Medi-Cal Fee-For-Service (FFS) Mitigating Health Impacts of Secondary Stress due to the 2019-Novel Coronavirus (COVID-19) Emergency

April 7, 2020

The Department of Health Care Services (DHCS) is actively monitoring the evolving COVID-19 situation, and is taking proactive steps to lessen the immediate impacts of COVID-19 on its health care systems and communities. DHCS also recognizes the importance of providing critical information to all Californians to help address and wherever possible, mitigate the secondary health effects of this pandemic. While Californians have come together to practice ‘physical distancing’ to slow the spread of COVID-19, public anxiety regarding COVID-19, compounded by the economic distress due to lost wages, unemployment, and financial assets; mass school closures; and necessary physical distancing measures can result in an increase in stress-related morbidity and mortality. Widespread communicable disease outbreaks, such as COVID-19, natural disasters, economic downturns, and other crises result in well documented, short- and long-term physical and mental health impacts, including increased cardiovascular, metabolic, immunologic, and neuropsychiatric risk. These impacts result from:

  • Disruption of access to care, including preventive care and medications;
  • Disruption of access to resources needed for health maintenance such as nutritious foods and safe places to exercise; and
  • Overactivity of the biological stress response, resulting in neurologic, endocrine, and immunologic dysregulation, also known as the toxic stress response.

Specifically, the negative health outcomes can include:1

  • Increased rates of heart attack and stroke.
  • Increased blood pressure.
  • Exacerbations of chronic obstructive pulmonary disease and asthma.
  • Increased hemoglobin A1c levels among diabetic patients.
  • Immune dysregulation – with increased risk for infection, autoimmune disorders, and poorer oral health.
  • Poorer perinatal and birth outcomes, including preterm birth and low birth weight.
  • Increased intimate partner violence.
  • New or recurring mental and behavioral health conditions, including: depression, anxiety, suicidality, post-traumatic stress disorder, obsessive-compulsive disorder, and substance use disorder (inclusive of alcohol and drugs).

How Can Medi-Cal Providers Help?
Medi-Cal providers play an essential role in helping to address and, where possible mitigate, some of the negative health outcomes identified above with appropriate adaptations to provide disaster-responsive, trauma-informed care, and supplement care with measures aimed at regulating the stress response system.

To mitigate secondary negative health outcomes, it is crucial that Medi-Cal providers stay informed as to the most current guidance and best practices relative to COVID-19, as well as do the following, whenever possible:

  • Support continuity and integration of medical and behavioral health services via telehealth and related adaptations in service delivery during the crisis. (Please see DHCS COVID-19 specific guidance on Telehealth and Virtual/Telephonic Communications.) Providers have a crucial responsibility to ensure strong care coordination and service linkage among primary care, behavioral health, and other specialty care, among other areas of health care services. During a public health crisis such as COVID-19, this role is more important than ever.
  • Increase knowledge and awareness of disaster-responsive approaches, such as trauma-informed care. This education and training should include such crucial roles as:
    • Ensuring physical and emotional safety of patients.
    • Building trust between providers and patients.
    • Recognizing and responding to the signs and symptoms of stress on physical and mental health.
    • Promoting patient-centered, evidence-based care.
    • Ensuring provider and patient collaboration in treatment planning.
    • Sensitivity to the racial, ethnic, cultural, and gender identity of patients and any disabilities they may have.
    • Supporting provider resilience.
  • Learn the signs of and assess for stress-related morbidity, and create responsive treatment plans, including supplementing usual care with measures that help regulate the stress response system (see #29 on List of Resources/References at the end of this notice), such as:
    • Supportive relationships.
    • Age-appropriate, healthy nutrition.
    • Sufficient, high-quality sleep.
    • Mindfulness and meditation.
    • Adequate physical activity.
    • Mental health care.

