Investing in Primary Care:One State’s Story –

The Good, The Bad & The UglyNovember 3, 2015

Gregory K. Griggs, MPA, CAEExecutive Vice President

NC Academy of Family Physicians

• A Strong Infrastructure for Primary Care• NC Office of Rural Health• Community Care of North Carolina• ACOs in North Carolina

• Private Sector Investment in Primary Care• Blue Quality Physician Program• Pipeline Investments

• But, the Bad and the Ugly• Politics Get in the Way• Moving Forward

• Questions / Comments

Today’s Presentation

• History of the Office• Created 42 years ago to develop network of Rural Health Centers

and has helped develop FQHCs as well.• Since that time, the Office has expanded to help communities

develop innovative strategies to improve access, quality and cost-effectiveness of health care.

• Works to develop community-based approaches to improve care.• Research and Demonstrations have included:

• Community Care of NC (CCNC)• CHIPRA• Perinatal Quality Collaborative of NC (PQCNC)• Project Lazarus: Chronic Pain Initiative

NC Office of Rural Health

• Provider Recruitment and Retention• Recruits needed healthcare professionals to rural and

underserved areas :• Primary Care Physicians • Nurse Practitioners and Physician Assistants• Dentists and Dental Hygienists• General Surgeons• Psychiatrists

• Compatibility matches between community and physician.• Works to ID shortage Areas (HPSAs).

NC Office of Rural Health

• Provider Recruitment and Retention• Leverages Federal, State and Private-Sector Loan Repayment:

• Up to $100K in state loan repayment over 4 years, or • Up to $50K bonus over 4 years for those without loans.• One stop to qualify for federal, state or private sector Foundation

funding in NC.• Database matching applicants with openings and ongoing

tracking of placements.• 2015 State Fiscal Year Placement Services:

• 130 new health professionals recruited• 79 new state incentive payments• An average of 143 placements each year over the last 5 years

NC Office of Rural Health

• Examples of Other Investments in Primary Care• NC Rural Health Centers: $2.6 million in state funding • Community Health Grants: $5.4 million/year to help support safety net

primary care • FQHCs, Free Clinics, Health Departments, School-Based Centers) • Provided service to 157,000+ low income patients in 60 counties.

• Medication Assistance Program – Provides access to prescription drugs• $3.5 million of state funding• Allowed almost 44,000 patients to access $151 million in Rx last year.

• Technical assistance and financial support including:• Directing members of the public to where they can find free and low-cost care.• Advising small health centers on how to adapt to improve business practices.

NC Office of Rural Health

• Spawned from work of Office of Rural Health• One of the Early PCMH Models

• 14 Geographic Networks• Deciding How to Address Local Problems in Medicaid• Quality Improvement / Practice Improvement Initiatives• PMPM To Network and To Practice

• Care Managers• PharmDs• Mental Health Professionals

• Helped with Other Payers Too• Led to Multi-Payer Pilot with CMS• Process Measures Already High with Privates Started Examining

Metrics

Community Care of NC

• The Results: It Worked• Showed consistent savings and quality improvement• Studies showed small investment brought at least 3 to 1

savings compared to expenditures• From Milliman to our Own State Auditor – All positive reports.• $200 to $300 million in savings annually.

Community Care of NC

Evolution of ACOs in NC• Helped by early adoption of PCMH in NC• NCAFP published Family Physicians Guide to Accountable Care in 2010

• NC Medical Society forms Toward Accountable Care Consortium in 2012

• 18 Medicare Shared Savings Programs in NC• Four began as early as 2012• A mix of Physician driven and healthcare system driven

• At least 10 ACOs have contracts with commercial payers• Approximately half of those overlap with MSSPs

Evolution of ACOs in NC• Some Examples of Evolving ACOs in NC

• Key Physicians – Wake Key Community Care• Key (comprised of 220 independent physicians in the

Raleigh-Durham area) • Contracts with two insurers • MSSP with local hospital system• Narrow network for BCBS NC Exchange Plan

• Cornerstone Health Care• A fast growing, physician-owned, multi-specialty group

with over 85 locations. Formed an MSSP with others and moving most private contracts to value-based contracts

• Blue Cross & Blue Shield of NC• Blue Quality Physician Program – Began Fall of 2009

• Designed to supplement contracted payments to independent practices who maintain high standards of quality.

