NCMS Board Begins New Year; Launches New Governance System

The 2016 North Carolina Medical Society (NCMS) Board of Directors held their initial meeting of the new year last Saturday, Jan. 9, at the NCMS Center for Leadership in Medicine in Raleigh. This was the first gathering since the 2015 Annual Meeting in October and adoption of a new governance system, which shifts policymaking authority from a House of Delegates to the NCMS Board.

This inaugural Board meeting offered an immediate example of how the new system will work. Matthew Olin, MD, an orthopedic surgeon from Greensboro, and current president of the North Carolina Orthopedic Association (NCOA), along with Richard Bruch, MD, former NCMS President and former NCOA President, appeared before the Board to request the NCMS adopt a policy on certificate of need (CON) reform.

Over the years, this issue has proved highly controversial among various specialty groups that make up the NCMS membership. CON reform legislation has been introduced in the past several legislative sessions, and came close to passing in this most recent session. The issue will most likely be debated by legislators again this year, according to Steve Keene, NCMS General Counsel and Deputy Executive Vice President for Government Affairs and Health Policy.

Drs. Olin and Bruch encouraged the Board to take action now with the possibility that the ‘house of medicine’ would be able to present a united front on this issue in the upcoming short session. Dr. Olin said that the current CON system is not fair and needs to be opened up to assist in achieving the ‘triple aim’– achieving better care for patients, better health for communities and lower costs — as the health care system moves toward value-based medicine.

Board members questioned the guests and then debated the issue for nearly half an hour. Earlier in the meeting they had heard from North Carolina Department of Health and Human Services Secretary Rick Brajer, [see related article in this issue of the Bulletin] who told Board members that he foresees the state gradually moving away from CON. Several Board members agreed that CON no longer serves a purpose, and could be detrimental to achieving the ‘triple aim’ mentioned by Dr. Olin.

After a lively discussion the Board authorized NCMS CEO Robert Seligson to retain an outside and objective source to do a study on the ramifications of any changes to the CON law. The Board also is seeking comment from the larger NCMS membership. Please weigh in with your thoughts on this issue by posting a comment at the end of this article. Your comments and the results of the research study will be brought to an NCMS Task Force made up of representatives from all concerned specialties within the membership to make a definitive recommendation to the Board on a policy change.

Under the new governance structure, if you have a policy issue you would like the Board to consider, please complete the online form. In addition, the Board of Directors will be holding their meetings throughout the state this year to make them more accessible to the entire membership. The next meeting will be held in Wilmington in March. An evening ‘Mix and Mingle’ event will be held before the meeting on Friday, March 18. This is an opportunity to speak with Board members in a casual setting. Watch the Bulletin and your email for more details on this eastern NC meeting.



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  • dino cona

    elimination of con laws leads to self referral for purposes of self enrichment with no added value to patient care

  • Matt Mauro

    Dear Sir:

    I would like to express my strong objection to the movement of eliminating the CON rules within the state of North Carolina. The CON process is designed to regulate the purchase and utilization of expensive medical imaging equipment. All citizens of this state need access to advanced imaging for diagnosis and management. The deregulation of the CON process will drive advanced imaging to those with a financial incentive to utilize these units. Hence, a marked overutilization will occur which has been well demonstrated in the literature and noted by CMS. Furthermore, complex imaging produces a margin for our rural hospitals allowing them to keep their doors open and provide the needed care for our citizens—particularly those with limited resources. This action financially motivated by those who can purchase units and self refer to them. Removing CON would certainly be financially beneficial to those disciplines that will self refer (orthopaedics) but not to the people of North Carolina.

  • I wish the proponents of changing the CON laws would at least admit the financial incentive for them to argue for it. It’s one thing to talk about access and need and efficiency, but please don’t leave out that doing things this new better way also lines your individual pockets with a lot of extra cash. Hard to have an honest debate when the financial cards aren’t all on the table.

  • Kevin M. Cregan

    Abolishing North Carolina’s CON laws is a controversial and contentious issue. We are asked to re-visit this issue annually by the subspecialists who will gain financially by eliminating the CON laws. The stated goal of achieving the triple aim, “better care, better health, and lower costs”, sounds lofty and altruistic. But it also reminds me of the orthopedic triple spot for auscultation: the fictitious location where one can hear breath sounds, heart sounds, and bowel sounds. The triple aim is fiction as well. There is no way to prove that the triple aim will be achieved with CON repeal.

