Reshaping a State: Preventive care thrifty in GOP eyes

Lawmakers hope to save $90 million by extending health efforts to Medicaid clients.

Staff writerMay 22, 2011 

  • The House budget calls for cutting $465.5 million from the Department of Health and Human Services - a reduction of about 9.5 percent from the $4.9 billion base budget. Here are a few of the ways legislators propose making their numbers:

    Cut Medicaid reimbursements to hospitals and other health care providers, excluding doctors, and eliminate automatic increases for inflation to save $109.3 million. Reimbursement rates will be cut 7.3 percent for hospitals and 2 percent for other providers.

    Save $16.5 million by cutting or changing a variety of Medicaid services. For example, routine eye exams for adults are eliminated. Adults will be able to see eye doctors only in emergencies. Dental fillings for tooth surfaces (not cavities) will be limited to four teeth.

    Cut $37.6 million, or 20 percent, of the money that goes to Smart Start, the early childhood health and education program. Each local Smart Start office must decide how to handle the cut.

    Cut $20 million from local mental health services, or 5.8 percent, leaving $323 million available to purchase care for people not covered by Medicaid or other insurance.

  • A budget speaks loudly about a state's priorities, and the proposed House plan would change much about how we pay for government - and what we get from it. On coming Sundays, The N&O will examine issues rising from the budget being considered by the General Assembly.

    Next Sunday: Teacher assistants may disappear.

  • Unlike the governor's proposed Medicaid budget of $10 billion, shown above, legislators are looking to spend about $9 billion on Medicaid next year. The federal government pays about two-thirds of those costs, with the state picking up the rest.

    How the money is spent:

    Mandatory services54%

    Optional services/children17%

    Optional services/adults29%

  • About the Community Care Network

    Community Care started in the late 1990s through an agreement with Medicaid and the state Office of Rural Health.

    It consists of 14 regional networks that focus on "patient-centered care." Patients are assigned a primary care doctor and a case manager who works with doctors, public health agencies, social service agencies and community health centers to make sure needed care is received.

    Each regional network and the primary care doctors are paid monthly fees - money provided by the federal government and the state - to provide specific coordination services and manage costs.

    Community Care serves 1.1 million people across the state.

Third in a weekly series

In their push to save money, state legislators have turned to a program that helps poor people get the health care they need. But rather than cut its budget, legislators want the state's Community Care program to enroll more elderly, blind and disabled Medicaid recipients.

The reason? Getting this group preventive care could save the state $90 million.

The stakes are high: If Community Care doesn't save enough, the state Department of Health and Human Services, which oversees Medicaid, would have to make the cuts elsewhere. That means patient medical services and money for doctors and other health-care providers could be reduced if Community Care fails to hit the $90 million mark.

"It is an aggressive target - one that if everything works out, they can potentially achieve," said Lanier Cansler, the health and human services secretary.

Community Care of North Carolina has a national reputation for its ability to find doctors to watch over the care of people insured under Medicaid, the government program for the poor and disabled. The doctors' offices are in networks of hospitals and pharmacies that work together on patient care.

Care coordinators make sure patients remember doctor appointments and take needed medicines. The aim is to keep the insured patient's health from deteriorating to the point that they need expensive emergency room treatment, and to make sure they do not receive unnecessary tests.

Community Care built its reputation by showing that it could reduce costs to care for people with chronic diseases.

Medicaid is expected to cost taxpayers about $9 billion in North Carolina next year, nearly $3 billion of that covered by state taxpayers. Republicans, who are in charge of the legislature for the first time in more than a century, want to use Community Care in an aggressive effort to curb costs. It's part of their larger effort to use the budget to reshape government by cutting taxes, eliminating jobs, adding fees and cutting grants for higher education.

Priorities: sick people, those at risk

Janay Gill and her mother, Brandy Dunston, have been working with a nurse assigned by the Community Care network in Wake and Johnston counties for about two months to help Janay control her asthma.

Each morning before school, Janay sits for 10 minutes near the front door of her home in Knightdale with a child-size mask on her face, inhaling from a machine the medicine that is meant to ward off her symptoms.

The 5-year-old does the same in the evening and takes medication before bed.

