarah, Karen, thank you so much for joining us, and thanks to all of you for joining us. And please stay safe. And everyone be well. Thank you.