Advocacy

ADVOCACY

By Gregory K. Griggs, MPA, CAE

NCAFP Executive Vice President

STATE

Legislative Session Proves Mostly Positive

2021 has certainly been a unique year, and that is no different when it comes to the North Carolina General Assembly. Fortunately, due to great collaboration within the House of Medicine, it has been generally a positive year on Jones Street in Raleigh. However, the General Assembly continues to meet to finalize budget provisions and redistricting, among other items.

During the 2019 long session, the General Assembly and the Governor could not come to agreement on a complete state budget, so a series of mini budgets were enacted, leaving many areas utilizing “continuation budgets” at levels that were approved back in 2017. At the time of this writing, there is still hope that a complete budget will be enacted in 2021. However, we are already in the second quarter of the fiscal year.

Earlier this year the House and Senate had each approved their own version of the budget. In September and early October, House and Senate leaders negotiated their differences behind closed doors before presenting a confidential proposal to the Governor. Since that time, the Governor and General Assembly leaders have been negotiating several provisions, including tax cuts, education spending, and possibly expanding Medicaid.

On the positive side, there appears to be some

consensus on increasing spending in a few healthcare areas, such as loan repayment, but this will not be confirmed until a final budget is enacted. The NCAFP and other groups within healthcare continue to advocate for increased funding, as well as mechanisms to close the health insurance coverage gap. Stay tuned, we may know more even before this article hits your office via the mail.

In other policy areas, early in the legislative session it appeared that medicine was under attack from every angle, including physician mandates, government interference with the physician-patient relationship, and various bills that seemed to confer medical degrees to others who have not undergone as rigorous training. Thanks to great collaboration within the House of Medicine including the NCAFP, the NC Medical Society, the NC Pediatric Society, the NC Psychiatric Association, and many others, most of these issues have been resolved. But let’s look at a few of them in more depth.

Mandates and Interference with the Physician Patient Relationship

Several bills were proposed that would have mandated how you care for your patients, what you prescribe and even what continuing education you receive. Others would have severely interfered with the physician-patient relationship. Fortunately, as of this writing, each of these remain bottled up in committee, have been changed significantly to address concerns, or have failed outright.

A number of these bills have required very careful tactics. As a result, while you may not always hear the NCAFP shouting about what we are working on, our Government Affairs team is nonetheless hard at work. In many instances, quiet, behind-the-scenes negotiations are much more effective than making loud public statements, and that has been the case this year. Our strategy is based on being effective versus issuing loud proclamations. And believe us, it truly worked this year with several controversial bills.

article continues on next page

Pharmacists

Early in the session, it appeared that some legislators believed that pharmacists were the answer to all healthcare access issues. While we value our pharmacist colleagues, there is certainly significant differences in training and the specifics of each role. Proposals this year would have allowed pharmacists to “prescribe and dispense” a whole host of medications including all tobacco cessation medications (including those that have behavioral health side effects), epinephrine, short-acting bronchodilators, all contraceptives, Prep and PEP for HIV treatment, opioid antagonists, and any travel medication. The proposal also would have allowed pharmacists to “test and screen for any minor, non-chronic health condition,” with no further definition on what a minor, non-chronic health condition is.

Fortunately, through a coalition led by the NCAFP, NC Medical Society and NC Pediatric Society, the final bill was much more narrow. The bill allows pharmacists to “dispense and deliver” Nicotine Replacement Therapy (no other tobacco cessation medications), prenatal vitamins, post-exposure prophylaxis for prevention of HIV, Glucagon, and self-administered oral or transdermal contraceptives after the patient completes an assessment consistent with the CDC Medical Eligibility Criteria. This was probably the most contentious provision, with some physicians concerned about safety and missing other care at contraceptive visits, while other physicians touting the public health merits of easier distribution of contraception. When a pharmacist dispenses any of these medications, they must notify the individual’s primary care physician within 72 hours if they have a medical home. If the patient does not have a medical home, the pharmacist must give the patient information about the importance of having one.

Finally, the bill did allow pharmacists to administer many injectable medications but only pursuant to a specific prescription order, leaving physicians still in control of medical decision making. If a physician does prescribe an injectable, the pharmacist must report administering the injectable to the prescriber within 72 hours unless it is a psychotropic medicine, then they must notify the prescriber within 48 hours. In addition, the final bill did not allow pharmacists to test for or treat minor non-chronic conditions.

While not a completely ideal piece of legislation, overall, the House of Medicine felt like the outcome balanced access and public health with patient safety and the important role of the medical home.

Regulating PBMs and Reducing Out of Pocket Expenses

A wide-ranging bill containing several important health care provisions (Senate Bill 257) passed both chambers of the General Assembly and was signed into law by the Governor. The first section of the bill requires Pharmacy Benefit Managers to be licensed and regulated by the NC Insurance Commissioner, including numerous provisions regulating how a PBM can interact with a pharmacy in North Carolina.

The bill also requires that both pharmacy co-pays paid directly by the individual patient and other payments paid on behalf of that individual (for example, discounts covered by manufacturer programs) contribute to the patient’s deductible, reducing the out-of-pocket burden a patient may have. As you know, many patients with chronic conditions requiring expensive medications rely on co-pay assistance programs to help cover the cost of pharmaceuticals. Before this law was passed, some insurance companies refused to count outside co-pay assistance toward an individual’s deductible or out-of-pocket maximum, leaving patients with higher medical costs. Numerous patient advocacy groups, the NCAFP, and others in the House of Medicine all supported this bill.

