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A woman on a screen is masked and holding a tooth.

Your dentist can see you remotely

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Your dentist can see you remotely - North Carolina Health News

North Carolina lawmakers establish standards for the practice of teledentistry. Gov. Roy Cooper signed the bill into law last week.

 By Anne Blythe

Shaun Matthews, an evangelist for telehealth in the United States and abroad, was giving a presentation to the International Association of Dental Research on a Zoom call last week when he learned that North Carolina lawmakers had just approved a bill formalizing the use of teledentistry.

As part of his presentation on “The Rise of Teledentistry in Clinical Practice: An Inevitable Response to a Global Pandemic or a False Dawn,” Matthews mentioned work he had done in North Carolina while at the UNC-Chapel Hill dental school.

During his Zoom segment, Jane Weintraub, former dean of the UNC Adams School of Dentistry and the woman who recruited Matthews to Chapel Hill from Great Britain, dropped a message into the chat discussion for her colleague.

She had just received word that Senate Bill 146, an act establishing standards for the practice of teledentistry in North Carolina, was sailing through the General Assembly with broad support in both chambers.

On Friday, Gov. Roy Cooper signed the bill into law.

Matthews, a clinical professor in Oral and Maxillofacial Surgery and Hospital Dentistry at the Indiana University School of Dentistry since August 2020, swelled with pride.

For two of his five and a half years at the dental school in Chapel Hill, Matthews was director of telehealth while juggling his clinical and teaching work.

Teledentistry, Matthews and other supporters say, can help expand basic oral health care to people in areas where it can be difficult to see a dentist, to underserved children and to the aging. With special cameras, audio and visual technology, clinicians can do consultations and some follow-up visits with patients remotely, often saving the patient the cost of traveling to the appointment and the need to take time off from work.

Power of telehealth

During the pandemic, telehealth visits rose sharply, especially in the spring of 2020. In an Oct. 2020 report posted on the Centers for Disease Control and Prevention website, a team of scientists concluded that there was a 154 percent increase in telehealth visits during the last week in March compared to the same time frame in 2019. 

“Telehealth could have multiple benefits during the pandemic by expanding access to care, reducing disease exposure for staff and patients, preserving scarce supplies of personal protective equipment, and reducing patient demand on facilities,” the researchers concluded. “Telehealth policy changes might continue to support increased care access during and after the pandemic.”

Some estimates put the adoption of telehealth even higher. The management consulting firm McKinsey estimates that beyond an initial explosion of telehealth use in early 2020, telehealth use has stabilized at 38 times higher than pre-pandemic levels.

“After an initial spike to more than 32 percent of office and outpatient visits occurring via telehealth in April 2020, utilization levels have largely stabilized, ranging from 13 to 17 percent across all specialties,” the McKinsey authors found. 

In the early days of the pandemic, when Matthews was still in North Carolina, he worked with Weintraub and others at the Adams School of Dentistry to create the Carolina Dentistry Virtual Oral Health Care Helpline.

COVID-19 had spread across the country and state with a vengeance.  

The UNC dental school had held its second teledentistry summit in early March of 2020, hoping to persuade others that the use of such technology could expand oral health care access to underserved populations and remote parts of the state.

When many dental offices across North Carolina were forced to close except for emergency services, Matthews and others built on their teledentistry models to set up a system in which people who perhaps cracked a tooth or had some other oral health issue could call into the hotline.

Putting ideas into action

If necessary, the caller could get a virtual assessment through a video or Zoom call.

In the first month, 337 telephone calls were answered, according to an article the dental school colleagues published in the Journal of the American Dental Association about the hotline. Dental pain was the reason that more than half of the people called. Seventy-nine of the callers received consultations from virtual providers, the authors stated, and 33 of those callers did not require follow-up.

Using teledentistry to connect dentists and oral health care providers to their patients virtually during the pandemic underscores many of the benefits that advocates have been touting for years.

They include:

  • Virtual consultations in which dentists can assess a patient quickly and remotely to determine whether to recommend medicine, a trip to an emergency clinic, hospital or their dental offices.
  • Saving patients the expense of travel and unnecessary time off from work for a check-up after an operation if it can be done online.
  • Through the use of intraoral cameras, a hygienist or nurse can share images from inside the mouth of a patient they’re seeing at a nursing home, school or other remote site and discuss a treatment plan with a dentist.