    What is not fiction are the abuses inherent in self referral. Dr. David Levin from Thomas Jefferson has published extensively on how self referral has led to abuse in imaging. Self-referring physicians are 2-3 more times likely to order imaging studies on their patients. Dr. Levin presented to the NC Legislature in the spring of 2014 and helped to defeat anti-CON legislation. It died in committee. His data is real, based on querying the Medicare database.

    Therefore repealing CON will cause the cost of imaging to skyrocket. Proliferation of ASCs all over the state will also occur with CON repeal. The patients with private insurance and Medicare will be siphoned from hospital’s ORs. Hospitals will be left with MEDICAID and TRICARE. The surgical subspecialists who have ownership in ASCs will no longer need to be on staff at hospitals. Ophthalmology coverage for ERs will likely disappear. Orthopedic coverage could be affected as well. North Carolona will turn into Florida with imaging centers and ASCs on every corner and tacky medical billboards lining every highway. Overall imaging and surgical procedure volume will increase, rural hospitals will go bankrupt, and ER coverage will have large gaps. Is this the triple aim I’m hearing about?

    There will be no unified position in the House of Medicine re: CON repeal. Modification of the existing CON laws represents a compromise that can be achieved. Bob Seligson has managed to maintain a period of relative harmony in the Medical Society by remaining neutral regarding CON. If the board chooses to do otherwise, the NCMS will be fractured again.

  • Satish Mathan

    There are a lot of interesting comments on this controversial topic. The CON conversation needs to take place in the context of self referral, access to care and managing overall public health costs involved with surgery and high end imaging. If CON is removed without considering these important aspects, overall access to care will be threatened as silos of care will enjoy access while other populations will not at an overall higher cost to the system.

  • I respect the concerns of the CON opponents. Most of these comments are all about MRIs. While this is important, can someone please tell me why I, an ophthalmologist, should not be able to do cataract surgery in my office? I get paid half what the hospital would for the same job, I’m not self referring, my surgery is less invasive than dental work, and I would welcome anyone to argue patient safety with me in my highly specialized field. Also please keep in mind that I looked back on the pro and con arguments for the GI changes to CON and they look much like what I’m reading on this forum. There was great fear about over utilization and patient care. Everything is fine ten years later. Yes, we had to change how we do things but money and more importantly lives have been saved. Utilization means care. Decreasing access saves money but does not treat disease. If we have to tease out what we like and don’t like about CON, I’m fine with it. But the law as it currently stands is antitrust. Plain and simple. It’s so antitrust that states made COPA laws to protect themselves from antitrust lawsuits. The FTC agrees.

  • Michael Holdeman

    Allowing any random group of investors to open a hospital or surgery center would siphon off the well-insured and monied patients from the non-profit and public medical centers providing care for the majority of the citizens of North Carolina and would be a death blow for these institutions. Ultimately, a greater burden will then fall upon the taxpayers in the state to support such hospitals and would likely result in an overall deterioration in the care provided. A deterioration in public healthcare would then have spiraling costs and consequences to the state. Do not be fooled. those who want to eliminate the certificate of need process are motivated by one factor and one factor alone – greed.

  • Leonard Gibson

    Of course, the proponents of “reforming” the CON laws in N.C. argue that they only wish to perform a great public service to increase access to Healthcare for the underserved and disenfranchised. What they really seek is money. This money will come from the coffers of the government, i.e. taxpayers, and individuals in the form of increased insurance premiums. Once a private practice has imaging equipment and the ability to self refer patients then a magical thing happens. This magical thing is utilization. A physician that used to order 10 imaging studies a week now orders 30 a week. The financial incentive is too great to resist. This drives up the cost of medicine for everyone. The cost is passed down the line from CMS and private insurers all the way down to the individual citizen’s wallet. If North Carolina is honest about a desire to hold down costs and keep healthcare providers accountable, then the CON laws will be upheld.

