Implementation of the Patient Protection and Affordable Care Act of 2010 is underway and impending changes to the health care delivery system present new challenges and opportunities for physicians and their patients.  The North Carolina Medical Society (NCMS), in its mission to provide Leadership in Medicine, is partnering with News 14 Carolina to convene a televised forum to engage physicians and other health care leaders about preparing for health reform and what it means to patients and medical practices. 

NCMS members and the medical community at large are invited to attend the discussion, which will be taped for broadcast, on September 22, 7:00 pm, at the Harris Conference Center in Charlotte.   The forum will be a panel-style discussion facilitated by News 14 Carolina Anchor Heather Waliga.

Panelists include: Michael Dulin, MD, Family Medicine, Charlotte; Jeffrey P. Engel, MD, State Health Director; Ophelia Garmon-Brown, MD, Family Medicine, Charlotte; Maureen O’Connor, Executive Vice President/Chief Strategy Officer, Blue Cross Blue Shield of North Carolina; Robert Seligson, Executive Vice President & CEO, NCMS; and Michael C. Tarwater, CEO, Carolinas Healthcare.

Attendance is limited to 150, so register today.  To reserve your seat, visit https://secure.ncmedsoc.org/legacysecure/pages/meetings_and_events/event_reg_form.jsp?id=707.

One provision of the Patient Protection and Affordable Care Act that takes effect at the end of this year is the restriction on physician ownership of hospitals in the Medicare program.  The health reform law also places major limits on the expansion of existing physician-owned hospitals.

New physician-owned facilities that are not certified as Medicare participants by December 31, 2010 will no longer be allowed into the program after that date.  Other changes to the law include capping levels of physician ownership, ending some exceptions to Stark self-referral bans and mandating more disclosure of physician owners’ potential conflicts of interest, if they send their patients to their own facilities.

Past legislative attempts to limit physician ownership of hospitals often targeted specialty hospitals such as orthopedic, cardiac and other surgical facilities.  However, limitations enacted by the PPACA will also impact acute care facilities, even some community hospitals that may have been financially supported by their physicians in the past.

Until many pending federal lawsuits are settled, existing plans for new or expanding physician-owned hospitals are in a holding pattern.  The new law caps ownership levels to where they were at the bill’s passage (March 23, 2010).  According to the Physician Hospitals of America, there are currently 265 physician-owned facilities in 34 states that employ more than 75,000 workers with an average bed size of 233 general acute care beds that will be negatively impacted by the restrictions.

NCMS staff recently visited the Hey Clinic in Raleigh to attend one of the scoliosis and spine surgery practice’s weekly Learning and Quality Meetings. Lloyd Hey, MD, MS and his medical team meet every Thursday morning to discuss the previous week’s surgeries, patient clinical experiences, and the upcoming week’s procedures. Staff and Dr. Hey also identify Very Important Patients (VIPs), meaning those who may have extraordinary circumstances during the course of their care, and discuss how to best meet the needs of those individuals.

The group uses this weekly time to evaluate new initiatives that are working in the office as well as to problem solve where improvements can be made. The Hey Clinic refers to this evaluation system as “ELI,” which stands for “Error, Learn and Improve.” As part of the practice’s quality initiatives and to keep patients well-informed of the care they are receiving, Dr. Hey sends each patient home with an easy-to-read clinic note and photo.  He also asks each patient (referred to as “guests”) to complete an exit questionnaire to evaluate their Hey Clinic experience.

These efforts in addition to grant-funded research that the Hey Clinic performs in conjunction with NC State University are intended to provide personalized and high-quality patient care to guests of the Hey Clinic.

With quality improvement at the forefront of Health System Reform, the NCMS is eager to share what physicians across the state are doing to meet the challenge.  Let us know if your practice has tools to share.

On Monday, August 23, 2010, members of the Triad-area physician community attended a forum with third party payer medical directors and North Carolina Insurance Commissioner Wayne Goodwin.  The event entitled “Third Party Payer Meeting: Which is it? Health Reform or Insurance Reform?” was organized by the Greater Greensboro Society of Medicine and the High Point Medical Society.  North Carolina Medical Society Executive Vice President, CEO, Robert Seligson moderated the meeting, which was attended by about 100 physicians.

