Medicaid Reform Progress — Don’t Give Up Now

legislative-buildingAs legislators reach consensus on a state budget, the debate over Medicaid reform has progressed to a point where several big questions appear to have been decided – the state will no longer assume the financial risk for Medicaid and will transfer that risk to a mix of managed care and provider-led entities. This does not mark the end of the battle for a Medicaid system that puts patients at the center and the providers in key leadership roles, but the beginning of another phase in reform.

The North Carolina Medical Society (NCMS) has redoubled its efforts at the legislature, clearly outlining the fundamental provisions needed under the proposed ‘hybrid’ system to preserve the heart of our original, 3-year-old proposal – physician-led, patient-centered care – whether it is through a managed care organization or a physician-led entity. You can read what we, in partnership with other stakeholder organizations, have determined to be the essentials of any Medicaid reform legislation here.

In listening to you, we understand that few physician practices are ready to assume the financial risk of the state’s Medicaid program. But some provider-led entities are ready, and they should be allowed to prove themselves as a viable alternative to managed care. Likewise, the safeguards we want to see in any final legislation will help ensure the managed care organizations abide by the principles of patient-centered care, quality metrics, patient satisfaction and that practicing physicians will have key, decision-making roles in any patient care policies.

The battle underway now is to convince legislators to take other states’ bad experiences with managed care as cautionary tales and use that knowledge to enact legislation to truly protect our most needy and vulnerable patients.

Now is not the time to turn away from this issue, thinking the war on behalf of your Medicaid patients is over. This is an important battle in what likely will be a long series of debates as North Carolina’s mammoth Medicaid system is transformed. Now is the time to take action to make sure legislators understand what is at stake for you and your patients. Send your legislator a message now.

The view from the frontlines – watch NCMS Director of Legislative Relations Chip Baggett explain the status of Medicaid reform.


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1 Comment

  • Adrienne

    I started a pediatric practice in Northwestern North Carolina eight years ago in the medical home model. Because we made the decision not to limit Medicaid enrollment, the practice is now 80 to 85% Medicaid, and we struggle to stay afloat. The practice currently consists of 5 staff, a pediatrician (myself), two nurse practitioners, an LPC providing full time mental health care, and we give free space to a full time occupational therapist, a full time speech therapist, and a speech pathologist who is here 1 day a week. In addition to our “well” children (who being poor often have obesity, asthma, allergies, etc.), we also work closely with the specialists at Wake Forest University Brenner Children’s Hospital and pull children with chronic illness, medical fragility, special needs, school and mental health issues from 10 rural North Carolina. Our complexity is 1.9 times state average. I currently have 5 children on home ventilators in my own practice.

    In 2014, we saved Medicaid $750,000, $750,000 in 2013, and $1,000,000 in 2012 compared to other practices in the state. Our patients are hospitalized 50% less often than state average. For every 3 children statewide who goes to the ED with asthma, only one of our patients goes. We apply fluoride varnish 50% more often. We write fewer prescriptions and have fewer ER bounce backs. We also frequently spend time fighting with the schools in the area to get basic needs met for our kids with disabilities. We have reported to the Office of Civil Rights multiple times and worked with Legal Aide. I have been to more IEP meetings than I would like to count. It is amazing anyone learns to read.

    The snag is that I have averaged $15,040 a year in salary (we have taken $272,769 out of the practice or $38,967 per year; however, the practice has $167,485 of debt still so the actual “profit” we’ve seen from the business is $105,284 or $15,040 per year), and I work 50 to 60 hour weeks. When Medicaid pay parity was passed as part of the Affordable Care Act, things improved (prior to that I averaged $6000 a year); however, since the Medicaid pay parity act ended January 1st, the practice is losing $3000 a week in income. Medicaid pays about 50% what private insurance pays and about 70% of what Medicare pays. Also, the more time you spend with a patient (and we often have extended visits with our very complex kids) the less you make. [More info here: If, for the last 7 years, I had earned the $180,000 per year I was making before I started this practice, we would have an additional $1,260,000 in income. As it is, we struggle to stay afloat.

    Northwest Community Care (our managed care Medicaid entity) was sure we were doing something wrong so, a few years ago, we sent our books to the head of rural health in NC who had run a very lucrative multi-specialty practice previously. His answer, we just are taking too much Medicaid. When we talked to the head of Medicaid for the state, we were told that “our payer mix was wrong.” In other words, we should turn away poor and disabled kids who have no control over the type of health care they have.

    We change lives at the cost of one pediatrician’s salary, and NO ONE cares. We have called and written news organizations, state and federal government officials, etc., etc., etc. When North Carolina switched to paying Medicaid out through a new system (NC Tracks), they screwed up, and we actually didn’t get paid at all for 3 months. Our farm went into foreclosure briefly, and our dedicated staff had to wait on their paychecks. With the end of Medicaid pay parity, we have again had to put money into the practice and ask our excellent staff at times to hold their pay checks. The poorest patients are the sickest patients yet physicians are compensated the least for caring for them. In addition to poor children (currently 22% of children in the US), children with disabilities have Medicaid as a primary insurance even if their families have private insurance. Where are they going to go? We are actually in the process of working to set up a non-profit to help us fund our work. This takes lots of time that I would really rather spend caring for patients.

    Finally, North Carolina has gutted the mental health system here. Access for the working poor is a joke. Right now, we have no child psychiatrists who take Medicaid to refer to in driving distance of our practice. I actually went back and did a mini fellowship in pediatric psychopharmacology to cover all the overflow. In addition, the state has made having a co-located therapist very difficult despite all the evidence that this is a more effective mental health model. Every year, we have to go through an extensive recertification process for our therapist (an LPC) which includes documentation of every state and county I have lived in since turning 18 because I own the practice and creating an “org chart” (which thank goodness my husband knew how to do) among a variety of other equally ridiculous steps. I don’t have to go through this type of scrutiny to practice as a physician. The majority of providers will not bother.

    If you are interested in knowing more about our numbers or our practice, please feel free to contact me. This video will give you a sense of what we do: