By Rose Hoban
At the beginning of Wednesday evening’s Medicaid reform “listening session,” North Carolina Health and Human Services Sec. Rick Brajer asked for a show of hands for how many of the 200-plus people in the room had read his department’s 66-page proposal for reforming Medicaid.
Brajer expressed pleasant surprise when a sea of hands went up.
But when he asked how many people in the room were actually Medicaid beneficiaries, only a few hands raised.
That gap between people with a vested professional interest in the proposed changes to North Carolina’s Medicaid program and beneficiaries themselves marked the first of a dozen of the public hearings to be held around the state in the coming month.
And while the audience was largely respectful, many participants expressed a deep skepticism about the reform plan, which was mandated last fall by the General Assembly.
The Medicaid overhaul will move Medicaid, which serves 1.9 million children, some of their parents, people with disabilities and elderly in nursing homes, from a fee-for-service plan to one administered by a number of private managed care companies.
“Are you sure the services you are saying you’re going to provide, you’re going to provide with this managed care model?” asked Michelle Ogle, an HIV doctor from Vance County. “The answer to that is no.… The answer to that is no.”
Biggest request: expand
About 200 people showed up to the McKimmon Center on the NC State University campus to attend the meeting, conducted by the Department of Health and Human Services on the department’s draft Medicaid reform proposal. About 30 people signed up to spend two minutes each talking about what they wanted to see from the plan.
Suggestions ranged from technical comments about administration and billing codes to requests by parents of children with developmental disabilities looking for clarity on their loved one’s care.
“One thing I’ve always wanted from Medicaid is an ,” said Julie Simmons, who has a son she described as “profoundly disabled.”
“I have no idea how much his health care costs,” she said. “It might make a different in our utilization. It might make me think twice about how much we’re spending.”
She was one of the few people who spoke who was connected to a program beneficiary. Most of the speakers were health care professionals or advocates.
Simmons was also in the minority in that she was one of the only speakers who did not ask Brajer to expand Medicaid to cover an estimated half million adults who currently don’t qualify.
Adults in North Carolina can get covered if they earn less than $5,700 a year. Those earning less than $16,242 don’t make enough to receive subsidies to help pay for insurance obtained through the Affordable Care Act marketplace.
“When patients become insured, they are better able to care for their children and are more likely to help them enroll for insurance,” said Gary Greenberg, a physician who runs the free clinic at Urban Ministries of Wake County. “Closing the health insurance gap will provide better economic security for more families and better economic security for the state as a whole.”
“Our organization … believes that human dignity is a fundamental part of all we believe. Safe, sound and accessible health care is a key to that dignity and to the sanctity of life,” said Greenberg, who spoke on behalf of Carolina Jews for Justice.
‘That ship has sailed’
The Medicaid draft proposal calls for program beneficiaries to choose a provider from as many as five managed care companies.
“There will be more involvement, [patients] will work with their health care providers to be healthier,” Brajer explained. “Those health care providers will be incented to focus on their health outcomes and care will be centered around them.”
However, according to the Kaiser Family Foundation, in 16 of the 37 states with Medicaid managed care plans half or more beneficiaries did not choose on their own and were instead auto-enrolled into coverage.
Physician practices will be obligated to become part of managed care networks and will be paid, in part, a per member, per month fee and paid, in part, based on how well their patients do.
Bill Dennis, a family practitioner from Vance County, expressed concern that the increased complexity would be difficult for patients and providers alike and would impede the ability to recruit new doctors to rural areas.
“Taking care of Medicaid patients is hard, but it’s very rewarding,” he said.
“But the requirements are going to increase. We’ll have all these layers of bureaucracy and prior-authorization types of things and different quality measures. How are we doing to keep up with all of that?”
Dennis bemoaned the dismantling of the state’s current Medicaid management system, Community Care of North Carolina, which uses 14 networks of caregivers around the state to work together to improve quality.
CCNC, a not-for-profit quasi-governmental organization, returns savings to the state and has been lauded nationally for its innovation.
“Now we’re gonna throw that out and do something entirely different,” Dennis said. “But I think that ship has sailed, politically.”
“Under this reform proposal, I’m not sure we can keep doing the things we do,” said Dave Tayloe, a pediatrician who runs Goldsboro Pediatrics, a practice with some 20,000 patients.
He described how his patients in seven counties would fall into three of the six care regions created under the reform plan, meaning the practice could potentially have 13 or 15 different Medicaid payers.
“Currently, we have one payer, one group of care coordinators,” he said. “The current system really works.”
Skeptics
During the comment period, Ogle got up to point out that HIV providers like her, who are reimbursed under federal Ryan White CARE Act funding, have not been included in the current plan.
But her bigger concern was for patients’ access to specialized care.
“You’re going to see them cutting services, or they’re cutting reimbursement,” said Ogle. “That’s the only way this model works.”
“I was in Michigan when they did this,” she said. “What’s going to happen is physicians are going to cap the number of patients they see. They’ll say, ‘I’m not going to have more than, say, 10 percent of my practice as Medicaid. After that, you have to find someone else.’”
Ogle said that about a quarter of her patients are on Medicaid.
Tayloe expressed frustration at the profit that will come out of the system and flow into the coffers of private managed care companies.
“Right now, we’re getting paid 77 percent of Medicare [rates] for our most common office visit. Then they take another 6 percent.… You just have to do the math,” he said. “Our fees have been pretty much frozen since 2004.”
Tayloe said that once the new system rolls out, his practice would probably simply tell patients to enroll in one specific managed care plan.
“If [patients] can’t figure it out, they’re out of luck,” he said.
Republish our articles for free, online or in print, under a Creative Commons license.
