North Carolina has made serious strides towards paying for healthcare through alternative payment models. The most significant change has come in the form of CMS approval for North Carolina’s changes to their Medicaid transformation program, which aims to move 80 percent of Medicaid beneficiaries to managed care. Managed care organizations running North Carolina’s Prepaid Health Plans (PHPs) are required to adopt alternative payment models and increase usage by 20 percentage points a year, or a minimum of 50 percent of expenditures, by the close of 2021. This 1115 waiver also established a Medicaid Advanced Medical Home which will serve as North Carolina’s primary care case management program, with tailored plans to better meet the needs of individuals with intensive conditions by focusing on social determinants of health (SDoH). North Carolina’s Medicaid waiver is the first approved by CMS to explicitly link payment reforms to addressing SDoH.
The state still has far to go in increasing health outcomes and decreasing healthcare costs. In 2017, 10.7 percent of the state’s population were uninsured, with 88 percent of the uninsured being nonelderly adults, driving up healthcare costs. North Carolina has yet to expand Medicaid, though the program covers almost one in every five residents. In addition, like many other Southern states, North Carolina is besieged by rural hospital closures, losing 5 rural hospitals between 2010 and 2019. Because rural hospitals overwhelmingly rely on Medicare and Medicaid, and rural residents tend to be poorer and older than their urban counterparts, an analysis estimates that expanding Medicaid would benefit 650,000 people and would generate over $1.8 billion annually in hospital reimbursements.
Arizona ranked 43 out of 47 states plus DC, with a score of 22.3 out of 80 possible points in the Hub's 2021 Healthcare Affordability State Policy Scorecard.
North Carolina has become the 40th state to expand Medicaid under the Affordable Care Act, according to The New York Times. This expansion will allow low-income residents to access free health insurance through the state’s Medicaid program, estimated to cover 600,000 people. The expansion will take effect once the state adopts a budget, which is expected by June.
North Carolina small businesses are facing increasing health insurance costs that are hindering their growth, reports Spectrum News 1. These revelations come from a Small Business for America’s Future survey of 109 small business owners in North Carolina. Each of the business owners had up to 500 employees, although the majority had 10 or fewer employees. According to the survey, 72 percent of respondents reported that they don’t provide employee health insurance because it is too expensive. Furthermore, 86 percent of small business owner respondents feel strongly that healthcare affordability for small business owners is an issue that lawmakers must address. According to survey authors, the key issue for these business owners is urgency around the issue – they want quick action from lawmakers.
About 20 percent of North Carolina residents have medical debt in collections, reports the St. Louis Post-Dispatch, making it the state with the fourth-highest level of unpaid medical debt. According to data from the Urban Institute, the levels of medical debt correspond to poverty levels, with many of the most impoverished counties experiencing the highest levels of medical debt. Advocates hope that by expanding Medicaid in the state, they can reduce the incidence of debt, while others point to additional legislation targeted at shielding consumers from the worst aspects of having their debt in collections.
Across North Carolina, an estimated 4 million residents don’t have access to reliable broadband service, reports NC Health News, which hinders their ability to access telemedicine. This issue particularly affects rural residents, many of whom live in communities that tend to suffer most from a low supply of health professionals. Although telehealth is often promoted as the solution to increasing access to healthcare, rural residents of North Carolina without reliable internet are often left behind, stymying attempts to improve access, equity and outcomes. In addition, Census data shows that roughly a quarter of people in Western North Carolina’s rural counties are 65 or older–one of the main goals of the state’s Office of Rural Health is to ensure digital literacy and internet connectivity for this population.
Upon realizing that their white patients fared better than patients of color, the North Carolina Association of Free & Charitable Clinics launched a new initiative focused on health equity in 2021, reports NC Health News. The initiative brought together a 29-member Health Equity Task Force composed of association staff, board members and clinic leaders for discussions about health equity. As a result, many of the member clinics undertook intentional equity work, often focusing on narrowing gaps in access to vaccines and COVID testing and treatment. The next steps for the Association include creating a long-term task force focused on health equity, rather than one that is time limited.
