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.

North Carolina Context

The NC Sickle Cell Syndrome Program provides genetic counseling, education, medical services, reimbursement for treatment, screening, and care coordination.187 It includes nine regional Educator Counselors, one Community-based organization, the Piedmont Health Services and Sickle Cell Agency, six comprehensive sickle cell medical centers, and state program staff.188 The NC Sickle Cell Syndrome Program offers a DPH-Sickle Cell Benefit Plan for individuals aged 19 and over with SCD at or below 100 percent of the Federal Poverty Level. This program employs a fee-for-service payment model and reimburses services at the same rate as Medicaid. Individuals who do not qualify for Medicaid or Medicare, have reached these programs’ payment limits, or do not have insurance can rely on DPH’s plan as a safety net. This plan covers outpatient visits, ED visits, hospitalization, medications, dental visits, and vision visits, with limits for many of these services. Prior authorization is required for any reimbursement under this plan. In a stakeholder interview, a representative from the DPH Sickle Cell Program stated that the plan currently has around 150 enrollees. This representative also explained that individuals transitioning from Medicaid to DPH’s Benefit Plan usually continue seeing their same 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 mitigate some of the problems associated with Medicaid churn. One study found that compared to individuals with consistent Medicaid coverage, individuals with multiple transitions into and out of Medicaid had 10 percent to 36 percent more ED visits, outpatient visits, and hospitalizations, and 19 percent lower usage of prescription medications on average.190 By covering medications, the DPH-Sickle Cell Benefit Plan may allow its patients greater access to prescription medications than the average individual who transitions into and out of Medicaid can obtain. Regular use of medication may, in turn, lower the outsized rates of ED visits and hospitalizations for the churn population. Thus, DPH’s plan likely protects the health of individuals living with SCD during periods when they are ineligible for Medicaid coverage. In addition to protecting the health of individuals transitioning in and out of Medicaid, the DPHSickle Cell Benefit Plan likely also provides cost-savings to Medicaid itself. One study of Medicaid churn in the population with diabetes found program expenditures increased $239 (in 2008 U.S. dollars) per member per month, on average, for the first three months after a lapse in coverage. These increased program costs were likely driven by heightened ED use and inpatient