Gov. Pat McCrory and Health and Human Services Sec. Aldona Wos came to the State Health Directors’ meeting where they focused on big picture. But local public health officials are looking to insure the viability of public health into the future.
By Rose Hoban
Department of Health and Human Services Sec. Aldona Wos brought Gov. Pat McCrory to the state health directors’ conference in Raleigh Thursday, where they each addressed the state’s public health leaders on their priorities for the coming year.
Both Wos and McCrory talked to the group about mental health and Medicaid reform and celebrated additional staffing in the state medical examiner’s office.
But as they met for their annual meeting, the directors and workers from the state’s public health departments had other topics on their minds. Top of that list is how public health departments will survive.
According to the National Association of County and City Health Officers, 71 percent of public health departments in North Carolina have lost funding in recent years. Combined with an increasing number of uninsured people looking to public health departments for services and the possibility that newly insured patients will leave for other clinics, departments face an uncertain financial future.
“Public health has traditionally been involved in some level or other of primary care, and we have opportunities to be engaged in it more as we move forward,” Gibbie Harris, the Buncombe County health director, told the crowd. “We have expertise specifically in communicable disease. But we have to continue to build that expertise in chronic disease, because that’s where the issues are these days, as we continue to stay focused on communicable disease.”
McCrory thanked those gathered for their work and told the crowd that he admired public health workers for their dedication to their constituents, calling them “unsung heroes.”
“People don’t realize what you do or the pressures you’re under,” he said. “It’s a 24-hour-a-day job; there’s no release from what you’re doing. I know, because I’ve got one of those jobs.”
In his remarks, McCrory emphasized his commitment to doing something about substance abuse, in particular among young people.
“I’m concerned that acceptance of getting drunk or high will lead to more people being dumb, apathetic and unproductive,” he said. “I feel strongly about addiction. Addiction is destroying our society, families, communities and individuals.”
McCrory said his administration was creating a program to work with higher-education institutions around the state on reducing addiction on campuses, but was short on details of what the program would entail.
Also without details were Wos’ plan for reforming the state’s Medicaid program, which she said she would deliver to the legislature in mid-March, and a mental health crisis plan.
Wos praised the efforts of public health workers and emphasized a recent pay raise for nurses and doctors working in state-operated facilities, as well as increased salaries that have helped the state recruit pathologists to staff the medical examiner’s office.
“What we do well doesn’t end up in the newspaper or in the news,” she said.
Wos announced the appointment of Rear Admiral Penelope Slade-Sawyer, currently a deputy surgeon general, to be the new head of the state Division of Public Health.
Meanwhile, many of the health directors in attendance expressed concern about what the future holds for their departments.
“Our number-one challenge is the whole funding picture for public health departments going forward,” said John Morrow, health director in Pitt County and outgoing president of the North Carolina Association of Local Health Directors.
In the past, many services, such as immunizations, sexually transmitted-disease treatment and maternal child care, were provided in public health clinics run by county health departments. Medicaid reimbursement for some patients has subsidized the care of other patients who are uninsured, Morrow explained.
He said those dollars also paid for other traditional public health activities, “Things that everyone wants us to do, like chronic-disease prevention, wellness, improve diet and exercise, smoking cessation.”
“But we haven’t had funding to deal with all these other things that people say public health does … like health education, because these things are not billable,” Morrow said, noting that the number of uninsured people seeking services at local health departments has grown.
The general assembly has cut funding to the Division of Public Health in the last three budgets. And individual counties also cut funding for those services in recent years, in part because county officials believed that the state would expand the Medicaid program.
“It really is putting on a lot of financial pressure, particularly on smaller health departments,” Morrow said. “And if they don’t have some source of payment for those services, then they’re looking at closing clinics, and some already have.”
A way forward
One way local health departments could survive financially is by becoming part of the new accountable care organizations (ACOs) that are springing up around the state. ACOs are a model of care whereby providers get paid based on patient outcomes, not on how many procedures they perform.
That was the message of the day’s first speaker, Judith Monroe from the Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support, who said that language in the Affordable Care Act means that ACOs have to incorporate public health activities into their plan.
She said that in Oregon, “There are local health departments that are already in the financial game with ACOs.”
Monroe noted that health departments need to make the case to ACO managers that their expertise is in population health. She said that the health department might deliver some of those services or instruct the ACOs in how to do so.
“And so they become part of that bundled payment, part of that ACO,” she said.
Morrow agreed that this strategy is a good one for local health departments, especially since ACO rules require the integration of “essential community providers” into their systems.
“All of our health departments are considered essential community providers,” he said. “They’re going to be coming to us and saying you’re an essential community provider, we want you to join in our ACO.”