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Technology has done amazing things for us, as individuals and as a society. We take our ability to order items online and have them delivered to our front door for granted. 

We can order groceries online and either have them brought to our car in the parking lot without having to enter a store or have them delivered to our house. And that information we freely provide on Facebook and Instagram has allowed aspiring entrepreneurs to target us down to a specific niche with products we didn’t realize we wanted and most likely don’t need.  

But perhaps it takes a pandemic for us to appreciate this technology and expand it. Because there are many other areas of our lives that could be positively impacted by technology, if only we would allow it. 

As the coronavirus began to spread, two of the immediate healthcare concerns revolved around limited access to medical professionals and a fear of being in the same facility of someone who has the virus. After all, we’re supposed to be social distancing. Thankfully, telemedicine is available to provide you healthcare access in your living room. 

To expand access, we began to see states waive the requirement that you can only use an in-state physician in March. Mississippi did that. And then just as quickly walked back that change to only allow this if you have a prior patient-physician relationship, greatly limiting your options as a consumer. Mississippians should be able to access the doctor or nurse practitioner of their choosing, regardless of the state they are licensed and whether or not you have had a previous face-to-face visit.

The same story holds in education. As every school in the state was shut down, an order from Gov. Tate Reeves called for all school districts to adopt distance learning for their students. Prior to that, Mississippi has had a number of chances to make online learning a reality. Unfortunately, the decision makers have shown no interest in the idea. 

Mississippi has a virtual public school, but it’s simply a couple courses a student can take, not a full distance learning program. Every student in the state should have the ability to choose from a plethora of digital options to serve their needs. We are told how hard it is to bring teachers for specific subjects to the most rural or impoverished regions of the state. This could fill that void.

Moreover, virtual charter schools are prohibited in Mississippi’s limited charter law. Some states even have a hybrid mix of homeschool/ charter school facilities where students attend a couple days per week while still doing most of their education at home. Families are able to decide if and what is the best option for their children. Some do a 100 percent virtual program. But not here.  

And the renewal of the Education Scholarship Account program for students with special needs strips online learning from the inclusion of educational expenses families can be reimbursed for, a move that was championed by opponents of the program. It hasn’t exactly aged well. 

Where else do we limit technology? After healthcare regulations, the most commonly lifted regulations during the pandemic revolved around alcohol. Which makes sense because it is one of the most overregulated industries, often related to prohibition-era policies. 

In another move that hasn’t aged well, the Senate soundly defeated a bill to allow direct shipment of wine to your house just a couple days before the legislature originally recessed. We then saw some alcohol regulations lifted by the Department of Revenue, but having alcohol delivered to your door – either what you purchase from a winery in California or by using a delivery app like Drizly, which functions similar to Uber Eats or DoorDash – remains illegal. 

Is this the most important issue in the state? Obviously not. But it is symbolic of a state that often does not trust its citizens to make the best decision for themselves and rewards incumbents who play the political game. The technology is there, whether it’s for your child’s education, to sell food you make from home online, or something that an entrepreneur creates tomorrow, we just need to let it happen. Unleash technology and consumers will benefit. 

This column appeared in the Meridian Star on May 8, 2020.

Healthcare has long lagged behind other industries when it comes to innovation. But that is usually because of regulations, not because of a lack of entrepreneurs.

Telemedicine is an option that has picked up momentum as the coronavirus pandemic spread and people began looking for safer options than an in-person visit at a healthcare facility. But it is often underutilized – both by healthcare professionals and individuals, often because of state or federal regulations. 

The same is true of the delivery of medications. 

About half the states in America, mostly west of the Mississippi River, allow some form of telepharmacy. What is telepharmacy? As the name implies, it is the delivery of pharmaceutical care via technology to patients at a distance, often in areas where access to a pharmacist is limited or not available.  

The regulations around telepharmacy vary greatly by state. For example, a common anti-competitive regulation is to prohibit telepharmacies from operating near traditional pharmacies. 

