The head of the state’s Department of Health and Human Services has received less than a wholehearted reception as she’s traveled the state explaining the governor’s proposed Medicaid overhaul.
By Taylor Sisk
“What we’re trying to do is ask you, the state of North Carolina, to step up to the table,” Secretary of Health and Human Services Aldona Wos told a gathering at the Carolina Heart Institute in Greenville last Thursday.
“That’s the goal.”
Wos was on the final day of a week of public appearances – in Greensboro, Reidsville, Durham, Greenville and Winston-Salem – on a “Partnership for a Healthy North Carolina” tour, accompanied by state Medicaid Director Carol Steckel.
Doctors, nurses, health care educators, public health officials and other health care professionals mostly made up her audiences – and her objective was to pump up support for, and receive input on, the recently announced proposed Medicaid overhaul, announced by Gov. Pat McCrory on April 3.
Under the Partnership for a Healthy North Carolina plan, three or more organizations, called comprehensive care entities, will bid for contracts to administer and coordinate the physical, mental and dental care paid for the state’s 1.58 million Medicaid recipients – people with disabilities, the low-income elderly, pregnant women and children.
These CCEs could be for-profit entities and would compete against one another for clients.
The plan will require approval by the state legislature and the federal government.
Along the tour, Wos and Steckel were met with a mostly respectful if often skeptical reception. Many were unconvinced that the hypothetical table to which they were being invited was laid with nourishing fare.
“For profit”? “Privatization”? “Out-of-state enterprises”? These terms – and more – were being circulated.
McCrory has called Medicaid “broken,” but a substantial number of those in the field aren’t buying it. Community Care of North Carolina (CCNC) – a not-for-profit statewide network of primary care practices that focuses on preventive measures and continuity of care – is a model program, they argue, it’s not broken and it’s where we should be investing.
“The goal is something that we all agree on, and that is a partnership for a healthy North Carolina in a predicable, sustainable model,” Wos said in Greenville, a message she delivered, with some variations, at each stop.
In January and February, the Department of Health and Human Services asked stakeholders for feedback on what the state’s health care system is doing well and not so well. Some 160 responses were received, Wos said, from “institutions, associations, providers, families, citizens – across the spectrum” Three themes emerged.
The first was that the system is siloed. “We do not take care of the patient as a whole in our present system,” Wos said.
The second was that that the department’s IT system was extremely complicated. And the third, that its bureaucracy was riddled with unnecessary complexities and duplications.
Out of that input, Wos said, a framework for the Partnership for a Healthy North Carolina emerged. CCEs operating statewide would address siloed services. Meanwhile, the new NC Tracks IT billing system is due to go live July 1, and the department’s NC FAST system for confirming eligibility is scheduled to be up Oct. 1.
In traveling the state, Wos said, she and Steckel had seen that there was much good about North Carolina’s health care system – a number of effective, often innovative programs and practices – and much that could be improved.
She was now asking for support in charting yet another new course.
‘Thank you for sharing’
On tour, Wos and Steckel were challenged at times by their audiences – most particularly, in Reidsville and Durham.
At the Reidsville forum, Khalil Nassar, CEO of Healthcare in Surry County, spoke of providers being “mistreated” by state officials. In a subsequent interview, he described a “very, very fragile system,” with talented health care professionals leaving the state, aggravated.
Nassar expressed his own frustration at what he perceived as no firm direction in general and, in particular, a lack of substance to Wos and Steckel’s presentation.
“If you can’t answer my questions as a provider, as an advocate, as a consumer, as a family member,” Nassar asked rhetorically, “how can you go forward?”
But both Wos and Steckel emphasized throughout that they had come to listen and learn from the professionals in the field, and carry that back to Raleigh.
During the question-and-answer session in Durham, Charles van der Horst, a UNC professor of medicine, expressed his desire to see Wos use her position of power as a bully pulpit.
“Your goal is to serve the people; you can be a bully pulpit when the legislature or even your boss, the governor, starts saying things that are nutty,” van der Horst said, to much applause.
He spoke of a bill pending in the legislature that would make North Carolina the only state in the country to require teens to get parental approval for mental health, substance-abuse or reproductive health care, and another that would overturn local smoking bans.
“That’s nutty,” van der Horst said, to more applause. “You need to tell them that.”
“Thank you for sharing,” responded Wos.
The most pointed exchange came in Reidsville, when Steve Luking, a family physician, spoke of his frustrations with the state’s decision not to expand Medicaid, as allowed under the Affordable Care Act.
“There will be people in this county who will die because of the decision that your boss made and that your silence, Dr. Wos, agreed with,” he said.