• Based primarily on PCMH criteria• First iteration – 52% fewer visits to specialists; 70% fewer ER visits

• NC PATH: NC Program to Advance Technology for Health• Partnership that helped offset the cost of EHRs for free clinics and

small private practices

Private-Payer Investment

• Blue Cross & Blue Shield of NC• Multi-Payer Advanced Primary Care Demonstration

• $1.8 million over 3 years for community-based care management• 49 practices, 168 primary care providers• Jointly with Medicaid, Medicare, State Health Plan• Rural Areas of NC

• Pipeline Initiatives• Partnered with NCAPF Foundation to invest in Medical Student

Interest.• $1.2 million from their Foundation over six years.• Decided to give students early clinical experience plus ongoing

mentoring (when possible)

Private-Payer Investment

• Medicaid Reform in NC – Politics Get in the Way• Beginning in 2013, First Republican Control of Both

Chambers and Governor’s Mansion in Modern History (Since Reconstruction)

• Tax Reform Mindset• Privatization Mentality• Free Market Competition Approach• Led to the Medicaid Reform Debate

But, The Bad and the Ugly….

Medicaid Reform in NC• “Medicaid is Broken” Mantra

• First cry as new Governor took office – Partnership for a Healthier NC

• There had been recent cost overruns, but primarily due to budgeting and forecasting errors• Had moved mental health to a local non-profit capitated

environment (large one-time costs)• Miscalculation of Federal Match, particularly when

Resource and Recover Act enhanced match ended• Mindset that Medicaid was gobbling up the budget

• Our Response• Build on What Has Worked – CCNC and Medical Homes• Don’t Outsource Scarce Healthcare Dollars to Out of State,

Profit-Driven Companies (10-15% off the top)• Let The Provider Community Help Craft the Solution• 2014 Proposal to Move Toward a Plan Based on Accountable

Care Organizations With Greater Risk Bearing

Medicaid Reform: A 3-Year Debate

Medicaid Reform: A 3-Year Debate

• Summary:• State Senate: full capitation & managed care only.• State House: provider led solution.• Multiple reports come out touting CCNC savings to the NC

State Auditor, including one commissioned by Legislature – $300 per member savings

• The Compromise: Described as a Hybridectomy• Full-risk capitated plans, but….• 3 statewide entities – either MCO or PLE (Provider Led Entity)• Up to 12 regional PLEs in 5-6 regions (max of two per region)• PLE can be statewide but MCO can only be regional

Medicaid Reform: A 3-Year Debate

• Some wins:• It’s not just MCOs.• Provider and patient protections through insurance statutes.• Some limits on administrative burden, like uniform credentialing

and one Preferred Drug List.• Role for CCNC throughout the transition period at a minimum.• Approximately a four-year glide path.

• Why not all provider led/why not shared risk?• Intense lobbying and political spending by managed care industry.• Desire for greater competition.• Desire for budget predictability.• But, NC per recipient spending is actually down over the last 5

years.

The Future Outlook• Where We Hope to Go in NC:

• Clinically Integrated Network for Independent Primary Care Practices

• Ongoing practice transformation – CMS grant to CCNC -- $18.4 million over four years

• Work with state Health and Human Services to make sure Medicaid waiver is well written

• Partner with private sector payers to push for value• Develop direct relationships with true purchasers of healthcare -- employers

The Future Outlook• Following the Gospel according to Dr. Paul Grundy• How Do You Herd Cats? You Move Their Food (but

only a little at a time, otherwise you get chaos).• We’re Only Addressing Some of the “Dials”

• Practice Transformation (going well in NC)• One of highest levels of PCMH in the country.

• Quality Improvement (also going well in NC)• Payment Reform (some, but not enough)• Patient Engagement/Responsibility (a little)

• We must use all the dials to truly change healthcare

Questions-Comments?Greg Griggs, Executive Vice President

ggriggs@ncafp.comwww.ncafp.com

Tel: 919-833-2110