Health and Human Services Secretary Rick Brajer gives a rundown of the draft Medicaid reform proposal Wednesday evening at the McKimmon Center on the NC State University campus in Raleigh.
Health and Human Services Secretary Rick Brajer gives a rundown of the draft Medicaid reform proposal Wednesday evening at the McKimmon Center on the NC State University campus in Raleigh. Photo credit: Rose Hoban

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The state Department of Health and Human Services holds its final Medicaid reform hearing – and hears plenty from pediatricians.

By Taylor Sisk

“You really see democracy in action,” state Department of Health and Human Services Sec. Rick Brajer said Monday evening.

He was referring to the series of public hearings his department convened to receive feedback on the state’s impending proposal to move Medicaid from a fee-for-service model to one administered by private managed care companies and local provider-led entities.

Department of Health and Human Services Sec. Rick Brajer said the “strongest voice” in Medicaid reform hearings has been that of pediatricians. Photo credit: Taylor Sisk

Brajer was speaking as an audience of about 75 filed out of Moore Hall Auditorium on the campus of UNC-Pembroke. This was the last of a dozen of those hearings, and he had listened as about 20 people shared their concerns about the future of Medicaid, the state/federal partnership that serves 1.9 million children, some of their parents, people with disabilities and the elderly in nursing homes – roughly one in five North Carolinians.

Those who spoke on Monday were almost all health care professionals, were unfailingly respectful and shared many of the same anxieties: Will privatized managed care result in restricted care? Will it provide for flexibility? Will CCNC – the state’s current not-for-profit Medicaid management system – be a part of the new system?

Some expressed what DHHS officials have heard repeatedly throughout the state: that Medicaid expansion is critical to the success of any statewide health care plan.

And from a number of pediatric providers came pleas to be particularly careful not to allow reform to harm children.

Christoph Diasio of Sandhills Pediatrics noted that kids comprise some 60 percent of the state Medicaid program’s enrollees but a considerably lower percentage of its costs.

“Children ought to be left out of this waiver,” Diasio told Brajer.

Provider supports

The federal Centers for Medicare and Medicaid Services pays two-thirds of the cost of North Carolina’s Medicaid program, and state officials must thus gain its approval for any changes to the program.

David Tayloe, who runs a pediatric clinic in Goldsboro, speaks at the Pembroke meeting on Monday, asking Brajer for a statewide provider-led entity. Photo credit: Taylor Sisk

The plan the state will be presenting to CMS is called an 1115 waiver to the Social Security Act of 1965, the law that created Medicaid. The intent of the overhaul is to both save money and encourage innovation.

The waiver will be submitted June 1, at which point a lengthy back-and-forth with CMS will commence. It could be several years before the waiver is even approved, and another one to two years before the public sees any changes.

“We’re going to continue to listen and innovate,” Brajer told Monday’s audience. “This is an ongoing discussion between ourselves and CMS and between ourselves and the rest of the state, especially on the issues that are maybe the most contentious.”

Brajer said the plan will transition health services in the state from what’s now termed the “triple aim” of health care – a more satisfactory patient experience, improved health outcomes and lower per-capita costs – to a “quadruple aim,” with the addition of a focus on provider supports.

These supports, Brajer said, would include assistance with “administrative burdens.”

He said that in drafting the waiver, DHHS has engaged some 50 associations from throughout the state.

“If there’s an association that we didn’t talk to, I’d love to know what their name is,” he said, “because we spent a lot of time with a lot of folks in developing this waiver.

“It would probably be closer to being true to call it a crowd-sourced waiver,” Brajer said, “It reflects the input of a lot of folks.”

He said that a primary objective is to offer beneficiaries more choice. They will have the option to choose from up to three statewide and two regional plans, with contracts that will run for four or five years. Behavioral health services will not be included in the waiver for at least four years.

Brajer said the state will offer plan enrollment assistance on request.

‘The Kids Sent Me’

“Without a doubt, the strongest voice has been by pediatricians in terms of the challenges they face from a rate perspective, from a systems’ perspective,” Brajer said, summing up the input received from the hearings.

Christoph Diasio of Sandhills Pediatrics told Brajer that, “Children ought to be left out of this waiver.” Photo credit: Taylor Sisk

“If you’d told me prior to the public hearings that the loudest voice in all these meetings would be pediatricians – loudest in terms of the most frequently heard – I wouldn’t have predicted that,” he said.

Pediatric providers certainly played a prominent role in Monday’s discourse. Among them was Sandhills Pediatrics’ Diasio, who wore a “The Kids Sent Me” button.

Diasio said that in his role as chair of the American Academy of Pediatrics’ Section on Administration and Practice Management, “I’ve been unable to find a single pediatrician, nationwide, who has nice things to say about managed care Medicaid. They envy what we do in North Carolina … impressed with the good work that CCNC does.”

“Children in North Carolina are not where the cost is,” Diasio said, urging that kids not be included in the managed care waiver.

Rural needs

Asked how, if at all, input differed in a rural area such as Robeson County, where the UNCP campus is located, from that received in the hearings held in cities, Brajer said, “What you hear more about are the social determinants of health, how the economy impacts health.”

Cherry Maynor Beasley, a professor in UNCP’s department of nursing, a nurse practitioner and a member of the Lumbee tribe, shared some of those concerns during the hearing, discussing “health, place, wealth and race.”

Cherry Maynor Beasley, a professor in UNCP’s department of nursing, stressed the importance of hearing from rural communities in shaping Medicaid reform. Photo credit: Taylor Sisk

Beasley said that 47 percent of children in Robeson County live in poverty, the infant mortality rate is nearly double the state average and twice as many children are born to mothers who don’t have a high school education.

She stressed to Brajer the need for a plan that includes a greater emphasis on health education and incentives for inter-agency collaboration. Beasley said that rural communities should be actively engaged in the reform process to determine the services that best meet their particular needs.

Brajer said his department was also consistently hearing from rural residents about the need for incentives to retain or attract health care providers, mentioning, in particular, OB/GYNs and psychiatrists.

“Workforce development becomes more important in an environment like this,” he said. He added that his department will be proposing to the legislature “taking graduate medical-education dollars and reorienting them … to needed providers in rural areas.”

That proposal, he said, is “teed up for the short [legislative] session.”

Correction: In a photograph, David Tayloe was originally identified as Robeson County minister Mac Legerton.

[box style=”2″]This story was made possible by a grant from the Winston-Salem Foundation to examine issues in rural health in North Carolina. [/box]

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Taylor Sisk

Taylor Sisk is a writer, editor, researcher, producer and documentary filmmaker who served as the rural health reporter from 2015 into 2016. He has served as a managing and contributing editor of The Carrboro...