APRNs and PAs

The legislature continues to consider a bill that would allow all Advanced Practice Registered Nurses -- regardless of what point in their career they are or whether they attended an online APRN program -- to practice without any collaboration from a physician regardless of the setting. The House of Medicine and

the NCAFP continue to oppose the bill, expressing particular concern around APRN schools that provide all didactic training online and require students to find their own rotations and preceptors, without providing preceptors with curricula or evaluation tools.

In a separate bill that the House of Medicine supports, the specific supervising relationship between a physician and a physician assistant could change in very specific circumstances. Once a PA has been out of school for a certain defined period where he or she has worked closely under an individual physician’s supervision, and only if the PA practices in a teambased setting (a setting with physician involvement and ongoing quality improvement for all clinicians), then individual reporting paperwork for the Physician Assistant could be eliminated. The team-based practice would still have to maintain certain materials on site indicating ongoing quality improvement activities and the scope of practice for the PA (the Medical Board could ask for this information at any time), but this would not have to be regularly reported to the Medical Board.

The NC Academy of Physician Assistants has worked closely with the House of Medicine to develop the specifics of the legislation. While it has passed one chamber of the General Assembly, all parties are asking to wait to the 2022 legislative session before moving forward. Specifically, the NC Medical Board is working on some potential clarifying language, as well as a framework for potential rules that would be used to implement the bill. This specific bill aligns well with a set of principles on scope of practice of other clinicians previously adopted by the NCAFP Board. The NCAFP Board policy places patient safety first, acknowledges the significant differences in training between primary care physicians and other clinicians, but also places a high value on other clinical colleagues and the important role they play in healthcare.

All in all, it has been a very busy legislative session, with the session ongoing as of this writing.

FAMPAC

Empowering Family Medicine

JOIN THE FIGHT FOR FAMILY MEDICINE

Participating is easy --

• Get to know your elected officials and become their trusted healthcare advisor.

• Contribute so we can support candidates that support Family Medicine. • Participate in NCAFP’s ongoing advocacy events and efforts.

To learn more about FAMPAC and donate, visit www.ncafp.com/fampac

STATELine

Medicaid Managed Care Implementation Now in Its Second Quarter

Plan CMOs to Attend NCAFP Annual Meeting to Answer Your Questions

July 1st ushered in a new era of Medicaid in North Carolina with the implementation of Medicaid Managed Care, including five “Prepaid Health Plans (PHPs)” and Medicaid Direct for those patients who are not in managed care. The state has now moved beyond the initial implementation period and we are now well into the second quarter of managed care.

While there have certainly been bumps in the road, due to the tireless work of NC Medicaid and ongoing advocacy with health plans by NCAFP and others, the pain of this transition has generally been less than anticipated. The NCAFP, the NC Pediatric Society, the NC Medical Society, and others continue to work with Medicaid and the PHPs to reduce administrative burdens, address any payment issues, and monitor implementation.

Recently, NC Medicaid enacted several measures around transparency and accountability. For example, Medicaid has rolled out several dashboards to shed light on Medicaid enrollment (by county, region, and health plan), quality metrics, financial metrics, and even the percent of claims being paid and denied by each of the Prepaid Health Plans. You can find all of this information and more at medicaid.ncdhhs.gov/reports/dashboards. We realize there are still issues as our members navigate the complexities brought about by moving from one government payer to multiple payers. If you are having an issue, the first step is to contact your plan representative. If that does not work and you have not gotten the issue resolved satisfactorily, you should contact the Medicaid Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs. nc.gov or call 866-304-7062. You can also let the NCAFP know about significant issues by e-mailing EVP Greg Griggs at ggriggs@ncafp.com. The NCAFP is working with the NC Medical Society and other specialty societies to help identify problematic trends that may become systemic. However, always contact the plan first and give them the first opportunity to resolve the issue.

At our upcoming Annual Meeting in Asheville this December, Deputy Secretary and Medicaid Director Dave Richard and Chief Medical Officer for Medicaid Dr. Shannon Dowler will update attendees on the managed care roll out. This session will take place Saturday morning, December 4 at 8:30 am. We are fortunate to have a great family physician in the CMO role at Medicaid.

Each of the individual health plan Chief Medical Officers, along with Dr. Dowler and Mr. Richard, will be available to answer any questions from 10:00 am to 12:00 noon that same Saturday morning in the Eisenhower Room at the Grove Park Inn. Please drop by to meet the CMOs of each of the plans. Fortunately, NC plans have strong primary care physicians in these roles who are very willing to listen and try to address concerns from our family medicine community. Please take this opportunity to get to know each of them a bit better and ask any questions you have. The Chief Medical Officers for each plan include:

Michelle Bucknor, MD, MBA, a Pediatrician – UnitedHealthcare NC Medicaid Plan.

George Cheely, MD, MBA, a General Internist – AmeriHealth Caritas NC.

Genie Komives, MD, a Family Physician – WellCare of North Carolina.

William Lawrence, MD, a Pediatrician – Carolina Complete Health.

Michael Ogden, MD, MMM, a Pediatrician – Healthy Blue NC.

We look forward to having each of them join us in Asheville.

MEDICAID MANAGED CARE

Dashboards Aim to Equip Physicians and Practices with Latest Medicaid Enrollment, Quality and Expenditure Data

North Carolina Medicaid has introduced a new enrollment dashboard. The dashboard (below), shows Medicaid enrollment by Managed Care Plan and by category of enrollment. You can also look at enrollment by county, as well as historical funding and expenditures for our state’s Medicaid program. Finally, the data shows how Medicaid is doing in several key quality metrics, including HEDIS measures. To view, visit medicaid.ncdhhs.gov/reports/dashboards.