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SHP, Folwell offer additional sign-up period for hospitals, providers on reimbursement contracts

The State Health Plan and state Treasurer Dale Folwell have re-opened the sign-up period for the controversial Clear Pricing Project, though it was unclear Monday whether any more hospitals will join.

The new enrollment period starts Friday and ends Aug. 5, marking the second time Folwell has extended the sign-up period.

Hospitals and medical providers that do not sign the contract could be out-of-network for more than 727,000 SHP participants starting Jan. 1.

Right now, that would include the three main Triad hospital systems — Cone Health, Novant Health Inc. and Wake Forest Baptist Medical Center — and all but four of the 126 hospitals in the state.

Cynthia Charles, communications and public relations director for the NCHA, said that decisions "about whether or not to opt-in to the treasurer’s new offer remain up to individual hospitals and health systems."

"At this time, it is unclear whether this new proposal will result in any movement. We are not surprised by the treasurer’s announcement. He had to address the network inadequacy issue."

Cone said July 1 it was rejecting the contract. Novant said it continues to review the contract and Wake Forest Baptist said it will not discuss its plans.

A Cone Health official, on his own accord, blasted the state lawmakers, SHP and Folwell for its reimbursement cuts.

“Your plan to cut payments to hospitals could possibly be the most moronic idea I have ever seen come out of our state government,” Frank Kauder, Cone’s assistant finance director, said in his blunt critique that closed by urging the recipients to “burn in hell you sorry (SOBs).”

Employers and health insurers negotiate rates that provide in-network discounts to individuals covered by an employer-based plan.

Without the negotiated discount, out-of-network costs can be significantly higher for most medical procedures.

The Republican-controlled state legislature has given the treasurer the authority to decide on reimbursement cuts to hospitals and providers as part of a mandate to reduce overall SHP expenses.

“The decision to readjust rates comes after many meetings and discussions with hospital officials and others,” Folwell said. “We realize that our members need to have additional hospitals for the plan to have coverage.”

As an enticement during the latest sign-up period, the SHP and Folwell have agreed to raise reimbursement payments again.

The new proposal increases payments to about 61,000 medical providers from 182% to 196% of Medicare rates on average. Urban hospitals will see their combined inpatient/outpatient ratios go from 178% to 200% of Medicare on average.

SHP participants’ decision-making process begins in early fall when they chose which providers they want for 2020 coverage.

There have been more than 27,000 medical providers to sign the contract through Monday, according to the treasurer’s office.

The SHP said hospitals statewide will receive an additional combined $116 million over the rate proposal announced in March. State taxpayers are projected to save $166 million under the latest proposal and SHP members save $34 million in reduced costs.

By comparison, Folwell’s initial proposal in October aimed to save SHP members up to $60 million initially and $300 million overall.

The plan is North Carolina’s largest purchaser of medical and pharmaceutical services at $3.2 billion in 2017.

Folwell said the SHP will provide increased reimbursement payments to most independent primary-care physicians, behavioral-health specialists and many rural hospitals.

“We believe what we’re offering is extremely fair,” Folwell said.

Folwell said he and the SHP have not received a firm counter-proposal from the N.C. Healthcare Association.

UNC Health Care has ramped up its lobbying with legislative leaders from both parties and Democratic Gov. Roy Cooper to get Folwell and the SHP to delay, if not halt, the contract roll out. Cooper’s office said it is reviewing the UNC Health Care proposal.

House Bill 184, which would halt Folwell’s initiative for at least a year in favor of a legislative study report, cleared the state House by a 75-36 vote April 3.

It has yet to be acted upon in the Senate since being sent to the Rules and Operations committee April 4. Senate leader Phil Berger, R-Rockingham, has signaled he has no desire to address HB184.

Cone and the NCHA have said Folwell “has turned a deaf ear on our repeated pleas to work collaboratively to switch state employees to a plan where clear and sustained cost savings are achieved, not simply a reduction in prices.”

