1.3 DPH Existing Programs NC DHHS should support legislation to increase funding for the NC Sickle Cell Syndrome Program to ensure continuous care and treatment for people with SCD. Implementation: • NC DHHS should support legislation to increase funding for “Sickle Cell Adult Treatment” (fund code 1421) and “Sickle Cell Support – Children” (fund code 14A0), which fund the NC Sickle Cell Syndrome Program, in the state budget.
PCP and hematologist. Thus, the Benefit Plan helps to mitigate the care disruptions that usually result from Medicaid churn. DPH’s Sickle Cell Educator Counselors are each responsible for a different region of the state.189 They provide counseling care management support to individuals with SCD throughout their life, as well education and advocacy on SCD to providers and the general public. The Educator Counselors work with all individuals with SCD in North Carolina, regardless of their income status or insurance coverage. Evidence
The DPH-Sickle Cell Benefit Plan can provide coverage for individuals living with SCD who churn in and out of Medicaid, especially for adults. Thus, the plan can be leveraged to North Carolina Context mitigate some of the problems associated with The NC Sickle Cell Syndrome Program provides Medicaid churn. One study found that compared genetic counseling, education, medical services, to individuals with consistent Medicaid coverage, reimbursement for treatment, screening, and individuals with multiple transitions into and out care coordination.187 It includes nine regional of Medicaid had 10 percent to 36 percent more Educator Counselors, one Community-based ED visits, outpatient visits, and hospitalizations, organization, the Piedmont Health Services and and 19 percent lower usage of prescription Sickle Cell Agency, six comprehensive sickle cell medications on average.190 medical centers, and state program staff.188 By covering medications, the DPH-Sickle Cell The NC Sickle Cell Syndrome Program offers a Benefit Plan may allow its patients greater DPH-Sickle Cell Benefit Plan for individuals aged access to prescription medications than the 19 and over with SCD at or below 100 percent of average individual who transitions into and out of the Federal Poverty Level. This program employs Medicaid can obtain. Regular use of medication a fee-for-service payment model and reimburses may, in turn, lower the outsized rates of ED visits services at the same rate as Medicaid. and hospitalizations for the churn population. Individuals who do not qualify for Medicaid Thus, DPH’s plan likely protects the health of or Medicare, have reached these programs’ individuals living with SCD during periods when payment limits, or do not have insurance can they are ineligible for Medicaid coverage. rely on DPH’s plan as a safety net. This plan covers outpatient visits, ED visits, hospitalization, In addition to protecting the health of individuals transitioning in and out of Medicaid, the DPHmedications, dental visits, and vision visits, Sickle Cell Benefit Plan likely also provides with limits for many of these services. Prior cost-savings to Medicaid itself. One study of authorization is required for any reimbursement Medicaid churn in the population with diabetes under this plan. In a stakeholder interview, a representative from the DPH Sickle Cell Program found program expenditures increased $239 (in 2008 U.S. dollars) per member per month, on stated that the plan currently has around 150 enrollees. This representative also explained that average, for the first three months after a lapse in coverage. These increased program costs were individuals transitioning from Medicaid to DPH’s likely driven by heightened ED use and inpatient Benefit Plan usually continue seeing their same
Part II. Sickle Cell Disease Recommendations 43