“Now I’m just supposed to trust you that the 67 percent of kids in my practice on Medicaid are going to get good care by this [Partnership for a Healthy North Carolina]?” Luking asked.
“In reference to your roundabout way of commenting about Medicaid expansion … in North Carolina, based on our constitution, the issue of Medicaid expansion or not, actually, was the commissioner of insurance’s,” Wos said. “Just so that you all know that and are aware of that.”
The office of Insurance Commissioner Wayne Goodwin subsequently took strong exception to that statement, saying that its officials had urged Medicaid expansion.
Both houses of the General Assembly passed legislation to reject expansion and McCrory signed the bill into law on March 6.
Goodwin asked for a retraction of Wos’ claim and an apology, but neither was provided publicly.
By the time the tour hit Durham, discussion of Medicaid expansion was off the table. When, during question-and-answer, an audience member expressed her perplexity at the state’s decision, Steckel responded, “We hear your opinion about Medicaid expansion. Let’s talk about how we can improve the existing Medicaid program.”
Perhaps the most intriguing theme pursued throughout the series of forums was an evolving discussion of “privatization.”
In Durham, Genie Komives, a Hillsborough family physician, asked if the state would be accepting CCE applications from out-of-state corporations.
Steckel’s response occasioned some confusion.
“That has been the biggest myth of what we’ve talked about,” she replied. “And as we’ve been designing the framework – just even the framework – that never was an issue.”
Health care advocates have questioned whether there are state-based entities equal to the task.
In Greenville, Steckel said of “privatizing” that she “didn’t know where that term came from,” adding that, “Everything that we’re doing now in North Carolina is with a private entity.”
Advocates point out that within the context of our state’s health care system, “privatization” is, in fact, an imprecise term.
Laurie Coker, executive director of North Carolina Consumer Advocacy, Networking, and Support Organization, who attended the Winston-Salem forum, said that not only is the system a public-private partnership – with private companies providing services – but the managed care organizations that coordinate behavioral-health services for the state hold sufficient authority that “they might as well be private.”
Assuming contracts are tightly defined and operations are transparent, Coker sees advantages to recruiting outside companies with experience in providing managed care.
“There are some managed-care companies that are already doing far more advanced recovery-focused care than is happening in this state,” she said.
Coker also sees benefits to having CCEs competing with one another.
“I think choice is absolutely necessary to drive quality,” she said, “and it also is necessary to help consumers of mental health services become more empowered.” As things stand, she said, those consumers feel as if they have no ownership of their health care.
But Coker echoed the support for CCNC that was voiced at several of the forums; she cited CCNC’s success in being responsive to the particular needs of a community.
Wos and Steckel spoke repeatedly of leveraging the successes of CCNC.
“We want to take what works in North Carolina, and what is good in North Carolina, and prop it up, make it stronger, better, more successful,” Wos said in Durham.
“We are 100 percent committed to the CCNC model,” she said “and trying to strengthen it, expand it and get it to the next generation, as we say.”
Steckel called upon CCNC to provide more comprehensive behavioral-health services along with its primary care.
Wos said she couldn’t imagine that CCNC wouldn’t submit a proposal to be a CCE: “That doesn’t pass the common-sense test.”
Not the budget
As for holding for-profit CCEs accountable for providing quality services, reinvesting in services, pursuing innovation and being responsive to the needs of those who are among our state’s most vulnerable – and not returning each year requesting increasingly more funding – “That’s our responsibility,” Wos affirmed.
“All of that is what we’re working through,” she said.
The decision to overhaul the system wasn’t a budgetary one, Wos said: “The governor not once has said to me, or in my presence, ‘Madame Secretary, I want you to take 3, 5, 30 percent off the top and save us the money.’
“Not once has there ever been any thought about this being a budget exercise.”
“There are significant gaps in the system, there are siloed programs, and we need to continue to improve it,” Steckel said, “and that is what our intent is.”
But in presenting their budget this week, Senate leaders talked of Medicaid being a drag on the state budget. Senate leader Pete Brunstetter (R-Winston-Salem) called Medicaid’s budget a “juggernaut,” and Health and Human Services Appropriations chair Sen. Ralph Hise (R-Spruce Pine) told his committee that Medicaid was “driving” the state budget.
Legislative leaders announced last Friday that they will be asking the federal government to grant the state a waiver to undertake this overhaul. Wos said that process typically takes 12 to 18 months.
The administration’s goal is to have the new system in place by July 2015.
“We need talent, we need your knowledge, we need your partnership, we need your advice,” Wos said to her Greenville audience. “We have an open-door policy.”
Rose Hoban in Reidsville and Amy Ellis in Greenville provided reporting for this story.