Medical students Eli Tiller and William McLean (back) present to Medicaid Reform Advisory Group.


In their second public hearing, members of the Medicaid Reform Advisory Group heard from doctors, patients and business interests.

By Rose Hoban

“Preserve Community Care of North Carolina.” That was the message delivered by hundreds of medical students from around the state to the Medicaid Reform Advisory Group during the committee’s second meeting, at the State Archives building in Raleigh on Wednesday.

To a letter penned by UNC medical students William McLean and Eli Tiller, hundreds of students from all five of the state’s medical schools signed their support for CCNC, the program for managing the care of more than 1.4 million of North Carolina’s low-income, disabled and pregnant patients, young and old.

Medical students William McLean (l) and Eli Tiller (r) put the finishing touches on their presentation for the Medicaid Reform Advisory Group Wednesday.
Medical students William McLean (l) and Eli Tiller (r) put the finishing touches on their presentation to the Medicaid Reform Advisory Group as they waited their turn Wednesday. Photo credit: Rose Hoban.

“As a physician-driven, not-for-profit organization with a history of delivering high-quality and cost-effective care to the citizens of the state, CCNC gives us reason to be proud of our state’s Medicaid system,” read McLean from the letter, as he addressed the advisory group.

“Your support for this organization would send a message to medical students in this state, as well as around the country, that North Carolina is committed to fostering one of the most innovative, successful medical communities in the United States.”

McLean said the idea for writing the letter came when he and Tiller were interviewing for the family-medicine residency program at Duke.

“In the middle of the interview, we had a break and we were talking about the changes going on in the state and discussions of Medicaid reform. And for all the talk of Medicaid being ‘broken,’ we had a lot to be proud of in CCNC,” McLean remembered. “Eli said, ‘We ought to do something.'”

The effort gained steam during a family-medicine conference in December that gathered almost all of the family-medicine students in the state to talk about policy and practice. McLean said his friend Cleveland Piggott was the “mastermind” of the grassroots campaign that took place at each school. Between Sunday and Wednesday, an additional 50 students signed onto the letter to bring the total to more than 300.

One voice in a chorus

Wednesday’s meeting kicked off with a presentation given by legislative fiscal research economist Steve Owen, who noted that North Carolina’s Medicaid spending trends have shown per-member, per-month costs decreasing by more than 11 percent since 2008, even as Medicaid per-member, per-month costs increased by 6 percent in the rest of the United States.

Medicaid spending trends 2008-2013.
N.C. Medicaid spending trends 2008-13 (blue) compared to national trends (red) during the same time period.

Owen said that much of that drop is due to a large number of children in Medicaid, who are cheaper to care for. But Owen also said he attributed about a quarter of the savings to CCNC’s efforts.

However, he predicted that Medicaid costs will continue to grow at a rate similar to the increase in health care costs nationwide.

The medical students’ letter reinforced a chorus of voices in support of CCNC throughout Wednesday’s daylong meeting, which featured more than 40 speakers, ranging from lobbyists to physicians to parents of children with disabilities, many of whom lauded the program.

Speaker after speaker praised CCNC as a “homegrown” program that has been effective at cutting costs. The Community Care program evolved over several decades of experimenting with different ways of organizing the care of Medicaid patients. The program uses the “medical home” model, wherein patients choose or are assigned a primary health care provider who works in a clinic with intensive case management services.

This model of care has garnered national attention from health policy makers, and has provided a template for Medicaid revision in other states, such as Connecticut. An actuarial study commissioned by the state Medicaid program in 2011 found that CCNC saved North Carolina upwards of a billion dollars in costs over the previous five years.

Only a handful of speakers urged the panel to consider moving the state away from CCNC and toward a managed-care model run by larger companies – both for-profit and not-for-profit – wherein doctors and clinics assume more responsibility for the spending on patients.

Members of the Medicaid Reform Advisory Group listen to speakers during the meeting Wednesday.
Members of the Medicaid Reform Advisory Group listen to speakers during the meeting Wednesday. L to R: Sen. Louis Pate, Richard Gilbert, MD, Dennis Barry (chair), Peggy Terhune, PhD, Rep. Nelson Dollar. Photo credit: Rose Hoban.

“Two-thirds of state Medicaid programs have transitioned to comprehensive risk-based, coordinated-care plans for the Medicaid population,” Jeff Meyers, head of the national trade association for Medicaid managed-care plans, told the panel, calling North Carolina’s current Medicaid system “simply incomplete.”

“Innovation is muted and the state does not get budget predictability that it needs to provide for all the other state priorities like education and infrastructure funding,” he said.

Meyers told the panel that as North Carolina develops a plan to reform Medicaid, the state should “open the door to fully integrated, risk-based, comprehensive-care models, in which privately run health plans, both for-profit and nonprofit, coordinate quality patient care.”

Only one other speaker from a managed-care company presented to the group.

Panel member Richard Gilbert, an anesthesiologist from Charlotte, said he had thought the day would bring more comments from the managed-care industry. “I was a little surprised,” he said about the relative lack of voices supporting managed care.

Others speakers expressed strong support for tweaking CCNC to have doctors and clinics assume some financial risk, but not the kind of financial stakes that are associated with managed care.

“No state has a silver bullet,” speaker Judy Group told the panel. Group represents a Cary-based company that manages medications for medically complex patients who take an average of eight drugs. She said her company works in North Carolina as well as in states that have managed care.

Disability voices

Some of the strongest statements during the forum came from people with disabilities ranging from mental health to developmental to physical.

From his wheelchair, Matthew Potter made an impassioned plea to the panel to keep people such as him in the forefront as they make their decisions, telling the panel, “I feel that the voices of clients and consumers are often lost in this process.”

Matthew Potter offered a scathing assessment of the system of care for people with disabilities in North Carolina.
Matthew Potter offered a scathing assessment of the system of care for people with disabilities in North Carolina. Photo credit Rose Hoban.

Potter offered a scathing assessment of the multiple changes in North Carolina’s system for providing care to people with mental health, physical  and developmental disabilities, noting that in his eight years in the state, he’s seen the system change as many as four times.

“This administration and others before it have been moving with the efficacy, forethought and stability of a dog attempting to run on a linoleum floor,” Potter said, “because all they want is to be able to put a political feather in their cap to say that they did something.”

He said the panel should maintain advisory bodies that allow for patients and consumers of care to give feedback to providers.

“Another thing not to do is to put this system into the hands of an out-of-state or private insurance company who’s primary interest is to maximize profit margins,” Potter said.

Mary Short brought her developmentally delayed 36-year-old daughter, Katie, with her to the podium to plead for reimbursement for family members who provide care for their disabled relatives. In particular, Short urged the state to develop reimbursement for a service called protective supervision.

Short has been fighting with the state’s Medicaid program to get reimbursed for the many hours that she provides care for Katie, care that keeps her daughter from more expensive institutional placement.

“It’s simply the acknowledgement that this individual cannot be left alone,” she said. “We need to preserve the ability of family members to remain as family caregivers.”

Short also criticized the current system of state-based managed care organizations that coordinate care for people with disabilities. These MCOs, organized by geography, don’t always cover the same services.

“It’s like we live in 10 different states; there is no standardization, ” Short sighed. “It is incredibly frustrating.”

After the meeting, Gilbert said he was gratified to have had the opportunity to hear from people who will be affected by the reforms the panel proposes.

“It really gave me, individually, a broad spectrum of what people think and what their perspectives and objectives are – how it impacts them personally, individually and collectively,” Gilbert said.

The panel will meet one more time, in mid-February, before presenting its recommendations to legislators in March.

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