Adverse Childhood Experiences (ACEs) Screening
DHCS, in partnership with the Office of the California Surgeon General (OSG), is providing Medi-Cal providers with training, clinical protocols, and payment to screen patients for ACEs that lead to toxic stress and ACEs-Associated Health Conditions. Individuals with a history of ACEs are at increased risk of negative health outcomes with subsequent major stressors, such as that currently being experienced as a result of the COVID-19 pandemic. By screening for ACEs, providers can better determine the likelihood a patient is at increased health risk due to a toxic stress response, which can inform patient treatment, including the use of trauma-informed, evidence-based care for toxic stress. Detecting ACEs and toxic stress early and connecting patients to interventions, resources, and other supports can improve the health and well-being of individuals and families and across the state’s communities. All providers are encouraged to receive training to screen patients for ACEs, and by July 1, 2020, all providers who bill Medi-Cal for providing ACEs screening, must self-attest to completing the training to continue receiving Medi-Cal payment for conducting ACE screenings.

Training to screen for ACEs and toxic stress is available at the ACEs Aware website. The two-hour online curriculum is easy to access for a wide range of health care professionals and provides Continuing Medical Education (CME) and Maintenance of Certification (MOC) credits.  DHCS will reimburse Medi-Cal FFS providers up to $29 per trauma screening for children and adults with Medi-Cal coverage. To bill Medi-Cal, FFS providers should use the Healthcare Common Procedure Coding System (HCPCS) codes based on the results of the screening – HCPCS code G9919 is used for high-risk screens that have a score of 4 or greater and HCPCS code G9920 is used for lower-risk screens that have a score of 0 to 3. More information and resources on how to bill Medi-Cal for ACE screenings can be found on the ACEs website and updates to the Medi-Cal provider manual will soon be released on the Medi-Cal website.

Additional resources on how to mitigate the stress-related health outcomes anticipated with COVID-19 can be found on ACEs resources and information for Medi-Cal’s Trauma Screenings and Trauma-Informed Care Provider Trainings can be found on the DHCS webpage.

For COVID-19 specific information, please visit DHCS’s COVID-19 Response webpage, which serves as a central repository for all COVID-19 related information, including but not limited to additional guidance for providers and partners relative to providing services amidst the COVID-19 situation.  

For additional COVID-19 information and resources, providers are encouraged to review the following resources:

List of Resources/References:

  1. Fonseca VA, Smith H, Kuhadiya N, et al. Impact of a natural disaster on diabetes: exacerbation of disparities and long-term consequences. Diabetes Care 2009; 32: 1632–8.

  2. Kario K. Disaster hypertension - its characteristics, mechanism, and management -. Circ J 2012; 76: 553–62.

  3. Rosenberg SL, Miller GE, Brehm JM, Celedón JC. Stress and asthma: novel insights on genetic, epigenetic, and immunologic mechanisms. J Allergy Clin Immunol 2014; 134: 1009–15.

  4. Uddin M, Aiello AE, Wildman DE, et al. Epigenetic and immune function profiles associated with posttraumatic stress disorder. Proc Natl Acad Sci USA 2010; 107: 9470–5.

  5. Kario K, McEwen BS, Pickering TG. Disasters and the heart: a review of the effects of earthquake-induced stress on cardiovascular disease. Hypertens Res 2003; 26: 355–67.

  6. Mattei G, Pistoresi B. Unemployment and suicide in Italy: evidence of a long-run association mitigated by public unemployment spending. Eur J Health Econ 2019; 20: 569–77.

  7. Fujiwara T, Yagi J, Homma H, et al. Symptoms of Post-Traumatic Stress Disorder Among Young Children 2 Years After the Great East Japan Earthquake. Disaster Medicine and Public Health Preparedness 2017; 11: 207–15.

  8. Dube A, Moffatt M, Davison C, Bartels S. Health Outcomes for Children in Haiti Since the 2010 Earthquake: A Systematic Review. Prehospital and Disaster Medicine 2018; 33: 77–88.