“We urge state employees to voice their objection to the Clear Pricing Project’s lack of hospital coverage by contacting their lawmakers,” Cone said.

Folwell said that “there are those on one side of this issue who support secret contracts and higher health costs. There are those on the other side who support open contracts and lower health costs.

“I believe it’s telling that the side supporting open contracts has made compromises and the side that doesn’t support them hasn’t.”

Folwell said his compromise also includes asking the SHP’s board of trustees to create an advisory committee of health care professionals and others to recommend plan changes, including the consideration of alternative payment models, such as bundling, alternative care organizations and other alternative payment arrangements.

“We’ve had hundreds of conversations with hospitals and other medical providers,” said Dee Jones, the SHP’s executive administrator

“We are absolutely committed to looking at all options that will maintain price transparency, reduce costs and improve outcomes for our members.”

Charles said that while the NCHA is "encouraged that the treasurer is thinking of developing an advisory board," the group believes the legislation with HB184 is a better approach to reaching a compromise "that supports the health and well-being of its members, ensures choice, supports local providers and saves money."

Surgery like ‘dismantling an atomic bomb’

First it was an eye spasm. Then Andrea Herath felt the spasms in her shoulder and, eventually, they would trickle down her arm like a slow poison.

Each new symptom, a result of an inoperable blood-vessel abnormality in her brain, drew her threateningly closer to permanent paralysis.

But 18 years after the ordeal began, a meeting with a Winston-Salem neurosurgeon gave her new hope — a chance at surgery the doctor likened to “dismantling an atomic bomb.”

“I woke up from surgery, paralyzed on the left side. I felt numb. I couldn’t move,” said Herath, a Mount Airy native. “I didn’t realize how difficult it was going to be until it happened.”

Doctors had warned Herath, 44, about temporary paralysis after her January surgery, and, fortunately, it slowly subsided in the days that followed as she began to recover.

More importantly, the abnormality was removed, the spasms were gone and the slow-motion slide into a lifetime of paralysis was over.

“I had the belief that ‘I can make it through this.’ I know that I have a strong resolve to just make it through,” said Herath, who is expected to make a near- to full-recovery. “... When I decide to do something, I don’t give up.”

Overcoming challenges

The surgery marked the end of an 18-year-journey as Herath waited — and hoped — for technology to catch up with her diagnosis.

The congenital brain abnormality, known as a cavernous hemangioma, was discovered in 2001 after Herath began experiencing bouts of vertigo while driving.

Then age 26, Herath said the diagnosis — which doctors told her could lead to seizures, weakness, balance and vision problems and eventual paralysis — was devastating.

“Where it was located, it was inoperable. They couldn’t do anything,” Herath said. “In the beginning, it was very scary. I was afraid I’d just drop dead one day.”

The diagnosis came with its own set of limitations, like not being allowed to ride roller-coasters lest it cause a brain bleed.

It also robbed Herath of the motor control she needed to play the piano and dashed her childhood dreams of becoming a professional pianist and playing at Carnegie Hall.

Instead, Herath used her passion to work a mix of music-related jobs, moving to Texas and New Mexico to work a mix of live-music stage production, studio and live-music engineering, concert booking, show merchandising and event-security jobs.

“I really worked so hard in school and throughout my whole life to study piano,” said Herath, who graduated with a degree in music-industry studies from Appalachian State University. “It was tough, but I had to give it up.”

Determined to stay ahead of her worsening condition, Herath, who began playing piano at age 5, dedicated herself to the gym and daily runs to stay healthy.

In 2008, she decided to go to massage school, focusing on clinical pain management, to give her life a new purpose.

“I wanted to take the focus off myself to help other people. That way, I wouldn’t feel sorry for myself,” Herath said. “I couldn’t do anything about my brain situation.”

While in massage school, the spasms began advancing to her elbow, posing an additional challenge, but she never gave up and worked as a masseuse for several years.

‘I always believed’

As the spasms eventually progressed to affect her entire arm, they began to take away Herath’s ability to do the things she loved, like playing the piano, making jewelry, cooking and doing crafts.

