Preserving critical public health services: Creating reimbursement strategies with private and public health plans

Thursday, March 7, 2019

The Situation

With little or no available funding, many public health authorities at the state and local level struggle in their mission to deliver essential health services to their communities’ most vulnerable populations. To overcome these obstacles, they are seeking funding through alternative methods.

The Affordable Care Act (ACA) expanded the set of services eligible for third party reimbursement, and certain preventive services are now mandated for coverage by both public and private plans. This creates opportunities for public health officials to expand their sources of funding, helping them to deliver critically important services and better outcomes for their communities.  

The Challenges

In 2009, H1N1 flu pandemic spread to 74 countries around the globe. In Massachusetts, the Department of Public Health (MDPH) responded quickly to ensure that that public providers had access to the H1N1 vaccine. However, the MDPH was challenged in helping already over-burdened communities to pay the additional, unbudgeted costs of administering the vaccine.

Health plans understood the grave urgency of responding to the pandemic in a thorough and timely fashion by providing their members with as many ways as possible to access the vaccine. At the same time, they expressed concerns about providing services outside their respective primary care networks.

The Solutions

Through initial funding and assistance from MDPH, UMass Medical School’s Commonwealth Medicine division helped to establish a mechanism for public providers to submit claims and receive reimbursement for flu immunization services.

Subsequently, Commonwealth Medicine was able to draw on its experience in responding to the flu pandemic in partnering with state and local authorities in Massachusetts and Maine, helping develop a variety of billing and reimbursement solutions for the challenges faced by public providers. These include the following:

  • For cities, towns, and school districts in Massachusetts and Maine, key contracts were established to provide a comprehensive solution for centralized billing and reimbursement.
  • By enrolling the Massachusetts State Public Health Laboratory (MSPHL) as a provider for the state’s Medicaid plan (MassHealth), Medicare, and various private health plans, the MDPH was able to bill and receive reimbursement for services offered by its Sexually Transmitted Infectious Disease Unit. This unit, which receives specimen submissions from providers across the state, provides comprehensive laboratory services for disease surveillance and investigation, ensuring the critical link to care that is consistent with public health goals in the treatment and prevention of sexually transmitted infections.  
  • Commonwealth Medicine also identified opportunities for MSPHL to streamline the collection of billing data to more effectively navigate ever-changing requirements for submission of claims. This helped ensure that the laboratory continues to receive funding for another critically important program – Childhood Lead Poisoning Prevention Program.

Results

The Centers for Disease Control (CDC) cited the vaccine reimbursement program pioneered by Commonwealth Medicine as one of six “Billing Success Stories.” The CDC also frequently recognizes MDPH for achieving some of the highest immunization rates in the country.

The effectiveness of Commonwealth Medicine’s support for public health initiatives across New England is clearly reflected in the numbers:

  • Annual revenue collected for services provided at local vaccination clinics in Massachusetts and Maine reached $2.2 million in 2018, up from $330,000 in 2010
  • The number of local health departments, school districts and visiting nurse associations taking part in the vaccine reimbursement program increased from 80 to 189 over the past decade
  • The number of public and private insurers paying for the vaccination clinics doubled from six to 12 (2009 – 2015)
  • Reimbursement to municipalities has expanded from the administration of influenza and pneumococcal vaccinations to include all child and adult vaccinations routinely recommended by the CDC’s Advisory Committee on Immunization Practices.
  • The MSPHL experienced steady reimbursement growth for sexually transmitted infection and blood lead testing service, with more than $1.6M anticipated for FY2019 laboratory services.