Greg Griggs, North Carolina AFP, presented on Investment in Primary Care at the State Legislative Conference on November 7, 2015.

1. Investing in Primary Care:
One State’s Story –
The Good, The Bad & The Ugly
November 3, 2015
Gregory K. Griggs, MPA, CAE
Executive Vice President
NC Academy of Family Physicians

2. • A Strong Infrastructure for Primary Care
• NC Office of Rural Health
• Community Care of North Carolina
• ACOs in North Carolina
• Private Sector Investment in Primary Care
• Blue Quality Physician Program
• Pipeline Investments
• But, the Bad and the Ugly
• Politics Get in the Way
• Moving Forward
• Questions / Comments
Today’s Presentation

3. • History of the Office
• Created 42 years ago to develop network of Rural Health Centers
and has helped develop FQHCs as well.
• Since that time, the Office has expanded to help communities
develop innovative strategies to improve access, quality and cost-
effectiveness of health care.
• Works to develop community-based approaches to improve care.
• Research and Demonstrations have included:
• Community Care of NC (CCNC)
• CHIPRA
• Perinatal Quality Collaborative of NC (PQCNC)
• Project Lazarus: Chronic Pain Initiative
NC Office of Rural Health

4. • Provider Recruitment and Retention
• Recruits needed healthcare professionals to rural and
underserved areas :
• Primary Care Physicians
• Nurse Practitioners and Physician Assistants
• Dentists and Dental Hygienists
• General Surgeons
• Psychiatrists
• Compatibility matches between community and physician.
• Works to ID shortage Areas (HPSAs).
NC Office of Rural Health

5. • Provider Recruitment and Retention
• Leverages Federal, State and Private-Sector Loan Repayment:
• Up to $100K in state loan repayment over 4 years, or
• Up to $50K bonus over 4 years for those without loans.
• One stop to qualify for federal, state or private sector Foundation
funding in NC.
• Database matching applicants with openings and ongoing
tracking of placements.
• 2015 State Fiscal Year Placement Services:
• 130 new health professionals recruited
• 79 new state incentive payments
• An average of 143 placements each year over the last 5 years
NC Office of Rural Health

6. • Examples of Other Investments in Primary Care
• NC Rural Health Centers: $2.6 million in state funding
• Community Health Grants: $5.4 million/year to help support safety net
primary care
• FQHCs, Free Clinics, Health Departments, School-Based Centers)
• Provided service to 157,000+ low income patients in 60 counties.
• Medication Assistance Program – Provides access to prescription drugs
• $3.5 million of state funding
• Allowed almost 44,000 patients to access $151 million in Rx last year.
• Technical assistance and financial support including:
• Directing members of the public to where they can find free and low-cost care.
• Advising small health centers on how to adapt to improve business practices.
NC Office of Rural Health

7. • Spawned from work of Office of Rural Health
• One of the Early PCMH Models
• 14 Geographic Networks
• Deciding How to Address Local Problems in Medicaid
• Quality Improvement / Practice Improvement Initiatives
• PMPM To Network and To Practice
• Care Managers
• PharmDs
• Mental Health Professionals
• Helped with Other Payers Too
• Led to Multi-Payer Pilot with CMS
• Process Measures Already High with Privates Started
Examining Metrics
Community Care of NC

8. • The Results: It Worked
• Showed consistent savings and quality improvement
• Studies showed small investment brought at least 3 to 1
savings compared to expenditures
• From Milliman to our Own State Auditor – All positive reports.
• $200 to $300 million in savings annually.
Community Care of NC

9. Evolution of ACOs in NC
• Helped by early adoption of PCMH in NC
• NCAFP published Family Physicians Guide to
Accountable Care in 2010
• NC Medical Society forms Toward Accountable Care
Consortium in 2012
• 18 Medicare Shared Savings Programs in NC
• Four began as early as 2012
• A mix of Physician driven and healthcare system driven
• At least 10 ACOs have contracts with commercial
payers
• Approximately half of those overlap with MSSPs

10. Evolution of ACOs in NC
• Some Examples of Evolving ACOs in NC
• Key Physicians – Wake Key Community Care
• Key (comprised of 220 independent physicians in the
Raleigh-Durham area)
• Contracts with two insurers
• MSSP with local hospital system
• Narrow network for BCBS NC Exchange Plan
• Cornerstone Health Care
• A fast growing, physician-owned, multi-specialty group
with over 85 locations. Formed an MSSP with others
and moving most private contracts to value-based
contracts