  • Shawn Quillin

    The CON laws maintain quality medicine in the hands of those who perform the highest quality care. Please leave CON laws in place. The physicians (who will be self-referrers) operating these non-CON facilities may subject their patients to needless operations and imaging in order to enrich themselves at their patients’ expense based on prior data. In addition, rural hospitals remain under intense financial pressure and the easing of CON will make access to quality healthcare an impossibility for those institutions.

  • Karl Chiang

    Con laws prevent self-referral over-utilization. In non-CON states like Florida, there is MRI on every street corner. The bottom line of this debate is the ability to have a MRI in your office and increase reimbursement. Medicine is now driven my monetary concerns.

  • Norris Crigler

    The proposed changes to our CON law seeking to deregulate Diagnostic Centers and Single Specialty Ambulatory Surgery Centers and Endoscopy Rooms will be bad for North Carolina because:

    1. The physicians (who will be self-referrers) operating these facilities will subject their patients to needless operations and imaging in order to enrich themselves at their patients’ expense. The United States General Accounting Office (GAO)in an October 2012 report stated:

    “physicians who self-referred Medicare patients in 2010 made 400,000 more referrals for advanced imaging services costing Medicare about $109,000,000 than non self-referrers.

    Switchers – new self-referring physicians (which will be the operators of the Single Specialty Am Surg Centers) increased their number of patient images prescribed by 67% annually.

    The unnecessary cost to the health care system is only part of the problem. The damage to the patient arising from radiation for unneeded CT scans and MRI’s is the increased risk of cancer.”

    2. The Orthopaedic Association has relied on the CON law changes in 2005 that permitted endoscopy procedure rooms to be exempted from CON in their claim of savings. Endoscopy procedures are simple, straightforward and universally recommended as a means of preventing colon cancer. The procedures that the Orthopaedic Association seeks to perform are not simple and straightforward. They want to do knee replacements, hip replacements and similarly complex surgeries.

    3. Rural community hospitals are currently under intense financial pressure. Approximately 30% of our North Carolina hospitals operated at a revenue loss in 2014. Their patient mix is heavily weighted towards government reimbursement through Medicare and Medicaid. Allowing Ambulatory Surgery Centers without CONs as described in HB 200 will further weaken our rural hospitals and force them to make cutbacks to services. This will damage our rural communities in their search for industry and jobs for their people. They will not be able to recruit new industries without hospital services.

    4. The assertion that the physicians operating these new Ambulatory Surgery Centers and the diagnostic centers that will be paired with them meet the standards for serving indigents and other medically underserved populations as local hospitals is absolutely untrue. There is no staff in the CON section or in DHHS capable of auditing or reviewing the failure to accept high risk-high cost patients at these facilities equivalent to the number of patients treated at their local community hospital. The 7% commitment in Section 7 also lacks any enforceability. The DHHS has no authority to audit or to permanently shut one of these facilities down for failure to fulfill their commitment. There is no penalty imposed upon the doctor owners of such facilities for failure to meet their obligations.

    • Karl Chiang

      I could not agree more with Norris Crigler. The driving force to deregulate and rescind CON laws is to increase self-referral. I hope that this is self-evident to NCMS.

  • Mustafa Bashir

    Removing the CON laws or opening them too much will encourage self-referral, resulting in more unnecessary/costly procedures and lower quality of care. There is room for thoughtful reform that accounts for the above issues but increases access to care.

  • Allen

    In agreement with Dr Ebert’s comment above:

    “I agree with others that the time has come to revise the CON laws/regulations in North Carolina. I support system reforms that ensure that CON laws are applied fairly while protecting the overall CON laws that provide financial stability to our community hospitals. It would be great if we could live in an unregulated, free market environment, but this is utterly impossible with our present system of medical reimbursement. Elimination of thoughtful CON laws would result in chaos” and destruction of hospital service for the less economically advantaged patients.

  • Dr. Walt L.

    I am all for more competition!

    As long as the CON reform law states that no caregiver can refer to an advanced imaging site in which they or their family members have any financial interest whatsoever, or engage in a tit-for-tat relationship with another caregiver to trade such referrals, I am supportive of this CON reform. That way we will not see unethical self-referral, yet anyone can buy an MRI unit and put it out there on the competitive market.

    Of course there is no competition when one self-refers. All paying patients get self-referred, and non-paying patients all get sent to the hospital.

