Mississippi is projected to have the medical resources needed when the state hits its peak medical equipment usage from the coronavirus pandemic on Thursday. 

That projection is according to the Institute for Health Metrics and Evaluation at the University of Washington.

The state will need 100 ICU beds, while 340 are available. The state will need 410 hospital beds, with 5,733 available. Eighty-nine ventilators are needed.

Louisiana is the only neighboring state to have insufficient resources. It hit its peak on April 14, with 648 ICU beds needed and 477 available.

Most shortages were in the Northeast, which has been the national hotspot for coronavirus. Connecticut, New Jersey, and New York all had deficits of hospital beds and ICU beds. Massachusetts did not have enough ICU beds. 

For the most part though, beds have not been an issue. 

"Saving Mom’s Sanity, LLC is a ministry that helps moms keep their households running smoothly.

"We offer task-specific packages named for biblical women. Appointments were made through our Facebook page. Since the shelter-in-place, we have been unable to work, unable to come alongside moms, unable to earn income.

"The last month has been extremely difficult. We’ve gone from serving 15 to 20 families per month to zero. As a ministry, cost has never hindered service: we work within each family’s budget.

"We’ve lived on a shoe string budget ourselves in order to serve others. With no income, it has been extremely difficult.

"Beyond the infringement issue, it’s well beyond time to put our people back to work. Those who are afraid should stay where they are most comfortable and let the rest of us resume business with common sense protocols in place."

Tia McArthur
Saving Mom's Sanity
Clinton, Mississippi

Medicaid is a joint state-federal health insurance program partially funded by each state and the federal government. The program, in fact, provides little opportunity for states to adapt to diverse healthcare challenges, such as changing demographics and rising healthcare costs.

During the initial COVID-19 outbreak, however, the federal Centers for Medicaid and Medicare Services (CMS) offered states some flexibility via three different types of waivers. In turn, the Mississippi Division of Medicaid took advantage of these opportunities, pivoting quickly to get existing Medicaid resources to the elderly and the disabled. This brief will examine the three different types of waivers – 1115 waivers, 1915 waivers and 1135 waivers – that are available to increase access during pandemic outbreaks like that brought on by COVID-19.

Use 1115 Waivers to Expand the Supply of Healthcare

An 1115 waiver allows states to waive certain statutory requirements related to their Medicaid programs. Typically, 1115 waivers have been used to expand Medicaid services or enrollment to new populations, but the Trump administration has rightfully urged states to consider reforms aimed at channeling care to the most vulnerable of the uninsured.

Effective March 1, 2020, CMS created a fast track process that allowed states to “focus agency operations on addressing the COVID-19 pandemic” by using “established” waivers with “proven program outcomes.” The waivers expire no later than 60 days after the initial coronavirus health emergency ends.

One of the available waivers would extend home-based services to individuals who would otherwise require care in an institutional setting. The target populations are the elderly and the disabled who have functional and chronic illnesses or disabilities. This waiver interacts with the 1915 waiver discussed below. 

A second 1115 waiver enables states to “accept self-attestation of applicant resources.” In effect, this waiver suspends verification tools (such as those created by the HOPE Act) that ensure Medicaid resources are being used by those who actually need them. At the same time, the waiver blunts the arguments of those who might claim we need to expand Medicaid during the current crisis. In any event, CMS also seems to be fast tracking Healthy Adult Opportunity waivers meant to encourage Medicaid expansion to able-bodied, childless adults. 

In what follows, we wish to suggest 4 additional 1115 waivers the Mississippi Division of Medicaid should adopt as we recover from the current COVID outbreak and prepare for additional outbreaks. These waivers will help increase access for patients in urgent care situations as well as provide additional options to existing Medicaid beneficiaries. 

--> Increase cost sharing for unnecessary emergency room visits and missed appointments

Hospitals and other medical providers are already strained to the breaking point by COVID-19. In recognition of this, the Trump administration is allowing some flexibility regarding EMTALA requirements. (The Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals that accept Medicare funding to screen and treat or stabilize any individual seeking emergency care, regardless of ability to pay.)

Likewise, Mississippi Medicaid should discourage unnecessary emergency room visits by using an 1115 waiver to require a higher copay.^[1] At least one state, Arizona, has a limited waiver to charge a copay for non-emergent ER visits. Mississippi should do the same.  

Clearly, hospital emergency rooms must be able to fully focus on medical emergencies, both COVID and non-COVID related. Charging a copay for non-emergent visits will preserve scarce resources for those who need them. This is especially the case as we are seeing hospitals hit capacity limits in hot spot areas. This policy will also reduce the exposure of Medicaid patients to the coronavirus.   

Likewise, Medicaid patients who miss medical appointments should be charged a copay. Studies show that Medicaid patient no-show rates are almost twice as high than it is for other patients and, in one study, five times higher than for uninsured patients.