This may be another store, which serves as an expansion of a current retail pharmacy or a kiosk. 

The store-based model is staffed by one or more certified pharmacy technicians, supervised by a pharmacist, who reviews prescriptions and conducts live-video consulting with patients before drugs are dispensed. 

Beyond stores, we also have kiosks that allow patients to get their prescription from what is essentially a vending machine. When we speak about social distancing, this is the tool that can meet that need, along with newfound convenience. 

No, you can’t just go and get whatever you’d like without a prescription. The kiosks, which have a pharmacist on call for your help, have a digital address to which prescribers can e-prescribe or users can scan their phone with their prescription. Depending on the provider, you can upload your prescription to an app and know when it will be ready. Customers then enter their identification and insurance information and can pay with cards or cash. In some cases, the kiosks may be outside a hospital or on a college campus. Or they may be outside a retailer.

We’ve seen this technology before. Similar to ATM machines or RedBox, the kiosks provide a new level of convenience – as well as privacy – to customers. And they usually cost less without the staffing and other overhead expenses usually incurred by traditional brick and mortar pharmacies. 

This is technology that is available today that is benefiting residents of other states. It can lead to cost savings for consumers and allow us to keep our distance in a world of social distancing.

First, Mississippi would need to legalize the technology. 

In this episode of Unlicensed, MCPP’s Brett Kittredge talks with James Broughel of the Mercatus Center at George Mason University about the regulatory changes we have seen in light of the coronavirus pandemic and where we go from here. 

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As a virus sweeps across the nation, it was revealed that we were critically short on certain medical necessities including hand sanitizer, masks, and ventilators. Many feared for what would be a soon to come shortfall on these items that are medically critical to prevent further spread of the virus and effectively treat those who have it.

Thankfully, private enterprise has stepped up to the plate in a historic way. Businesses are transitioning to fill the existing gaps and provide the supplies that the country needs. In Mississippi, we have seen local business leaders bravely take risks in order to fill critical medical needs. 

A few days ago, I had the chance to speak with Wright Scott of Great Scott, a high-end clothing store from Jackson that many across Mississippi know well. Wright and his dad, who founded the company in 1986, have shifted their business and have now produced a large quantity of masks to support local healthcare workers.

It’s the classic American small business success story. What started as one man’s vision almost 25 years ago is now a thriving part of the North Jackson economy and culture. Esquire Magazine even ranked Great Scott in the top 50 of men’s stores across the entire country. Before the virus outbreak, they had a thriving professional clothing store, tailor, and even barber shop.

Unfortunately, the virus struck at the height of their events season from February to May, forcing them to shut down the store at a critical time. They acted quickly to transition their business model as much as they could. Great Scott has used a variety of technological approaches including email, texts, calls, and FaceTime to connect with their customers and check in on them.

A trip to New York, before the crisis began, showcased to Wright the rising trepidations over the virus, and he saw this upon his return to the store as more and more people feared the spread and began to change their habits. He knew that precautionary measures needed to be taken, and so the store took very early steps to guarantee as sanitary and safe an environment as possible. Wright noted to me that, “as a business, they just want to do the right thing.”

As of this writing, since shelter-in-place orders were enacted, approximately 26 million people have been forced to file for unemployment. Recognizing this, the blessing of continued employment has become all the more critical for folks trying to keep bread on the table. As Wright noted to me, “we consider everyone who works here as part of our family.” To Great Scott, this wasn’t just an aspirational principal, but something they acted on as they gave all of their tailors the opportunity to stay employed through the store.

Retaining their tailors allowed them to answer the call when Methodist Rehabilitation Center reached out to see if Great Scott might be able to make them masks. With haste, the experienced tailors of the store moved to begin making high end masks that would ensure the safety of MRC workers. Wright wasn’t the least bit surprised that his tailors were able to make the transition to masks, saying that “not only are they great tailors, but they’re great people. They can do anything!”