    So as long as safeguards against unethical and financially motivated self referral are rock solid, and it is truly a competitive situation where the facility with the best price and best service wins, I am all for CON reform.

  • In agreement with Dr Ebert’s comment above:

    “I agree with others that the time has come to revise the CON laws/regulations in North Carolina. I support system reforms that ensure that CON laws are applied fairly while protecting the overall CON laws that provide financial stability to our community hospitals. It would be great if we could live in an unregulated, free market environment, but this is utterly impossible with our present system of medical reimbursement. Elimination of thoughtful CON laws would result in chaos” and destruction of hospital service for the less economically advantaged patients.

    • Terry Forrest

      “Elimination of thoughtful CON laws would result in chaos” and destruction of hospital service for the less economically advantaged patients.” Quite the contrary, as CON restrictions are leading to a marked decrease in surgical subspecialist availability in smaller and more rural North Carolina communities. More and more patients from these areas are being forced to travel 1-3 hours to larger medical centers to obtain specialty care. This flow of services away from smaller hospitals and communities does not help the cash straped rural hospitals. Hybrid systems such as the monthly itinerant surgical services available at some smaller hospitals are also not ideal for rural patient care. When said patients experience post operative complications, they are then forced to drive long distances rather than having those services available locally.

      CON laws are driving specialty surgical and medical services away from smaller hospitals and communities by making it uneconomical for specialists to make a go of it in smaller cities and counties: Lenoir County once had three ophthalmologists including a pediatric ophthalmologist, but now is down to one surgeon. When this ophthalmologist retires, there will be no replacements. Sampson County has lost its only ophthalmologist and will never see another. Wilson County once had a thriving practice with four ophthalmologists and now has only two. Pitt County, an epicenter of medical care in eastern North Carolina, has lost it’s only pediatric ophthalmologist and it’s only neuro-ophthalmologist and will never be able to attract replacements. Green, Duplin and Johnston Counties have large enough populations to support an ophthalmologist, but will never see one if current CON laws remain in place.

      By allowing CON laws to persists, we are, as a society, tacitly approving of a healthcare system which is driving specialty care away from smaller hospitals and communities and, in my opinion, is exacerbating the access to specialty care by patients in those communities. It bears noting that as these patterns of referral to larger centers develop, fewer and fewer of these services are being performed at smaller hospitals. Just ask the hospital administrator at Lenoir Memorial Hospital how many cataract surgeries they perform each month in 2016 as opposed to ten years earlier.

      I’m not theorizing about how rural hospitals will go bankrupt if CON laws are repealed or how emergency rooms in said counties might not be able to survive financially, I’m giving you factual, practical examples of how CON laws are harming patients and hospitals in smaller communities.

  • Many other states have much less regulation than NC. We are the third most restrictive state in the US. They still have thriving hospitals and great access. The chicken little defense is baseless. Our hospitals will not even share their financials or how they charge and run day to day business. This is a substantial obstacle when assessing whether they are in the red or black. it is hard to have real conversations about finances when no finances are shared. In my town the local hospital drug the ACO over the coals for over a year fighting their right to a CON saying there was not a need. Now 10 years later, it is hard to get an appointment at either facility. Hundreds of thousands of dollars were spent and a lot of lawyers have pools and for what? Keep in mind that hospitals do not pay ANY state, federal, property or sales taxes. This is a sizable gift when running a business. Physician run ASCs would have to pay all taxes and keep sufficient volume to function. Sink or swim. It is ludicrous to think that a physician group would succeed in a rural area where a non profit hospital failed. I live in rural eastern NC. This is not Raleigh or Charlotte. I know rural.

  • Valerie Jewells

    I am in opposition to removal of CON laws. Not only can their removal result in substandard care, but can also in the case of imaging result in complete loss of patient access. CT’s and MRI’s 24/7 are necessary for care of stroke and trauma patients in particular as is the ready access of a hospital in every county/region of the state. Removal of the CON will allow the formation of imaging centers/addition of high ticket imaging to offices run by businessmen as well as physicians that will compete directly with hospitals and will do so by only imaging patients will private insurance. The siphoning off of paying patients will change the balance of the budget in many hospitals who are dependent upon the revenue from the technical component of imaging to keep their doors open. To the best of my knowledge, there are currently 12 hospitals across the state of NC operating in the red, some of which are not small institutions and many of which may be the only hospital in their county. If these hospitals close their doors there will certainly not be improvement to access or quality of care in NC. Thank you!

