On the Front Lines of COVID-19: A Blueprint for Health and Human Services from Washington State

Introduction

In January 2020, Washington State reported the first positive novel coronavirus (COVID-19) case in the United States. The number of cases in the state has since swelled to over 5,000, with 201 deaths, as of March 31, 2020. Since that first diagnosis and the COVID-19 outbreak that followed at a long-term care facility in a Seattle suburb, the public health departments for Seattle and King County, the Washington State Department of Health, Governor Jay Inslee, and others have been among those leading the US response, working tirelessly to create and implement plans to best serve Washington State residents. The latest data indicate that the state may be slowing the spread of the virus, and on April 5, Governor Inslee announced that the state would return more than 400 ventilators to the national stockpile for use by other states. The Washington State Health Care Authority (HCA), under the leadership of coauthor Susan Birch, oversees care for 2.5 million Medicaid beneficiaries and public employees and has been an integral part of the state’s efforts to combat COVID-19. This article outlines the major initiatives taken and the lessons learned in this intense and historic six-week period.

Setting Priorities

At first, the state COVID-19 response was frenetic. As diagnoses and deaths increased, a flurry of activities and information gathering occurred at all levels of government. HCA, which sits at the intersection of the state’s health providers and public and private insurers, began to serve as a crisis hub and a liaison between the Centers for Medicare and Medicaid Services (CMS) and the governor’s office. Once epidemiological data indicated that Washington State’s anticipated surge in health care needs would likely occur in the first couple of weeks of April, it was clear that a thoughtful, well-organized plan was needed. With that in mind, Washington State has focused on four areas:

• Bolstering care delivery, including preparing for the demand for beds, clinicians, and needed supplies;
• Building a cohesive and clear community response at the local, county, state, and federal levels;
• Enhancing access to care through coverage expansion and support of health providers; and
• Encouraging coordination across local, state, and federal government agencies.

Bolstering Care Delivery

Supplies and workforce. As one of our first steps, we focused on increasing the availability of supplies, such as testing equipment, ventilators, and personal protective equipment like masks and gowns for health care professionals. To that end, the governor is working closely with Vice President Mike Pence, point person for the federal COVID response, to assure more supplies are on their way. The state has also brought in private industries to help with the supply chain and distribution. For example, top purchasing and distribution managers from Amazon and Microsoft have been working with state officials, and Walmart has offered use of its warehouses.

To ensure we have enough health care workers to meet the anticipated need, an executive order signed by Governor Inslee permits new health care workforce flexibility. The order reduces delays in professional credentialing and waives any costs associated with treatment given while credential applications are pending. Additionally, it permits managed care organizations and health care facilities to more easily fill positions or cover absences with substitute health care providers.

At the same time, Washington State is working with the military—through the US Department of Health and Human Services (HHS) and the Federal Emergency Management Association—to obtain additional resources, including equipment, staff, a large pop-up hospital facility, and a medical field station. Activating the Washington National Guard will be critical as we prepare for the surge because they are useful in domains such as staffing food banks and traffic control.

Telehealth. Given the strain on the health care workforce and the need to keep people at home to reduce the spread of the virus, Washington State has made telehealth more available through legislation, governor’s executive orders on telemedicine payment parity, and new federal flexibility on privacy and billing rules for Medicare and Medicaid enrollees. HCA has purchased and is distributing Zoom for Healthcare licenses for video conferences, giving priority to health providers who serve the most vulnerable populations and who do not otherwise have access to this technology. However, the rapid implementation of telehealth is challenging, especially for small providers, so the state is offering phone support to help providers navigate this transition.

Additionally, HCA has finalized a contract with the nonprofit Oregon Community Health Information Network to support a streamlined version of the Epic electronic medical record (EMR) to be used by health care providers that work with communities of need, for community-based patients. This application can be used for testing and triaging for COVID-19 in pop-up sites such as tents and can ultimately be integrated with existing EMR systems.

Rural health providers support. Because the rural health care system is critical to the state’s health care delivery system, yet is financially fragile, the state legislature created and the governor supported a $2 million Rural Health Hospital Emergency Fund for the smallest, most financially strapped critical access hospitals, which serve patients who would otherwise have to travel long distances for hospital care. These funds will be needed to keep hospitals’ doors open as they care for COVID-19 patients and cut back on elective procedures. Many of these hospitals have a patient population that is between 60% and 80% Medicaid and Medicare patients, which reimburse at lower rates than commercial payers, and have very small cash reserves. HCA is partnering with our Washington State federal delegation in Washington, DC, as well as CMS officials, to work on Medicare payment relief and an infusion of funds to rural communities where Medicare payments are provided prospectively and then reconciled to actual costs at the end of 2020.

Behavioral health. Washington State is also taking steps to address the essential need for behavioral health services, which have been disrupted by the outbreak. Many of these practitioners are already in a marginal position financially. We hope to eliminate barriers to compensation and are actively promoting alternative types of care visits such as telehealth and phone conferencing.