Just four out of 21 randomly sampled hospitals complied with hospital price transparency requirements in 2021, reports the Center Square. This revelation comes from a report by Patient Rights Advocate, which randomly sampled 1,000 hospitals across the U.S. As of January 2021, hospitals are required to fully disclose online prices for services, unveiling negotiated rates between hospitals and insurers. A Wall Street Journal report showed that hundreds of hospitals, including Winston-Salem's Novant Health, were using embedded codes to block access to their pricing lists. The North Carolina Attorney General also released a report in January 2022 that reviewed 147 hospitals in the state, and found that 16 were not compliant with the requirement to provide a machine-readable list of services and prices, one was not compliant with the requirement to provide a consumer-friendly shoppable list and eight were not compliant with either requirement.
In North Carolina, nonprofit hospitals billed low-income patients who would otherwise be eligible for charity care at a higher rate than the national average, reports Wilmington Biz. A report by the North Carolina State Treasurer’s office shows that only 18 of the state’s 105 nonprofit hospitals reported actual dollar figures for bad debt—debt that the hospital cannot recover—incurred by patients eligible for charity care. Of those 18 hospitals, the average share of eligible charity care to bad debt is 29 percent, nearly three times the national average. In addition, hospitals attributed an estimated 12 percent to nearly 29 percent of their bad debt to patients otherwise eligible to receive charity care. Furthermore, the study’s authors cast serious doubts on the accuracy of hospitals’ reporting practices that show all patients eligible for charity care received it, as those hospitals are in counties with relatively high poverty rates.
An investigation by NC Public Radio and WRAL-TV found broad price differences for the same services, depending on insurance plan and hospital in the Triangle area. Following a Trump Administration rule that went into effect in January 2021, hospitals must now post detailed price and negotiated rate information online for 300 procedures. Across the Triangle's largest hospitals, the negotiated rate for a colonoscopy runs from $504 to $5,397. The investigation revealed that while hospitals in the Triangle are following the rules better than those in other parts of the nation, big information gaps still create blind spots for consumers who want to effectively shop for healthcare services. A separate report by Patient Advocate Rights randomly selected ten North Carolina hospitals and just one provided complete transparency as the mandate instructs. However, advocates note that even if every hospital complied fully, consumers would still need to understand the information provided to avoid surprise medical bills.
A woman in Indian Trail, North Carolina, went to an in-network hospital for surgery five times in 2020, thinking she was covered for anesthesia services, reports WBTV 3. When she received a bill from Novant Health Presbyterian Medical Center several months later, however, it claimed that she owed Providence Anesthesiology Associates $15,744.58 and her insurance, UnitedHealthcare, only covered $782.42. The patient found a statement on UnitedHealthcare's online portal showing that inpatient hospital stays include services for anesthesiologists; however, on it's website, the Center indicates that UnitedHealthcare terminated their contract in March 2020. This means that when the patient went in for surgery, no one told her she was no longer covered for anesthesia services, even though she went through a pre-approval process for each surgery.
A North Carolina task force established to address inequalities amplified by COVID-19 in communities of color has recommended looking at pressing public health issues such as “sick buildings” that can increase COVID spread, reports Costal Review Online. The problem of “sick buildings” is caused by legacy pollutants, such as radon, asbestos, mildew, and mold, that can arise from delayed maintenance of aging buildings, according to the task force’s first biannual report. The report notes that, “Nowhere is this problem more apparent than in NC’s public schools, especially those in hyper-segregated, concentrated poverty communities,” and that this issue disproportionately impacts communities of color. The report goes on to explain that because of aging and poorly functioning HVAC systems, children in “sick” school buildings are exposed to chemical and biological contaminants that adversely affect their health. The report also notes that these “sick buildings” with poor ventilation can also exacerbate COVID-19 by increasing its spread.