    • Terry Forrest

      The “removal of CON laws” would not lead to substandard hospital care. The quality of care provided to patients in North Carolina hospitals, ASCs and private offices is, and will remain, excellent.

  • Edwin C. Bartine, DO, DMD

    I am an anesthesiologist who has undergone training in military/public/private venues and had the opportunity to practice in the military, at locums’ sites, including oral surgeons’ and plastic surgeons’ offices and a Federal Correctional Institute, and in private practice at a 400 bed community hospital.
    The first element so few want to address because it comes too close to individual proceduralists’/hospital administrators’ sensitivities is money. Under present Federal reimbursement rules, the hospitals are experiencing a ‘need’ to do more in their ORs/procedure rooms besides cases reimbursed under Medicaid/Medicare in order to maintain a viable business model. In fact as others have noted, without the retention of cases reimbursable not only by Medicaid/Medicare but also by private insurance carriers, smaller or rural facilities stand an increasing risk of closing, thereby leaving behind unserved populations. Realizing this, some smaller institutions have attempted to embark on larger revenue generating/complex procedures without sufficient volume to support the requisite establishment of/ongoing maintenance of skill level needed to safely do these cases. The unfortunate upshot has been a greater rate of complications in these institutions.
    Also, in order to secure greater control of staff practitioner work flow, some larger hospital organizations have bought up/started ‘private’ practices or tilted towards closing their medical staffs so as to encourage proceduralists to do their work in house and ‘incidentally’ generate a facility fee for the institution. This is anathema to those who seek to more control of their practices/patient pool and wish to compete with others in the same specialty without their patients receiving a facility fee charge, levied by hospitals but undesired by patients and private insurers.
    The second element is patient safety. All of us pay considerable lip service to the mantra of patient safety, but it must be acknowledged how long it took for practices like time outs, surgical site initializing, proper timing of antibiotic dosing, and the necessity for careful patient warming to become commonplace rules. And these measures were not the result of a spontaneous movement arrived at by the majority of OR personnel simultaneously having an ‘AHA’ moment and throwing off the shackles of ignorance and lesser standards. These safety measures are/were, in fact, enforced by such unloved entities as the JCAHO/The Joint Commission/CMMS until they become/became the standard standard of care/practice.
    So, how does this all come together? Money and its ‘driver,’ the efficient use of time, are powerful incentives for all stakeholders in the complex endeavor of patient care. The government has a vested interest in the public’s welfare as guardian of its safety and payor in chief for its health care. The issue of whether American medicine will continue its path in a business model of increased verticalization that claims inherent cost savings through less redundancy and economies of scale or towards one where the adherents of private practice can substantiate their claims of efficiency and cost reduction through no payment for unperformed/’irrelevant’ services is as yet unsettled. But safety is or should be the prime requisite for all concerned. If the absence of CONs does not worsen the hard won decrease in surgical/procedural complications, then a case may be made for their elimination. But, if as many surmise, private practices and hospital organizations need to be held accountable via unannounced examinations by effective truly independent authority in order for the performance of best practice to stay commonplace, then we need fewer, not more, opportunities for potential shortfalls to occur.