Hygienists and local anesthesia

Zachary Brian, director of the North Carolina Oral Health Collaborative, has long advocated for teledentistry as a way to provide more public health care at schools, nursing homes, rest homes and facilities for people with special needs.

North Carolina dental hygienists have been urging dentists and others in this state to give them the freedom to clean teeth and screen patients for cavities and other problems even if a dentist is not in the room or office with them.

Masked male dentist and masked female hygienist drill inside a patients mouth
Dentist Bill Milner of Access Dental Care and hygienist Mary Elizabeth Andreyev extract a patients broken tooth at Moses Cone Infectious Disease Clinic. Photo credit: Anne Blythe

Additionally, they have argued that they could take X-rays, apply sealants, and in some cases prevent further tooth decay with silver diamine fluoride outside the physical presence of a dentist.

In early 2020, the state legislative rules commission amended the scope of practice for licensed hygienists in North Carolina, making it possible for them to work without a dentist on-site in federally qualified health care centers, some public schools, and special-needs and some elder-care facilities.

The new law establishes standards for the practice of teledentistry that will make it possible for hygienists to work in such facilities without a dentist there with them.

The law also authorizes registered hygienists to administer local anesthetics, another expansion of their scope of practice in a state that is among the most restrictive in the country for what a hygienist can do outside the presence of a dentist.

North Carolina hygienists now will join the ranks of their peers in 44 other states and Washington, D.C., already authorized to give injections. The change, Brian said, could help improve efficiency and perhaps reduce the cost of care.

“This is an important step toward a more equitable oral health landscape in North Carolina,” Brian said in a statement.

There are challenges, though.

There’s a paucity of broadband infrastructure in much of rural North Carolina, making telehealth visits less likely in just the regions such programs could better serve.

Questions remain, too, about whether insurers will continue to cover teledentistry and other online health care visits after the pandemic.

The stakeholders who brought together lawmakers from both parties to show broad support for teledentistry in North Carolina say it was important to bring many to the table and educate them about the public health benefits and business advantages for dentists.

The North Carolina Dental Society played a crucial role, too.

“It is always great to see bipartisan support for common-sense health care reform,” Ben Popkin, political strategist for the Foundation for Health Leadership and Innovation, said in a statement.

‘Over the moon’

Matthews, the former UNC dental school professor recruited to Indiana University to help advocate for telehealth in the Hoosier State, was still jazzed several days after the North Carolina law was adopted.

“I am absolutely thrilled, over the moon,” Matthews said during a telephone interview.

The Indiana governor signed a bill into law in April that authorizes dentists, hygienists and other health care providers to use telehealth with their patients, a change that came, in part, because of Matthews.

Though approval of the law in North Carolina came several months after the Indiana action, Matthews said this state’s establishment of standards for the practice of teledentistry is a step further.

“To hear it literally coming through hot off the presses as I was giving my presentation was so impressive,” Matthews said.

Weintraub, who has been busy looking up teledentistry activities in the corporate world now that this state will be able to offer it as a service, summed up the law after the international conference.

“This bill is a major step forward in aligning our state with the rest of the country to improve the accessibility and efficiency of dental care,” Weintraub said in a statement. “It clarifies the provision of teledentistry that benefits those who can’t easily get to a dental office because of geography, disability, a pandemic, or who desire greater convenience.

“It makes it possible for people to obtain preventive services from qualified dental hygienists in many community settings without on-site dentist supervision.  NC is one of the last states to allow trained dental hygienists to provide local anesthesia. The first state did so 50 years ago in 1971.”

shows a man in personal protective equipment standing with testing equipment in his hands. He's standing under a tent, where they're doing drive through testing and vaccines for COVID-19

Federal program gets vaccines to qualified facilities, rural residents, migrant workers

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Federal program gets vaccines to qualified facilities, rural residents, migrant workers - North Carolina Health News

The Health Center Covid-19 Vaccine Program is a major step toward vaccinating the migrant workforce, keeping America's agricultural operations unobstructed, the White House says.

By Liz Carey

Daily Yonder

While some rural areas are struggling to use all the vaccines they’ve been given, a new program from the Biden Administration is helping others get the vaccinations they need.

Administrated by the Health Resources and Services Administration (HRSA), the Health Center Covid-19 Vaccine Program is designed to ship doses of the vaccines directly to Federally Qualified Health Centers (FQHC), many in rural areas, as a way to get shots into arms of those disproportionately affected by the disease – the homeless, public housing residents and migrant workers.