Also seated at the moderator’s table were:

William F. Hopper, MD, President, Greater Greensboro Society of Medicine

Perry E. Jones, MD, President, High Point Medical Society

Henry A. Fleishman, MD, President, Rockingham County Medical Societ

Palmer Edwards, MD, President , Forsyth-Stokes-Davie County Medical Society

North Carolina’s third party payers were represented by the following Medical Directors:

Bruce Norman, MD, Aetna

Catherine Palmier, MD, UnitedHealthcare

Edward N. Hunsinger, MD,CIGNA HealthCare

Don W. Bradley, MD, Blue Cross and Blue Shield of North Carolina

The panel of insurer representatives and Commissioner Goodwin answered prepared questions regarding medical loss ratio, most favored nation clauses, physician payment models and the future of the health care industry under new reform laws as well as a number of questions from physicians in the audience.

With the expansion of Medicaid and the individual mandate to obtain health insurance brought about by Health System Reform comes the need for expanded access to quality health care providers.   In an attempt to address the inevitable shortage of medical providers the Patient Protection and Affordable Care Act has called for the creation of a National Health Care Workforce Commission.   The legislation requires that this group be appointed and operational no later than September 30^th of this year and to prepare, the U.S. Government Accountability Office has been seeking recommendations for members throughout the summer. 

The Commission will be tasked with determining if the demand for health care workers is being met, identifying possible barriers to health care workforce development and making recommendations to Congress based on their findings.

Fifteen members will serve on the Commission, each appointed to three year terms by the Comptroller General. Health care professionals cannot constitute more than half of the workforce, leaving other seats open to representatives of employers, third party payers, health care economists, consumers, labor unions, educational institutions, and state or local workforce investment boards.

Legislators have penned specific priorities for the Commission to focus on throughout the course of their evaluations which include integrated workforce planning for nursing, oral, mental, public, allied, and emergency health providers.  Also of significance is the Commission’s ability to evaluate existing scopes of practice in the health care sector and make recommendations to Congress.

The creation of the National Health Care Workforce Commission is accompanied by a number of development grants for eligible State Workforce Development Boards to analyze local health care workforce needs and provide resources to help meet those needs. Individual providers may also apply for a number of workforce development grants or loan repayment programs.   Many of these opportunities are focused on growing the nursing field, however programs also exist to repay loans for pediatric and public health physicians as well.

The North Carolina Medical Society (NCMS), in its mission to provide Leadership in Medicine by helping physicians and patients navigate the transformation in health care, will partner with News Channel 14 to convene a televised forum on September 22 in Charlotte to engage leaders in the health care sector, elected officials and the public on the implementation of health system reform legislation.

The forum will be a panel discussion facilitated by a News Channel 14 anchor. Participants will include physician leaders in public health, rural and urban practice settings; a representative from the insurance industry; and representatives of both the hospital and physician perspectives.

The “Health Reform and You”  forum is scheduled for Wednesday, September 22, at 7 pm at the Harris Conference Center on the campus of Central Piedmont Community College in Charlotte.  The forum is open to the  medical community and the general public. Seating is limited and registrations are being accepted online.

Cindy Mann, Director, Center for Medicaid, CHIP and Survey and Certification (CMCS) for the Centers for Medicare and Medicaid, spent Wednesday in the Triangle meeting with state officials and health care leaders. Mann was the keynote speaker for the North Carolina Institute of Medicine’s annual meeting at the McKimmon Center in Raleigh. She spoke on Health Reform – A View from the Federal Level and participated in a question and answer session. Also participating was DHHS Secretary Lanier Cansler.

Click here to view remarks made by Cansler and Mann (this link is hosted by NC State University Continuing Education and may only be available for a limited time.)

While in the Triangle, Mann toured the Carrboro Community Health Center and talked with local officials and community leaders about the benefits of federal stimulus funds.  The Carrboro CHC is one of four entities in the Triangle to receive stimulus funding. The others include the Lincoln Community Health Center in Durham, Wake Health Services, Inc., in Raleigh, and the North Carolina Department of Health and Human Services.

The Health Resources and Services Administration funded nearly $190 million to North Carolina in 2009 for various areas, including health facilities, health professions, primary health care, rural health and for HIV/AIDS.  $2.2 million was given to Piedmont Health Services to assist with increased demand and capital improvements.  The NCMS joined Piedmont in celebrating its 40^th anniversary earlier this month at its headquarters in Carrboro.

The North Carolina Medical Society (NCMS) and the North Carolina Hospital Association (NCHA) are partnering with Moses Cone Health System and WakeMed Health & Hospitals to work with Thomson Reuters and CareEvolution to launch the North Carolina Healthcare Information Exchange (NCHEX).  The exchange will allow physicians to assemble a “continuity of care” record for each patient, comprising the patient’s clinical information from all of the providers participating in the exchange. The enhanced patient information will enable better quality and more efficient patient care.