Two years ago, the spasms began in her left foot and she had to stop running to stretch until it would become manageable again.

Permanent paralysis was becoming closer to a reality.

“Even though they told me there was nothing that could be done except wait and try different medications that never worked, I always kept in mind I’d meet the right (doctor),” said Herath, who saw doctors across the country throughout the years. “I always believed.”

When she met with Novant doctors last November, her optimism proved to be well-founded.

Dr. Rashid Janjua, a neurosurgeon at Novant Health Brain and Spine Surgery in Winston-Salem, said the surgery would be like taking out a pea embedded in Jell-O without leaving much of a trace, but they were confident they could successfully operate.

Meeting Janjua was designed by God, said Herath, whose faith has buoyed her in the hard times.

The day before her six-hour craniotomy, she was a bundle of nerves and visited the Greensboro Science Center with her husband of nearly four years, Mahesha, in anxious anticipation.

But as they rolled her into the operating room Jan. 8, 2019, she said a feeling of calmness and warmth blanketed over her and she knew everything was going to be OK.

“I had to get it done. I would’ve eventually been paralyzed with no hope for recovery without surgery” said Herath, who moved to Charlotte two months ago. “... I finally met the one doctor who could do it. He’s my rock star.”

Following surgery, Herath spent several months in a wheelchair and then used a cane as she worked on getting her strength and balance back.

Recently, Herath walked a mile without assistance.

While her grip is still improving, making it hard to hold a water bottle without dropping it, Herath hopes to get back to playing the piano soon after her two-decade hiatus.

“If I knew how hard this was going to be, I might’ve run in the other direction,” Herath said. “I’ve learned not to give up. I’m very strong and I can survive.”

137 local jobs at stake as IFB Solutions faces loss of federal contract

A major workforce reduction is bearing down on IFB Solutions Inc.’s Winston-Salem operations following two recent legal setbacks.

At stake is the expiration of three U.S. Department of Veterans Affairs contracts involving its optical laboratories.

Those contracts affect 137 of 556 local jobs, including 76 employees who are blind and 15 who are veterans. IFB is the largest employer of the blind in the United States. It has about 1,000 employees overall.

There’s also $15.4 million in annual revenue for the nonprofit group formerly known as Winston-Salem Industries for the Blind Inc. That represents nearly 20% of IFB’s total revenue.

IFB has been providing prescription eyewear products to the VA since the late 1990s.

The group has been attempting for nearly three years to preserve its optical laboratories as a mandatory source for eyeglass manufacturing for the VA.

“The VA is about 97% of the production we have with our optical portfolio,” said Dan Kelly, IFB’s chief operating officer, who is blind.

Legal rulings in federal appellate court in November and May were in favor of a disabled veteran-owned optical business, PDS Consultants of Sparta, N.J., that has provided visual products to the VA since 1998.

The rulings represented a defeat for the AbilityOne program that has provided federal government contracts for groups that employ the blind or severely disabled.

IFB officials were told by the VA that the first contract would end June 30.

However, that end date was extended to July 31. If the contract is not reviewed, IFB said it would have to eliminate 47 jobs.

The other optical contracts would end Sept. 30 and Oct. 31, respectively. The remaining members of the lab’s work force, or 90 jobs, would be cut if the extensions are not granted.

“We do not believe that Congress ever intended to benefit veteran-owned small businesses at the expense of people who are blind or severely disabled,” Kelly said.

“There is plenty of business for both veteran-owned small businesses and AbilityOne nonprofits, many of whom, like IFB Solutions, also employ a significant number of veterans.”

Lobbying Congress

IFB officials are lobbying Congress, including members of the North Carolina delegation, to persuade the VA to delay, if not halt, the end of the contracts.

David Horton, IFB’s chief executive, and IFB optical lab employee Scott Smith will join other AbilityOne nonprofits in speaking Wednesday and Thursday with members of Congress, including Reps. Virginia Foxx and Mark Walker and Sen. Thom Tillis from North Carolina.