  9. Wang C-W, Chan CLW, Ho RTH. Prevalence and trajectory of psychopathology among child and adolescent survivors of disasters: a systematic review of epidemiological studies across 1987–2011. Social Psychiatry and Psychiatric Epidemiology 2013; 48: 1697–720.

  10. Haw C, Hawton K, Gunnell D, Platt S. Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors. Int J Soc Psychiatry 2015; 61: 73–81.

  11. Probst LF, Pucca Junior GA, Pereira AC, Carli ADD. Impact of financial crises on oral health indicators: an integrative review of the literature. Cien Saude Colet 2019; 24: 4437–48.

  12. Parmar D, Stavropoulou C, Ioannidis JPA. Health outcomes during the 2008 financial crisis in Europe: systematic literature review. BMJ 2016; 354: i4588.

  13. Simou E, Koutsogeorgou E. Effects of the economic crisis on health and healthcare in Greece in the literature from 2009 to 2013: a systematic review. Health Policy 2014; 115: 111–9.

  14. Filippidis FT, Gerovasili V, Millett C, Tountas Y. Medium-term impact of the economic crisis on mortality, health-related behaviours and access to healthcare in Greece. Sci Rep 2017; 7: 46423.

  15. Filippidis FT, Schoretsaniti S, Dimitrakaki C, et al. Trends in cardiovascular risk factors in Greece before and during the financial crisis: the impact of social disparities. Eur J Public Health 2014; 24: 974–9.

  16. Kotsiou OS, Zouridis S, Kosmopoulos M, Gourgoulianis KI. Impact of the financial crisis on COPD burden: Greece as a case study. Eur Respir Rev 2018; 27. DOI:10.1183/16000617.0106-2017.

  17. Karanikolos M, Heino P, McKee M, Stuckler D, Legido-Quigley H. Effects of the Global Financial Crisis on Health in High-Income Oecd Countries: A Narrative Review. Int J Health Serv 2016; 46: 208–40.

  18. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet 2020; 395: 912–20.

  19. Hagan JF. Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician. PEDIATRICS 2005; 116: 787–95.

  20. Trevisan M, Celentano E, Meucci C, et al. Short-term effect of natural disasters on coronary heart disease risk factors. Arteriosclerosis 1986; 6: 491–4.

  21. Tan CE, Li HJ, Zhang XG, et al. The impact of the Wenchuan earthquake on birth outcomes. PLoS ONE 2009; 4: e8200.

  22. Gautam S, Menachem J, Srivastav SK, Delafontaine P, Irimpen A. Effect of Hurricane Katrina on the incidence of acute coronary syndrome at a primary angioplasty center in New Orleans. Disaster Med Public Health Prep 2009; 3: 144–50.

  23. Quast T, Andel R, Sadhu AR. Long-term Effects of Disasters on Seniors With Diabetes: Evidence From Hurricanes Katrina and Rita. Diabetes Care 2019; 42: 2090–7.

  24. Wu P, Liu X, Fang Y, et al. Alcohol abuse/dependence symptoms among hospital employees exposed to a SARS outbreak. Alcohol Alcohol 2008; 43: 706–12.

  25. Liu X, Kakade M, Fuller CJ, et al. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Compr Psychiatry 2012; 53: 15–23.

  26. King S, Dancause K, Turcotte-Tremblay A-M, Veru F, Laplante DP. Using natural disasters to study the effects of prenatal maternal stress on child health and development. Birth Defects Res C Embryo Today 2012; 96: 273–88.

  27. Schumacher JA, Coffey SF, Norris FH, Tracy M, Clements K, Galea S. Intimate partner violence and Hurricane Katrina: predictors and associated mental health outcomes. Violence Vict 2010; 25: 588–603.

  28. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach | SAMHSA Publications. (accessed Oct 16, 2019).

  29. Burke Harris N. The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. Boston: Houghton Mifflin Harcourt, 2018.