"I was very unknowledgeable about asthma," Dunston said. Karla Theobald, a nurse who works for the local network and is Janay's case manager, taught Dunston ways to make Janay's inhaled medicine more effective and talked to her about what can set off attacks.

After Janay made several trips to the emergency room because she was having trouble breathing, her doctor suggested that working with Community Care could cut down on emergency room visits.

Theobald "calls me once a week to remind me of the things I need to do for my little one," Dunston said.

Theobald has thousands of patients assigned to her, but most are healthy and don't need hands-on help. She calls or visits 50 to 60 patients weekly or monthly. "Our priorities are sick people, or people a provider feels have a high risk," she said.

Case managers provide all kinds of help - making sure people without cars can get to appointments and reminding them to refill prescriptions, for example.

As legislators have looked for budget savings, they've directed Community Care to enroll more Medicaid recipients who are elderly, blind and have disabilities. That means an all-out effort in the next few months to find people who may not have primary care doctors.

Elderly people and people with disabilities are about 25 percent of the 1.5 million North Carolinians on Medicaid, but because they tend to have more health problems, they account for a disproportionate share of the costs. State officials say the new group of about 160,000 will be difficult to find.

"When we get in this next population, they're going to be a little bit more complex," said Dr. Allen Dobson, president of the Community Care board of directors and a former state Medicaid director. "They may be in adult care facilities, nursing homes, or have mental health disorders we haven't identified yet."

Doctors have skin in the game

If Community Care doesn't meet the target, doctors, hospitals and patients could face financial and medical consequences. Cansler will have to reduce the rates the state pays medical providers and cut optional Medicaid services to get the savings.

Neither would be good for patients. If rates drop too low, some doctors may decide to stop treating Medicaid patients. And the state already has slowly whittled optional services.

The budget passed by the House saves about $16.5 million next year by reducing or changing a variety of health services. As a result, adults on Medicaid will be able to see eye doctors only in emergencies.

Community Care won't have much time to show progress. It can take months to get federal approval for rate and service cuts, so by early fall, it must show that its money-saving strategies will work.

Rep. Nelson Dollar, a Cary Republican who helped assemble the House budget, said he was confident Community Care can reach its goal. Based on its track record, Dollar said, Community Care can probably save more than $90 million.

"It's a number well in the range of CCNC's capability," he said. According to an independent evaluation, Community Care saved more than $1.6 billion in state and federal costs from 2003 to 2008.

The rate cut and service cut alternatives were put into the budget so health care providers "have skin in the game," Dollar said, and they'll work with Community Care rather than risk rate cuts.

But Verla Insko, a Chapel Hill Democrat, said budget writers have avoided making difficult decisions and obscured the threat of rate and service cuts by pushing the responsibility onto Cansler. The public cannot react to a threat it doesn't know is coming, she said.

"They need to know what their elected officials are doing, what they stand for," she said. "They don't vote for Secretary Cansler."

The Senate is putting together its version of the budget and may choose to identify more or different cuts.

Optional service is essential to many

Trying to avoid making more service cuts, the Department of Health and Human Services has started working on a plan to enroll more elderly and disabled people in Community Care.

Since many they need to enroll may not be connected to a primary care doctor, Community Care and DHHS officials are meeting with county social service departments, people who run skilled nursing facilities, assisted living and adult care homes, Cansler said. They are making sure people who work regularly with elderly people know that Community Care wants them.

"It's a much more focused effort than what we've done in the past," he said.

Cansler said he has not considered what optional services would go if he has to make a choice. Optional services cover expenses that most people consider essential, such as prescription drugs and visits to the dentist.

"It's not an easy thing to do," Cansler said.

The specter of more cuts weighs on families that don't know what to expect next year.

"Whenever we hear these discussions of budget cuts, we're on pins and needles," said Sarah Gamble of Raleigh. Her 7-year-old son, Cameron Powell, has cerebral palsy and receives physical, occupational and speech therapy to help him move and communicate.

Through therapy paid for by Medicaid, Cameron learned to sit up and use a walker, so he's able to go with his family to movies, the mall and to see his older brother's basketball games, Gamble said.

"He's doing amazing," Gamble said, "and it's due to the support he's received." or 919-829-4821

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