    • Terry Forrest

      Hospitals and health service entities in the smaller counties and health care markets continue their march toward monopolization of procedural services. This will likely starve independent practitioners and eventually prevent new independent partitioners from moving into smaller communities and setting up practice. What ophthalmologist with an IQ above room temperature would choose to start his/her career in a smaller city or community in North Carolina where they will be prevented from performing in office cataract surgery under topical anesthesia when they could set up shop in almost any other state without the shackles of CON?
      Technology has dramatically changed the services that we offer our patients, but the antiquated health care laws of North Carolina force our patients to wear the CON burqa and forbids them from obtaining 21st century care in the office of their ophthalmologists. The freedom of market choice and the power of a healthcare free market have been stolen from our patients by the North Carolina legislature.
      Many whom oppose CON reform hide behind the curtain of “safety and quality of care concern”. This is a smoke screen, a misdirection aimed at diverting the public’s attention from the issue of real healthcare reform and the possibility of a healthcare market that would be forced to bend to the will of the consumer. My response to questions of quality and safety would be that there should be no reason why one would expect the safety and quality of hospital based care to be inferior to the care that would be obtained in a physician’s office.
      There is no denying that a modern blood-less, suture-less, needle-less, patch-less cataract surgery is far less invasive and is safer than a dental extraction. Dental extractions and other commonly performed dental procedures frequently involve injections of local anesthetic agents and, at times, inhalational gases. They involve blood loss and morbidity associated with oral bacteria, yet thousands of these procedures are performed daily in private offices in the state of North Carolina. Even with the occasional misadventure, one does not hear an outcry to drive these and other more invasive procedures to hospital surgery centers.
      As to the issue of hospital subsidization, this is an issue of concern which requires broad-based societal discussion and solution. Our current system of shifting the cost of uninsured/underinsured hospital patients to medicare patients, most of whom live on fixed incomes, is grossly unfair. In addition, younger, better insured patients are driving outside of their small community hospitals and counties to obtain their services at ASCs and other more efficient centers, further exacerbating the financial straights of their local hospitals and providers.

  • Those who don’t want change have the luxury of speaking softly.

  • Chalres Burke

    I oppose the repeal of the CON law. Thoughtful reforms may be appropriate but only after careful study. This is a very divisive issue; I would like to believe that the NCMS will represent all NC’s physicians, not just factions who speak the loudest.

  • CON reform is long overdue. All the surgeons at Orthocarolina will continue to push for CON reform.

  • Christopher Duggins MD

    CON reform must include measures to maintain the financial stability of North Carolina’s hospitals. The complete abolition of CON laws would result in a two-tier surgical system where insured patients are cared for in specialty hospitals/ASCs and the uninsured patients in the tertiary medical centers. Community hospitals would be forced to close.

  • John Ebert

    I agree with others that the time has come to revise the CON laws/regulations in North Carolina. I support system reforms that ensure that CON laws are applied fairly while protecting the overall CON laws that provide financial stability to our community hospitals. It would be great if we could live in an unregulated, free-market environment, but this is utterly impossible with our present system of medical reimbursement. Elimination of thoughtful CON laws would result in chaos.

  • Dayton Kirk

    CON laws need to be completely abolished by our legislature. “Fair” application of a complex grossly expensive process by politicians will simply not happen, never has and never will. If hospitals are being unfairly compensated because of Federal law requiring them to treat “all comers” then the US Treasury (read taxpayer) needs to compensate them properly for work done. And any illegal persons treated must have their governments reimburse the US Treasury or any aid to those countries reduced by that cost.

  • There is no trend toward private ASC ownership in our state. The SHCC has to actually grant a CON for that to happen. One of the few ophthalmic centers was started many years ago though and is functioning alongside the hospital-it is in Hickory..

  • Jeffrey Coston

    I am in favor of CON reform with reservation and a caution. Certain smaller hospitals would probably be hurt because in my experience some physicians (read shareholders) who currently use ASCs/GI labs take the majority of paying patients there and leave M-care/caid and self pay patients for the hospitals. If the massive hospital systems are allowed to continue buying primary care practices CONs or the lack thereof won’t really matter much. The employed PCP will have to join “independent” ACOs and CINs which will refer to the system’s ASC/GI/radiology/chemo centers and use their contracted physicians. That is what is happening in my geographical area. Soon, there will be few to no independent PCPs and therefore no competition.

  • Kent Robertson, MD

    I a a retired Anesthesiologist in Hickory, NC. My biggest concern is that, as less complex cases are moved from hospitals to outpatient centers, a large portion of hospital income is diverted to other venues. Our hospitals are struggling to meet the requirements to care for patients who are uninsured and under insured. They make up this shortfall by volume in areas with a bettor payor mix. I suspect that if the trend toward non-hospital-owned ASCs continues or accelerates, many more community hospitals will close their doors.
    This is just another example of how government-mandated healthcare has negative repercussions.