UNC Health, North Carolina’s largest academic health system, has rolled out its new cost transparency tool via an app and on their website, reports North Carolina Health News. The tool makes it possible for consumers with or without insurance to estimate how much an office visit, simple procedure or inpatient service will cost. The tool results from a new rule from the Centers for Medicare and Medicaid Services (CMS), effective Jan. 1, 2021, in which all hospitals are required to provide public lists of standard charges for healthcare services in an easily accessible, easily searchable format. Transparency initiatives such as these, however, have had mixed success in getting patients to use them. For example, in 2007 New Hampshire created a website that provided negotiated out-of-pocket costs and negotiated prices for common procedures, but a 2014 study found that only about one percent of patients actually used the service over the course of three years.
The North Carolina Department of Health and Human Services (NCDHHS) and the Cherokee Indian Hospital Authority (CIHA) have entered a contract to support the Eastern Band of Cherokee Indians (EBCI) address the health needs of American Indian/Alaska Native Medicaid beneficiaries through an Indian Managed Care entity, according to a press release by NCDHHS. This Indian Managed Care entity if the first of its kind in the nation and will establish a new delivery system, the EBCI Trial Option. The Option will manage the healthcare for North Carolina’s approximately 4,000 tribal Medicaid beneficiaries, with a strong focus on primary care, preventive health, chronic disease management and providing care management for high-need members.
The State Treasurer of North Carolina, who manages the state employees’ health plan, has spent years trying to persuade hospitals to accept lower payments, but has struggled to discover the existing rates the plan pays each hospital and enact policies, reports Kaiser Health News. In North Carolina, hospital inpatient prices for private insurers, which typically drive health premiums, rose by 10 percent from 2014 to 2018. In an effort to help the state control healthcare costs, the Treasurer proposed to base prices on a percentage of Medicare rates, a form of reference pricing, giving hospitals 175 percent of what Medicare reimbursed for inpatient services and 225 percent for outpatient services—a move that would resulted in payment cuts to most hospitals. In response, the North Carolina Healthcare Association warned customers that if no agreement could be reached with the state plan, the hospitals would be considered out-of-network providers. In many states, hospital associations are political powerhouses, with lobbyists and influence from being the largest employer in many legislative districts.
Residents in North Carolina face serious hurdles to accessing dental care, reports the Carolina Public Press. In 2019, residents in 98 of the state’s 100 counties lived in a region designated by the federal government as a Dental Health Professional Shortage Area. Even if residents can find a provider, cost may still be a barrier. Many low-income residents may not have dental insurance and those who qualify for “medically necessary” dental care through Medicaid may have difficulty finding providers who take Medicaid.
Despite decades of federal and state efforts to bolster the healthcare workforce in some of North Carolina’s most remote areas, many rural counties in the state still face provider shortages, reports North Carolina Health News. Among the strategies to combat provider shortages is loan repayment, whereby state and federal programs forgive a portion of school loans of health professionals in exchange for service in areas of high need, but assessing the success of this strategy is difficult. Theoretically, the state’s rural areas should have gained more than 250 new providers in the last year, but the actual number is far lower. Cities also have pockets of high need and providers can choose placement there. All in all, advocates for rural health believe there needs to be a more coordinated plan for increasing rural healthcare access.
North Carolina’s largest insurer says that its push to reform its payment system through value-based care has already saved more than $153 million in its first year of operation, reports the Triangle Business Journal. Blue Cross Blue Shield of North Carolina launched its value-based care plan, Blue Premier, in January 2019, alongside five of the state’s largest hospital systems, replacing the traditional “fee-for-service" model and reimbursing providers on quality of care rather than quantity of services provided. The company says it has generated an estimated $153 million in cost savings, quality improvements and a slowdown in the rate of spending on healthcare. In addition, Blue Premier physicians increased screenings for colorectal cancer by 3,041 members and controlled blood pressure for 13,412 more members than in 2018, showing health benefits alongside cost savings.