“There are more than 1,300 Community Health Centers serving almost 30 million people across the country,” the White House said in a statement. “Two-thirds of the population that these centers serve are living at or below the federal poverty line and 60 percent are racial and/or ethnic minorities. The program will be phased in, with the first centers able to start ordering vaccines as early as the week of February 15. The initial phase will include at least one Community Health Center in each state, expanding to 250 centers in the coming weeks.”

Since rural populations tend to be older, sicker and poorer, the program is helping some rural clinics address the needs in other populations as well.

In Toppenish, Washington, the Yakima Valley Farm Workers Clinic serves residents of a mostly poor and mostly minority community. The clinic is an FQHC located on Yakima Indian Territory and is the agricultural center for Yakima Valley. Since its founding in 1973, the single health care center has grown into one of the largest community health centers in the Northwest, with over 40 clinics in 18 communities, most of them rural, in Washington and Oregon. Residents are mostly non-white and minority and 29 percent of the clinic patients are seasonal and migrant farm workers.

Prior to the rollout of the Health Center program, getting a vaccine was a shot in the dark, says Lori Kelley, Senior Director of Quality and Patient Safety at the Yakima Valley Farm Workers Clinic.

“Some weeks we’d get some doses from the state, but then the next two weeks, we would get any,” Kelley said. “It was very inconsistent and frustrating. The state did everything they could, but we got zero vaccines several weeks in a row.”

That changed when they accepted an invitation to join HRSA’s program as one of the first 25 health care centers to get the vaccines directly from the federal government.

“We are first of all, so grateful to be a part of the program,” Kelley said. “We’re in the second set of shipments this week. Already it’s made such an impact on our communities.”

The FQHC went from having no doses to giving 8,177 first dose shots in two weeks, she said. Now, after not knowing how many vaccines she would get, if any, she’s able to go online and order vaccines, knowing that they will be delivered.

Even as vaccines are being delivered to large chain pharmacies, it’s important that the FQHCs get the vaccine, she said.

“There is no pharmacy in Toppenish,” she said. “Farm Workers Clinic is the pharmacy.”

Washington state is currently on Phase 1b, she said. The state is expected to go to the next phase of the vaccine distribution, which includes teachers, childcare workers, and migrant and seasonal farm workers, on March 22.

Getting vaccines into the arms of migrant workers is important too, she said.

“They can’t do their jobs from home,” Kelley said.

Allison Crittenden, Director of Congressional Relations with the American Farm Bureau Federation, agreed.

“We certainly would want agriculture to have that prioritization, if possible,” she said. “It’s been incredibly important during the pandemic for farmers and farmworkers alike to ensure that their workplaces are safe and there are measures in place to mitigate the spread of Covid. That’s something that farmers across the country have really taken seriously. And we think vaccine prioritization is the next logical step.”

As the year inches towards H2A season – where migrant workers come to America for a specific time to pick crops on a single farm – plans are being put in place to make sure those workers quarantine and get the vaccine. While farmers would prefer that migrant workers get vaccinated before they leave their home country, they want to ensure that they do get vaccinated one way or the other.

The Farm Bureau has been in talks with the Centers for Disease Control and Prevention (CDC), she said, to address how to get vaccines into the arms of migrant farm workers on the move.

“We had conversations with folks from the CDC that are working on both agricultural guidance as well as getting vaccines out to the essential workforce,” she said.

“We’ve also spoken with the CDC individuals who actually are leading the charge for rural communities and migrant communities…We want to make sure that these community health groups, and state health departments are deploying those first round of vaccines that match with the appropriate second round wherever the individuals may end up as they travel throughout the growing season.”

Providers stand around a bed in a training about opioid use disorder at MAHEC in Asheville last year.

Initiative aims to connect patients to addiction treatment by building better networks

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Initiative aims to connect patients to addiction treatment by building better networks - North Carolina Health News

A UNC-MAHEC partnership will create regional referral networks using a “hub and spoke” model to better care for those with substance use disorders.

By Liora Engel-Smith

As coronavirus tears through North Carolina, upending nearly every aspect of life, some experts are focusing on another ongoing crisis that has gotten less attention in recent weeks: opioid overdoses.