    • Terry Forrest

      The financial viability of hospitals required to provide care to all who present to their ERs is an issue that will not go away. There is a need for a broad based societal discussion regarding the most equitable means for subsidizing needed, but failing institutions in our state, particularly those in smaller, more rural counties. It is an unfortunate fact that the current CON regime forces surgeons and patients to use less efficient, more costly, CON-mandated hospital based facilities, thereby subsidizing the money-losing, but essential, care that is mandated by state and federal laws. Sadly, most of the patients being forced to obtain their care at hospital based facilities are also those least able to afford the inflated costs associated with hospital based surgery centers, i.e., the elderly, most of whom live on fixed incomes and many of whom have insufficient, or no, co-insurance. A more equitable solution would, perhaps, involve a state or county wide gas tax or similar tax to spread this burden to all tax payers. Continuing our with our current CON regime only serves to accelerate the cost of healthcare and prop up cumbersome, bureaucratic and inefficient hospital based care. As citizens, we can’t have it both ways. We either demand lower cost, more efficient health care or we agree that we allow the market to drive costs down. We should, at the same time, discuss, investigate and implement more equitable means for subsidizing failing, but essential institutions.

  • Brad Huggins, MD

    Agree with all of the above-CON laws cause increased cost and decreased access by limiting efficiencies of operation. If you have to have a law to protect a program (hospital owned/operated facility services only), then that program must not be competitive in the free, open market!
    CON laws are long overdue for repeal.

  • Terry Forrest

    The current CON regime goes beyond harming patients financially. It increases the complexity of care by driving minor procedures and surgeries that could (and should) be performed in lower cost, local, and more accessible sites. Rather than having a minor procedure at an office or surgery suite in their local communities, patients and their families are forced to drive increasingly longer distances to “centers of excellence” in order to obtain their care. This “vertical integration” of care has wide reaching consequences which extend well beyond the customarily inflated costs. More and more, physicians and surgeons in smaller communities are being driven out of autonomous practice in order to continue to offer their services, services that the state of North Carolina forbids them to offer their patients in their offices. The current CON regime makes it almost impossible for a newly-trained surgeon to begin their own practice independent of a “larger”, aka, controlling entity. Recruiting new surgeons into smaller cities and communities in North Carolina has become all but impossible. In my specialty, ophthalmology, in the eastern half of the state, we have had a significant decline in the number of surgeons practicing in the smaller cities of North Carolina. Repealing our states CON restrictions would not only make it easier for new surgeons to start practices in underserved areas, but would allow physicians and surgeons in smaller communities to reconcile the significant investments in the new technologies and machinery necessary to perform routine and minor procedures in smaller communities and cities. In other words, we, the people of North Carolina, should drive care into local communities. This would lower costs and increase access to those who need medical services most. If it were always better to have procedures in larger specialty centers and hospital ORs, then why not begin sending all “minor” dental procedures, all D&Cs, and all dermatological excisions and treatments to hospitals? Surely the outcomes would be better? This is, of course, a rhetorical argument and is absurd, but it serves to illustrate how the current CON regime maintains and increases the inefficiencies in the delivery of care to patients. Over the past two decades there has been immense progress in the performance of minor surgical services and amazing technological advances that improve the delivery of care. Unfortunately, the current CON regime is acting like a dam, preventing the downstream flow of improved surgical services to patients in their doctor’s offices in their communities.

  • Current CON laws significantly hamper healthcare access and increase costs in eastern NC. Our Urology group in Greenville does not have the OR time or equipment needed to treat all the Urological disease in our region. This problem could be ameliorated by changing CON law. We can manage surgicenters and lithotripters better and more efficiently than hospitals and mega corporations.

  • In response to one of the above posts the gentleman referred to physician owned ASCs as substandard care on naive patients for profit. This is what we currently have. I have to spoon feed the surgical staff at our hospital ASC. If patients new how little each staff member knew about my specialty, they’d be shocked and this is the same in every multi specialty center I’ve ever been in to the point that I have to hire my own employees paid out of my surgeon fee to help out. Patients are naive to this and the inflated costs thinking this is the way the rest of the country does it. And finally with hospital charges being between two to three times that of privately owned ASCs, and lobbyists all over Raleigh to protect this profit, their not for profit classification is laughable.

  • Dan Murrey

    CON reform is long overdue in North Carolina. It stifles competition and innovation, and it is directly responsible for higher costs and less choice for our patients.