If that doesn’t work, IFB plans to file a petition by Aug. 8 to the U.S. Supreme Court to hear its appeal.

A decision could come in November on whether the Supreme Court accepts the appeal. If it does, it likely could take 18 to 24 months for a decision.

Foxx said in a statement Friday that "while visiting the Industries for the Blind Solutions facility in Winston-Salem, I’ve seen the great output and incredible impact that this business has on the livelihoods of differently abled individuals in the community."

"It is very unfortunate to see that two procurement programs that Congress intended to be complementary have been interpreted by courts as competing against each other, especially when the jobs of veterans and others who have been using the AbilityOne program for 80 years are at stake.

"While the courts have limited Secretary Wilkie’s influence over the issue, I’m keeping open channels of communication with industry stakeholders and the VA to find a fix," Foxx said. "The procurement process shouldn’t be a zero-sum game for beneficiaries of the AbilityOne program and the Veterans First Contracting program."

The office of Sen. Thom Tillis, R-N.C., said last week that his chief of staff met with the IFB Solutions contingent.

The senator "is concerned that recent court rulings could lead to the unintended consequence of blind or severely disabled North Carolinians losing their jobs," according to a statement from Tillis' office.

"For decades, both the general disabled community and the disabled veterans’ community have existed in a harmonious balance when it came to securing jobs and competitive contracts with the federal government.

"Senator Tillis is committed to working with his colleagues to address this problem and return these two programs to mutual coexistence," according to the statement.

Legal background

For decades, IFB’s VA contracts have come through the AbilityOne program.

AbilityOne goes back to legislation Congress approved in 1938 that gives federal government preference to companies that employ the blind or severely disabled.

The legal case, which began in August 2016 involves “the relationship between two statutory regimes designed to benefit two historically disadvantaged groups: veterans and disabled persons,” the court said in its ruling.

The Veterans Benefits Act of 2006, also known as Veterans First legislation, is one of the ways Congress recognizes and repays disabled veterans for their military service.

PDS’ legal claim has been that businesses owned by disabled veterans should have priority over those from AbilityOne, based on a U.S. Supreme Court interpretation of the act.

The act’s language includes what is known as “a ‘rule of two’ analysis.”

The act requires attempting to procure the eyeglasses involved in the VA contract from at least two businesses owned by disabled veterans before attempting to buy them “from any other source, including a nonprofit agency for the blind or significantly disabled,” according to the appellate court panel’s decision.

The three-judge appellate court panel ruled in November that “the VA is required to use the rule of two even when goods and services are on the (procurement) list.” In May, the full appellate court upheld the panel’s ruling.

Where to turn?

A bipartisan letter clarifying the intent with the contracts in support of AbilityOne was signed recently by 34 members of Congress, including Foxx and Walker, and delivered to VA Secretary Robert Wilkie.

“AbilityOne nonprofits, like IFB Solutions, provide employment for more than 45,000 people who are blind or severely disabled,” Kelly said.

“If we aren’t vigilant in protecting the jobs as intended by Congress when it created the AbilityOne program, those individuals may have nowhere to turn.”

Kelly said it would take a significant retraining initiative for the affected optical lab employees who are blind ... if there are job openings in other local production segments that include apparel, mattresses and office and janitorial assembly and packaging.

Kelly said “what’s at stake are the nearly 1,800 jobs for people who are blind or with severe disabilities, including many veterans, generated by the $81.9 million in VA contracts with AbilityOne nonprofits,” Kelly said.

“Individuals who, without jobs through the AbilityOne Program, face a devastating 70% unemployment rate,” he said. “The harm of losing their jobs would be severe and irreparable.”

Kelly said that by comparison, the VA provides about $5.4 billion annually in contracts to veteran-owned small businesses.

“We are hard-pressed to understand the motivation behind cutting out AbilityOne nonprofits from our very small share of the overall contracting pie,” he said.