When it comes to reopening, the Great Scott team is hoping to get back to work as soon as possible, so they can begin once again making suits and reconnecting with their customers at the store. As to when this might be, Wright noted that he’s “hoping that’s sooner rather than later,” but his primary concern is everybody’s healthy and safety stating that, he “want[s] to do what’s best for the store, the employees, and also what’s best for everyone beyond his own walls.”

At the moment, Wright stated that they don’t have any plans to continue a luxury mask line once this crisis comes to an end, but he’s open to it if people want them. However, business will undoubtedly be different moving forward. We will likely see a transition to a shopping environment that continues to mandate limited numbers present in stores and alternative means of connection with customers, including digital options.

While many are likely missing the experience of shopping at Great Scott or getting a haircut or suit tailored there, I think that folks will appreciate the store all the more in the future, especially knowing how Wright Scott and his team took business risks to help his community when it was most in need. As Wright said to me with such great truth, “as a society we’ll emerge from this even stronger.” 

I think we all hope that that’s the case, and look forward to the day, not too far in the future now, that we can return to more regular work and life routines.

These actors deserve to be highlighted, and so the Mississippi Center for Public Policy is publishing a series dedicated to doing just that. Over previous weeks, we’ve highlighted businesses making masks, making hand sanitizer, and aiding the move to online education. We aim to continue showcasing the stories of these local businesses, who have willingly given up their normal operating procedures to help as many people as they possibly can.

If you know of a local Mississippi business that is helping those in need during this critical time, we’d love to highlight the work that they’re doing. Please email Hunter Estes via [email protected] to discuss further.

Gov. Tate Reeves announced today that the state will be taking a measured approach to reopen Mississippi as the current shelter-in-place order is replaced with a new, safer-at-home order. The new order will be in effect Monday at 8 a.m.

“We are facing a historic economic crisis,” Reeves said. “The economic damage has been particularly cruel to the working class. Those who work on their feet, those who don’t have a home office, or paid leave.”

Many currently closed businesses will be allowed to open under certain circumstances. Retail stores can reopen, but they must reduce capacity by 50 percent based on their designated full capacity. Masks are highly recommended, but not mandated.

A large grouping of currently closed businesses – including movie theaters, bars, museums, casinos, salons and barber shops, gyms, and clubs – will remain closed. Restaurants remain limited to curbside, take out, or delivery as dining rooms are still closed. 

Gatherings of 10 or more remain prohibited, and Reeves said this will be enforced. There is also a classification of the most vulnerable, including the elderly and those with pre-existing health conditions, who are required to continue sheltering in place. 

Still, Reeves continued to stress personal responsibility asking all Mississippi to stay at home except for essential travel.

“That’s still the safest behavior,” Reeves added. “You still have to be smart. You are responsible for your safety and the safety of your loved ones. We trust Mississippians to make good, personal decisions.

“There is not a government replacement for wisdom. We believe in personal responsibility. You should do what you think is best for your family.”

Municipalities are allowed to be more strict, but they are not allowed to be in conflict with the state order as it relates to designated essential businesses.

The order is in effect for two weeks, though Reeves sounded very confident that they may review the order prior to see if more of the state can open up. 

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:

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:

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:

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. 

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.

Jackson Mayor Chokwe Antar Lumumba has extended the city's stay-at-home order.

Initially implemented at the end of March, the order has been extended until April 30. Hinds county has also extended their closure until May 1. Hinds county has the most coronavirus cases in the state at 301, as of April 16.

Generally speaking, these orders close nonessential businesses and only allow residents to leave their home for specific, approved needs.

Under an order, you can still shop for groceries, pick up medications, pick up food from a restaurant, help family members in need, and exercise outdoors. 

Essential businesses include hospitals, healthcare facilities, grocery stores, pharmacies, child-care centers, as well as a variety of sectors such as utilities, transportation, and finance and banking. 

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