  • Tom Fehring

    CON has been abandoned by many progressive states who recognize that the triple aim is not well served when the competitive forces that affect cost containment are legislatively prevented -many states have found that quality healthcare can be delivered in a convenient fashion at a lower cost without CON -it’s time for North Carolina to abandon this policy as well

  • Thomas H. Phillips, MD

    Time has come to have CON reform in NC.

  • John Meade

    CON reform is long overdue. Lower costs and high quality surgical care for a large portion of the population will be enhanced by opening up opportunity for competition that the existing law certainly restricts.

  • Mike Nichols

    This is a complex issue with solid arguments before and against reform. What must be considered is opening the door for substandard care being delivered to unsuspecting and naive patients in the name of profit. Please keep an open mind in regard to the complexity of this issue. There may be some specialties where reform is needed and others where it is not.

    • Terry Forrest

      Substandard care/ Quality of care… those are entirely unrelated to the CON issue. To argue that they are related is to throw a smoke screen around the CON debate, the issues of lower cost and easier access to surgical/procedural services by the public. Substandard care should never be tolerated and there are strict standards that are and should continue to be enforced by state and federal agencies, but, again, this is an entirely separate issue.

  • Virgil Willard, MD

    I wholeheartedly agree with the above. It is well passed time the CON laws are amended/deleted

  • Rodney Stanley

    As others above have stated, it is nice to see the NCMS is looking into CON reform. Change of current rules will benefit all North Carolina patients.

  • James Alexander

    Agree. Its is definitely time for CON reform in North Carolina.

  • James R. Gavigan, M.D.

    I’m retired now, but still frustrated and angry that our Urology group was never able to perform many procedures in-office because of the resistance by the hospital lobby. They could have been done just as safely as at the Surgi-Center, and at about 1/4-1/2 the cost.

  • Robert Erdin

    CON laws are from a by-gone era. CON reform will help provide more efficient and more cost-effective care to the patients (citizens) of NC. Thanks to the NCMS for taking a leadership role in bringing about this change!

  • Scott Biggerstaff

    I am in support of all of the comments. It is time for CON reform in NC. It is time for us to be able to provide a lower cost option to our patients while providing high quality care.

  • Douglas Sheets

    I agree that the time has come to eliminate CON, for the reasons stated above.

  • Brian DeLay

    Aa an orthopaedic surgeon performing mostly outpatient surgeries, there is no doubt in my mind that the cost of medicine and the quality of care would be improved if the CON reform occurred. Thanks for considering the issue. I truly hope you will support reform.

  • Van Sikes

    NC needs to move forward woth CON reform

  • Bobby Morgan

    As an orthopeadic surgeon, I am appreciative of NCMS actions for COM reform in our state. CON reform would be extremely beneficial to our patients.

  • Mark McGinnis

    One consequence or ramification of CON laws is that hospital controlled outpatient surgery centers charge the same fees as inpatient surgery for time in the OR. Based on itemized patient bills I have seen, this results in charges of approximately $100/minute in the OR (in 15 minute increments). The charges for the time utilization in the OR are the same whether a patient is having a minor procedure or open heart surgery. This doesn’t seem to pass a common sense test.

  • CON reform is needed in our state. I am glad to see that NCMS is taking a serious look at how reform would benefit the patients in North Carolina.



  • Leo Spector

    I agree with the above comments. CON reform is long overdue in NC.

  • Daniel Gordon

    CON laws stifle competition particularly in radiology where they drive costs higher by pushing referrals for expensive tests out of the outpatient arena and towards hospitals. By eliminating or reforming CON individual practices compete in a fair market adding value

  • The 170 physicians of OrthoCarolina are firmly committed to CON Reform. We applaud the actions of the NCMS in taking positive actions to help accomplish this which we believe will benefit all the citizens of NC and help achieve the Triple Aim.

  • CON laws help a very small portion of our healthcare system (massive hospitals). They hurt every other aspect. CON laws must be dismantled to move toward a physician led healthcare system. Nearly all members of our legislature would not let this kind of regulation occur in their own professions, yet they assume it works in medicine. History will show that this policy was a dark time in medicine.

  • john fagg

    Agree the time has come