NCHEX, which is launching with seven hospitals, three freestanding emergency departments and 57 physician practices, is the first step toward a statewide health information exchange (HIE) for North Carolina. It meets all the criteria for an HIE outlined in the ARRA HITECH Act for Meaningful Use.

The exchange will be open to all NC healthcare providers and will actively seek to contract with existing regional health information organizations, health information exchanges, and healthcare information technology systems by leveraging Nationwide Health Information Network Connect and other HIE standards.

Organizations and physician practices interested in joining NCHEX or seeking additional information can visit http://www.nchex.net/.

Thomson Reuters is an international company that provides information for businesses and professionals.  Read the Thomson Reuters news release about NCHEX.

The Business Journal of the Greater Triad Area – by Steve Ivey Staff writer

Health care providers in North Carolina are mobilizing in attempt to halt another round of Medicaid cuts in the state’s budget that could eliminate $100 million from the bottom line of doctors and hospitals statewide.

When legislators passed the annual budget in Raleigh this summer, it included contingency cuts to Medicaid if Congress didn’t pass an aid package to help states pay for health care, education and other necessary services.

Congress did pass the aid last week — including $643 million for North Carolina — but the N.C. Department of Health and Human Services has said it intends to still implement the $27 million contingency cut Sept. 1, which amounts to about a 1.4 percent reduction in payments to doctors, hospitals and other providers.

Because state Medicaid funds are matched by federal dollars, the total impact statewide will be $100 million less flowing to providers who treat patients on the low-income government insurance plan.

A little over half of the federal aid, $343 million, is targeted for Medicaid and other budget items, less than the state initially requested. But another $300 million was earmarked for education, which is about $124 million more than the state expected. Health care providers say the state should adjust its budgeted state funds to reflect the increased education funding and move that money over to Medicaid.

“We as a health system and hospital community are frustrated that these cuts are coming into effect,” said B.J. Miller, director of government affairs for Moses Cone Health System in Greensboro.

Providers say Medicaid only covers about 85 percent of their true out-of-pocket costs to treat those patients and don’t account for higher charges that might normally be assessed to patients with higher-paying private insurance. Moses Cone officials said, for example, that the system lost $27.1 million last year treating Medicaid patients.

The N.C. Hospital Association reports that hospitals statewide lost $572 million last year on Medicaid.

“For these cuts to continue, it’s a real impact on the business community,” Miller said. “We have to have a slim profit margin to invest in the people and technology we need. So the result is cost-shifting to private payers, whose premiums are covered by employers.”

Joanne Ruhland, vice president of government affairs at Wake Forest University Baptist Medical Center, said the cuts are especially disappointing given how hard health providers lobbied for the federal aid.

“With so much opposition to spending and concern about the deficit, it was a hard fight to get it,” Ruhland said. “We’re writing a lot of letters and making a lot of phone calls.”

Tight budgets

Brad Dean, spokesman for the state Department of Health and Human Services, said the cuts are necessary amid such a tight budget year because the recession and high unemployment has sent more patients onto the Medicaid rolls.

For example, the number of people eligible for Medicaid in the 12-county Triad stands at about 252,000 this month, up from 207,000 two years ago. Statewide, the number has risen from 1.28 million to 1.45 million.

“It’s going to be a lot more of a challenge in the coming years,” Dean said. “When health reform takes effect in 2014, many uninsured people are going to be covered through Medicaid, probably pushing our numbers up 40 percent.”

Health care providers say that because Medicaid has been cut to subsidize education in the past, the state should adjust its budget to include more of the federal aid for Medicaid this year.

“Medicaid is the most cost-effective way to treat these patients; otherwise they end up seeking care in the emergency room, which is far more costly to taxpayers and employers alike,” said Bob Seligson, CEO of the N.C. Medical Society. “The state says its hands are tied, but that’s not entirely true.”

Jim Tobalski, senior vice president of government affairs at Winston-Salem-based Novant Health , which lost $103 million on Medicaid last year, said providers will soon be faced with decisions about whether to see Medicaid patients at all.

“It’s at the heart of our mission, so we will continue,” Tobalski said. “But this downward spiral is going to affect everything we do. And because of the poor economy, our ability to cost-shift is going away.”

The state medical society has sent a letter to Gov. Bev Perdue and state Health Secretary Lanier Cansler asking them to halt the cuts. But Cansler has signaled the intent to implement them Sept. 1.