A collaboration between Duke University, the Health Care Cost Institute (HCCI) and Blue Cross and Blue Shield of North Carolina combined healthcare spending data for North Carolina residents in 2016 and 2017, combining healthcare spending across several distince sources of healthcare insurance coverage with data held by different institutions. The project includes Medicare, Employer-Sponsored Insurance and North Carolina Medicaid data to calculate total healthcare spending by county and per-person spending, broken down across counties, populations, age groups and service categories. The data and it's visualizations present detailed windows into healthcare costs and spending characteristics in the state.
The North Carolina Department of Health and Human Services has been awarded $1.5 million to support and expand the Hope4NC program, which connects North Carolinians to mental health supports that help them cope and build resilience during times of crisis. Historically marginalized populations in the state have been hit hardest by the COVID-19 crisis; the Hope4NC program is being intentionally designed to provide essential supports and better links to care for people in these communities. The Hope4NC was repurposed at the beginning of the COVID-19 crisis from it's original state to support behavioral health needs following natural disasters.
Since 2017 the North Carolina Department of Health and Human Services has been incorporating whole-person care into all of its priorities, focusing on food, housing, transportation, employment and interpersonal safety/toxic stress. An article in Health Affairs describes four, interconnected initiatives that aim to (1) better align financial incentives for healthcare providers and Medicaid health plans to address both medical and nonmedical drivers of health; (2) introduce a standard screening process to identify people with unmet resource needs; (3) establish NCCARE350, an innovative technology platform that allows healthcare providers and human services organizations to connect people with social resources and track outcomes; and (4) launch large-scale Healthy Opportunities Pilots to evaluate the impact of nonmedical health interventions on the health outcomes and healthcare costs of high-need Medicaid beneficiaries.
The North Carolina Department of Insurance has seen an uptick in consumer complaints surrounding low-cost, but limited, short-term health insurance plans, according to North Carolina Health News. The department logged 75 complaints related to short-term insurance in 2019, up from 48 the previous year. Over half of the complaints involved issues surrounding denied claims, exclusions of pre-existing conditions and delayed payments to consumers. However, in absence of data on the size of the market and the number of people enrolled in these plans, regulators remain in the dark about trends in that part of the health insurance market.
North Carolina’s Medicaid system has found a way to save as much as $6,000 annually per patient with the help of a unique care management program, reports Health Data Management. The management program – provided by the Community Care of North Carolina (CCNC), a public-private partnership of healthcare providers and payers – focuses on providing medical homes, community support and data analysis to meet the needs of Medicaid beneficiaries in the state. CCNC’s report notes that the organization uses administrative data to create an “impactability score” for Medicaid members that focuses on Medicaid utilization patterns that go beyond medical care to include social determinants of health and other variables.
Joshua Bates was rushed to an emergency room in North Carolina for what turned out to be acute apendicitis; however, the hospital turned out to be out-of-network with the insurance plan provided through his employer. In this edition of Kaiser Health News' Bill of the Month, we learn that Joshua was charged $41,212 for his surgery, one night at the hospital and the emergency room charges. After payments by both Joshua and his insurer, the hospital sent him a bill for the balance, just over $28,000. Joshua was "balance billed" because he went to an out-of-network hospital - even though this was an emergency, he fell through the limited protections in existing law. A balance bill is the difference between what insurers pay toward a bill and a provider's "list charges," what facilities set themselves and often bear little or no relationship to actual costs. Joshua would be helped by a federal law providing consumers with protection against balance billing, because his employer-sponored insurance is regulated by the federal government, meaning that state regulations for state-regulated plans do not apply to him.
Researchers looking into North Carolina’s Medicaid program released a case study detailing the poor health outcomes and high-cost Medicaid beneficiaries in Graham County, North Carolina, and paired these stories with policy recommendations to reorient the Medicaid program around patient needs, according to a Health Affairs blog post. Graham County has seen a gradual decay of outpatient care delivery infrastructure, and patients suffer from a lack of providers and lack of transportation, often forcing them to use emergency medical services as primary care or for transportation. Policy recommendations include investing in telehealth, deploying the existing workforce more efficiently, and empowering local officials by providing them with adequate funding for the increased responsibilities they shoulder.
