2020 Legislative Session in Review

ADVOCACY

By Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President

~ ACADEMY IN ACTION ~

In mid-July, the 2020 Session of the North Carolina General Assembly came to a close, well, sort of a close. The General Assembly will technically return in early September to address additional financial issues related to the coronavirus. However, several important bills were finalized during the 2020 legislative session. Key bills are summarized below.

Medicaid Transformation – Senate Bill 808

A bill designed to move Medicaid Transformation forward and fully fund Medicaid’s fiscal needs over the next year passed both chambers of the General Assembly and was signed into law by the Governor. Senate Bill 808 sets July 1, 2021, as the go live date for Medicaid to move to the managed care model. The bill also sets aside funding for a new Department of Health and Human Services headquarters in Wake County (the legislature had previously threatened to move DHHS out of Raleigh), fully funds the Medicaid rebase, provides additional funding to the Department to assist in managing the COVID-19 pandemic, and provides additional resources needed to implement Medicaid Transformation. Originally, the bill required penalty payments to the managed care plans if transformation does not go live by July 1st of next year. Those penalties were eliminated, but the legislation does direct the Department to move the

additional managed care contracts from three years to four years, acknowledging that the delay has impacted those companies who won contracts as managed care plans.

The legislation is particularly crucial to primary care practices because it eliminated the possibility of steep Medicaid rate cuts at a time when primary care practices are already hurting fiscally due to COVID-19. Without an adequate rebase to fund Medicaid, the Department would have been forced to implement substantial provider rate cuts. The move to managed care had been delayed due to a budget impasse. Beyond Medicaid Transformation, the bill added $100 million for COVID-19 testing, contact tracing, and trends tracking and analysis, and appropriates $20 million for early childhood health initiatives. The NCAFP supported this legislation and worked to successfully modify a few initial provisions that proved problematic.

Direct Primary Care Practices – House Bill 471

House Bill 471 clarifies that Direct Primary Care agreements are not subject to regulation by the State Insurance Commissioner nor subject to the provisions of Chapter 58. The bill does establish minimal standards for agreements between a Direct Primary Care practice and the patients they serve. The Governor signed this bill into law July 1. The NCAFP generally supported this legislation.

Step Therapy Reform – Senate Bill 361

After a nearly five-year effort, the General Assembly passed step therapy reform in North Carolina as part of a larger bill, Senate Bill 361. The bill requires insurance companies to have a Pharmacy and Therapeutics Committee to review any restrictions on access to covered prescription drugs or devices, and establishes an exception process for prescribers to provide nonformulary drugs or devices if it is determined to be medically necessary and appropriate for the patient. The bill requires insurers to grant an exception request if there is suf

See ‘Review’ on page 10

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REVIEW from page 9 Pediatric Society), opposed several provisions in House ficient documentation that any of the following apply: Bill 918. All of the organizations were concerned that the patient has tried alternate drugs while covered by provisions in the bill could result in pregnant women the current or previous health plan; the alternate drugs not seeking prenatal care, could pose challenges for rehave been ineffective in the treatment of the disease unification of foster children and further exacerbate the or condition; the alternate drugs shortage of foster homes. While the are expected to cause a harmful or bill passed the General Assembly, it adverse clinical reaction; the drug was a very close vote, and all the has been approved as an exception We have been told by legislaorganizations wrote letters asking to the clinical protocol pursuant to the insurer’s exception procedure; tive leaders that assistance to the Governor to veto the bill. The Governor formally vetoed the bill or the prescriber certifies in writall types of independent on July 2nd. ing that the patient has previously used an alternative nonrestricted physician practices is still access drug and it has been detribeing considered, dependWork Still Outstanding mental to the patient’s health or ineffective in treating the same ing on tax revenue and how The NCAFP and the NC Pediatric condition and is likely to be detCongress says the remaining Society fought hard to secure addirimental or ineffective in treating funds can be utilized. tional fiscal relief for independent the condition again. However, priprimary care practices adverseor authorization processes may still ly impacted by the COVID-19 apply. The Governor signed this pandemic. North Carolina rebill into law July 1. The NCAFP ceived substantial fiscal assistance supported the Step Therapy Reform effort. from the federal government for various impacts of The NCAFP, along with several other medical organizations (NC Medical Society, NC Ob/Gyn Society, NC COVID-19. Some of the funding was passed on to hospitals and health systems. However, no funds have Miscellaneous Healthcare been allocated from the state to independent practices. Appropriations The General Assembly did not allocate 100 percent of the federal funding the state received, vying to wait to Several bills had key appropriations for healthcare. see what July tax collections looked like due to the ecoFor example, House Bill 1023 allocates $4.8 million nomic downturn, as well as for further direction from for UNC School of Medicine Asheville Campus joint Congress on how the funds to the state may be able to program for COVID-19 related response activities and be used. The General Assembly is also waiting to see $2.6 million for the NC HealthConnex health inforif there is additional assistance forthcoming from the mation exchange network for certain COVID-19 refederal government. We have been told by legislative lated improvements and operations. House Bill 1087 leaders that assistance to all types of independent phyallocates $9 million to the Southern Regional Area sician practices is still being considered, depending on Health Education Center in Fayetteville. tax revenue and how Congress says the remaining funds can be utilized. We are continuing to advocate that Expedite Permanency/DHHS Report – hope the General Assembly will appropriate funding House Bill 918 for this purpose in September.