“We haven’t gotten a lot of positive response, but we hope they’ll turn the corner and realize this is the right thing to do,” Seligson said. “These patients need access. Our state needs to reassess what’s been done.”

Reach Steve Ivey at (336) 370-2909 or sivey@bizjournals.com.

The Patient Protection and Affordable Care Act expands state Medicaid eligibility to almost anyone under the age of 65 with income up to 133% of the Federal Poverty Line (FPL).  As of 2009, this percentage equals $29, 327 for a family of four.  A family of four with an income of 400%  of the FPL (approximately $88,000 per year)  will also be eligible for subsidies.  This drastically changes the current face of the Medicaid program, especially due to the inclusion of many childless adults. Taking into account the drastic mandate for eligibility and other new requirements of the law, the ultimate reach of the program will be heavily dependent upon implementation at the state level.

The North Carolina Institute of Medicine, together with the NC DHHS Secretary Lanier Cansler and NC Insurance Commissioner Wayne Goodwin, has convened a Medicaid Work Group to begin looking at the major changes ahead for the NC Medicaid program.

By 2014, the Department of Health and Human Services estimates over 500,000 new Medicaid enrollees due to expanded eligibility as well as current eligibles who are not enrolled at this time. Half of this influx will be comprised of childless adults.  Other sources have projected this number to be even higher based on past enrollment trends.

The Act allows states to implement the new eligibility category options today, but only at the original NC FMAP rates.  At this time the state does not plan to implement this option due to the loss of future federal matching funds.

The law as currently written requires the federal government to finance the majority of spending for newly eligible Medicaid enrollees.  States will receive 100% funding from 2014-2016, 95% in 2017, 94% in 2018, 93% in 2019 and 90% thereafter.  However, the state will be financially responsible for those who are currently eligible but who have not enrolled in the past. The law also requires states to maintain eligibility standards that were in place as of the date of passage (March 23, 2010).  

The Kaiser Family Foundation estimates that the state of North Carolina will spend anywhere from $1.02 to $1.8 billion during the first five years of Medicaid expansion. This will increase total spending on Medicaid from the current $12 billion to over $17 billon.  This range is based upon expected enrollment of the total eligibility ranging from 57-75%.  The federal government will pay the remaining 93-95% of costs, totaling $21-25 billion in North Carolina alone.  Under the new law states must also increase reimbursement for primary care procedures to 100% of Medicare payment rates. The federal government will cover the cost of the enhanced rate in 2013 and 2014.

The mass expansion of Medicaid coverage to over half a million new patients and the pending provider rates cuts at both the state and federal levels threatens patient access to care more than ever before. To address this challenge, we must stand together to ensure that the value of your services provided under the physician fee schedule is preserved.  State budget shortfalls and fallout from the recession should not be borne on the backs of the physicians and PAs that are providing the highest quality and most cost effective medical care to our Medicaid population.

The North Carolina Medical Society is encouraging physicians to review and comment on the Draft Operational Plan for the NC  Health Information Exchange (NCHIE), which can be viewed here. Comments must be submitted via email by this coming Wednesday, August 25th to nc.hie@healthwellnc.com. This is an opportunity for physicians to provide input to the development of the statewide health information exchange, which will influence the availability of your patients’ health information.

NCMS staff will review the operational plan in detail over the weekend and post our comments on the NCMS website prior to the deadline.  One recommendation of the plan that we would like to see modified concerns patient consent under the Legal and Policy Section (pp 93-109), subsection 8.5 (p 101).  The current recommendation would give patients the ability to prohibit certain providers from disclosing their information into the NC HIE.  NCMS believes that patient records accessible over the HIE should be complete.  Patients should not be able to selectively exclude portions of their record from the exchange.  

Physicians have been actively involved in the development of the Draft Operational Plan, with the final draft prepared by Manatt Health Solutions approved by the NC HIE Board.  NCMS Past President G. Hadley Callaway, MD, and several other physicians serve on the NC HIE Board.  For a list of all physicians participating on the NC HIE Board, click here.

The Office of the National Coordinator for Health Information Technology (ONC) within the U.S. Department of Health and Human Services is hosting a series of informational calls to provide an overview of, and answer questions related to, the temporary certification program for electronic health record (EHR) technology.  

Participants will hear an overview of the program and be able to ask questions.