Building a Community Response

The only way to fight the pandemic is by building a unified community ready to respond and do what is necessary to stop the spread of the virus. Governor Inslee was quick to establish an Emergency Operations Center, and HCA has played a key role in informing the center’s priorities as it has evolved. Governor Inslee was one of the first governors to call on state residents to do their part to limit spread by closing schools, restaurants, and public gathering sites. On February 29, he initiated a Stay Home–Stay Healthy order for all but essential services.

A state COVID-19 web page has been created to provide up-to-date information, including guidance for providers, the general public, health care workers, and businesses. The web page also includes daily statistics on the incidence of the virus and a hotline for people to call with questions.

In addition, for any communication with enrollees or insurance carrier members, a newly formed HCA committee ensures all information is consistent, clear, and up-to-date. More recently, the information is also shared with the Emergency Operations Center. Communications are translated into key languages.

Enhancing Access to Care

To ensure more Washington State residents have access to care, especially in the wake of COVID-19’s economic impact, we are focusing on both coverage and support for health care providers:

• Washington State obtained a federal 1135 waiver that allows for streamlined enrollment in Medicare and Medicaid services, as well as allowing care in virtual settings and waiving prior authorization for more services.
• Partnering with the Washington State Health Benefit Exchange, Washington’s individual insurance marketplace, we have extended open enrollment and are offering Medicaid with no coverage gaps to people who have lost their jobs.
• We are working closely with our Medicaid managed care partners to support very financially vulnerable providers and to reduce providers’ administrative burdens.

Encouraging Coordination

All of the work being done in Washington State by HCA is dependent on coordination with sister state HHS agencies—the Department of Social and Health Services; the Department of Children, Youth, and Families; the Washington Health Benefits Exchange; and the Washington Department of Health—as well as the governor’s office. A prime example is HCA’s collaborative work with the state insurance commissioner to ask health plans to waive all cost-sharing associated with testing for COVID-19.

To improve coordination, Governor Inslee on March 22 appointed retired Navy Vice Admiral Raquel C. Bono to lead the COVID-19 health care response team. In this role, Bono is advising the governor and his staff and state agencies on actions needed to address the capacity and strain across the health care system. She is working closely with acute care, long-term care, clinics, primary care providers, and tribal facilities, along with the federal government, to assess and address the greatest needs. Her role also includes working to ensure medical staffing needs are met, as well as developing standard protocols across facilities and coordinating with the state Emergency Operations Center to operationalize statewide efforts.

As a Medicaid agency from one of the first states facing this crisis, HCA has worked directly with the federal government and has had access to top leadership to meet Washington State’s specific needs. CMS has helped the state develop waivers and identify options for modifying its Medicaid program and recently released sweeping new regulatory changes to improve access to care.

Lessons Learned

In light of all that Washington State has done so far, what do we know now that we wish we’d known at the beginning?

• The importance of a mobile-ready state workforce equipped with laptops and software to allow them to work remotely, and the need for government workers to be able to shift to evolving policy quickly and efficiently.
• The ongoing importance of supporting and listening to our own internal staff. We needed to create ways for employees to share information and feel supported in their telework, such as through internal newsletters.
• The importance of communication and coordination with our participating health plans for public and school employees and Medicaid managed care organizations to ensure we are delivering coordinated messages to health providers. Health plans have clinical and leadership expertise to help all of us in problem solving.
• The importance of telehealth. Telehealth is one of the key ways of delivering health care in this pandemic, yet the guidance on billing is still confusing for many providers and not all of them have the necessary technology.
• The importance of engaged hospital and long-term health jurisdiction partners.

Most important, we have learned about the “culture clash” ingrained in any bureaucracy. “Sprint” teams, creativity, and a command of military-type language is critical as emergency management and state government teams work together. Both teams need to work through understanding who is in charge and who can make decisions in a given situation. In times of a crisis, we need a clear, centralized decision-making structure.

In the midst of this disaster, we have been fortunate to have a governor, legislature, and public health system working together to respond. Even with all of that, the number of cases of COVID-19 and the number of deaths continue to rise. Our work to flatten the incidence curve requires us to be nimble and collaborative, and we are grateful for recent signs of progress.

About the Authors

Sue Birch MBA, MSN, RN, Director of the Washington State Health Care Authority, serves as the state’s largest health care purchaser for more than 2.5 million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board Program, the School Employees Benefits Board Program, and the COFA Islander Health Care Program. Appointed by Governor Jay Inslee in January 2018, Birch oversees efforts to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

MaryAnne Lindeblad, BSN, MPH, the Washington State Medicaid Director, brings a broad health care and administrative background to the top position in the Washington State Medicaid program. Lindeblad, has been an active health care professional as well as a leader spanning most aspects of health care including acute care, long-term care, behavioral health care, eldercare, and services for people with disabilities.

Eileen Cody, RN, Legislative Representative, House of Representatives 34^th District, currently serves as chair of the House Health Care & Wellness Committee, where she has worked for improved patient safety, mental health parity, public health services, and restoration of the universal purchase of vaccines. More recently, she has led efforts to implement the federal Affordable Care Act at the state level. Largely because of her work, Washington’s online health care marketplace, Washington Healthplanfinder, is a model for the rest of the country, helping thousands of Washingtonians access affordable coverage.