Overdoses of both prescription and illegal opioids killed an average of five North Carolinians a day in 2018, according to data from the North Carolina Department of Health and Human Services. By comparison, 53 North Carolinians died of COVID-19 since March 25, which seems like a lot, but remains less than the average daily toll from opioids.

Related: Forty-one N.C. counties classified as “high risk” in opioid study

A collaboration between University of North Carolina at Chapel Hill School of Medicine and Mountain Area Health Education Center (MAHEC) aims to help people with substance use disorders find the care they need with an eye for making a dent in North Carolina’s opioid deaths in the long run.

A small headshot of a physician that's involved in developing a hub and spokes model for opioid treatment.
Dr. Shuchin Shukla. Photo credit: MAHEC

The partnership is funded by a more than $1 million, two-year grant, from the national Foundation for Opioid Response Efforts and western North Carolina-based Dogwood Health Trust. The idea is to create stronger connections between clinics that care for low-income people with experts at MAHEC and University of North Carolina at Chapel Hill so patients receive seamless care, said Dr. Shuchin Shukla, physician at MAHEC and clinical assistant professor of medicine at UNC. It will also give MAHEC resources to help providers in community centers and health departments better care for patients with opioid use disorders.

Addiction care across the state tends to be sparse and fragmented. Patients typically need some level of specialty care when they first enter recovery, especially if they require medications such as methadone or buprenorphine, which reduce opioid cravings.

When patients stabilize later on, a primary care provider can continue to monitor them and prescribe their medication. But there’s a shortage of doctors who have the training and licensing requirements to prescribe such medications. As of March 9, North Carolina had 3,351 providers who can prescribe opioid replacement medication, according to the Federal Substance Abuse and Mental Health Services Administration, and many of them tend to congregate in cities. A JAMA analysis released last summer found that 41 counties in North Carolina had high rates of opioid overdoses and not enough providers who can prescribe these medications.

The “hub and spokes” model addresses some of these challenges.

‘What a referral system should be’

In traditional referrals, patients may remain with a specialist for a long time and their family physician may or may not be involved in the treatment plan.

The hub and spokes model closes the referral loop between the “spoke” — primary care providers at a community health center, for example — and the “hub” — a clinic with addiction specialists.

“[It’s] really the ideal of what a referral system should be,” said Melinda Ramage, medical director of Project CARA, a MAHEC program that uses the model to help pregnant women with opioid addiction. “ … What makes the hub and spokes model work is the idea that it is alive and it is a network where the providers that deliver care have to understand and have relationships with each other.”

A photo of a medical building that houses MAHEC, an agency which among other things is part of a hub and spokes effort to help people with opioid addiction.
UNC Health Sciences at MAHEC building on MAHEC’s Asheville campus. The Western North Carolina organization is working with UNC to develop a “hub and spokes” referral system to help people with opioid use disorder get treatment. Photo credit: MAHEC.

The idea of such integrated care is not new. Other states, including Vermont,  New Hampshire, Washington and California have used the model to increase access to opioid treatment, and Shukla, who is involved with the new UNC-MAHEC effort, said both institutions are eager to eventually scale up the project to include eastern North Carolina.

But first, MAHEC will work with community health centers and health departments in western North Carolina to develop the hub and spokes relationships, Shukla said.

It’ll take at least a year before the network is robust enough to begin taking new patients in the western part of the state, he added. The rise of coronavirus cases may prolong the timeline because many health departments and health centers are busy responding to the outbreak. The program’s other hub in Chapel Hill is already running.

Addressing a mismatch

Dr. Robyn Jordan, assistant professor at UNC Chapel Hill, came to the hub and spokes model a couple of years ago. Jordan, medical director of addiction medicine at UNC, said their clinic had a resource problem.

“Our clinic was full of stable patients that we couldn’t transition to the community, which meant that we couldn’t take on new patients,” she said.

A photo of a woman with long hair with a blurred background. She is Dr. Robyn Jordan, who is part of an initiative to help people with opioid use disorder find treatment.
Dr. Robyn Jordan. Photo credit: UNC

That meant that patients who needed an addiction specialist couldn’t get one, and the clinic’s existing patients were seeing addiction specialists when they didn’t need that level of care.

To fix the mismatch between what patients needed and what they got, Jordan said, the clinic had to reconfigure how it provides care and create strong referral relationships with clinics from other agencies.