Blue Cross and Blue Shield of North Carolina and Cambia Health Solutions will drop their plans to combine, following the resignation of the North Carolina insurer's chief executive, Patrick Conway, according to the Wall Street Journal. These insurers had initially planned to combine and generate $16 billion in annual revenue, covering over six million people through Blue Cross Blue Shield plans - the new entity was to be lead by Conway.
North Carolina’s Medicaid 1115 waiver allows the state to spend up to $650 million in state and federal Medicaid funding on “Healthy Opportunities Pilots,” designed to cover select services related to housing, food, transportation, and interpersonal violence that directly impact enrollees’ health outcomes, according to Managed Healthcare Executive. The state’s Medicaid managed care plans, known as Prepaid Health Plans (PHPs) have been set up in four regions of North Carolina to address these social determinants of health. Typically, Medicaid funds are not used to pay directly for non-medical interventions targeting social determinants of health, so this pilot will offer insights to how addressing social determinants of health may impact costs and health outcomes.
For the third year in a row, the number of people without health insurance in North Carolina remained roughly the same, according to North Carolina Health News. More than 1 million North Carolinians, or 10.7 percent, did not have health insurance in all of 2018, reports the U.S. Census Bureau, who attributed the national trend in increasing uninsured rates to a decline in Medicaid enrollment. By contrast, North Carolina's Medicaid enrollment hasn't changed significantly in three years, and the state has the 9th highest uninsured rate in the country. It's estimated that expanding Medicaid in North Carolina would reduce the state's uninsured rate by 3 percent.
The North Carolina Department of Health and Human Services will partner with Phreesia, a patient intake platform, to address individuals' social determinants of health using real-time data and screening questions, according to HealthITAnalytics. The platform provides screening questions to help healthcare organizations identify patients with unmet social needs and can send real-time alerts to providers and care coordinators about patients' individual needs. A large number of North Carolina residents struggle in finding affordable housing and with food insecurity. It is hoped that this initiative will reduce costs, improve outcomes and increase patient satisfaction, as previous studies have shown addressing social determinants of health can do.
North Carolina is in the early stages of turning away from te traditional fee-for-service model and towards a model based on health outcomes, according to the New York Times. Under the new model, providers will be paid based on health outcomes, whereby the better they perform, the more they can earn - the goal is to keep people healthy and out of the hospital and to save money on healthcare spending. It's estimated that the state's changes will increase the share of total healthcare dollars that go to primary care physicians, as opposed to specialists, hospitals and other places.
For the North Carolina Cherokee, self-governance has meant adopting an integrated care model designed by Alaska Natives to deliver care that not only improves patients’ health, but is also tailor-made for the needs of the tribe, according to Kaiser Health News. The Cherokee have opened a 20-bed hospital and have started construction on an 18-bed mental health clinic scheduled to open in 2020. Self-governance also allows tribes to be eligible for Medicare, Medicaid, private-sector health insurance, partnerships with larger health systems, and even federal grants that are designed for underserved communities – all of which can be limited for the Indian Health Service. Half of the Indian Health Service budget is now managed by Indian tribes to various degrees, but it remains to be seen how widely the full control, which has worked out well for tribes with resources like the Eastern Cherokee, can be applied. For instance, geographic isolation, poverty and a lack of resources make new healthcare investments difficult for tribes such as the Rosebud Sioux or the Oglala Lakota on the Pine Ridge Indian Reservation.
State Treasurer Dale Folwell reopened enrollment in the North Carolina State Health Plan with increases in how much medical providers could charge for their services, according to News & Record. According to the State Health Plan, the revision would increase what 727,000 current and retired state employees covered by the plan pay by $116 million. However, with coverage details for next year in limbo, thousands covered do not know for sure whether their local hospital and current medical providers will be in network or not. Folwell and the State Health Plan have been disagreeing with major health systems across the state, some of which have declined to enroll.