CMS has yet to allow states to charge a copay for Medicaid beneficiaries who fail to cancel an appointment.^[2]During the COVID-19 outbreak, however, such a waiver makes good sense. Moreover, we need to set in motion policies that will encourage an efficient use of resources in a post-COVID healthcare landscape. Such policies will enable providers to give targeted care to patients who actually need to see a doctor. 

--> Innovate Medicaid transportation services

One reason some Medicaid patients miss appointments is because of inefficiencies related to Medicaid transportation providers. Thanks to a 2017 rule change from the Trump administration, healthcare providers may now provide free or low-cost transportation services to patients. The administration is also looking at an additional rule change that would provide more flexibility in this area.  

Mississippi already offers generous transportation services for Medicaid insurance beneficiaries, with no copay required. The state is currently using a broker to supply transportation. It is unclear what cost savings is being derived from this arrangement. In any case, states need to be incentivized to work with rideshare services like Veyo, Uber Health and Lyft. An 1115 waiver could be crafted that allows the state to divert savings from non-emergency transportation to high-need areas, such as home and community based services waiting lists. Administrative changes might also make this possible. The thing to keep in mind is that the state needs to be able to pocket the savings that comes from using innovative ridesharing services.  

In light of the COVID-19 crisis, it is also important to reduce instances of missed appointments, which would help protect providers from financial losses.

It’s time for Medicaid to start to use existing transportation technology more effectively. As we have discovered during the coronavirus outbreak, healthcare resources are not infinite.   

--> Encourage more use of telemedicine

Telemedicine is a technology a patient can use to access a healthcare provider even when the provider is not physically present. This can be done through a variety of electronic services that enable providers to remotely offer care to their patients without the overhead costs associated with the traditional medical office model. In response to the current coronavirus outbreak, the Mississippi Division of Medicaid expanded telemedicine availability. Not only do these changes need to be made permanent, they need to be expanded upon.

The COVID-19 outbreak has exploded the myth of infinite supply in healthcare. Supply is not limited. It never has been, which is one reason healthcare in the United States is so expensive. But the supply of quality healthcare can be increased by cutting red tape. For instance, multiple rules and regulations have been hindering the supply of telemedicine in Mississippi.

Even before the coronavirus outbreak, Mississippi Medicaid was expanding access to telemed. More can be done. In particular, Governor Tate Reeves should pursue reforms that allow healthcare providers licensed in other states to offer telehealth services to Medicaid beneficiaries in Mississippi.

A study published by the American Journal of Emergency Medicine found that telemedicine substantially lowered healthcare costs, diverting patients away from “more expensive care settings.” In the current COVID world, such diversions can also lower potential exposure, reducing the need for even more expensive interventions. Mississippi Medicaid should do all it can to expand the use of telemedicine so as to provide relief for over-burdened hospitals and provide safe, high-quality care to patients.

--> Incentivize high-quality alternative surgical options 

Mississippi has among the highest COVID-19 hospitalization rates in the country. With this in mind, it is vital that the state Medicaid program incentivize the utilization of ambulatory surgery centers (ASC) in order to reduce pressure on hospitals struggling to respond to the coronavirus pandemic. The use of ASC has great potential in further mobilizing all medical resources to respond to future outbreaks.

This move to incentivize ASC could be accomplished through an 1115 waiver (or, as applicable, administrative changes) that increases the current copay for hospital outpatient department (HOPD) use. (The current copay for both ASC and HOPD is $3.00 per visit.)^[3] Prior authorization requirements should also be reviewed so as to encourage the usage of ASCs over HOPDs.

Diverting patients from more expensive hospital settings would preserve hospital resources for high-risk patients. Additionally, prior-authorization requirements for HOPD would make sure that these settings are being utilized by the patients who need them most. 

Ambulatory surgery centers have saved billions of dollars for both commercial insurance and Medicare insurance beneficiaries. In the state of Mississippi alone, Medicare saved $70.1 million from ASC use in 2017. It’s time for Medicaid to follow private and Medicare insurance providers in obtaining similar efficiencies.

Use 1915 Waivers to Help the Elderly and the Disabled

A second type of federal waiver being used to provide assistance to high-risk populations during the coronavirus outbreak is a 1915(c) waiver. These waivers are issued under the authority of section 1915(c) of the Social Security Act. The so-called Appendix K addendum allows for the expansion and or modification of Medicaid-funded home and community based services (HCBS) during an emergency.

Mississippi has approximately 23,000 people enrolled in HCBS waivers. The purpose of the waivers is to provide home-based care that allows people to avoid being placed in an institutional setting, such as a hospital or nursing home. The primary beneficiaries are the elderly and the disabled.   

Mississippi is using the 1915(c), Appendix K waiver to increase the availability of home-delivered meals and home-based services, among other things. The waiver will be in place until January 26, 2021.  

