There is a lot to be said about the new budget just enacted by the NC General Assembly. This was arguably the most difficult budget year in modern times for health-related issues. Medicaid funding was already seriously undermined by the actions of the NC General Assembly and the NC Department of Health and Human Services in 2009. Moreover, Congress has not yet extended supplemental funding to deal with ballooning Medicaid enrollment during the economic downturn (known as Federal Medical Assistance Percentage, or FMAP). If not ultimately approved by Congress, North Carolina will lose up to $500 million in Medicaid funding in 2010-11.
To address this problem, the NC General Assembly chose to enact contingency provisions in the budget. It is in the contingency budget that physician Medicaid payments are being targeted. In addition to the $82 million planned cut from 2008-09 levels, enacted in last year’s 2009-10 budget (which, incidentally, was arbitrarily increased to $101 million by North Carolina DHHS), the General Assembly cut rates in the contingency budget by another $26.6 million. The NCMS, working within a coalition of medical organizations, was able to insert two provisions in the final budget to minimize the damage.
First, if the federal funding is approved to help with ballooning Medicaid enrollment, there will be no further reductions in the rates paid to physicians. While this obviously does not address our goal of maintaining physician unity, equalizing rates for all specialties in Medicaid, and protecting the primary care “engine” (CCNC) that produces savings for the whole program, it does take further cuts off the table if adequate FMAP funding is enacted by Congress.
Second, a provision was added to make clear that the only reduction to physician rates that will occur in the contingency budget is the $26.6 identified by the General Assembly. Other across-the-board cuts in the contingency budget will not apply to Medicaid rates. The Secretary of NC DHHS has discretion, however, regarding the implementation of rate cuts in the contingency budget, and could implement the cuts even before Congress had finished debating the question of supplemental funding. NCMS and the coalition pushed for protection from further cuts if the Secretary determines that early implementation of the contingency budget is necessary, but the General Assembly did not provide that protection.
The NCMS will continue fighting to restore reasonable fees for services provided to Medicaid enrollees.
Scope of Practice:
Physical Therapy – Within the physician community, there has been tremendous interest in efforts by the national PT advocacy groups to eliminate physician-owned PT services (POPTS). The PTs have been successful in a few states. Recent proposals by PTs in the NC General Assembly, if passed, would move North Carolina closer to prohibiting POPTS. The NCMS supports POPTS and has worked to ensure this option continues to be viable in North Carolina. There has also been concern about the use of electrodiagnostic testing by PTs. Today, the PTs claim authority to perform the tests based on a letter once sent to the PT Board by the NC Medical Board. According to the Board’s letter, PTs are prohibited from making a medical diagnosis based on the test. The PT proposal would have added electrodiagnostic testing and diagnosis to their scope of practice. NCMS does not support those provisions. To address our concerns, we negotiated several provisions in this year’s PT bill. The bill did not move because the PTs were not able to resolve concerns raised by the Athletic Trainers regarding their role in delivering PT services.
Midwifery – The Joint Midwifery Committee, organized to regulate nurse midwives, was asked by the General Assembly in 2009 to consider recommendations for the licensure of lay midwives in North Carolina. The committee met throughout the period between the 2009 and 2010 sessions of the General Assembly. In its final recommendations, the group did not recommend licensure of lay midwives. This is attributable to the excellent work of the physicians who participated in the study, and the physicians and other individuals who worked on the issue for the NC Ob/Gyn Society and NC Medical Society.
Naturopathy – For the seventh consecutive year, the licensure of naturopathic practitioners has been proposed. After opposing the measure for several years, the NCMS, in 2006, spelled out some conditions under which it could remove its opposition to licensure of some naturopathic practitioners. The NCMS naturopathy white paper has been widely circulated to educate legislators and others involved in the debate. The naturopaths promoting the legislation, who have better training than the naturopaths opposing the legislation, initially agreed to the preconditions identified by the NCMS. Since then, there has been persistent controversy regarding a number of issues related to patient safety. The NCMS has continued to oppose bills that do not meet its preconditions. Again in 2010, NCMS opposed naturopathy licensure legislation proposed by Sen. Ellie Kinnaird (D, Orange). The bill did not move during the 2010 session.
Uniform Apportionment of Tort Responsibility Act, (a.k.a. Repeal of Contributory Negligence):
The NCMS worked within a coalition of business representatives to address concerns with a proposal made by the NC Advocates for Justice (i.e., the plaintiffs’ bar) to move from a contributory negligence to a comparative fault system in North Carolina. NC is one of four jurisdictions in the United States that has a contributory negligence statute on the books, barring a plaintiff from recovery if they negligently contributed to their own injury. In contrast, comparative fault systems permit plaintiffs to recover from others even if they are partially responsible for their own injury.
The legislation passed the House in 2009, and was then referred to a subcommittee in the Senate for study. The last proposal from the subcommittee contained several provisions that were unacceptable to the coalition. The coalition proposed changes that were reasonably aimed at addressing genuine concerns, and that ensure a balanced civil justice system for North Carolina. Throughout the coalition’s discussions, the NCMS advocated for a balanced proposal that addresses the concerns of the medical profession. One provision in the coalition’s proposal supported by NCMS is a proposal to allow juries to hear accurate information about the amounts actually paid by injured parties for past medical care, rather than hearing only about full charges before contractual and government reductions. The balanced proposal offered by the coalition was rejected by the plaintiff’s bar. The bill ultimately failed to get a hearing in the Senate, and the session ended without further action on the bill. There is a provision in the study bill, however, that is likely to bring this issue back before the General Assembly in 2011.