Winston-Salem man says his attorneys misrepresented plea deal on two murders.

A Winston-Salem man told a Forsyth County judge Monday that the only reason he pleaded guilty to fatally shooting two men was because his attorneys convinced him that if he took a plea deal, he would be guaranteed a sentence of 13 years to 16 years in prison.

Franklin Bowden Jr., 30, said he took the deal but got a much longer sentence — 36 years and 10 months to 47 years and four months in prison.

“I trusted that number,” Bowden said in court on Monday.

Bowden was 15 when he was arrested for the fatal shootings of Gerardo Santiago-Arias and Michael Monte Jordan in two separate incidents two weeks apart in 2004. He was 17 when he pleaded guilty to two counts of second-degree murder on May 8, 2006. At the time, the case was headed toward trial and he was facing two counts of first-degree murder. If he had been convicted of first-degree murder, he would have been sentenced to life in prison without the possibility of parole.

Bowden, dressed in a dark jumpsuit, was in Forsyth Superior Court Monday for a hearing on his motion for appropriate relief. Bowden is seeking to overturn his murder convictions based on allegations that his two trial attorneys, Lisa Costner and Jerry Jordan, provided ineffective assistance of counsel.

Judge David Hall of Forsyth Superior Court presided over an evidentiary hearing on Jan. 26, 2018, where Jordan took the stand and denied the allegations. Hall continued the January hearing and ordered Bowden’s attorney, Don D. Carter, to file an amended motion for appropriate relief. Carter filed the amended motion in June 2018. Hall presided over the hearing Monday on the amended motion.

Costner also testified Monday. She denied the allegations that she provided poor legal representation but also said she doesn’t remember much about a case that she worked on more than 10 years ago. She said most of her records for that case have long since been destroyed.

In his motion, Carter argued that Jordan and Costner spent a total of 2.6 hours visiting Bowden at the Forsyth County Jail over a two-year period. Carter also alleges that Costner and Jordan never obtained school records that would have shown Bowden could neither read nor write.

Carter also said that the two attorneys misrepresented a plea deal to Bowden that made Bowden think he would get far less prison time than he wound up receiving.

During the hearing Monday, Carter hammered on a couple of points, including the amount of time Costner spent visiting Bowden in jail and the fact that Costner did not pursue a claim of self-defense in Bowden’s case.

Carter went over several witness statements that she would have had access to as Bowden’s attorney. He said at least one of the witnesses told police that before the shooting, Jordan was attempting to pull out a gun.

“You’re asking me to recall documents I haven’t seen in 15 years, and I’m not in a position to do that,” Costner said.

Instead of filing a notice for self-defense, she filed a notice of an alibi defense, meaning Bowden would be arguing to a jury that he could not have killed the two men because he was not at the crime scene.

If Bowden had provided her with information for self-defense, she would have pursued it, she said. But she said remembers receiving information for an alibi defense. Carter argued that prosecutors provided her no evidence for an alibi defense but did provide evidence for a self-defense claim.

Costner said even if there was evidence of a self-defense claim, she wouldn’t have pursued it unless it came from Bowden. She would need her client’s cooperation in order to pursue a self-defense claim, she said.

Bowden said his attorneys took advantage of him. Up until the day he pleaded guilty, he wanted to go to trial and Costner and Jordan knew that, he said in court.

Assistant District Attorney Jonathan Friel pointed out that he indicated on the plea transcript that he was pleased with the legal services of his attorneys. Bowden said the only reason he said that was because he believed he was going to get 13 years to 16 years in prison.

Friel also pointed out that Bowden apologized to the families of both victims in the case during the sentencing hearing. Friel asked him several times whether he would tell the truth about what happened in 2004. Several times, Bowden invoked his Fifth Amendment right against self-incrimination.

Hall didn’t make a decision after the hearing Monday. He said he would take the issue under advisement but hoped to have a decision within two weeks. He also told the attorneys to come back this morning with oral arguments in the matter.

NC Department of Corrections