Medicaid Reform Update

Now that both the North Carolina House and Senate have laid out their respective Medicaid reform proposals, the North Carolina Medical Society (NCMS) has a clearer outline for our advocacy efforts in the weeks and months ahead.

The NCMS has allocated the necessary resources to make Medicaid reform its top priority this session to protect our members’ interests in what is sure to be a contentious and lengthy debate. We plan to stay focused on the elements in both the House and Senate plans that uphold the basic principles our members support – patient-centered and provider-led are key tenets we will work to ensure.

Even before the House bill was introduced several weeks ago, the NCMS had engaged with the North Carolina Hospital Association, long-term care organizations and over 70 other individuals representing Medicaid beneficiaries to craft a unified reform plan to help shape the House proposal. Much of what this disparate group of stakeholders sought was indeed included in the House bill (HB372), which places Medicaid in the hands of ‘provider-led entities.’ The House approved this bill on Tuesday on a vote of 105-6, setting the stage for negotiations with the Senate.

The Senate’s Medicaid reform proposal is contained within their budget – a procedural strategy to help ensure reform is achieved this session. Highlights of the Senate budget. The Senate’s plan focuses heavily on corporate managed care organizations (MCOs) as a means to reform Medicaid, but their plan also includes physician-led entities and some quality assurance measures.

Both plans endorse a full capitation model. The difference between the House and Senate lies in what entity would assume the risk – MCOs or physician-led entities or a combination of the two. See a side-by-side comparison of the two plans.

As always, NCMS members guide our advocacy work, and our members say they are not knowledgeable enough, as doctors, to take on the full organizational and underwriting burden of Medicaid.

“Doctors are not insurance companies; they are first and foremost caregivers,” said NCMS President Robert E. Schaaf. “Our job going forward is to make sure our patients’ care comes first regardless of what ‘entity’ manages the state’s Medicaid program.”

To prepare for the likelihood that the underwriting risk would fall to an insurance company, the NCMS Government Affairs staff lobbied hard to have language included in both the House and Senate reform plans making the “Triple Aim” the standard for whatever group assumes the risk.  The Triple Aim, the goal guiding most accountable care organizations, focuses on 1) improving the health of a population of patients, 2) enhancing patient experience and outcomes and 3) reducing the per capita cost of care for the particular population.

Retaining this crucial provision will be a focus going forward as a way to protect patients especially in light of other states’ negative experiences with managed care organizations. If included in the final legislation, North Carolina would be establishing new ground by incorporating the triple aim into its Medicaid statutes.

The federal government also recently introduced an update to its Medicaid managed care regulations –the first major change to Medicaid and CHIP managed care regulations in more than a decade. This proposed rule aims to “improve beneficiary communication and access, provide new program integrity tools, support state efforts to deliver higher quality care in a cost-effective way and better align Medicaid and CHIP managed care rules and practices with other sources of health insurance coverage,” according to the Centers for Medicare and Medicaid Services (CMS). Read the proposed rule. The comment period for this proposed rule closes on July 27.

The battle over Medicaid reform will be long and challenging. Legislators have indicated reform will get done this session, which may mean the General Assembly won’t adjourn until fall. Watch your NCMS Bulletin and email for updates and calls to action when necessary over the next few months.


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