Sensible Medicaid reform for North Carolina

The North Carolina General Assembly made a bold decision at the end of its uncommonly long session last fall. Legislators decided to invite managed care organizations as well as provider-led entities to administer our state’s Medicaid program, which provides health care for the approximately 2 million North Carolinians who have no other option to get the care they often desperately need.

Our legislature, rather than continuing to struggle with ongoing budgetary headaches due to the constantly fluctuating needs of the Medicaid population, chose to shift the financial risk to an as yet-to-be-determined assortment of out-of-state managed care corporations and entities led by those providing the care. In doing so, the state hopes to regain some financial certainty by allotting a set payment per Medicaid recipient to each entity and letting them work out their budgetary balance sheets.

This massive shift in how Medicaid is run requires an enormous amount of planning, analysis and expertise to ensure that patients have access to and receive proper care and that those providing the care are treated fairly.

Now that this is the law of the land in North Carolina, the North Carolina Medical Society is working diligently to protect the interests of Medicaid patients by advocating for the physicians and the health care team that care for them. We are meeting regularly with the state officials charged with implementing the Medicaid reforms, other Medicaid stakeholders and the managed care organizations that want to be part of the lucrative Medicaid business in North Carolina. We are actively promoting the following core values:

▪ The patient must be central. Properly caring for the whole person may include community services to sustain the individual’s health with a mechanism in place to ensure these services are part of the program.

▪ Physicians have the clinical knowledge to know what constitutes excellent patient care and therefore should be in positions to make the policies governing that care at each organization.

▪ Each entity providing care should use the same quality performance measures that are clinically relevant and not an additional burden to physicians. This will allow true – apples-to-apples – comparisons between organizations.

▪ The data measuring the quality, costs and savings must be transparent for physicians and all providers as well as the taxpayers.

▪ The program must strive for administrative simplicity during this transition period leading to sensible and streamlined enrollment and credentialing procedures among others once the system is in place for both doctors and their patients.

▪ Network adequacy standards should be based on federal law or regulations to ensure access to care for patients.

Overall, the NCMS has long advocated the “triple aim” of achieving better care for patients, better health for our communities and lower costs through improving our health care system.

As the myriad details are being hammered out in this lengthy and complex process, we are at the table advocating these principles. While it’s impossible to know for certain, we believe the state’s new Medicaid program will not begin enrollment until January 2018 at the earliest – an aggressive timeframe given the magnitude of the change.

The most immediate signpost on this pioneering trek is when DHHS Secretary Rick Brajer reports to the General Assembly in March outlining the department’s progress toward implementing the Medicaid reform legislation. Other markers on the timeline include DHHS’ application to the Centers for Medicare and Medicaid Services for federal approval of the state’s Medicaid reform plans. It is unknown how long the approval process will take, but once approved, the General Assembly has allowed 18 months to select the managed care organizations or provider-led entities to serve patients and begin enrollment.

In the meantime, the NCMS will continue to champion a sensible approach to implementing the reform decision by the General Assembly, one that protects the patients, their medical providers and the taxpayers of North Carolina.

Docia Hickey, M.D., is president of the North Carolina Medical Society.