independent practices receive some of this support and

Physician Well-Being During the COVID-19 Crisis: Leadership in the Time of COVID-19

By Jason Horay, Manager of Health Strategy and Well-Being, Curi

Physicians and their practices across the country feel the impact of COVID-19 every day, and the decisions physician leaders make now in the face of the pandemic will impact their future success. To be an effective leader for your practice during times of crisis, it’s important to have a reliable toolbox of habits and identified character strengths to draw from.

As a leader, it’s important that you communicate across the organization clearly and frequently, explain your decisions, and tie them back to your organization’s mission, vision, and values. Here are five recommendations from healthcare consultant Paul DeChant to mitigate workforce burnout and help navigate employees through an unsettling world:

Be visible. Break out of committee meetings and conference rooms as much as possible to spend more time in clinical areas observing the work and communicating with clinicians. This face time can go a long way toward mitigating doubt and building trust. Provide resources. Do everything you can to provide your clinicians the staffing, equipment, and supplies they need now and will need later. As you work to anticipate clinician needs and follow through with fulfilling them, your leadership shows. Empower decision-making at the point of care. Rein in micromanaging. While at times you may feel out of control, enforcing tight control can demoralize your clinicians and result in bad decisions. People in the midst of chaos often have more insight into problems than leaders do, and they typically have great solutions. Trust them. Express gratitude. Take every opportunity to thank your teams; anything from a quick handwritten card to broad public acknowledgement can do the trick. Your people are going way above and beyond, risking their health and potentially their families’ health to serve their patients. Showing your gratitude will further establish and maintain their respect, loyalty, and determination. Anticipate short- and long-term changes. Pull back from the immediate crisis to look around and begin identifying and assessing next steps. It’s not too early. Looking to next week, next month, and next year is smart and can instill a sense of confidence and control.

Another way to reinforce leadership and problem-solving abilities is to identify your character strengths. Character strengths are positive parts of your personality that impact how you think, feel, and behave, and according to the VIA Institute on Character, scientists have identified 24 character strengths that we all have the capacity to express. Knowing and applying your dominant character strengths is the key to you being your best self, which in turn can reinforce your abilities to lead and problem solve. Visit viacharacter.org to take the institute’s character strength survey and discover your unique character strengths profile and lean on those strengths in crisis times.

Much rides on how well your organization comes out of this volatile environment. Workforces are challenged by exhaustion and waning morale, and they’re looking to you for leadership. Be ready to spend more time and effort supporting your clinicians, communicating, providing resources, empowering decision making, expressing thanks, and strategizing next steps. Discover your character strengths for handling stress and developing relationships with those who matter most, including your employees. While disruption and uncertainty couldbreak an organization, they can be opportunities to nimbly pivot to a successful recovery. The strength and effectiveness of your leadership could make all the difference.

If you have questions about these strategies or how we can support the well-being of your employees further, please contact me at jason.horay@curi.com.