Staff now tell patients from the outset that the goal is to stabilize them and refer them to a permanent medical home after a time, Jordan said. Clinical care managers help with that transition and specialists at the clinic follow up on patients throughout and after the referral. Even once patients settle at their medical home, providers from the clinic keep in touch, monitoring and lending expertise as needed.

The collaboration with MAHEC, Jordan said, will help UNC solidify its hub. The funds will allow them to hire peer support specialists, who will keep in touch with patients and make the transition to another medical home easier. UNC will also assist MAHEC in setting up its hub, while MAHEC will help support and train providers in community health centers to care for patients with opioid use disorders.

Jordan said the clinic is still collecting data on how patients fare with the new system, but the hub and spokes model helped the clinic at UNC to see more new patients.

Last year, the clinic took on 42 new patients without adding any new physicians, she added. This year, they’ve seen more than 60 new patients.

Stronger medical homes

A robust referral system is only part of the equation: in order to leave a specialist clinic, patients need a medical home that can help them maintain their recovery.

That’s where community health centers come in, said Alice Pollard, director of health access at the North Carolina Community Health Center Association. The state’s 42 community health center organizations already work with patients on many of their medical needs, including dental, mental health and primary care, she said. Of those organizations, 15 to 20 have some degree of expertise in treating opioid addiction, she said. But that expertise varies from having a robust program with numerous providers to a single provider who can prescribe buprenorphine.

A partnership with experts at MAHEC and UNC could help more centers create such programs, she said, or expand the substance use programs they already have.

“That’s one of the reasons we’re so excited to work with MAHEC and UNC,” she said. “ … But we also think health centers really bring a lot of expertise in helping people navigate some of those social barriers that they have to engaging in care.”

A doctor and patient in a community health center

Community health centers are again on the brink of federal funding lapse

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Community health centers are again on the brink of federal funding lapse - North Carolina Health News

The federal budget -- and with it funding for community health centers -- is set to lapse on Dec. 21.

By Liora Engel-Smith

Across North Carolina, community health centers are contending with what has become an unpleasant tradition: planning for a potential federal funding lapse.

The nation’s safety net clinics — 250 of which are in North Carolina — serve thousands of uninsured and underinsured patients and enjoy bipartisan support. But a battle between Congress and President Donald Trump over funding a border wall at the U.S.-Mexico border has stalled the passage of a full federal budget, which includes funding for community health centers.

Related: Congress Not Acting; Now Community Health Centers Weigh Closures

The federal budget nearly lapsed twice this year — in September and in November  — but two stopgap bills kept the government open and guaranteed short-term funding for community health centers. Without a new budget or a resolution to extend current spending, federal funding to health centers will lapse a few days before Christmas.

Community health center advocates from across the state say that Congress’ reliance on short-term spending bills and the specter of a funding lapse has created uncertainty that could hurt services to patients, many of whom are low-income.

“A five-year plan is short-term, a two-year plan is minuscule,” said Leslie Wolcott, a spokeswoman for the North Carolina Community Health Center Association.

“It’s like nothing, and here we are with three weeks of funding at a time.”

A map of all the community health centers in North Carolina.
42 organizations operate 250 community health center sites in North Carolina. Source: NC Community Health Center Association.

At issue is the federal Community Health Center Fund, which provides the bulk of federal funding to almost 1,400 health centers across the U.S. In the 2019 federal fiscal year, that fund had $4 billion, according to the National Association of Community Health Centers. In North Carolina, the loss of those funds could translate to community health centers losing almost half of their patients collectively, and a loss of almost 1,500 full-time jobs, a recent state-by-state analysis by the association said.

Even without the economic impact, the continued viability of health centers is important in the Tar Heel state, where the uninsured rate is 9th highest in the nation, Wolcott noted. With community health centers serving many of these low-income people funding instability makes an already difficult job even harder.

“It always keeps us somewhat tentative about making decisions long-term about where [our] funding priorities are because you want to make sure that you have enough money to pay for staff and pay for the services that our patients need,” said Reuben C. Blackwell IV, who heads OIC of Rocky Mount, a community health center in the eastern part of the state.

Located in Edgecombe County, which according to the N.C. Department of Commerce is the most economically distressed county in the state, OIC of Rocky Mount serves people with significant unmet medical needs. A more stable funding environment would allow OIC to expand its services to other critical areas, such as pediatrics, Blackwell said.