A study by AARP North Carolina found that more than 80 percent of family caregivers in North Carolina support expanded roles for advanced-practice registered nurses (APRNs). The survey, in response to the SAVE Act currently under consideration in the North Carolina legislature, also found that 90 percent of NC residents rated care they received from APRNs as “excellent” or “good.” The bill would allow APRNs to offer primary care services without physician oversight. Expanding the role of APRNs would help address doctor shortages in the state as well as increase access to care in the state’s rural communities, according to Public News Service.
Blue Cross and Blue Shield of North Carolina (BCBSNC) and five of the largest health systems in the state announced moving larger sections of their business towards value-based care, reports North Carolina Health News. BCBSNC has put contracts in place to move half their payments to these health systems to value-based by 2020. This move is aligned with other value-based initiatives happening in the state’s Medicaid program as well as successful ACOs programs that care for Medicare patients.
Aledade and Blue Cross Blue Shield of North Carolina are co-leading a new initiative to support physician-led accountable care organizations (ACOs). The aim is for physicians and other care providers to work collaboratively as a team to improve quality of care, improve management of chronic conditions and ultimately reduce costs. Participating physicians will have the opportunity to earn increased reimbursement rates and share in any health care cost savings achieved, according to Blue Cross Blue Shield.
The Free Clinics, serving North Carolina's Henderson and Polk counties, has seen success in caring for the areas most complex patients through its Bridges to Health program. The Bridges program enables patients to discuss social and emotional issues as well as medical concerns with an integrated care team, according to Robert Wood Johnson Foundation. In the first nine months of the project, the clinic reduced per-patient ER use by 72 percent and approximately 80 percent of the participants saw underlying health conditions improve. Bridges also made improvements in social determinants of health, such as housing and employment, for patients, which has helped build robust community support for the program. The Bridges to Health Program received the Robert Wood Johnson Foundation Award for Health Equity in 2017.
CMS has approved a North Carolina Medicaid reform demonstration to move from traditional fee-for-service payments to a managed care delivery system. The reform model is an attempt to increase quality of service as well as create a more predictable budget, according to Health Affairs Blog. North Carolina will partner with health plans in an effort to target high-need Medicaid patients and better coordinate care. Among other innovations, the state will pilot an intervention in select regions that addresses social determinants of health including food security, housing instability, reliable transportation, toxic stress and interpersonal violence.
North Carolina is transforming its Medicaid program to focus on patients’ social determinants as a main driver of health outcomes, according to a Modern Healthcare story. One of the changes to North Carolina’s managed care organizations would be a mandate to screen every Medicaid beneficiary for access to food, stable housing and transportation, though this change is dependent on regulatory approval to change their fee-for-service Medicaid program to managed care in 2019. The state has already developed a standardized tool for physicians and case managers to screen patients for social determinants of health and is piloting it in approximately 50 locations. They are also building a resource platform to help connect patients to various resources. According to the Secretary of Health and Human Services for North Carolina, “In a value-based context, the folks who figure out how to buy health and not just healthcare are going to be most successful.”
Dr. Gajendra Singh walked out of his local hospital’s outpatient department, having been told an ultrasound for some vague abdominal pain he was feeling would cost $1,200 or so, and decided enough was enough, according to Vox. Singh launched his own imaging business in Winston-Salem and advertised prices as low as $500 for an MRI. But his plan to open his own imaging center has been stymied by North Carolina's certificate of need (CON) law, which prohibited him from buying a permanent MRI machine. He has file a lawsuit arguing that the state's CON law gives hospitals a monopoly over MRI scans and other services and leads to high prices.
Dr. Gajendra Singh has filed a lawsuit in the North Carolina Superior Court arguing that the state's certificate of need (CON) law gives hospitals a monopoly over MRI scans and other services and leads to high prices. According to an article in Vox, after Singh decided to post his prices, as low as $500 for an MRI, he ran into the state’s certificate of CON law, which prevented him from buying a permanent MRI machine. As a result, his office couldn’t always offer patients one of the most important imaging services in medicine. Americans can sometimes be charged as much as $24,000 if they get an MRI at a hospital emergency department.
