By Jennifer Ferris
MedPage Today/ North Carolina Health News
When department store worker Margaret Autry needs a doctor, she knows she’ll have to wait. Although she’s seen the same family physician for nearly 30 years, she has to stand in line behind 1.4 million people who may need Allen Dobson, MD, more than she does.
“Getting an appointment with [Dobson] is like seeing Oz,” Autry said. “He wants to care for everyone. He means well, but he doesn’t know his own schedule.”
Dobson practices family medicine one day a week in Mount Pleasant, a two-horse town outside of Charlotte. He spends the other four days among Raleigh’s downtown high-rises, overseeing his brainchild, Community Care of North Carolina, the organization that manages the treatment for more than a million patients in North Carolina’s Medicaid “medical home” program.
But recent threats to Dobson’s award-winning medical home model have him pulling more overnighters in Raleigh, and sending patients off to his partners. Although multiple auditors found that Community Care saved North Carolina about $1 billion over a four-year period, some lawmakers are pushing to replace Community Care in favor of a privately run managed care model.
Even as some in the General Assembly have filed bills to end North Carolina’s contract with Community Care, the organization’s star has risen higher nationally. It has been contracted to help Arkansas create and run the state’s first-ever high-risk medical home program and is in negotiations with several other states for similar work.
“Bureaucrats have no experience in the community that they are making policy about,” Dobson said, addressing the apparent disconnect between local and national perceptions of the Medicaid management program. “You have to have someone with a notion of reality.”
From warbling jazz to the Welcome Wagon
As a young man, Dobson had no interest in national policy. He grew up idolizing his uncle, a family physician in rural Statesville. “Watching him, I knew I wanted to do something worthwhile,” Dobson said, remembering times he rode along on his uncle’s house calls to see patients.
In the 1970s, as an undergraduate in chemistry at N.C. State, Dobson honed his trombone skills, playing in a jazz big band evenings and weekends to earn spending money. He continued to play in groups throughout medical school at Wake Forest University and his residency at East Carolina University.
“I knew I wanted to be a doctor during my college years,” Dobson said, smiling at the memory of his college musical hijinks. “But I loved the trombone too. I liked giving people entertainment.”
As chief resident at ECU’s rural medicine program, Dobson saw the diversity of North Carolina’s medical needs. He focused on bringing medicine to the half of North Carolina residents who lived in remote locations, far away from hospitals and specialists.
“ECU was my opportunity to see the cross section of people and the cross section of needs in North Carolina,” Dobson said. “Someone has to take care of every community.”
The first time they visited Mount Pleasant in 1983, Dobson and his wife were met by the mayor, every member of the town council, the head of the chamber of commerce and the town’s only doctor, a man who was desperate to retire after more than 40 years of practice.
“Everyone was so genuinely nice,” Dobson recalled. “I knew if I came here it would be more than a job.” He eventually moved into the big old Victorian house on the town’s main throughway, a building that had housed the town’s doctor for more than a decade.
From his first day in clinic, Dobson was slammed with more patients than he could handle. He wanted to provide high-quality care. But without a network of local family doctors, delivering the right care to each patient proved a challenge.
Dobson faced the challenge head-on, opening three more regional offices and debuting a rural residency program that drew high-quality graduates from ECU and other medical schools.
“Our obligation was to the community,” he said. “It wasn’t just about me practicing medicine. It was about being part of the community, making it better.”
A ‘notion of reality’
Medical homes might be a new idea on the national stage, but the N.C. Office of Rural Health has been experimenting with them since the 1980s. Dobson’s colleagues say North Carolina’s reputation today as an innovator of the model is without a doubt due to the mustachioed doctor’s guiding hand.
In 1998, he got the nod from the governor to pilot the medical home program, and six years later more than 2,000 doctors were enrolled in what became known as Community Care of North Carolina. CCNC is a not-for-profit statewide network of primary care practices that focuses on preventive measures and continuity of care.
The network gets state money to coordinate and manage care for about 1.4 million of the state’s close to 1.8 million Medicaid patients.
Even as he helped architect the plan, which was eventually put in place in all 100 North Carolina counties, Dobson continued to see patients at his Mount Pleasant office, a practice he says kept him grounded and attuned to the needs of people instead of the wants of lobbyists.
In 2005, to his surprise, Dobson was tapped by the state’s governor to become the assistant state Medicaid director and secretary of health and human services. In this position, he expanded Community Care’s reach, tasking the organization with caring for the at-risk Medicaid population, giving the organization $6 million of additional state funding to complete the task.
As a now-expert in the implementation of statewide health policy, he was asked in 2008 to join the Brookings Institution as a visiting scholar. In this capacity, his idea became one of the inspirations for the medical home features of the Affordable Care Act.
“The ideas [Dobson] was working on were ones that can really succeed in helping doctors and other clinicians give better health care,” said Mark McClellan, former head of the national Centers for Medicare and Medicaid Services in George W. Bush’s administration and current Brookings director of the Health Care Innovation and Value Initiative. “With Allen, it’s really about the bottom line. It’s not doing things traditionally. It’s focusing on health.”
Moving backwards
Recent shifts of political power in North Carolina have led to lawmakers questioning the efficacy of medical homes and Community Care’s usefulness.
During the 2014 legislative session, Gov. Pat McCrory extolled a move to privately run accountable care organizations, a solution, the governor said, to Medicaid’s so-called massive cost overruns.
Dobson said the cost of Medicaid claims has been flat, countering lawmakers seeking to end Community Care. “We are the best in the country in terms of what we spend on medical care.”
State auditors are currently evaluating Community Care, but numbers released by the program – and accepted by the state General Assembly – count yearly cost savings in the hundreds of millions annually.
Dobson said the program is not perfect and that Medicaid needs repairs to the provider-payment system. But the delivery of care, he said, is the best in the country. Other experts agree.
Recently, the head of Virginia’s Medicaid Program, Cindi Jones, told a North Carolina legislative health subcommittee that Community Care was a model for the nation and said it’s what her state would choose were they building a system from the beginning.
Hometown boy
When Dobson returns to clinic in Mount Pleasant on Friday afternoons, he said he gets to shuck away higher-level worries to focus on his real passion: patient care. His nurse, Lisa Darnell, said she thinks the patients who wait weeks for an appointment have no idea that the man with the prescription pad is a player on the national health care stage.
“The majority of them know he does other things,” said Darnell, who has been working with Dobson since 1993. “Our small town is kind of ‘Mayberry’-ish. People just know he’s out doing something with the state.”
Dobson said he dreams of a retirement that involves a patient roster that numbers in the dozens, a lake house and a fishing pole. But until he knows the threats to Community Care have abated, he’ll continue to make the two-and-a-half-hour drive to Raleigh every week, arguing against those who would end Community Care.
“Being an outsider is an advantage,” Dobson said, “Only a physician can really understand health care.”
[box style=”4″]This story is part of a partnership between MedPage Today and North Carolina Health News. The collaboration will make it possible for us to publish regular profiles of health care professionals from North Carolina.[/box] Republish our articles for free, online or in print, under a Creative Commons license.