Blackwell said he’s had to consider contingencies if funding does lapse. OIC has roughly 150 employees, and though OIC managed to avoid staffing cuts when federal funding lapsed in 2017, Blackwell said he may have to make difficult choices ahead.

“We have to have plans in the event that money doesn’t come, who won’t have a job,” he said. “Or who would have less pay or how will we absorb this impact within the organization.”

‘The system would implode’

Community Health Centers have been here before. In 2017, Congress failed to reach a budget agreement and funding lapsed for five months before it was extended for two years. Back then, health centers resorted to closing clinic sites, laying off staff and reducing services to deal with the delay. A September survey from the Kaiser Family Foundation found that health centers across the country are already considering similar measures.

“I keep saying to anyone that will listen, ‘How does that make sense in the safety net environment?’ Because the larger health systems count on us. If we weren’t there … the system would implode,” said Kim Schwartz, CEO of Roanoke Chowan Community Health Center, which serves several counties in Eastern North Carolina.

Schwartz said the funding uncertainty has slowed the growth of the health center, which already serves 25,000 patients. Stable funding could mean opening two or three new sites in underserved areas, she said.

Part of her organization’s long-term plan, she said, is to reduce its dependency on federal funding by finding additional sources of income. The federal grant, she said, makes up about 20 percent of the Roanoke Chowan’s budget.

“So that means that [if funding lapsed] we would have to reduce everything by about 20 percent, she added. “So reduce our access to care, reduce our workforce if we don’t have that 20 percent to cover [these expenses].”

A path forward?

There are signs that longer-term funding for community health centers is on the horizon. Key leaders of U.S. Senate Committee on Health, Education, Labor and Pensions, and the U.S. House Committee on Energy and Commerce have reached an agreement to extend funding for community health centers for five years as part of a larger proposal that deals with surprise medical bills, according to a statement from the National Association of Community Health Centers. 

Though the proposal has bipartisan support, there is still no guarantee it’ll pass and be signed by the president before the December deadline.

Christopher Vann, spokesman from CommWell Health, a community health center with clinics in Sampson, Bladen, Brunswick, Johnston and Pender Counties, worried that the impeachment proceedings in Congress may delay the passage of the proposal.

“[E]verything hinges on the passage of the Continuing Resolution by 12/20,” he wrote in an email.

Shows Hurricane Dorian as it was over the NC Coast in September

Gov. Cooper signs Storm Recovery Act despite concerns

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Gov. Cooper signs Storm Recovery Act despite concerns - North Carolina Health News

Nearly $180 million in help is on the way for North Carolina recovery and resiliency projects related to hurricanes Dorian, Florence, Matthew and Michael.

By Anne Blythe

A political storm that brewed last week between Gov. Roy Cooper and Republican legislative leaders over language in the Storm Recovery Act of 2019 calmed this week.

The Democratic governor signed the bill into law, approving the release of some $180 million in state funds for recovery and resilience projects related to hurricanes Dorian, Florence, Matthew and Michael.

“This legislation helps families recovering from Dorian and previous storms, especially those left behind by the federal government,” Ford Porter, a Cooper spokesperson, said in a statement. “The Governor pushed for this funding and the Republican leadership was willing to risk losing it by attaching unrelated political power grabs, but the Governor believes helping these survivors must prevail.”

Related: Will Ocracoke and North Carolinians still struggling from Hurricane Dorian, Florence and Matthew get disaster assistance soon?

Ocracoke & Hatteras locals pull together to continue health care delivery post-flood

Hurricane Florence left destruction but also information on how to prepare for and respond to the next disaster

The bill was approved overwhelmingly last week by both General Assembly chambers amid a stalemate between Republican lawmakers and Cooper over the $24 billion budget he vetoed in late June.

Cooper vetoed the lawmakers’ budget for the fiscal year that began in July several days before the start of it, saying the spending plan did not include high enough raises for teachers nor include money to expand Medicaid eligibility to as many as 550,000 low-income adults who could qualify for the federal assistance.

That impasse resulted in the state House and Senate putting forward and adopting a series of mini-budgets to release money such as that in the Storm Recovery Act adopted on Thursday.

Shows a mobile clinic unit with piles of construction debris next to it.
A photo of the mobile health center taken while the North Carolina EMS workers were still in Ocracoke village. Debris from buildings needing repair has piled up on the roadsides all over the village. The blue Ocracoke Health Center building is in the background. Photo credit: Connie Leinbach/ Ocracoke Observer

Before any votes were taken last week, Cooper’s office raised concerns about language in the bill that they contended would shift control over money the state receives for lawsuit settlements to the General Assembly.

