A proposal that would put flesh on a hybrid state Medicaid reform initiative received support Tuesday from health-care providers and the legislative architect of the effort.
The joint venture — known as Carolina Complete Health — has been formed by nonprofits N.C. Medical Society and the N.C. Community Health Center Association with Fortune 500 company Centene Corp.
The goal is creating and operating a physician-led health plan that provides Medicaid managed care services in the state.
“A key feature of the joint venture will be the active participation of physicians in the ownership and governance of the health plan,” the groups said in a statement.
State GOP leaders have long believed that the state Medicaid program needs reform.
A hybrid reform compromise reached in September 2015 culminates their pursuit of coordinating physical, behavioral, dental, pharmacy and long-term-health services. There have been projections by state health officials of $400 million in savings in the first five years of implementation.
Altering the program requires a waiver from certain federal requirements. A waiver request was submitted June 1 to the federal Centers for Medicare and Medicaid Services by the McCrory administration.
The request started a three- to five-year process with an end goal of Medicaid oversight being placed in the hands of three statewide managed-care organizations, likely pre-paid health plans from commercial insurers and up to 12 provider-led entities, likely to involve not-for-profit health-care systems.
However, the request has not been acted upon by CMS officials, primarily because the agency chose to wait on the next presidential administration to be in place.
“This is exactly the kind of innovative approach we envisioned when we started down the path to reform Medicaid and transform health care in North Carolina,” Rep. Donny Lambeth, R-Forsyth, said. Lambeth was the chief author the House hybrid reform model.
“Moving toward population health management will improve outcomes and patients will be more satisfied and have more access to the right levels of care,” Lambeth said.
The waiver request is the same one that Gov. Roy Cooper is attempting to amend with CMS officials to include an expansion of the state Medicaid program that could cover an additional 500,000 North Carolinians. The program already covers 1.9 million individuals and a $14 billion-a-year program.
The organizers of Carolina Complete Health said that while Centene will manage the financial and daily operations, the health network will be owned jointly by the medical society, physicians, physician assistants, nurse practitioners and federally qualified health centers.
“With the changes taking place in our health care system at the state level with Medicaid reform and new programs at the national level, the medical society remains committed to ensuring that physicians are the ones making the clinical decisions in the best interest of their patients,” Robert Seligson, the medical society’s chief executive, said in a statement.
Michael Neidorff, Centene’s top executive, said the group has had success — signified by “better health outcomes for members at a lower cost to the state” — in similar joint ventures.
As President-elect Donald Trump sets his national health policy, his nominee for secretary of health and human services, Tom Price, may hold the key not only to whether the waiver is approved, but also to whether it will be substantially altered in a for-profit direction.
Lambeth said “linking in the federally qualified health centers is an essential part of the success going forward since many of our Medicaid patients are cared for at these sites.”
The N.C. Hospital Association has been attempting to organize a similar hybrid strategy with several of the state’s largest not-for-profit health-care systems. “A strong Medicaid program will benefit everyone in our state,” the group said.
Mark Hall, a law professor at Wake Forest University who is a national expert on health care, said Carolina Complete Health “potentially offers an innovative combination of capabilities.”
“It is encouraging to see something that is not just a standard managed care organization enter the market.”