11. • Blue Cross & Blue Shield of NC
• Blue Quality Physician Program – Began Fall of 2009
• Designed to supplement contracted payments to independent
practices who maintain high standards of quality.
• Based primarily on PCMH criteria
• First iteration – 52% fewer visits to specialists; 70% fewer ER visits
• NC PATH: NC Program to Advance Technology for Health
• Partnership that helped offset the cost of EHRs for free clinics and
small private practices
Private-Payer Investment

12. • Blue Cross & Blue Shield of NC
• Multi-Payer Advanced Primary Care Demonstration
• $1.8 million over 3 years for community-based care management
• 49 practices, 168 primary care providers
• Jointly with Medicaid, Medicare, State Health Plan
• Rural Areas of NC
• Pipeline Initiatives
• Partnered with NCAPF Foundation to invest in Medical Student
Interest.
• $1.2 million from their Foundation over six years.
• Decided to give students early clinical experience plus ongoing
mentoring (when possible)
Private-Payer Investment

13. • Medicaid Reform in NC – Politics Get
in the Way
• Beginning in 2013, First Republican Control of Both
Chambers and Governor’s Mansion in Modern
History (Since Reconstruction)
• Tax Reform Mindset
• Privatization Mentality
• Free Market Competition Approach
• Led to the Medicaid Reform Debate
But, The Bad and the Ugly….

14. Medicaid Reform in NC
• “Medicaid is Broken” Mantra
• First cry as new Governor took office – Partnership for a
Healthier NC
• There had been recent cost overruns, but primarily due to
budgeting and forecasting errors
• Had moved mental health to a local non-profit capitated
environment (large one-time costs)
• Miscalculation of Federal Match, particularly when
Resource and Recover Act enhanced match ended
• Mindset that Medicaid was gobbling up the budget

15. • Our Response
• Build on What Has Worked – CCNC and Medical Homes
• Don’t Outsource Scarce Healthcare Dollars to Out of State,
Profit-Driven Companies (10-15% off the top)
• Let The Provider Community Help Craft the Solution
• 2014 Proposal to Move Toward a Plan Based on Accountable
Care Organizations With Greater Risk Bearing
Medicaid Reform: A 3-Year Debate

16. Medicaid Reform: A 3-Year
Debate
• Summary:
• State Senate: full capitation & managed care only.
• State House: provider led solution.
• Multiple reports come out touting CCNC savings to the NC
State Auditor, including one commissioned by Legislature –
$300 per member savings
• The Compromise: Described as a Hybridectomy
• Full-risk capitated plans, but….
• 3 statewide entities – either MCO or PLE (Provider Led Entity)
• Up to 12 regional PLEs in 5-6 regions (max of two per region)
• PLE can be statewide but MCO can only be regional

17. Medicaid Reform: A 3-Year
Debate
• Some wins:
• It’s not just MCOs.
• Provider and patient protections through insurance statutes.
• Some limits on administrative burden, like uniform credentialing
and one Preferred Drug List.
• Role for CCNC throughout the transition period at a minimum.
• Approximately a four-year glide path.
• Why not all provider led/why not shared risk?
• Intense lobbying and political spending by managed care industry.
• Desire for greater competition.
• Desire for budget predictability.
• But, NC per recipient spending is actually down over the last 5
years.

18. The Future Outlook
• Where We Hope to Go in NC:
• Clinically Integrated Network for Independent Primary
Care Practices
• Ongoing practice transformation – CMS grant to CCNC
-- $18.4 million over four years
• Work with state Health and Human Services to make
sure Medicaid waiver is well written
• Partner with private sector payers to push for value
• Develop direct relationships with true purchasers of
healthcare -- employers

19. The Future Outlook
• Following the Gospel according to Dr. Paul
Grundy
• How Do You Herd Cats? You Move Their Food (but
only a little at a time, otherwise you get chaos).
• We’re Only Addressing Some of the “Dials”
• Practice Transformation (going well in NC)
• One of highest levels of PCMH in the country.
• Quality Improvement (also going well in NC)
• Payment Reform (some, but not enough)
• Patient Engagement/Responsibility (a little)
• We must use all the dials to truly change healthcare

20. Questions-Comments?
Greg Griggs, Executive Vice President
ggriggs@ncafp.com
www.ncafp.com
Tel: 919-833-2110