Sen. Phil Berger’s (R-Eden) office disputed the governor’s claims, contending the language in the bill “reaffirms what state law is — money received by the state goes to the state treasury.”

Now that Cooper has signed the bill into law, the next question is how and when the $121 million in state matching funds included in the overall plan will be released.

In health care funding, the Storm Recovery Act of 2019 includes:

  • $70.8 million for the Hurricane Florence Disaster Recovery Fund established in 2018 to provide matches for federal disaster assistance programs.
  • $33.1 million to the State Emergency Response and Disaster Relief Fund to provide $11.1 million for programs related to Hurricane Matthew and $4.1 million for programs related to Hurricane Michael.
  • $17.8 million in state matching funds for Hurricane Dorian, which whipped and flooded Ocracoke Island.
  • $17.6 million to the Department of Environmental Quality to match additional federal funds for the Clean Water State Revolving Fund and the Drinking Water State Revolving Fund.
  • $1.5 million in annual funds in each of the next two years to cover the long-term service contract for software and service upgrades to the Voice Interoperability Plan for Emergency Responders (VIPER) system.

Cooper’s office also announced this week grants of $50,000 each from the Kate B. Reynolds Trust to support “infrastructure-related capital needs, emergency supplies and equipment to sustain services during emergencies and natural disasters.”

Beneficiaries include health departments in storm-affected eastern North Carolina counties, community health centers in the region, as well as Bladen County and Hoke County hospitals.

Disclosure: The Kate B. Reynolds Trust is an underwriter of North Carolina Health News.

An African American man stands in front of a podium, behind him there's a slide about disparities. There are also two women sitting in front of a table at his side. This was a press conference to discuss OIC of Rocky Mount and among other topics, medicaid transformation came up.

In Medicaid transformation rollout, ‘more questions than answers’

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In Medicaid transformation rollout, ‘more questions than answers’ - North Carolina Health News

The leader of a community health center in Rocky Mount has concerns about the state’s ambitious plans to peg reimbursements to patient health.

By Liora Engel-Smith

As the state health department races to roll out an ambitious plan that would tie Medicaid payments to patient health outcomes, at least one regional provider has expressed concerns about the implication of the so-called transformation.

The state health department plans to move 1.6 million Medicaid recipients to the pay-for-value system on Feb. 1, but a protracted budget dispute between Gov. Roy Cooper and the General Assembly, largely over Medicaid expansion, may delay that timeline. At a meeting earlier this month, lawmakers said a July 1 start date may be more feasible even as Health and Human Services Sec. Mandy Cohen warned that such a delay would be costly.

Related: March to Medicaid managed care switch looking rocky

Bill to extend health insurance benefits to low-income workers finally gets started

But for at least one provider, the plan’s go-live date isn’t the only uncertainty. With Medicaid transformation, the state will increase its focus on the social determinants that play an outsized role in people’s health: poverty, transportation access and living conditions to name a few.

Reuben C. Blackwell, IV, who heads OIC of Rocky Mount, a community health center that also offers education opportunities, hopes the state’s payment structure will take into account this big vision.

Thus far, he said, his organization has “more questions than answers.”

Breaking a vicious cycle

In Rocky Mount the interplay of health and social challenges — poverty, housing instability and more — on health is crystal clear. A city of 54,000, Rocky Mount straddles what locals call “the twin counties.” Separated by train tracks running through the center of town, Edgecombe and Nash Counties may as well be worlds apart. Edgecombe, the poorer of the two counties is predominantly African American and has some of the poorest health outcomes in the state.

Its more affluent twin, Nash County, is whiter and more economically stable. Residents there generally fare better on health outcomes.

A map of Rocky Mount that shows health disparities among between the Edgecombe County and Nash County sides. Medicaid transformation is slated to help people in Rocky Mount who are struggling because of social determinants of health
A map of Rocky Mount shows that the much of the Edgecombe County side is economically fragile (denoted in red and yellow), while much of the Nash County side is economically stable or strong (denoted in green). Photo courtesy of OIC of Rocky Mount.