CHAPTER AFFAIRS

By Gregory K. Griggs, MPA, CAE NCAFP Executive Vice President

~ FIGHTING FOR YOU ~ Payment Reform and Reduced Administrative Burdens

Over the past few years, the NCAFP has enhanced its efforts to improve investment in primary care and reduce the administrative burden faced by family physicians. These goals were set as a direct result of feedback you, our members, provided in an extensive survey in early 2018. The fruits of these efforts are now beginning to be seen.

For example, in late June, Blue Cross & Blue Shield of NC (Blue Cross NC) announced their “Accelerate to Value” program. Independent primary care practices that choose to participate will receive supplemental payments to stabilize pre-COVID-19 revenue from Blue Cross NC. The design of the program is to “true up” practice revenue for core primary care services in 2020 and 2021 to what an average practice would have earned in 2019.

However, to participate, practices are required to join a Blue Premier program that provides an opportunity for shared savings and quality improvement bonuses. It also provides a glide path to (but does not require participation in) a prospective primary care capitation program that Blue Cross NC hopes to begin offering in 2022. The capitation program will pay a fixed monthly payment for a core basket of primary care services for all Blue Cross NC members attributed to a practice. Blue Cross did not require practices to make a commitment to accept PCP capitation this year but believes that it may be an attractive payment model in the future. In reaction to the Accelerate to Value Program, members of the NCAFP Executive Committee noted: “NCAFP appreciates the efforts of Blue Cross NC to move beyond our traditional fee-for-service delivery system to one based on value that truly recognizes the crucial and fundamental role of primary care in improving quality and lowering healthcare cost.”

Both AAFP and NCAFP have advocated for an alternative for fee for service payment that truly invests in primary care. In fact, earlier this year the NCAFP and many other organizations began calling for a “Marshall Plan” for primary care, noting that the COVID-19 pandemic had exposed the systemic underinvestment in primary care and public health. An op/ed that ran in the News and Observer and Charlotte Observer co-signed by our President, Dr. David A. Rinehart called for the following:

• A change in primary care payment from fee-forservice to a system rewarding prevention and care management;

• Accelerating the use of telemedicine in primary care, rather than only incentivizing it during a time of crisis;

• And expanding the number of family physicians by forgiving medical school tuition for graduates who choose primary care.

The editorial noted that the pandemic is an unprecedented crisis, but also provides an unprecedented opportunity for us to fix our healthcare system by strengthening its foundation: primary care.

A prospective primary care capitation payment model, such as Blue Cross NC is proposing, has the potential to reshape primary care in our state and nation by paying for keeping patients healthy versus payment for episodic sick care. It would let the physician decide, in conjunction with the patient, how care would be delivered to truly achieve healthy outcomes. But we must remain at the table to make sure the details of the plan are done in a way that improves the

See ‘Payment’ on page 14

New AAFP Website and Mobile App

Confirm Your Account Login Email Address

The launch of the new aafp.org and AAFP mobile app is the Academy’s first step in building a user experience that’s seamless across computers and mobile devices so members can easily use the wide array of AAFP tools to serve patients, manage practices, receive CME credit, succeed in medical school and residency, and advocate for themselves and their patients.

These upgrades brought changes to the login process for both the website and app, which switched to use the email address on file with the AAFP as each member’s default username.

If you have not confirmed your preferred email address with AAFP, please email the AAFP Member Resource Center at aafp@aafp.org or call 1-800-274-2237 x 0. Because each member will need their own username, it’s important to note that those with shared email addresses, such as generic practice addresses, will need to update their information as well. The NCAFP held a virtual, half-day Sports Medicine Symposium in early August that drew 184 registered attendees and a great lineup of speakers. Based on preliminary conference survey figures, over 97 percent of attendees rated the conference as excellent or very good, with 94 percent saying they are interested in additional virtual learning opportunities. Even more promising was that for 19 percent of attendees, it was the first time they had attended an NCAFP continuing medical education event. The Academy would like to extend a huge ‘thank Visitors to the new website will find:

easier access to all their AAFP needs, whether on a mobile device or a desktop; expandable mega-menus that allow visitors to find what they want more quickly; and content prioritized for different types of members -- practicing family physicians, residents and students.