Legislators in North Carolina have proposed a bill that would allow nonprofits to offer health plan benefits that would be exempt from nearly all federal and state regulations that govern health insurance. Supporters say it would allow for nonprofits to offer similar health insurance plans but could be cheaper than those on the ACA market. Critics worry the legislation would open the door to discrimination practices and few or no consumer protections. In early June, the bill passed the Senate, but failed to pass the House of Representatives with multiple members indicating more information is needed on this topic before rendering a vote.
North Carolina submitted an amended 1115 waiver to CMS in November 2017 seeking to invest $1.2 billion over five years in several targeted initiatives which look to transition from fee-for-service payments, advance the state’s goals to improve population health and increase high value care to improve access and sustainability.
North Carolina has the only statewide pregnancy medical home model in the U.S for low income women, according to The Pew Charitable Trusts. The program provides advanced obstetrical care as well as services to address other obstacles such as addiction, domestic abuse and a lack of housing and healthy food. North Carolina program members have seen a decrease in low-birth weight babies and Caesarean sections compared to women not in the program. Additionally there has been a decline in unplanned pregnancies, and a decrease in racial disparity in maternal mortality.
Mountain Area Health Education Center’s ob-gyn program is part of a statewide initiative in North Carolina that identifies low-income women with high-risk pregnancies, and provide the women care through “medical homes,” reports The PEW Charitable Trusts’ Stateline. The medical homes provide the most advanced obstetrical care, but they also seek to alleviate nonmedical circumstances that could put mother and child in jeopardy, such as addiction, domestic abuse and a lack of secure housing and healthy food. North Carolina’s program is the only statewide pregnancy medical home model in the country. According to the Institute for Healthcare Improvement, the “well-defined and rigorous” program will likely become a model for other states.
An amendment to North Carolina’s Medicaid waiver would allow for a shift to managed care, from fee-for-service by 2019 while also enticing physicians to treat North Carolina’s Medicaid population by paying off the physician’s debt, according to Modern Healthcare. Discussions of Medicaid expansion as well as Medicaid enrollee premiums and work requirements are taking place in the North Carolina legislature. Governor Roy Cooper says a successful managed care program through access to care is the priority.
Experts from the University of North Carolina at Charlotte use big analytics to study emergency department usage and other social determinants of health, according to Healthcare IT News. Michael Dulin, MD, leads the project and says that understanding the social determinants of health that exist within their consumer population and creating connections to align those consumers to resources is a key component to improving overall health outcomes.
A yearly report that measures 22 socioeconomic factors affecting the health of North Carolina children has given the state mixed reviews. The state scored well on insurance coverage indicators, insuring a record-high 96 percent of kids. The state scored lowest on measurements for economic security, with nearly 53 percent of children under age 5 living in poor or near-poor homes. The report shows there are deep racial and ethnic disparities in North Carolina and child poverty remains a critical public health issue within the state.
This report sets forth options and potential design features that will serve as a guide for the Department to execute a capitated program for dual-eligible beneficiaries in North Carolina, as required by the Medicaid reform bill passed in 2015, according to North Carolina's Department of Health and Human Services. The report also provides summaries on managed care programs in other states.
Cornerstone Healthcare is an example of Accountable Care (ACO) models struggling to standalone financially, according to the New York Times. The ACO experiment began as an idea to make doctors more mindful of costs and shift toward more value-based care, but many ACOs require a large upfront financial capital. Cornerstone has been acquired by Wake Forest Baptist, and it remains to be seen if the model will survive after this acquisition.
The Mountain Xpress reports that a newly formed partnership between UnitedHealthcare and an Accountable Care Organization provides an opportunity for patients to have access to healthcare services and continued care coordination between organizations. The collaboration is meant to provide patients with access to services that will better equip them to manage chronic health conditions.