 

OIC cares for many of the most vulnerable residents of these counties in its seven locations. Out of roughly 9,000 patients, Blackwell said, 60 percent are on Medicaid. Another 20 percent have no health insurance. Many of the patients, insured or not, struggle with chronic diseases, poverty, housing instability and more.

Providers at OIC do the best they can to educate patients and give them access to medications they need.

Blackwell worries that the new payment structure will penalize the community health center for not being able to resolve all the challenges that prevent patients from reaching their full potential. These barriers to health may be bigger — and costlier — for an organization such as his to tackle.

Blackwell said that through negotiations with the Department of Health and Human Services, community health centers have secured the same amount of Medicaid funding they get now, at least in the first stage of the transformation. But he isn’t sure what would happen to OIC’s payments after that initial period.

“We have to be adequately compensated for the work that we’re doing and for the risk that we’re taking,” he said.

Nathan Long, pharmacy director at the community health center, put it this way: Many of his patients cannot afford to pay for their medications and for food, he said.

A white man speaks to the microphone. He is pharmacy director Nathan Long and he brought up concerns about Medicaid transformation
Nathan Long was among the OIC staff who spoke about concerns over Medicaid transformation at a recent meeting. Photo credit: Liora Engel-Smith.

“They’re gonna choose their meal over their medication and they’re gonna lose their outcomes,” he said. “Their A1C [a measure of blood sugar management] is not going to be controlled, their blood pressure is going to be high and that all feeds back into their social determinants. It’s a vicious cycle.”

In an interview this week, Cohen said the outcomes will be measured at the population level, not at the level of individual providers. She provided assurance that DHHS will have a rate floor to guarantee that providers aren’t paid too little.

“If folks are concerned, we want to understand that a little better and see what we can do to either alleviate anxiety or change something if there is really a problem,” she said.

Healthy Opportunities

State health department officials have a plan to address some of the needs Blackwell and Long identified. The state is launching Healthy Opportunities, a project that will fund pilots that focus on social barriers to health. The Centers for Medicare and Medicaid Services authorized up to $650 million over the next five years for these initiatives, which the state says will focus on the highest-need Medicaid enrollees.

An infographic about the factors that contribute to premature death. Social factors and environment make up 60 percent of the risk.
Infographic credit: Liora Engel-Smith.

Blackwell said his organization plans to take part in a pilot project of this kind and has sought to make a difference in the lives of their patients in other ways. Sometime last year, OIC and other local organizations received a grant from Blue Cross Blue Shield to study and address housing barriers to health in their service area. Blackwell said OIC and its partners are in the process of studying the region’s housing needs and formulating a plan to address those needs. It will be a while before the program moves beyond the planning phase, and the transformation is likely to take effect first.

In the meantime, enrollment for the new Medicaid plans is underway and is expected to run until December. Thus far, 70,000 beneficiaries signed up for a managed care plan, Cohen said earlier this month. Those who don’t sign up by the deadline will be automatically assigned to a plan, but they can change their selection at any time.

But the sign-up process itself has been rife with confusion, Blackwell said.

Many of OIC’s clients are expressing confusion, saying they’ve found it hard to navigate the state’s website because of low literacy or lack of internet access, Blackwell said. OIC has designated two staff members who have been doing nothing but helping people sign up since open enrollment began, he said.

Inclusion, opportunity and struggle

Blackwell believes that despite the challenges ahead, his center, and the community, have a decent shot at meaningful progress. On a recent afternoon, Blackwell spoke to a group of journalists at the former Booker T. Washington High School about that hope.

The faded structure, which also serves as OIC’s headquarters, has long brick hallways that are reminiscent of its past. But the modest building is a source of great pride for the community. During the Civil Rights era, Rev. Dr. Martin Luther King Jr. visited the Rocky Mount High School in 1962 to test his famous “I Have a Dream” speech. The gathering was supposed to happen at the school’s auditorium, but so many people showed up that King gave his speech at the nearby gymnasium.

OIC is steeped in that legacy. Rocky Mount, Blackwell said, has always been and will be a place of “inclusion, opportunity and struggle.”

In the days to come, the parameters of transformation will become clearer, and the center will adapt to the new realities, Blackwell said.

“We don’t know what’s gonna happen until this enrollment period is over,” he said. “We have to see how many patients across North Carolina are enrolled online and then we’ll be able to see what kind of universe each of us is working with and then we’ll know what’s possible.”

NC Health Reporter Sarah Ovaska-Few contributed to this report.

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