The AAFP app switched to the new version for those who set their mobile apps to update automatically or it can be updated manually. It will offer:

a simpler interface for a better user experience; everything in one place, including leading journal content from American Family Physician and FPM; improved audio functionality for mobile learning; new members-only audio content; and in-app purchasing for select AAFP products.

Download the AAFP’s free mobile app on iTunes(itunes. apple.com) or Google Play(play.google.com).

For questions about any of these changes, please contact

NCAFP’s Virtual Sports Medicine Symposium a Success

the AAFP at 1-800-274-2237 x 0 or email aafp@aafp.org.

you’ to Dr. Bert Fields for putting together a great group of speakers. Speakers included Drs. Kevin Burroughs, Timothy Draper, Dominic McKinley, Sara Neal, and Dr. Fields himself.

In addition to the plenary sessions, the Academy Board of Directors also met and completed a full agenda which included the review of committee meetings held earlier this summer on payer and system advocacy, membership satisfaction and practice environment, and workforce pipeline.

PAYMENT from page 12

investment in primary care providing you additional tools to assist your patients. I expressed that desire in a recent phone conversation with the new President of Blue Cross NC, Dr. Tunde Sotunde.

Our advocacy efforts with Blue Cross have gotten us to the precipice of a new paradigm for primary care, but we must remain vigilant to make sure the details are done correctly.

This isn’t our only victory with some of the major payers in our state. Beyond Blue Cross, recent decisions by UnitedHealthcare and Humana have shown a greater commitment to reducing the administrative burdens our members face every day.

As each of you know so well, choosing the most cost-effective medication for a treatment plan poses difficulty due to different drug formularies that are payer dependent, constant formulary changes, and cost transparency to name a few. However, payers are beginning to put forth innovative solutions, including tools that integrate plan-specific information into Electronic Medical Records (EMR).

Humana is working to alleviate some of these burdens by incorporating technology into point-of-care decision making. The company developed a proprietary IntelligentRx solution that integrates with a physician’s EMR’s e-prescribing workflow. This gives the physician the ability to see a Humana member’s prescription cost and coverage at the point-of-care while using the patient’s preferred pharmacy as its source. The tool is meant to improve transparency between physicians and patients during a medical visit. Also referred to as real-time benefit check (RTBC), Humana’s IntelligentRx solution can present up to three low-cost formulary alternatives when the medication is not covered or has coverage restrictions. The software also helps with prior authorizations by incorporating the medication exception process into the EMR workflow.

UnitedHealthcare is also working to simplify the health care system and reduce administrative burden by using new technology. United has just announced a new technology called Point of Care Assist™. It allows for real-time patient information — including clinical, pharmacy, labs, prior authorization, eligibility, and cost transparency — to integrate with existing EMRs. The goal is to make it easier for physicians to understand what UnitedHealthcare members need at the point-of-care. The company is paying to integrate this tool into various Electronic Medical Record platforms to eliminate any cost to participating practices. UnitedHealthcare also hopes to partner with other insurers to broaden the scope of their technology.

Point of Care Assist integrates patients’ UnitedHealthcare data within the EMR to provide real-time insights of their care needs, aligned to the specific patient’s plan benefits and costs. This makes it easier for practices to see potential gaps in care, select labs, estimate costs, and check prior authorization requirements — including benefit eligibility and coverage details. The program provides point-of-care information about what pharmaceutical benefits are included in the patient’s health plan, including possible lower cost alternatives. The technology also helps identify lower-cost, high-quality sub-specialty referrals by indicating what out of pocket costs a patient will have for various in network sub-specialists by utilizing UnitedHealth Premium Care subspecialists who have met quality and cost-efficient care criteria.

While none of these developments represent a cure all for the problems of Family Medicine, combined they do show that our advocacy efforts are making a difference. We want to continue to work with insurers to convince them to invest more in primary care while reducing administrative burden.

As these various technologies are rolled out and new payment models developed, we look forward to receiving your feedback. We can best advocate for you when you let us know what is working and what is not. The key areas of greater investment in primary care and reducing administrative burden remain two of our top priorities as we work to improve the lives of our state’s family physicians every day.