Monitor the Use of 1135 Waivers

Mississippi was one of the first states to obtain an 1135 waiver in response to the coronavirus outbreak. The policy essentially waives various compliance requirements. The 1135 waiver for the state of Mississippi allows the following, among other things:

Waives/modifies pre-authorization requirements for fee-for-service benefits covered by Medicaid. … The state is allowed to temporarily waive or modify requirements that certain fee-for-service benefits receive preapproval. Pre-existing authorizations are also extended. Some examples of fee-for-service medical services that ordinarily require preapproval include:

•  Cardiac rehabilitation services
•  Physical therapy
•  Remote patient monitoring 
•  Expanded home health services

Allows Medicaid providers not located in Mississippi to enroll in Mississippi Medicaid as long as they are already enrolled in another state’s CMS program. … This waiver is only in effect as long as the current public health emergency lasts. It facilitates reimbursement to out-of-state providers.

Allows reimbursement to unlicensed medical facilities in the state of Mississippi due to emergency evacuations, as long as the facility is not utilized for more than 30 days. … The state must ensure that the setting meets reasonable standards of care.

Conclusion

While the 1915 and 1135 waivers discussed here are of limited duration, Medicaid needs to be transformed to better respond to an evolving healthcare landscape. Coronavirus and other outbreaks are likely going to return. The most pressing need for the long-term is to flatten the healthcare cost curve that plagues both private and public insurance beneficiaries in the United States. Flattening this curve while still providing quality insurance coverage to vulnerable patients should be the primary mission of Mississippi Medicaid. Utilizing the 1115 waivers discussed above would enable the Division to obtain some flexibility (with federal permission) to accomplish this task. 

^[1]The federal copay maximum for non-emergency use of an emergency room is $8.00 for those who earn up to 150 percent of the federal poverty level (FPL). A waiver is not necessary to charge a higher copay to those earning more than 150 percent FPL, unless the cost exceeds 5 percent of household income. 

^[2]CMS does allow providers to charge Medicare beneficiaries for no shows. Attempting to collect no-show fees from Medicaid beneficiaries might prove difficult, unless Mississippi Medicaid administered the fee directly, utilizing appropriate penalties.

^[3]Federal law prohibits any kind of cost sharing for emergency services, pregnancy-related services, preventive services for children and contraceptive services. Individuals who earn less than 100 percent of the federal poverty level (FPL) are subject to federal cost-sharing limitations, but states have some flexibility in increasing copays for those who earn more. The federal maximums for outpatient services are 10 percent of the state’s cost for those earning between 100 percent and 150 percent of FPL and 20 percent of the cost for those earning more than 150 percent FPL.

Mississippi’s certificate of need program might have a chilling effect on out-of-state healthcare operators trying to bring services to the state.

Scrutinizing staff analyses dating back to 2001 from the state Department of Health shows that the majority (more than 75 percent) of the 284 applications for a CON were from in-state companies. 

Mississippi regulators approved 244 CON applications, rejected 37, gave conditional approval to two projects and approved one application partially.

While 49 out-of-state healthcare providers received approval (20.8 percent of all approvals), 10 operators (out of 37 denials or 27 percent) didn’t receive approval.

Mississippi’s CON program is largely a rubber stamp, since 85.61 percent of all applicants received approval since 2001. 

Mississippi is one of 35 states that requires a certificate of need, which requires health care providers to seek approval from the state Department of Health to build a new facility, add beds or expensive diagnostic equipment to an existing facility, or any other capital-related project. 

The regulated areas include:

• Hospital and nursing home beds.
• Inpatient psychiatric beds for children.
• Beds in chemical dependency centers.
• Home health services.

CON approval is even mandated for non-care related capital projects such as medical office buildings, the installation of hurricane wind-resistant windows at one hospital on the Gulf Coast and authorization for a hospital to repair damage from a tornado. This requirement for healthcare providers to seek CON approval for post-disaster repairs was removed in 20

Providers are also required to provide updates on whether a project goes over budget. Any capital project by a provider is mandated to provide updates on progress every six months and at the project’s completion. 

Thirty seven requests for a CON were related to cost overruns on capital projects since 2001 or 13 percent of all applications.

Twenty providers applied for certificates of need for diagnostic equipment and all but one was approved. Forty six applications were for construction projects while 16 applications requested a CON to add beds to an existing facility.

When providers apply for a CON or an amendment to an existing one, this initiates a 90-day process. First, the application is reviewed by the Department of Health’s Division of Health Planning and Resource Development to see if it is in compliance with the State Health Plan. This document is a blueprint composed by health department officials to centrally plan the health care needs of the state’s population. 

Among the criteria reviewed by the division include:

• Need for the project.
• Economic viability.
• Possible alternatives.
• Access to the facility for underserved and indigent people.
• Relationship with existing providers in the area and in the state.
• Anticipated quality of care.