North Carolina's largest healthcare system, Carolinas HealthCare System, has kept medical costs high and suppressed competition by illegally imposing certain requirements on insurers with which it contracts, according to Modern Healthcare. The alleged restrictions include barring insurers from offering tiered networks that include competing hospitals in the top tier.
North Carolina has finalized a Medicaid Waiver plan and submitted it to the Centers for Medicare and Medicaid Services, according to the North Carolina Department of Health and Human Services. The plan includes paying for improved patient outcomes, clinically integrating physician and behavioral health, components addressing social, cultural and environmental barriers to health and tying payments to quality measures, among other things.
For individuals in North Carolina buying a low cost silver plan in the health-insurance marketplace, they can expect to pay an average of 20.6 percent more according to an article in the Winston Salem Journal. Many factors contribute to the increase, most notably, lack of competition within the state and increased costs of medical services and drugs.
Costs of some medical services in Charlotte are 20% higher than the national average, according to The Charlotte Observer. Charlotte’s average prices for certain procedures, especially imaging services such as CT scans and MRI tests, were higher than the state average and higher than prices in Raleigh. The study, published in Health Affairs by HCCI researchers and economists, is part of a push for greater healthcare transparency.
Amid criticism of wasteful spending and mismanagement, the North Carolina Senate has proposed to strip Medicaid administration from the state Department of Health and Human Services and instead, have a “Health Benefits Authority” with leadership appointed by the Senate, according to a News & Observer article. The newly created group would contract with three providers, establishing six state regions with two local providers each. The measure is designed to save money by switching from fee-for-service payments to global budgeting and is expected to stimulate much debate.
A new North Carolina law requires pharmacists to notify the prescribing physician when a biosimilar drug is substituted for a more expensive brand name biologic drug, according to North Carolina Health News. According to critics, the law -- similar to ones passed in a few other states -- could stifle development of potentially cheaper biosimilar drugs by creating additional barriers to market entry. [See the Hub’s Research Brief No. 5, Rx Costs: A Primer for Healthcare Advocates for more information on the impact of biologic specialty drugs on healthcare spending.]
According to a Triangle Business Journal article, House Bill 839 has been introduced to require pharmaceutical manufacturers to publicly report cost and utilization information. California and Massachusetts have introduced similar bills.
A recent evaluation published by the Association of Healthcare Journalists found that recently released price information associated with the Healthcare Cost Reduction and Transparency Act of 2013 is not consumer friendly. The author found that, although there is a search function and access to information such as the top 20 imaging procedures and outpatients surgical procedures, there are limited descriptions or explanations available on how to navigate the information. Blue Cross Blue Shield of North Carolina released a price transparency tool of their own that demonstrates the wide variation in payments to providers for the same procedures.
The North Carolina Department of Health and Human Services announced that the state’s 2010 smoking ban in restaurants and bars has improved air quality by 89 percent, decreased average weekly emergency department visits for heart attack by 21 percent, and had no negative impact on bar or restaurant income. A separate announcement celebrated the continued decline in cigarette smoking among North Carolina students; however, found a dramatic and concerning trend in the increased use of electronic cigarettes and other non-cigarette tobacco products.
Healthcare IT News announced North Carolina’s step towards transparency with the passage of the Healthcare Cost Reduction and Transparency Act of 2013. This legislation calls for the creation of a website that will publicly display the most current price information from Medicare, Medicaid, and the largest private insurers. The legislation also limits hospital's ability to take extraordinary measures to collect reimbursement of unpaid medical bills due to new limits on putting liens on residences and garnishing wages. Additionally, provider network directories must be maintained online, and available to consumers in many forms. At the time of passage, Maine and Massachusetts were the only other states publicly publishing price data.
NC Health News reports Community Care of North Carolina, the state Medicaid program that assigns patients to a “medical home,” has saved the state close to a billion dollars over a four year period, according to analysts who examined four years of state Medicaid cost data. The study found the use of medical homes not only reduced cost but also increased healthcare quality, especially among the high cost and high need patients.