One more call is scheduled for August 2010 (the first was held on August 18):

Wednesday, August 25, 2010, 1:00 – 2:00 p.m. EDT

Call-in Information
Phone Number: 888-324-9617
Participant Passcode: 4584230

Recordings and transcripts for each call will be made available on the ONC web site.

For more information about the temporary certification program and the final rule, please visit http://healthit.hhs.gov/certification

Subject matter experts will review basic information on both ICD-10 and 5010 and explain how they are interrelated. A question and answer session will follow the presentations.

When: Monday, September 13, 2010;
Time: 12:00 p.m. – 1:30 p.m. ET;

Target Audience: Medical coders, physician office staff, provider billing staff, health records staff, vendors, educators, system maintainers and all Medicare fee-for-service (FFS) providers.

The following topics will be discussed: ICD-10; ICD-10 implementation for services provided on and after October 1, 2013; Differences between ICD-10 and ICD-9-CM codes; ICD-10-CM basic information for all users; Tools for converting codes – General Equivalence Mappings (GEMs); Proposal to freeze ICD-9-CM and ICD-10 code updates except for new technologies and diseases; HIPAA Version 5010; Compliance dates and timelines (No contingencies); 5010 before and after ICD-10 Implementation; Readiness review for implementing HIPAA version 5010 and D.0; What you need to be doing to prepare; Medicare fee-for-service activities update; Other issues and considerations.

This toll-free teleconference will include a question and answer session. For more information and to register for this informative session, please go to

The North Carolina Medical Society (NCMS) hosted almost 100 physicians and consultants in Raleigh at the ACO Summit on Saturday, August 7, 2010.  Accountable Care Organizations (ACOs) are an emerging model for health care delivery for Medicare services under Health System Reform.  ACOs link groups of providers together to coordinate and improve quality and efficiency in health care by fostering greater accountability in the delivery of care.

ACO Summit attendees heard presentations offering perspectives on ACOs from the Brookings Institute, Crescent PPO, Community Care of North Carolina, Poyner and Spruill, LLP, and Smith Anderson.  Participants discussed how new business models can improve the delivery of health care and how physician participants can use existing successful programs as a foundation for ACOs.  The Summit also reviewed the NCMS current draft policy on Accountable Care Organizations, to be considered by the NCMS Board of Directors in September.

Presentations and materials from the ACO Summit can be found on the NCMS Health System Reform page http://www.ncmedsoc.org/healthreform. If you would like to offer feedback on the draft policy on ACOs or provide information on ACOs being developed in your area, please complete and submit the feedback form also found on the Health System Reform page.  Please submit feedback regarding the draft policy by August 30, 2010.

One of the many new entities created by the Patient Protection and Affordable Care Act (the Act) is the Center for Medicare and Medicaid Innovation or “CMI,” which will be part of CMS.  The goal of CMI is to test the impact that innovative payment and service delivery models have on the cost and quality of health care services.   

Preference for selecting new delivery models to test will be given to those models that improve coordination, quality, and efficiency of health care services. The models further must target a defined patient population for which there are “deficits of care leading to poor clinical outcomes or potentially avoidable expenditures.”   The Secretary also may limit testing to certain geographical areas.

CMI is required to consult with relevant federal agency representatives as well as with clinical and analytical experts in medicine and healthcare management.  “Open door forums” will be conducted to seek input from interested parties. 

Models will be evaluated based on an analysis of the quality of care furnished, including the measurement of patient-level outcomes and patient-centeredness criteria, and the effect of the model on program costs.   The Secretary is charged with publicizing the evaluation results for each model reviewed.

The Act requires that CMI be operational by January 1, 2011.  Over 10 billion dollars have been appropriated for CMI activities  for 2010-2019.  To read this section of the Act, click here.

The North Carolina Institute of Medicine has established eight Health Reform Workgroups that will serve under an NCIOM Advisory Committee. The new effort will be led by NC Department of Health and Human Services Secretary Lanier Cansler, and NC Insurance Commissioner Wayne Goodwin.  The goal of these groups is to identify the decisions that the state must make in implementing health system reform.  This initiative will also identify potential funding opportunities that will improve health, access to care and quality of care in North Carolina.

The eight workgroups that have been established will focus on: Prevention, Safety Net, Health Professional Workforce, Health Insurance Exchange and Insurance Oversight, Medicaid, New Models of Care, Quality, and Fraud and Abuse.  Each group will meet approximately once a month for the next year.  Meetings are open to the public and NCMS staff will attend each meeting. A calendar of meeting dates and times is available by visiting the North Carolina Institute of Medicine Website at http://www.nciom.org/calendar.php.