Then the division staff makes a recommendation on whether the CON should be awarded. The provider appears before an independent hearing officer who makes findings of fact and issues a second recommendation. The state’s health officer makes the final call on whether a provider receives a CON. 

The only way to dispute the decision is to file an appeal in chancery court within 20 days.

CONs originated from the National Health Planning and Resources Development Act of 1974 that was signed into law by then-President Gerald Ford. This act was intended to reduce annual increases in federal health care spending and one of the cost control measures was to require states to institute CON laws to regulate health care facilities. 

This requirement was later done away with by Congress. 

"I own and run a small catfish farm.

"I cannot sell my catfish to the processing plant because catfish sales are down. The plant I sell to predominantly sells to restaurants which are closed.

"Catfish can grow to big to be processed if we cannot keep restocking and growing catfish. When the economy is reopened, there may not be enough catfish to supply the restaurants that depended on our products."

Wendell Schmidt
Catfish farmer
Clarksdale, Mississippi

"I am the owner of a commercial and residential cleaning service, Cleaning By Brandy.

"My business grew exponentially since I started it in 2015. Up until March 23rd, it was a very successful and thriving cleaning service to most of the Golden Triangle area.

"As soon as stay at home orders were announced, customers started cancelling their appointments in fear of getting sick. In a matter of days we lost all but two of our regular customers, causing me to have to let my helpers go.

"Since I was considered an essential business, I maintained the only two I had left and worked hard to obtain new appointments. That didn't happen. As of now, I only have one weekly and one biweekly customer left.

"As a single mom, the loss of income has been devastating to me and my kids. Still have not been able to get unemployment or food assistance. I try not to worry since I like to believe God will provide.

"But the stress from trying to figure out how to pay all the bills alone has caused me to slip into a little bit of depression.

"We struggle daily now and if things don't change soon I don't know if I'll be able to keep my home. I feel like opening the state back up 100 percent would relax the customer base and in turn business would pick back up."

Brandy Gray
Cleaning By Brandy
Columbus, Mississippi

"I am the co-owner of the Glossary Salon in Florence and of the Tracy Branch Agency, which is a hair and makeup artist team who mainly works events like weddings, proms, pageants etc.      

"Between both small businesses that I own, we have nearly 45 people that work with and for us that are all independent contractors. We have had to close the salon and my team and I have been without pay for over a month. 

"Many of my stylists are the sole earner for their families. Because we get paid by the service, when we don’t work, we don’t get paid. As the owner, the bills for the rent, utilities, and systems don’t stop.    

"The salon is our livelihood. For my hair and makeup team, we are all forced to be out of work now as well because large gatherings are not allowed. Over the last two months- my team has lost hundreds of wedding and event jobs. This is the only way most of them make a living.     

"Assistance has been little to none as most of us are independent contractors and as of now 99 percent of us have been denied unemployment. We applied for the SBA loan but our applications had to be held until they opened it for independent/ self employed workers. 

"Yesterday we were told that the money has run out. I worry and pray for everyone in my work family and every small business owner. We need the ability to be open. We follow all guidelines of sanitation and we will ramp those up to the extreme if we need to, but I pray we can get back to work soon.  

"The financial strain is getting harder by the day and the mental wellness strain is also something I am seeing affecting my team.      

"We want to do the right thing for the health of the community but we also want the right to work and provide for our families."

Tracy Branch
The Glossary Salon/ Tracy Branch Agency
Florence, Mississippi

"I own The Cut Above Hair Salon in Meridian.

"This is my career. I have been a cosmetologist since 1979.

"I depend on customers for my income. We take every precaution for keeping our clients safe and ourselves.

"We are self-employed, so that means no clients no pay. I have utilities and bills to pay. But I need to work to pay these bills.

"Please reconsider opening salons so I can get back to work!"

Mary Miller
The Cut Above
Meridian, Mississippi

Gov. Tate Reeves announced today that he was extending the state's shelter-in-place for one week as the coronavirus pandemic continues to spread in Mississippi. The original order was set to expire on Monday.

"Right now, I have to ask you for one more week," Reeves said. "One more week of vigilance. One more week of sheltering in place. And then we can begin to reopen our state."

Reeves spoke about the financial hardship caused by the outbreak, noting that government resources have not kept up with demand.

"There is no replacement for paid work," Reeves said. "There is no replacement for providing for yourself and your family. We've pumped trillions into our economy and many small businesses are about to fold. I want this to end as quickly as possible."

The lockdown on non-essential businesses is easing some, with extended options for drive-thru, curbside, and delivery services now available for industries including clothing, florists, or sporting good stores. Lakes and beaches will also be able to reopen.

The new order will be in effect Monday at 8 a.m.